The document discusses nutrition support and the conditions that require specialized nutrition through enteral or parenteral means. It covers the indications, contraindications, advantages, and disadvantages of enteral nutrition support through various tube feeding routes and administration methods. The roles and responsibilities of nutrition support dietitians in implementing individualized nutrition care plans are also outlined.

1. NUTRITION SUPPORT
Noraishah Mohamed Nor
Dept Nutrition Sc
IIUM

2. INTRODUCTION

3. CONDITIONS THAT REQUIRE SPECIALIZED
NUTRITION SUPPORT
 Enteral
—Impaired ingestion
—Inability to consume adequate nutrition orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth
 Parenteral
 Gastrointestinal incompetency (diminished
intestinal fx)
 Hypermetabolic state with poor enteral
tolerance or accessibility
 Supplement to EN

4. CONDITIONS IN EN
Diminished food intake
 Preoperative malnutrition
 Coma
 Postoperative ileus
Hypercatabolic states
 Polytrauma
 Burn
 Sepsis
 Severe disease condition

5.  Diminished digestion and absorption
 Pyloric stenosis
 Pancreatic disease
 Biliary disease
 Malabsorbtion syndrome
 Short bowel syndrome
 Radiation enteritis
 Ulcerative colitis
 Duodenal fistula
 Chronic disease
 Chronic cardiac, hepatic, renal disease
 Malignant disease

6.  Changes in metabolic rate and nitrogen excretion
with various types of physiologic stress

7. INDICATIONS FOR ENTERAL NUTRITION
Inadequate amount nutrients
and/or calories ingested will lead
to malnutrition- associated with
an increased incident of:
 Poor wound healing
 Impaired immune response and response
to trauma
 Increased risk of sepsis
 Altered gut structure/function causing
malabsorption and spread of bacteria

8. Ultimately malnutrition will lead to:
 Prolong recovery period
 Increased need for nursing care
 Increased risk of serious complications
 Prolong hospital stay
 Increased medical cost

9. CONTRAINDICATIONS FOR EN
 Severe acute pancreatitis
 High output proximal fistula
 Inability to gain access
 Intractable vomiting or diarrhea
 Aggressive therapy not warranted
 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

10. ADVANTAGES - ENTERAL VS PN
 Preserves gut integrity
 Possibly decreases bacterial translocation
 Preserves immunological function of gut
 Reduces costs
 Fewer infectious complications in critically ill
patients
 Safer and more cost effective in many settings

11. ADVANTAGES - ENTERAL NUTRITION
 Intake easily/accurately monitored
 Provides nutrition when oral is not possible or
adequate
 Supplies readily available
 Reduces risks associated with
disease state

12. DISADVANTAGES—ENTERAL NUTRITION
 GI, metabolic, and mechanical complications—tube
migration; increased risk of bacterial
contamination; tube obstruction; pneumothorax
 Costs more than oral diets (not necessarily)
 Less ―palatable/normal‖: patient/family resistance
 Labor-intensive assessment, administration, tube
patency and site care, monitoring

13. DISADVANTAGES - PN
 Gut mucosal athropy
 Overfeeding
 Hyperglycemia
 Increased risk of infectious complications
 Increased mortality in critically ill pt

14. AIMS OF NUTRITIONAL SUPPORT
 Preserve lean body mass (protein)
 Increase protein synthesis
 Improve immune and muscle function
 More rapid recovery
 Shorten hospital stay
 Reduction of morbidity

15. ROLES OF NUTRITION SUPPORT DIETITIAN
 Working with other health care professionals inc.
pharmacist, nurse, clinician-to support, restore,
maintain optimal nutritional health for individuals
with potential or known alterations in nutritional
status
 Assures optimal nutrition support though
implementation of nutrition care process related to
delivery of EN and PN support (Fuhrman et al
2001)

16. Nutrition care process
Individual nutritional status assessment
Indentify nutritional diagnosis
Implement appropriate interventions
Monitor & reassess an individual’s response to the nutrition care
delivered
Evaluate outcomes-incl. the need for transitional feeding care plan or
termination of nutr. Support intervention
(Lacey & Pritchett, 2003)

