Nutrition is most common but neglected procedure in ICU patients. Here are some tips how handling neutron improves patients out come

1. HANDLING
NUTRITION
Dr Anand Nikalje
Consultant intensivist & Physician
MIT Hospital
MGM Hospital
Aurangabad

2. ■ The more impure bodies are fed, the more disease they will become.

3. Nutrition in critically ill patients
■ Enteral(EN) Vs Parenteral nutrition(PN)
■ EarlyVs Late EN
■ Partial parenteral nutrition(PPN)

4. Enteral Nutrition
■ GastricVs duodenal
■ Bolus or continuous
■ Use of pump?

5. Initiation of
tube feeding
• Insertion of Ryle’s tube
• How to confirm??
• GastricVs duodenal?
• Starter regimens

6. Administration
■ Bolus
■ Intermittent
■ Continuous

7. Bolus feeding
■ Infusion of up to 500 ml of enteral formula into the stomach over 15 (5-20 ) minutes,
usually by gravity or with a large-bore syringe.
■ Indications:
■ Recommended for gastric feedings
■ Requires intact gag reflex
■ Normal gastric function.

8. Advantages:
■ More physiologic
■ Enteral pump not required
■ Inexpensive and easy administration
■ Limits feeding time so patient is free
to ambulate,
■ Makes it more likely patient will
receive full amount of formula
Disadvantages:
■ Increases risk for aspiration
■ Hypertonic, high fat, or high fiber
formulas may delay gastric emptying
or result in osmotic diarrhea

9. Continuous Feedings
■ It is administered through pump or gravity, usually over 8- 24 hrs continuosly .
Indications:
■ Initiation of feedings in acutely ill patients
■ Feeding into small bowel
■ Intolerance to other feeding technique.

10. Advantages:
■ May improve tolerance
■ May reduce risk of aspiration
■ Increased time for nutrient
absorption
Disadvantages:
■ May reduce 24-hour infusion
■ May restrict ambulation
■ More expensive for home support
■ Pumps are required

11. Intermittent Feedings
■ Enteral formula administered at specified times throughout the day; generally in smaller
volume and
■ at slower rate than a bolus feeding but in larger volume and faster rate than continuous
drip feeding.Typically 200-300 ml is given over 30-60 minutes q 4- 6 hours
■ Precede and follow with 30-ml flush of tap water
Indications:
■ Intolerance to bolus administration
■ Initiation of support without pump
■ Preparation of patient for rehab services or discharge to home

12. Advantages:
■ May enhance quality of life
■ Allows greater mobility between
feedings
■ More physiologic
■ May be better tolerated than bolus
Disadvantages:
■ Increased risk for aspiration
■ Gastric distention
■ Delayed gastric emptying

13. Complications:Tube occlusion
■ Narrow-bore feeding tubes can become occluded by protein precipitates that form
when acidic gastric secretions reflux into the feeding tubes.
■ Standard preventive measures include flushing the feeding tubes with 30 mL of water
every 4 hours, and using a 10-mL water flush after medications are instilled.
■ If flow through the feeding tube is sluggish, flushing the tube with warm water can
restore flow in 30% of cases. If this is ineffective, pancreatic enzyme (Viokase) can be
used as follows :
– Regimen: Dissolve 1 tablet ofViokase and 1 tablet of sodium carbonate (324 mg) in 5
mL of water. Inject this mixture into the feeding tube and clamp for 5 minutes.
– Follow with a warm water flush.This should relieve the obstruction in about 75%
of cases
■ If the tube is completely occluded, advance a flexible wire or a drum cartridge catheter
through the feeding tube in an attempt to clear the obstruction.
■ If this is unsuccessful, replace the feeding tube without delay.

