Early Enteral Nutrition in Critically Ill Patients is the best for helping early recovery, decreasing hospital stay and decreasing malnutrition in ICU How? When? Formulas used? Access forms?

1. EnteralNutrition
BY:
DR. RIHAM HAZEM RAAFAT, MD

2. The Basics of Nutritional Support
• Most patients in ICU are unable to tolerate normal diet
• Many of them are malnourished on admission
• Nutrients can be delivered directly to the GIT by feeding tubes (enteral
feeding) or by intravenous (parenteral feeding)
• Nutrition is provided against a background of a continuously changing
physical status
• Few data directly compare feeding with no feeding in critical patients and it
suggests worse outcomes in underfed patients
• Catabolism in critically ill patients causes malnutrition
• Malnutrition closely associated with poor outcomes

3. • Stress, acute illness, surgery or trauma produce major changes in the metabolic
milieu of the body
- Changes in substrate utilization
- Altered substance synthesis rates
- Hyper-metabolism
- Catabolism

4. Why Malnutrition in Critically Ill
Poor intake
Stress
Hyper-
metabolism
Changes in
Substrate
Utilization
Surgery
Immobility
Prolonged
Bed Rest
Steroids

5. Consequences of Malnutrition
• Increased morbidity and mortality
• Prolonged length of stay in ICU
• Impaired tissue function and wound healing
• Defective muscle function, reduced respiratory and cardiac function
• Immuno-suppression, increased risk of infection
• Poor weaning from ventilator

8. Enteral Feeding
Early feeding is usually defined as starting within the first
24-48 hours of admission – Goal is reaching 50-65% of
caloric needs by the first week
(Meta-analysis suggests reduced infections if patients are
fed within 48 hours)

9. Indications for Enteral Nutrition
• Malnourished (unable to eat) >5-7 days
• Normally nourished patient (unable to eat) >7-9 days
• Increased needs that cannot be met through oral intake (e.g. burns,
trauma, stress)
• Adaptive phase of short bowel syndrome
• Mental incapacitation
• MV

11. Benefits of Enteral Feeding
• Prevents gut mucosal atrophy by preserving intestinal mucosal structure
and function
• More physiological
• Relatively non-invasive, cheaper, easier
• It reduces bacterial translocation and multi-organ failure
• Reduced risk of infectious complications of PN

12. Contraindications of Enteral Nutrition
Inability to gain access
• Paralytic Ileus (relative)
• Bowel Obstruction
• Intestinal ischemia
• Severe GI Bleeding
• Vomiting / Diarrhea
• High Output Proximal Fistula
Clinical shock / Hemodynamic instability
Expected need less than 5-7 days in malnourished or 7-9 days in normal

13. Enteral Access
Delivery method Common indications Precautions
Nasogastric/Orogastric
(up to 4-6 weeks)
(fine bore 5-8 FG or large bore)
(polyurethane, rubber & silicone)
- Unable to consume oral nutrition
(Intubated, sedated, neurologically impaired)
- Hypermetabolism in the presence of
functional GIT (e.g. burns)
- Tube must be secured
- Verify placement of tube by ausc. or x-
ray (gold) or PH or aspirate or cynography
- Higher aspiration risk in large bore ‘e
higher injury to nose/oes but ↓ clogging
Nasoduodenal/Nasojejunal
(up to 4-6 weeks)
(fine bore 6-10 FG)
1F = 1/3 mm so 12F = 4mm
-Inadequate gastric motility or intolerance
(gastroparesis, delayed gastric emptying)
- Partial gastric outlet obstruction
- Severe aspiration risk
- Oesophageal reflex - Coma lying flat
- After upper GI surgery - In high GRV
- Tube must be secured
- Verify placement of tube by X-ray
(fluoroscopy) or endoscopically
- Bedside is difficult and failure rate is 70-
85%
Gastrostomy (silicone or PU)
-PEG (pull, push, introducer, mini
laparoscopically guided)
-Radiological -Surgical
-Anyone who requires medium to
long term NG tube feeding ( > 1 month)
-Head and neck injury/surgery
-Neoplasm in UAWs or Oesophagus
- Caution in patients with severe
GERD or gastroparesis – Abs (6hr before)
- Contraindicated in patients with
ascites, coagulopathies, die <3M,
Jejunostomy (solid > balloon)
-PEJ
-Surgical
*Both G & J: 2 or 3 ports
- Injury, obstruction or fistula
proximal to jejunum
peritonitis, morbidly obese
- Monitor bleeding, not removed 14 ds,
early feeding (2hrs adults, 6hrs children)

17. Contraindications to NG and NJ intubation:
– Obstruction of the nasopharynx and esophagus,
– Recent foregut surgery that may predispose to perforation
– Craniofacial fractures. Contraindications of PEG:
– Intolerance to pre pyloric feeds, abdominal pain
with feeding, and repeated regurgitation of the
feeding solution
Relative contraindications to NG tube placement: include
– Severe gastroesophageal reflux,
– Coagulopathy, and
– Esophageal variceal bleeding.

