Early Enteral Nutrition

INTRODUCTION

Surgical and accidental trauma is well

known to cause a transient suppression of
the immune system, that increases the
infection risk.

There is consensus that nutritional

support is an essential component of the
multidisciplinary treatment of surgical
and critically ill patients, especially when
the illness is associated with prolonged
catabolism and with the inability to use
the GI tract.

INTRODUCTION

In the second half of the last century

several studies underscored the
importance of feeding surgical patients
adequately, to reduce the severity and
duration of the catabolic phase, thus
decreasing the postoperative infection
risk.

Postoperative nutritional support benefits

the high risk surgical patients, by
decreasing surgical morbidity,
maintaining immunocompetence and
improving wound healing

Why Enteral Nutrition?

Without enteral nutrition gut atrophy

because no nutrients for enterocyte &
colonocyte

Inadequate enteral nutrition barrier function

failure endotoxin&bacteria translocations

GOAL: To maintain intestinal mucosal integrity

(normal microvilli and intestinal barrier,
intestinel mucosal immunity)

The EN has a specific trophic effect on

the GI tract; such effect is potentially
valuable in preventing microbial
translocation from the gut to the blood
stream and subsequent gut derived
infection.

Time of EN ?

Early enteral feeding is well tolerated and

it reduces significantly the rate of
postoperative complications . As a
consequence, there is now consensus that
critically ill patients are candidates to
enteral feeding if they have a functioning
GI tract

Time of EN ?

The EN usually can begin

postoperatively as soon as the patient is
haemodinamically stable.

Preferably it should start within 24 hours

after surgery, and no later than 48 hours.
As long as there is no significant
abdominal distension, enteral feeding is
not contraindicated, even with markedly
diminished bowel sounds. Most patients
can be fed enterally without waiting for
flatus.

Why sould be Early ?

Immediate or early postoperative EN

stimulates the splanchnic and hepatic
circulation; it improves intestinal mucosa
blood flow, it prevents intramucosal
acidosis and permeability disturbances
and it eliminates the need for stress ulcer
prophylaxis

Definition

delivery of nutrients directly into the

stomach, duodenum or jejunum. Called
also enteral nutrition

Enteral Tube Feeding

Nutritional support via tube

placement through the nose,
esophagus, stomach, or intestines
(duodenum or jejunum)
Must have functioning GI tract
IF THE GUT WORKS, USE IT!
Exhaust all oral diet methods first.

Diagram of enteral tube placement.

Copyright 2000 by W. B. Saunders Company. All rights reserved.

Fig. 22-2. p. 468.

INDICATION

Malnourished patient who

unable to eat >5-7 days
Normally nourished patient
who unable to eat >7-9 days
Adaptive phase of short
bowel syndrome
Increased needs that cannot
be met through oral intake
(burns, trauma)
Inadequate oral intake
resulting in deterioration of
nutritional status or delayed

CONTRAINDICATION

Severe acute pancreatitis

High output proximal fistula
Inability to gain access
Intractable vomiting or
diarrhea
Aggressive therapy not
warranted

ASPEN. The science and practice of

nutrition support. A case-Based Core
curriculum. 2001; 143

Contraindications for EN

Inadequate resuscitation or
hypotension; hemodynamic instability
Ileus
Intestinal obstruction
Severe G.I. Bleed
Expected need less than 5-7 days if
malnourished or 7-9 days if normally
nourished

Choosing the Feeding Site

Can the GI tract be used?
No

Yes

Parenteral Nutrition

Tube feeding for more than 6 weeks?

No
Nasoenteric Tube

Yes
Enterostomy Tube

Risk for pulmonary aspiration?

No

Yes

No

Yes

Nasogastric Tube

Nasoduodenal
or nasojejunal tube

Gastrostomy

Jejunostomy

Gastric Access
Gastric Route Preferred

Adequate gastric motility

Minimum risk of aspiration
Gastric Route Contraindicated

Delayed gastric emptying (gastroparesis)

High risk for aspiration

Gastric Feeding Techniques

Nasogastric Tube

Gastrostomy

Short term

Long term

Manual or
radiologic
placement

Endoscopic,
radiologic, or
surgical placement

Rugeles S, et al. Universitas Medica 1993;34(I):19-23

Nasogastric Tube: Disadvantages

Short-term use only
Higher risk for aspiration
Difficult to confirm position
Small bore
Nasopharyngeal trauma/irritation
Accidental tube displacement