14. Regurgitation/Aspiration
■ Retrograde regurgitation of feeding formula is reported in as many as 80% of patients
receiving gastric or duodenal feedings
■ Gastric ResidualVolume
– Residual volumes of 150–250 mL are typically used to stop enteral feedings, but
clinical studies have shown that residual volumes up to 500 mL do not increase the
risk of aspiration pneumonia
– Tube feedings should not be stopped when the residual volumes are < 500 mL unless
there are other signs of intolerance to feedings (e.g., vomiting)
– When regurgitation of enteral feedings is evident, the head of the bed should be
elevated to 45º above horizontal, and the feeding tube should be advanced into the
small bowel (if it’s not already there).
■ Prokinetic therapy is an additional option, but the benefits are questionable.

15. Intolerant Patient
■ For patients who continue to be intolerant of tube feedings (e.g., repeatedly
regurgitate feedings or develop abdominal distention), a switch to parenteral nutrition
may be necessary.
■ However, the infusion of tube feedings should be continued at a lower, tolerable rate,
whenever possible, to provide some support for the antimicrobial defenses in the
bowel.

16. Diarrhea
■ Diarrhea occurs in approximately 30% of patients receiving enteral tube feedings.
■ The feeding formulas were originally implicated, but the consensus opinion now is
that other factors are involved.
■ The principal offender in tube-feeding diarrhea may be liquid drug preparations

17. Liquid drug preparation
■ Liquid preparations are favoured for drug delivery through narrow-bore feeding tubes
because there is less risk of obstruction.
■ However, liquid preparations have two features that create a risk for diarrhea: (a) they
can be extremely hyperosmolar (≥3,000 mosm/kg H2O), and (b) they can contain
sorbitol (to improve palatability), a well-known laxative that draws water into the
bowel lumen

18. Home-made “Blenderized” feeds may be unsafe
Concern Home-made
“blenderized”
Commercial enteral
Contamination2 Likely Unlikely
Consistent nutrient delivery3 No Yes
Suitability for volume-sensitive
patients1
Hard to make high-density
nutrition
Available at high-calorie
densities
Feeding tube flow1 Poor with gravity feeding;
difficult with pump
propulsion; sieve to lessen
problems
Few or no flow problems
Tolerance and immune function No special ingredients Available with tolerance-
promoting or other
pharmaconutrients
18
1.Sobotka L, ed. Basics in Clinical Nutrition. Fourth ed. Prague: ESPEN; 2011.
2. Sullivan MM, et al J Hosp Infect. 2001;49:268-273.
3. Sullivan MM, et al. Asia Pac J Clin Nutr. 2004;13:385-391.
Commercial feeding formulas are safe and have special benefits1

19. Hence the significant difference can
be noted at even after 1st hr

20. Potential Points for Contamination in the Preparation, Storage, Handling, and
Administration of Enteral Nutrition
Journal of Parenteral and Enteral Nutrition Volume 33 Number 2 March/April 2009 122-167

21. Harms of feed Contamination…
■ Contaminated feedings can result in morbidity and mortality. Gastrointestinal, as well
as extra-intestinal, nosocomial infections can result.
■ Hospitalized patients can be at enhanced risk of morbidity and mortality due to
immunosuppression secondary to cancer, human immunodeficiency virus infection,
thermal injuries, diabetes, severe trauma, or drug therapy.
■ The use of gastric acid suppressing medications may increase the risk of infection due
to elimination of the protective gastric acid barrier.
■ Infections due to contaminated tube feedings can also increase hospital and intensive
care unit stays.

22. MINIMIZING FEED
CONTAMINATION
Shift towards Liquid Nutrition

24. Guidelines recommend usage of Liquid
Nutrition(Ready to Hang) as preferred formulation
Commercially produced, pre-filled ready to hang feeds
must be used wherever possible as these are least likely
to become contaminated during preparation and use.