18. Complications of Enteral Nutrition
Reactions Possible Causes
Diarrhea +/- Nausea and Vomiting
Dehydration
Infection
Medications/C. difficile/lack of dietary fiber/hyperosmolar
formula/bacterial contamination/improper administration/fat
malabsorption
Constipation Inadequate fluid intake/insufficient fiber/GI obstruction
Aspiration of tube feeding/high
gastric residuals (>250 in 2 or 500 in 1)
Regurgitation of stomach contents/feeding while supine/delayed
gastric emptying/tube dislodgement/GERD
Hypoglycemia Sudden cessation of tube feeding in patients on oral HG/insulin
Hyperglycemia Diabetes/stress/trauma/corticosteroid/sepsis/refeeding $
Hypophosphatemia / Hypokalemia Refeeding syndrome / excessive losses
Others due to technique itself or after
tube insertion
(minor 13% or major 3%)
GERD/aspiration/wound infection/bleeding/misplacement:
pnthx/ epistaxis/ pneumoperitoneum/fistula/neoplastic
seeding/infection/mortality (1%)
Clogging/sinusitis/intestinal ischemia (if hemodyn unstable
EN)/dislodgment/malfunction/peristomal infection/leak/BPS

19. If Starvation for 7-10ds:
Arrhythmia, HF, RF  you have to correct imbalance before NS

20. Methods of Administration
Continuous Intermittent Bolus
Use - Intubated.
- Jejunostomy.
- Critically ill.
- Glycemic index control
- Refeeding.
- Intolerance to intermittent.
*↑ time of absorption
- In stomach.
- ↑ fluid tolerance.
- During day or sleeping hrs
by using alarm. -
↑aspiration
- Better ↑ in day & ↓ in
night→ ↑ QOL (in rehab &
home)
- Needs N gastric function
I. Bags → clamp.
II. Syringe & Funnel→ raise &
down or pressure.
- Mimic normal eating.
- ↓cost - ↑ aspiration,
distension, delay GE
- ↑movement of patient
Rate 20-60ml/hr &
advance by 10-20ml/hr/8-
24hrs
240-400ml (begin 60-120ml)
(1-3 cups) in →
30-45mins→
4-6 times daily (flush)
Gravity drip.
150-500ml/ 5-15mins/ 3-6 times.

25. Broad Lines
• Choose full strength, isotonic formulas for initial feeding regimen.
• Diluting formulas may increase the risk of microbial contamination  intolerance due to diarrhea
• Gastric Feeding and Stable Patients:
– Initiate with full strength formula: 50 ml/hr X 3-8 times bolus/gravity method.
– Increase up to 50-100ml/hr every 10-12 hrs till goal volume (usually 24-48hrs)
• Small-bowel feedings & Gastric feedings in critically ill patients or severely malnourished patients:
– A pump is generally required as the slower administration rate of continuous feedings often
enhances tolerance.
– Start as full strength (iso/hyperosmolar/elemental): 10-40ml/hr 3-8 feeds, if tolerates well  increase
by 10-20ml/hr every 10-12 hrs till goal reached.

26. • Elevate the backrest to a minimum of 30º, and preferably to 45º, for all patients receiving
EN unless a medical contraindication exists. Chlorhexidine mouth wash twice daily.
• If patient can’t tolerate high rates  feeding rate decreased till he adapts.
• If the GRV (amount of formula and GI secretions remaining) is > 250 mL x2 times a
prokinetic agent should be considered in adult patients (erythromycin / metoclopramide)
• If the GRV > 500 mL/6hr  hold EN and reassess patient’s tolerance by using an
established algorithm including: physical assessment, GI assessment, evaluation of
glycemic control, minimization of sedation, and consideration of promotility (prokinetic)
agent use if not already prescribed.
• Consideration of a feeding tube placed below the ligament of Treitz when GRVs are
consistently measured at > 500 mL

27. Catheter Care:
- Skin Care: water and soap is the best, avoid pressure, oral hygiene
- Clogging Prevention:
1. Flushing protocol: Flush with water 30-60ml (flush of choice) or pancreatic enzymes.
2. Medications: Administered separately, Flush before and after, Use liquid medications.
- Exchange and Removal: not before 2 weeks (or 4-6 weeks in IS, CS, Obese)  for G or J tubes
1- Removal at bed side with traction method:
Patient lies supine and bend his knees (For solid bolsters → tube grasped by force and For
balloon bolsters → balloon inflated and removed)
2- We better use surgical lubricant.

