The document provides an overview of enteral feeding including: - Enteral feeding involves providing nutrition via a feeding tube placed in the stomach or small intestine. It has advantages over parenteral feeding like maintaining gut health. - Common enteral feeding tubes are nasogastric, nasojejunal, gastrostomy, and jejunostomy tubes. Placement must be confirmed before use. - Standard enteral formulas provide balanced nutrition but disease-specific formulas also exist. Continuous or bolus feeding can be used. Complications like aspiration, diarrhea and tube issues require monitoring.

1. ENTERAL FEEDING
Gradian Health Systems
Basic Principles of Critical Care
NUTRITIONAL SUPPORT

2. Disclaimer
Basic Principles of Critical Care Training I Enteral Feeding
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 4
Gradian Health Systems
Basics Principles of Critical Care
Nutritional Support

4. Module 4: Nutritional Support
MODULE OVERVIEW
Lesson 1 I Enteral Feeding
Lesson 2 I Parenteral Feeding
Basic Principles of Critical Care Training I Enteral Feeding

5. Components of the Gradian CCV SystemLesson 1: Enteral Feeding
Lesson Objectives
• Describe aspects of enteral feeding
• Outline the types of enteral feeding tubes
• Identify patient conditions requiring enteral feeding
Basic Principles of Critical Care Training I Enteral Feeding

6. Components of the Gradian CCV SystemLesson 1: Enteral Feeding
Key Concepts
• Nutritional status
• Types of enteral feeding tubes
• Indications for enteral reeds
• Types of enteral feeds
• Complications of enteral feeding
Basic Principles of Critical Care Training I Enteral Feeding

7. Components of the Gradian CCV SystemEnteral Feeding
What is Enteral Feeding?
Enteral nutrition support refers to the provision of nutritionally complete feeds
containing calories, protein, electrolytes, vitamins, minerals, trace elements, and
fluids into the stomach or intestine through a tube.
The aim of enteral nutrition is to provide adequate nutrition to prevent or reverse
the development of malnutrition in patients who are not able to ingest or derive
sufficient nutrients from ordinary foods despite having a functional GIT.
Enteral nutrition is typically delivered into the stomach (gastric feeding).
However, it can also be administered into more distal parts of the alimentary
tract (post-pyloric-jejunum), particularly in those at high risk of aspiration or
gastric enteral nutrition intolerance. It can be supplemented with parenteral
feeding.
Basic Principles of Critical Care Training I Enteral Feeding

8. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeding Indications
• Critically ill patients
• Patients with limited or no oral intake due to:
• Postoperative patients – head and neck surgery
• Head injury
• Neuromuscular disorders (e.g. stroke)
• Cancer patients
• Upper GI obstruction
• GU dysfunction
• Poor mental health
• Increased nutritional requirements (e.g. burns, prolonged anorexia, HIV
wasting disease)
• Ventilated patients
Basic Principles of Critical Care Training I Enteral Feeding

9. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeding Contraindications
• Non-functional GIT
• Paralytic ileus
• Surgical discontinuity
• Peritonitis
• Acute pancreatitis
• Persistent vomiting and diarrhea
• Necrosis or mesenteric ischemia
• GIT obstruction
Basic Principles of Critical Care Training I Enteral Feeding

10. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeding Advantages
• Maintains mucosal mass
• Prevents infection by maintaining normal anaerobic flora and preventing
overgrowth of pathogenic organisms
• Maintains functional and structural integrity of the gut
• Inexpensive
• Simple placement of feeding tube into correct site
• Stimulation of GIT hormones and consequently regulated metabolism and
utilization of nutrients
• Ensures adequate supply of nutrition to the mucosal wall and protection
against atrophy of the intestinal wall
• Psychological protection against ulcer (buffering effect from gastric acids)
Basic Principles of Critical Care Training I Enteral Feeding

11. Components of the Gradian CCV SystemEnteral Feeding
Types of Enteral Feeds
• Many different products available
• Common differences between formulas include osmolarity, caloric density,
amount of protein per calorie, and differences in electrolyte, vitamin, and
mineral content
• Most are formulated to provide 100% of daily vitamin and mineral dose when
a delivering a minimum of 1,000 or more kilocalories per day
• Other differences:
• Intact versus predigested
• Presence or absence of fiber
• Presence of absence of disease-specific nutrients
Basic Principles of Critical Care Training I Enteral Feeding

12. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeds for Critically Ill Patients
• Standard enteral nutrition provides sufficient nourishment for most critically ill
patients if given with caloric adequacy
• Concentrated and predigested enteral nutrition may be preferable for selected
patients
Basic Principles of Critical Care Training I Enteral Feeding

13. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeds
• Daily amount of enteral nutrition is tailored to the nutritional and fluid needs of
each patient
• Most patients require supplementation of water
• All feeding tubes should have periodic water flushes to minimize cloggin
• Only water should be used for flushing
• Acidic fluids should be specifically avoided as they increase clogging
• Critically ill patients frequently require volume restriction (e.g. patients with
respiratory failure or volume overload); concentrated enteral nutrition may be
useful for such patients
Basic Principles of Critical Care Training I Enteral Feeding

14. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feed Types
• Standard feeds  1 kcal/ml with or without fiber
• High energy feeds  1.2-2 kcal/ml with or without fiber
• Milk free feeds
• Low sodium feeds
• Disease specific formulas:
• Renal – lower protein, potassium, magnesium, and phosphorous
• Liver disease – increased amino acids (valine, leucine, isoleucine)
• Diabetes / hyperglycemia – lower carbohydrates, higher fat
• Pulmonary disease – reduced carbohydrates (COPD), added fish oils
(ARDS)
• Jejunostomy / high output ileostomy
Basic Principles of Critical Care Training I Enteral Feeding

15. Components of the Gradian CCV SystemEnteral Feeding
Enteral Feeding Tubes and Routes
• Nasogastric tube
• Nasojejunal tube (NJT) – tube is in the
jejunum
• Gastrostomy – percutaneous endoscopic
gastrostomy tubes (PEG); surgical
• Jejunostomy – percutaneous endoscopic
jejunostomy tubes (JEJ or PEJ); surgical
Basic Principles of Critical Care Training I Enteral Feeding
Cancer Research UK / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)

16. Components of the Gradian CCV SystemEnteral Feeding
Nasogastric Tubes
• Nasogastric and nasojejunal tubes are for short-term use (3-4 weeks)
• Stomas (PEG, PEJ) are for longer-term feeding (>4 weeks)
• Mark at the nose should always be recorded
• Nasogastric tubes that are used for feeding are fine-bore tubes
• Easy to insert and less invasive as gastrostomy tubes
• Should not be used in patients with obstructive pathology, base of skull
fracture, sinus surgery
• After insertion, confirm position of NGT
Basic Principles of Critical Care Training I Enteral Feeding

17. Components of the Gradian CCV SystemEnteral Feeding
Methods to Assess Tube Placement
• pH
• Gastric aspirate should be less than 5.5
• Chest X-ray
• Radiopaque line should follow midline in chest to below the diaphragm
and 10 cm beyond the gastroesophageal junction
• Disadvantage is radiation exposure
Basic Principles of Critical Care Training I Enteral Feeding

18. Components of the Gradian CCV SystemEnteral Feeding
Chest X-ray for NGT Placement
• This is an adequate view that shows below
the diaphragm
• NGT remains midline
• NGT does to bisect the carina
• NGT tube tip is visible below the diaphragm
for about 10cm
Basic Principles of Critical Care Training I Enteral Feeding
Case courtesy of Andrew Murphy, <a
href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a
href="https://radiopaedia.org/cases/50337">rID: 50337</a>

19. Components of the Gradian CCV SystemEnteral Feeding
NGT Complications
• Accidental removal or purposeful removal by patient
• Malposition – lungs are the most common
• Aspiration – minimized by elevating head 300
• Blockage – tubes should be flushed with water before and after feeds
• Ulceration of the nasal mucosa
• Sinusitis
• Esophagitis and/or ulceration, especially with prolonged use
Basic Principles of Critical Care Training I Enteral Feeding

20. Components of the Gradian CCV SystemEnteral Feeding
Nasoduodenal and Nasojejunal (NJ) Tubes
• Distal tip is in the duodenum or jejunum and may be single, double or triple
lumen
• Placed under endoscopic guidance
• Placement confirmed with an abdominal X-ray
• Reduced incidence of gastro-esophageal reflux
Basic Principles of Critical Care Training I Enteral Feeding