17. ALGORITHM TO CHOOSE NUTRITIONAL
SUPPORT
Nutritional assessment of the patient
Normally nourished but will
Normally nourished malnourished
develop malnutrition because
of disease process if support
withheld
Normal feeding Nutritional support indicated

19. DIFFERENT WAYS TO PROVIDE NUTRITION
SUPPORT
 Oral
 Enteral
 Parenteral
 Combined

20. WHEN THE GUT WORKS – USE IT!

21. SIGNS OF FUNCTIONING GIT
 The present of bowl sound
 Soft, non-tender abdomen
 Passage of fistulas/stool
 Intact appetite

22. ENTERAL NUTRITION BY MOUTH
 Common sense
 Adequate
 Palatable
 Varied
 Nutritional complete
 Provided at regular intervals, more frequentyly than
regular meal times if necessary
 Progressively increasing in heaviness and complexity

23.  Cleanliness
 In preparation and serving of food and utensils to prevent GIT
infection
 Compassion
 Ensuring the patient ingests the preferred food
 Putting food in patient’s reach
 Conducive eating environment
 Involving dietitians in food selection and preparation

24. ENTERAL NUTRITION BY TUBE
 Nutrition provided through the gastrointestinal tract via a tube,
catheter, or stoma that delivers nutrients distal to the oral cavity
 Benefits of EN:
 Help maintain gut mucosal physiology
 May modulate immune response-prevent translocation of
bacteria and toxins (maintain gut mucosal integrity)- IgA in
EN (IgA prevent absorption of enteric antigents)-less risk for
infection
 Promote peristalsis
 Safer: fewer complication
 Lower cost-formula, delivery system and less patient care
 Simpler system-care and self-administrator

25. CLINICAL SETTING IN WHICH ENTERAL NUTRITION
SHOULD BE PART OF ROUTINE CARE
 PEM with inadequate oral intake of nutrients for the
previous 5 days
 Oral intake <50 % of required needs for the previous 7-
10 days
 Severe dsyphagia due to strokes, brain tumors, head
injuries, multiple sclerosis
 Major (>30 % of BSA), full thickness burns
 Short gut due to small bowel resection-enteral nutrition +
parenteral nutrition to stimulate regeneration of the
remaining intestine

26.  Clinical conditions in which enteral nutrition usually may
be helpful:
 Major trauma with functional GIT + inadequate oral intake for
7-10 days
 Radiation therapy for cancers of the lungs, head, neck and
cervix, and lymphomas
 Acute/chronic liver failure + severe anorexia + functioning
GIT
 Severe renal dysfunction (<5% of normal glomerular filtration)
+ anorexia + functioning GIT

27.  Contraindications for enteral feeding:
 Mechanical obstruction of GIT
 Prolong ileus
 Severe GI haemorrhage
 Severe diarrhoea
 Intractable vomiting
 High-output GIT fistula (>500 ml/day)
 Severe enterocolitis

28. TUBE FEEDING ROUTES

29. TRANSNASAL PASSAGE
 Transnasal
passage of feeding into the
stomach/intestine employed when possible
 A surgical procedure can be avoided
 Generally well tolerated when small-bore feeding
tube are used
 Disadvantages:
 tube can be readily removed by
disorientated/uncooperative px.
 When larger, stiffer tube used-irritation to nasal
passages, pharynx, esophagus & compromise
gastroesophageal competency

30.  Nasogastric
 insertion & placement of the tube is easier.
 Nasogastric, esophagostomy, gastrostomy
 feeding allow the digestive process to begin in the
stomach-decreasing risk of dumping syndrome.
 Disadvantage:
 higher risk of aspiration-only
gastroesophageal sphincter is operating
to prevent reflux

31.  Nasoduodenal, nasojejunal, jejunostomy:
 Advantage:
 Posed less risk of regurgitation-advantage of
gastroesophageal sphinctar & pyloric
sphincters
 Disadvantages:
 Higher risk of intolerance (nausea, vomiting,
diarhea, cramps)-when feeding are not
properly selected.
 The bactericidal effect of HCL in the stomach
is bypassed-need attention for sanitation to
formula and equipment

32. OSTOMIES
 Require surgical insertion.
 Indicated when insertion through transnasal
is impossible or when long-term feeding is
anticipated
 Advantages:
 irritation caused by the feeding tube is
eliminated
 Ostomies are unobtrusive between feeding time