Percutaneous Endoscopic Gastrostomy:

PEG Tubes
Rigid

Minard G. Nutr Clin Prac 1994;9:172-182

Flexible

Percutaneous Endoscopic Gastrostomy:

Advantages

The same as for surgical gastrostomy

No surgery / less invasive
Minimal sedation
Direct visualization
< 30 minutes to place tube
Lower costs

Percutaneous Endoscopic Gastrostomy:

Placement Criteria

Adequate passage for endoscope

Ease in identifying safe site
Ease in determining a safe tract
Functioning GI tract
Absence of ascites / morbid obesity
Stellato TA, et al. Ann Surg 1984;200:46-50
Lee M, et al. Clin Radiol 1991;44:332-334

Surgical Gastrostomy
Performed in operating room
Indicated when PEG is contraindicated or during other
surgical procedures

Requires general anesthesia and full surgical team

In observation during recovery
More expensive than PEG

Gastrostomy: Low-Profile Tube

Post-pyloric Access
Indications for post-pyloric route
Patient at risk for bronchial aspiration, gastric reflux

Gastric feeding contraindicated

Gastric motility disorders; e.g., gastroparesis
Upper GI tract condition; e.g., carcinoma,
stricture, fistula

Post-pyloric Access
Advantages

Disadvantages

Allows earlier post-op

feeding
Lower risk of
aspiration

Small bore tubes, prone to

obstruction
Tubes can be dislodged into
stomach
Difficult to maintain long term
Potential for dumping syndrome
Requires infusion pump

Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387

Post-pyloric Feeding Techniques

Short Term

Long Term

Nasoenteric
Nasoduodenal
Nasojejunal

Jejunostomy
Percutaneous endoscopic
jejunostomy or through the
PEG tube
Surgical jejunostomy

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875

Nasal Access: Tubes

Nasogastric

Easy
Short term
Y-Port

Nasoduodenal / Jejunal

Small bore
Weighted tip
Metal guidewire

Post-pyloric Enteral Nutrition:

Indications
History / risk of reflux or aspiration
Gastric motility disorders
Upper GI tract fistulae
Acute pancreatitis

Post-pyloric Enteral Nutrition:

Advantages
Easily accessible
Less invasive
Lower risk of aspiration
Manual, fluoroscopic, or endoscopic placement

Post-pyloric Enteral Nutrition:

Disadvantages
Placement can be difficult to achieve and maintain
Requires x-ray confirmation
Short term use only
Nasopharyngeal trauma / irritation
Small bore tube

Jejunostomy Feeding: Indications

Feeding
contraindicated for
upper GI tract

Gastric motility
disorders

History / risk of reflux

or aspiration

Nutrition by Jejunostomy:
Disadvantages
Small bore tube
Placement can be difficult to achieve and maintain
Difficult to maintain for long term

Percutaneous Endoscopic Jejunostomy

Tube placed with or without existing PEG
Requires endoscopy
Placed distal to Ligament of Treitz

Bumpers HL, et al. Surg Endosc 1994;8:121-123

Nasal Access: Multilumen Tubes

ENTERAL FORMULAS

Factors that influence the choice of enteral formula:

1. Functional status of the GI tract,
2. The extent of organ dysfunction (e.g., renal, pulmonary,
hepatic, or gastrointestinal)
3. The nutrients needed to restore optimal function and
healing
4. The cost of specific products

Low-Residue Isotonic Formulas

This low-osmolarity compositions

Provide a caloric density of 1.0 kcal/mL and need 15001800 mL to meet daily requirements

Provide baseline carbohydrates, protein, electrolytes, water,

fat, and fat-soluble vitamins (some do not have vitamin K)

Standard or first-line formulas for stable patients with an

intact gastrointestinal tract

Isotonic Formulas with Fiber

Contain soluble and insoluble fiber, which is most often soy

based

Fiber-based solutions delay intestinal transit time and reduce the

incidence of diarrhea

Fiber stimulates pancreatic lipase activity and is degraded by

gut bacteria into short-chain fatty acids (as fuel for colonocytes)