21. Components of the Gradian CCV SystemEnteral Feeding
Gastrotomy
• Recommended if feeding required for longer than 4-6 weeks
• Can be placed endoscopically (PEG), radiologically (RIG), or surgically
• Vary in size 9-24 FG
• PEG insertion is not a sterile procedure and prophylactic antibiotics is
recommended
• Contraindications include:
• Inability to pass the endoscope due to obstructing pathology in oropharynx or
esophagus
• Gastric outflow
• Ascites
• coagulopathy (relative contraindication)
• Insertion may be difficult in obesity
Basic Principles of Critical Care Training I Enteral Feeding

22. Components of the Gradian CCV SystemEnteral Feeding
Jejunostomy
• Passed beyond the duodenojejunal flexure
• Technically more difficult to insert than PEG
• Complications of Stomas
• Early – pain, bleeding, peritonitis, pneumoperitoneum, gastrocolic fistula (if
the colon is punctured between the stomach and the anterior abdominal wall)
• Late – local infection, tube blockage, over granulation
Basic Principles of Critical Care Training I Enteral Feeding

23. Components of the Gradian CCV SystemEnteral Feeding
Delivery of Enteral Feeds
• Feeding can be done as bolus or continuously
• Continuous  given over 16-18 hours
• Bolus  given over 15-60 minutes at 3-hour intervals
Basic Principles of Critical Care Training I Enteral Feeding

24. Components of the Gradian CCV SystemEnteral Feeding
Complications of Enteral Nutrition
• Gastrointestinal I regurgitation, aspiration, diarrhea, constipation,
dehydration, abdominal discomfort, drug interaction, and contamination
• Tube-related I malposition, knotting, perforation of GIT, obstruction, leakage,
infection and bleeding, erosion, ulceration, necrosis of skin and mucosal
hemorrhage
• Metabolic I electrolyte imbalance, hypo/hyperglycemia
Basic Principles of Critical Care Training I Enteral Feeding

25. Components of the Gradian CCV SystemEnteral Feeding
Nursing Care for Enteral Feeding
• Nurse the patient with head of the bed elevated at 30-45 degrees
• Flush tube with 20-30 mls of warm water hourly during continuous feeds and
administration of medications
• Monitor for gradual increase in residual volume  indicator for poor tube
feeding tolerance and/or aspiration
• Evaluate adequacy of gastric emptying, determined by presence or absence
of nausea, vomiting, high NGT output
• Stop feeding if residual volume is > 250 mls
• Reassess after 2 hours  resume feeding if volume is < 250 mls
• Assess colonic motility, determined by stool passage
Basic Principles of Critical Care Training I Enteral Feeding

26. Components of the Gradian CCV SystemEnteral Feeding
Nursing Care for Enteral Feeding
• Evaluate small bowel motility by presence or absence of abdominal
distension and bowel sounds
• Determine assimilation of nutrients, clinically indicated by absence of diarrhea
• Monitor circulating concentration of glucose, triglycerides, BUN, creatinine
ratio
• Maintain intake and output records
• Label the feeding  time and date started, rate
• Change administration tubes every 24 hours
• Avoid contamination of the feeds
• Check residual volume before each intermittent feed and every 4 hours for
continuous feeds
Basic Principles of Critical Care Training I Enteral Feeding

27. Components of the Gradian CCV SystemEnteral Feeding
Nursing Care for Enteral Feeding
• Maintain adequate hydration – 1 ml of water per calorie of formula received
• Weigh patient regularly
• Monitor vital signs
• Monitor blood sugar
• Promote coping ability – encourage and support the patient to adapt to
physical changes, convey hope based on reality
Basic Principles of Critical Care Training I Enteral Feeding

28. Components of the Gradian CCV SystemLesson 1: Activities
Basic Principles of Critical Care Training I Enteral Feeding
Question
An 94yr old male is admitted for pneumonia.
A chest X-ray is requested to assess
progression of pneumonia and confirm
nasogastric tube position.
1. What is the position of the NGT?
2. What needs to be done next?
Answers on the next slide
Case courtesy of Andrew Murphy, <a href="https://radiopaedia.org/">Radiopaedia.org</a>.
From the case <a href="https://radiopaedia.org/cases/50337">rID: 50337</a>

29. Components of the Gradian CCV SystemLesson 1: Activities
Basic Principles of Critical Care Training I Enteral Feeding
1. What is the position of the NGT?
• Answer: the nasogastric tube is
positioned within the left lower lobe
bronchus
2. What needs to be done next?
• Answer: repositioning is required
Case courtesy of Andrew Murphy, <a href="https://radiopaedia.org/">Radiopaedia.org</a>.
From the case <a href="https://radiopaedia.org/cases/50337">rID: 50337</a>