33.  Jejunostomies:
 Advantage:
 permits early post operative feeding
(unlike stomach & colon)-the small
bowel is not affected by postoperative
ileus.
 Relatively safe, comfortable, potential
for long-term use
 Disadvantage:
 Possibility of infection is high like other
ostomy procedure

34. EN ADMINISTRATION
 Administration of EN should be guided by:
 Px’s age
 Underlying disease
 Enteral access device
 Condition of GI

35.  When the patient should be started with EN?
 Eary initiation of EN is beneficial if px is
hemodynamically stable
 In ICU, when EN was initiated within 24-48 hrs of
admission:
 Lower rates of infection
 Shorter hospital stay
(Bar et a. 2004)

36. METHODS OF DELIVERY
Based on:
 Nutrient needs
 Feeding site
 Formula selection
 Current medical status
3 methods of delivery:
1. Bolus feeding
2. Intermittent bolus feeding
3. Continuous feeding

37.  Bolus feeding:
 Administered using a syringe/feeding reservoir
 Infused over a period of time
 Tolerance is dependent on the functional ability of the
gut
 Generally, the px is fed a vol of 250-400ml of formula-
5-8x/day
 Allow px greater freedom/movement between feeding
times
 Associated with high incidence of complications:
 Nausea
 Vomiting
 Diarrhoea
 Abdominal distension & cramps
 Aspiration

38.  Intermittent bolus feeding:
 Administered by slow gravity drip
 Each feeding is given over 30 min every 3-4 hrs
 Tolerance is dependent in the functional ability of the
gut
 Initiation of feeding with 50 ml of isotonic formula (<30ml/min)
every 3-4 hrs
 Progression of feeding regime with additional 50 ml every 8-12
hrs as tolerated
 Generally, prescribed vol of formula 250-400 ml
infused over a 20-30 min period 5-8x/day
 Allow px greater freedom/movement between feeding
times.
 Complications can be similar to bolus feeding

41.  Continuous feeding
 Utilised when bolus/intermittent feedings are not tolerate/in
critical ill patients/small bowel feeding
 Usually pump assisted
 Associated with reduced incidence of high gastric residual,
GER and aspiration
 Restricts px movement

42.  Continuous tube feeding
i. Initiation of tube feeding range from 20-50ml/hr
ii. Progression of tube feeding range from 10-20ml/hr
every 8-24 hrs until the desired volume is attained
iii. the strength can be increased as tolerated.
iv. If feeding is not tolerated-reduce the rate & strength
to previously tolerated level-gradually increase the
rate & strength again
v. Avoid altering rate & strength at the same time

43. PART 2--NUTRITION SUPPORT FOR
CRITICALLY ILL

44. ENERGY REQUIREMENT
1. Haris Benedict Equation
Male REE = 66.47+13.75W+5.0H-6.76A
Female REE = 665.10+9.56W+1.85H-4.68A
W= wt in kg
H = ht in cm
A= age in years
2. Formula FAO/WHO/UNU (1985)
Male 18 – 30 REE = 15.32W+679
30 – 60 REE = 11.2W+879
>60 REE = 13.5W+987
Female 18 – 30 REE = 14.7W+496
30 – 60 REE = 8.7W+829
>60 REE = 10.5W+596

45. 3. Ismail et al.(1998)
Men
18 – 30 years:BMR=0.0550(W)+2.480 MJ/d
30 – 60 years:BMR=0.0432(W)+3.112 MJ/d
Women
18 – 30 years:BMR=0.0535(W)+1.994 MJ/d
30 – 60 years:BMR=0.0539(W)+2.147 MJ/d

46. ACTIVITY AND STRESS FACTORS
 Activity Factor
=1.0 – 1.1 (bed rest)
= 1.2 – 1.3 (very light)
=1.4 – 1.5 (light)
= 1.6 – 1.7 (moderate activity)
=1.9 – 2.1 (highly active)
= 2.2 – 2.4 (strenuous)