28. • Flush feeding tubes with:
– 30 mL of water every 4 hours during continuous feeding.
– Before and after bolus/intermittent feedings in an adult patient.
– After measuring GRV (measured every 4 hrs till goal reached and in critically ill patients (decrease
measuring to every 6-8 hrs if patient is stable)
• Sterile water is usually recommended, for flushing and mixing medications (contribute to fluid intake)
• Precautions in flushing:
Orange Juice  Damages PU tubes.
Papain and NaHCO3  Damages PU & silicone tubes.
H2O + pineapple juice  Can be used.
↑ intact protein + Acidic medications  ↑ clogging so not use soda or cranberry juice for flush.

29. Formulations
Formula Composition: (1-2kcal/ml)
1. Carbohydrates (30-60% of Cal)
2. Fibers (+/-)
3. Fats (15-30% of Calories)
4. Proteins (15-25% of Calories)
5. Vitamins and Minerals (RDA)
6. Water (70-85% of Volume – 30-40ml/kg/d)
7. Osmolality (270-700 mOsm/kg) (iso/hyper)
8. Immuno-modulating Agents (arginine/glutamine/omega 3 …etc.)
Types of Formulas:
• Standard (polymeric)
• Disease specific
• Elemental or defined (mono/oligomeric)
• Home made
• Modular (only one)
Don’t Mix drugs or additives with enteral
formulas  flush before & after

30. Formula Selection Depends on:
– Patient’s Condition (age / allergies / tolerances / diseases)
– GI status
– Need of Fiber Modifications
– Enteral Route (gastric vs small bowel)
– Nutritional and Fluid Requirements

31. 1.2 up to 2 gm/kg/d
in critically ill

33. Open System Closed system
Advantages Product is into: powder or ready to fed
- Allows modulars such as protein and
fiber to be added to feeding formulas
- Less waste in unstable
patients (maybe)
- Containers are sterile until spiked for
hanging (ready to hang 1L, 1.5L, 2L)
- Can be used for continuous or bolus
delivery - Less waste of formula
- Less nursing time
- Increases safe hang time (24-48hr)
- Less risk of contamination
Disadvantages - Increase nursing time
- Increase risk of contamination
- - Shortens hang time (4-8 hrs)
- - Rinsing of bag and tubing
- No flexibility in formula additives
(can use Y port for additions)
- More Expensive than open formula

34. Monitoring
Tube
Placement
Medication
Nutrition
Goals
GIT Issues Aspiration
Metabolic
Complicati
ons

35. EN Safety
We should handle EN in a safe manner to avoid contamination in all aspects of care e.g.
preparation, manufacturing, infusion.
• Contamination: Precautions to avoid contamination:
- Use gloves, hand washing.
- Pump Cleaned daily.
- Cans with alcohol,
- Container sanitized and labeled with name & time.
• Sanitization
- Changed every 24 hrs.
- Use screw top connectors not flip top.
- Use spike set. - Connections differ than IV lines are better
- Infusion chambers→↓ retrograde bacteria.
• EN set (different hang times)
- Closed system - Open system → Refrigerated if not adm. immediate & the remaining is discarded

37. Transitional Feeding
- From continuous → intermittent → oral.
- Stop EN if oral intake → 66-75% (2/3) of total calories.
- Monitor tolerance (↓ duration, ↑ volume)

38. Videos that may help:
• https://www.youtube.com/watch?v=2MPM9XvadQo
• https://www.youtube.com/watch?v=_EDUAVTHQtk&index=2&list=FLa_kHXFy
UdiFBuZLLkzLMXg&t=24s
• https://www.youtube.com/watch?v=yRmRMHfG7g0&index=1&list=FLa_kHXFy
UdiFBuZLLkzLMXg
• https://www.youtube.com/watch?v=lpxdUFVOibk