25. Open System
■ Product is decanted into a feeding
bag
■ Allows modulars such as protein and
fiber to be added to feeding
formulas
■ Less waste in unstable patients
(maybe)
■ Shortens hang time
■ Increases nursing time
■ Increased risk of contamination

26. Closed System or Ready to Hang
■ Containers sterile until spiked for
hanging
■ Can be used for continuous or bolus
delivery
■ No flexibility in formula additives
■ Less nursing time
■ Increases safe hang time
■ Less risk of contamination
■ More expensive than canned formula

27. Closed vs Open System
■ Open System
■ Hang time 8 hours for decanted
formula; 4 hours for formula
mixtures
■ Feeding bag and tubing should be
rinsed each time formula
replenished
■ Contaminated feedings are
associated with pt morbidity
■ Closed System
■ Hang time 24-48 hours based on mfr
recommendations
■ Y port can be used to deliver
additional fluid and modulars
■ May result in less formula waste as
open
■ System formula should be discarded
p 8 hours

28. CLINICAL BENEFITS…

29. Care and cleanliness  safe handling
29
Blenderized1
• Vulnerable to
unsafe
ingredients
and handling
Powder2
• Sterile but
• Reconstitution
and handling
risk
Liquds2
• Sterile, closed
system (ready-
to-hang)
1. Jonkers-Schuitema C.. In: Sobotka L, ed. Basics in Clinical Nutrition. 4th ed. Prague: Galén; 2011:330-333.
2.Boullata J, et al. In:ASPEN, ed. A.S.P.E.N. Enteral Nutrition Handbook Ch3&6. Silver Spring:A.S.P.E.N.; 2010:93-158;
237-266.

30. Br J Nursing 1995;4:368.
Safety of Enteral Nutrition: Delivery Systems Can Impact
Contamination Rates
■ Dilution, additives, topping off, detaching, and reattaching tubing for flushing and
medications all increase the risk
■ Y-port recommended for medications and flushing
■ Sterile closed systems with hygienic handling procedures allow for longer
hangtimes

32. Minimal Handling
Select Ingredients
Assembly of feeding system
Mixing
Storage/transport of feed
Transfer of feed to nutrient container
Administration of feed
Pre-selected Ingredients
Administration of feed
Assembly of feeding system
Brit J Nursing 1995;4:368.
Blenderized Feeds Sterile Feed in Prefilled Containers

33. Minimal Manipulation
High contamination is associated with high levels of manipulation. As manipulation decreases,
contamination is reduced.
Br J Nursing 1995;4:368.
Nursing Times 1989;85:71.
Natural Foods
high
contamination
Powder
moderate
contamination
Ready-To-Hang
minimal
contamination
Ready-To-Use
low
contamination

34. NUTRITION ADEQUACY WITH LIQUID FORMULAS

35. % of Formula Received Compared to OrderedVolume Per
Patient in OpenVs Closed System

36. Nursing Convenience with Ready to
Hang Liquid Nutrition

37. J Burn Care Rehabil. 2003 May-Jun;24(3):167-72; discussion 166.
Comparative study of two systems of delivering supplemental protein
with standardized tube feedings.
Luther H1, Barco K,Chima C,Yowler CJ.
■ 4-hr hang time for manipulated open-system formulas in comparison with 24 hr for unopened closed systems
evaluated
■ Time study comparing the two methods and a nursing satisfaction questionnaire
■ Key Findings:
– Management of an open system consistent with national standards took almost twice as much nursing time
daily as the closed system with supplemental protein flushes
■ (36.6 +/- 17.1 min vs 18.6 +/- 3.6 min; p =.051).
– Sixteen of 17 nurses preferred the closed system.

38. Liquid Ready to Hang Nutrition in
Home Care

39. Key Benefits of
Ready-to-Hang Nutrition
Easy administration
Zero preparation
time
Easy to monitor
Saves quality
nursing time
Convenience of
usage
Sterile liquid formula
with FlexiFlo set
Minimal human
intervention
Minimal risk of cross
contamination
Reduces risk of
infections
Safety of the closed
system
Homogenous liquid
formula
High Calories
High Protein
Assurance of
consistent nutrition
Precise nutrient
delivery