Dr Dina Hamdy Selim
• An alternate means of providing nutrients to people who
cannot eat any or enough food .
Nutritional Support Service (NSS)
NSS is a consult service that provides:
• Nutritional Assessment & Recommendations for
nutritional management of hospitalized patients
requiring specialized:
a) Oral
b) Enteral Nutrition (EN)
c) Parenteral Nutrition (PN)
“If The Gut Works,
Use It Or Loose It”
Promotes gut motility
Reduces translocation of bacteria from gut
Less costly than PN
• Malnourished patient expected to be unable to eat
adequately for > 5-7 days
• Adequately nourished patient expected to be
unable to eat > 7-9 days
• Adaptive phase of short bowel syndrome(~200 cm
in adults)
• Following severe trauma or burns
• Recent severe loss of weight (>5% of usual body
weight in 3 weeks or >10% in 6 months)
• Critical ill who are haemodynamically stable +
functioning gut SHOULD be fed early if possible.
• Early EN------Reduction of infection.
------Reduction in hospital stay.
------ Reduced morbidity.
EEN 12-24 hours
• Minimal enteral nutrition
• Continuous infusion 10-15 ml/hr
• < 25% of the calories provided by enteral route :
*Stimulate or maintain gut function
*Decrease the chances of cholestasis.
• Severe acute pancreatitis
• High output enteric fistula distal to feeding tube
• Inability to gain access ( e.g. obstruction)
• Intractable vomiting or diarrhea
• Intestinal Ischemia /Perforation
Shock---reduced intestinal perfusion-----
be cautious.
Feeding through the GI tract via tube, catheter
or stoma delivering nutrients distal to oral
cavity.
Short term Long term
• Open feeding system: Formula to be transferred
from original packaging to feeding container.
• Closed feeding system: Formula prepackaged in
ready-to-use containers .
• Bolus and Gravity Drip Feeding: Delivery of
prescribed volume in less than 15 minutes
• Intermittent feeding: Delivery of prescribed volume
over20-40 minutes
• Continuous feeding: slow delivery at constant rate
over 8-24 hour period
• Feeding tube obstruction
• Feeding tube dislodged
• Nasal irritation
• Skin irritation
• Concentrated, viscous, and fiber-containing
feeding products
• Tube feeding contamination
• Checking of gastric residuals
• Small diameter tubes
• Powdered or crushed medication flushed through
tubes
• Tubes not routinely flushed after feedings are
stopped
• Flush the feeding tube, especially before and
after medication administration
• Use liquid formulations of medicines where
possible (but be careful of osmolarity)
• Do not mix medications with enteral feedings
• Avoid crushing sustained-release or enteric-
coated tablets
• Symptoms include dyspnea, tachycardia,
wheezing, anxiety, agitation, cyanosis , may lead to
aspiration pneumonia
• Keep head of bed elevated 30-45 degrees during
and 30-40 minutes after feedings
• Feed post-pylorically
• Small, frequent feedings or continuous drip
• Monitoring of gastric residuals may be helpful in
identifying delayed gastric emptying and increased
risk of aspiration
• Diarrhea
• Constipation
• Gastric distention/bloating
• Gastric residuals/delayed gastric emptying
• Nausea/vomiting
• Definition: >500 ml every 8 hours or more than 3 stools a day for
at least two consecutive days.
• Relates more to stool consistency than frequency
• Diarrhea was a common consequence of enteral feedings when
hyperosmolar feedings were routinely delivered via syringe
• Causes
• Intestinal atrophy due to malnutrition
– EN is the best stimulant for recovery
– Increase rate slowly as tolerated
• Bolus feeding in the small intestine: results in dumping
syndrome.
• Bacterial overgrowth of intestinal tract
• Contamination of the enteral feeding
– Avoid prolonged use of broad-spectrum antibiotics
– Use clean technique and closed system in handling enteral feedings
• Steatorrhea: characterized by frothy, odiferous stools
that float on water; caused by fat intolerance
– Use low fat enteral formula or one with higher percentage
of MCT.
• Lactose intolerance
– Most enteral products are lactose free but this may occur
with initiation of full liquid diet.
– Eliminate milk and dairy products
• Drug-induced diarrhea
– Meds may cause up to 61% of diarrhea in tube fed pts due
to
✓Hypertonicity
✓Direct laxative action
(magnesium, sorbitol, potassium).
– Diarrhea most common with antibiotics.
• Often related to delayed gastric emptying caused
by hypotension, sepsis, stress, anesthesia,
medications (analgesics )surgery
• Consider reducing/discontinuing narcotic
medications
• Administer feeding solution at room temperature
• Reduce rate of infusion by 20-25 ml/hr
• Administer prokinetic agent (metoclopramide,
erythromycin)
• Check gastric residuals(GRV)
• Consider antiemetics
(Refeeding Syndrome)
• Fluid and Electrolyte abnormalities , Glucose intolerance, Ca++,
Mg++, PO4 abnormalities.
• May result from long term nutrition deficits, acute stress, medications,
medical conditions.
• Electrolytes lost via stool, urine, ostomy or fistula
• Dehydration most common complication especially with high protein feeding
and insufficient fluid
• Often reflects acute stress, infection,
medications (especially steroids)
• Macronutrient distribution
• Most enteral feeding formulas fall within guidelines; could try formula
lower in carbohydrate
• Insulin management
• May result from long term nutrition deficits, acute stress,
medications, medical conditions.
• Electrolytes lost via stool, urine, ostomy or fistula
• Dehydration most common complication especially with high
protein feeding and insufficient fluid
• Often reflects acute stress, infection,
medications (especially steroids)
• Macronutrient distribution
• Most enteral feeding formulas fall within
guidelines; could try formula lower in
carbohydrate
• Insulin management
• Formula contamination
• Unsanitary equipment
• Failure to follow appropriate protocols
re handling of enteral feedings/changing
of bags and tubing