No contraindications for using fiber-containing formulas in

critically ill patients

Immune-Enhancing Formulas

Fortified with special nutrients to enhance immune or solid

organ function

Including glutamine, arginine, branched-chain amino acids,

omega-3 fatty acids, nucleotides, and beta carotene

The addition of amino acids to these formulas generally

doubles the amount of protein (nitrogen) found in standard
formula; however, their cost can be prohibitive

Calorie-Dense Formulas

Have greater caloric value for the same

volume

Provide 1.5 to 2 kcal/mL suitable for

patients requiring fluid restriction or
those unable to tolerate large-volume
infusions

High-Protein Formulas

Available in isotonic and nonisotonic

mixtures

Proposed for critically ill or trauma

patients

Nonprotein-calorie:nitrogen ratios
between 80:1 and 120:1.

Elemental Formulas

Advantage ease of absorption

Not indicated for long term use as a primary source

of nutrients because of the inherent scarcity of fat,
associated vitamins, and trace elements

High osmolarity, dilution or slow infusion rates

Used frequently in patients with malabsorption, gut

impairment, and pancreatitis

Higher cost than standard formulas.

Renal-Failure Formulas

Benefits lower fluid volume and

concentrations of K, P, and Mg needed to
meet daily calorie requirements

Contains essential amino acids

Has high nonprotein-calorie:nitrogen

ratio

Not contain trace elements or vitamins

Pulmonary-Failure Formula

Increased fat content to 50% of the total

calories and reduction in carbohydrate
content

Goal to reduce carbon dioxide

production and alleviate ventilation
burden for failing lungs

Hepatic-Failure Formulas

50% of the proteins are branched-chain amino acids

(e.g., leucine, isoleucine, and valine)

Goalreduce aromatic amino acid levels and increase

the levels of branched-chain amino acids to reverse
encephalopathy

Protein restriction should be avoided because patients

have significant protein energy malnutrition
predisposition of additional morbidity and mortality

MONITORING
PARAMETER

DURING
INITIATION

STABLE ACUTE
PATIENT

LONG TERM
PATIENT

Blood chemistry

2 - 3 times/week

Every 1 - 2 weeks

Every 6 months

Lytes, BUN,
Creatinine

Daily

2 - 3 times/week

Every 6 months

Triglycerides

Weekly

Every 1 - 2 weeks

Every 6 months

Glucose

2 - 3 times/week

Every 1 - 2 weeks

Every 6 months

Serum proteins

Weekly

Monthly

Every 6 months

Weight

Daily

2 - 3 times/week

Weekly

I&O

Daily

2 - 3 times/week

Weekly

Nitrogen balance

PRN

PRN

PRN

COMPLICATIONS

Tube feeding diarrhea, aspiration, vomiting,

distension, metabolic abnormalities, and tube
dislodgment

Aspiration minimized by elevation of the

head 30, use prokinetic agents, feedings
beyond the ligament of Treitz

Abdominal distention and cramps corrected

by temporarily discontinuing feedings and
resuming at a lower infusion rate

COMPLICATIONS

Diarrhea usually is not caused by the tube feedings

but by other therapies

Caused by use of medications via the tube (sorbitol,

antibiotics, prokinetic agents, magnesium antacids)
reversed by discontinuation of these medications

Reduce diarrhea by fiber-containing diet to provide

substrate for the colonocytes

Metabolic Complications
PROBLEM

CAUSE

TREATMENT

Hyponatremia

Overhydration

Change formula
Restrict fluids

Hypernatremia

Inadequate fluid intake

Increase free water

Dehydration

Diarrhea
Inadequate fluid intake

Evaluate causes of diarrhea

Increase free water

Hyperglycemia

Too many calories

Lack of adequate insulin

Evaluate caloric intake

Adjust insulin

Hypokalemia

Refeeding syndrome
Diarrhea

Replace K
Evaluate causes of diarrhea

Hyperkalemia

Excess K intake
Renal insufficiency

Change formula

COMPLICATIONS

Jejunal tube feedings pneumatosis intestinalis and

small-bowel necrosis

Pathophysiology: bowel distention and consequent

reduction in bowel wall perfusion (inadequate splanchnic
perfusion)

Factors: hyperosmolarity of solutions, bacterial

overgrowth, fermentation, and accumulation of metabolic
breakdown products

Enteral feedings in the critically ill patient should be

delayed until adequate resuscitation has been achieved