47.  Stress Factor :
=1.1(mild malnutrition, postoperate no complication
=1.2(mild illness confined to bed)
=1.3(mild illness ambulatory)
=1.2-1.3 (surgery major)
=1.3-1.4 (trauma skeletal)
=1.2 – 1.3(mild infection and stress)
=1.4 – 1.5(moderate infection and stress)
=1.6 – 1.8(severe hypercatabolic)
=2.0 – 2.2(sepsis)
=1.2 – 1.4(<20%BSA)
=1.5 – 1.7(20 – 40%BSA)
=1.8 – 2.0(>40%BSA)
=1.2 – 1.3(Fracture)
=1.4 – 1.5(respiratory or renal failure)
=1.4 – 1.8(COPD)
=1.5 – 1.6(Cancer with chemo or radiation,cardiac
cachexis)

49. TYPES OF ENTERAL PRODUCTS
 Standard/polymeric formulas
 Elemental
 Modular (Supplements)
 Condition Specific

50.  Polymeric formula
 Composed of intact proteins, disaccharides,polysaccharides,
variable amounts of fat and residue
 Require a functioning GIT for absorption and digestion
Category Characteristic Indication Products
Standard •Nutritionally Normal digestive & Ensure/Nutren
complete absorptive capacity Optimum/Osmolite
•Provide 1 kcal/ml
•Distribution:
50-60 % CHO
10-15 %
Protein
25-30 % fat
Fiber- •Similar to standard Constipation, Jevity/ Nutren
suplemented formula except for diarrhoea Fibre/Nutren
fibre content Diabetic
•4 – 20g of dietary
fibre/l

51. Category Characteristic Indication Products
Concentrated Similar to standard Fluid restriction Ensure Plus,
formula except Enercal Plus
provide 1.5 – 2.0
kcal/ml

52.  Elemental formula
 Partially hydrolyzed protein
Characteristic Indication Products
Nutritionally complete Reduced digestive & absorption Peptamen/AlitraQ,
Usually provide 1 kcal/ml capacity e.g. Crohn’s Disease, Short Elementum
Bowel Syndrome, long term fasting
with gut atrophy, post operative
May contain glutamine patients

53.  Modular Formulas
Single nutrient supplement, nutritionally incomplete,
usually low in electrolytes
Examples :
 Fat-MCT oil (Medium Chain Triglyceride)
 CHO- Carborie, Polycose (Glucose polymer)
 Protein- Myotein

54.  Condition specific products
Condition Characteristic Indications Product
Metabolically •Nutritionally complete Polytrauma /post Perative
stress •Provides 1.5 kcal/ml operative period
•High in protein: >20% kcal (following major
surgeries)
•May contain:
arginine,nucleotides, omega-3
fatty acids
Hepatic •Protein content: high in BCAA, Hepatic Falkamin
Encephalopathy low in Aromatic Amino Acids Encephalopathy
Protein, •Provides 2.0 kcal/ml Acute or chronic Suplena
electrolyte and •Low in protein kidney disease not (NA)
fluid restriction •Low in phosphorous on dialysis
Glucose •Nutritionally complete Hyperglycaemia :> Glucerna/
Intelorance •Provides 1.0kcal/ml 10mmol/L Nutren
•Low in CHO: 35% of kcal Diabetik/
Nutricomp®
•High in fat: 40-50% of kcal Diabetic
•Fibre supplemented

55. Condition Characteristic Indications Product
CO2 retention •Nutritionally complete Chronic obstructive Pulmocare
pulmonary disease
•Provides 1.5 kcal/ml
with CO2 retention
•High in fat: 55% kcal
&
•Low in CHO: 30%
kcal
Electrolyte •Provides 2.0 kcal/ml Acute or chronic Nepro/
and Fluid •Moderate in protein renal failure Nutricomp®
restriction •Low in phosphorous requiring dialysis Renal

56. IMMUNE-ENHANCING FORMULAS
 Have added ―immune-enhancing‖ nutrients (arginine,
glutamine, omega-3 fatty acids, nucleotides)
 Results of research have been mixed
 Multiplicity of active ingredients makes it difficult to
control variables
 Meta-analysis suggests that they might be most
beneficial in surgical patients
 Some evidence of harm in septic patients

57. EVIDENCE- BASED
 Glutamine should be added to standard formula in:
 Burn & trauma patients
 In Burns pt, the trace elements (Cu, Zn, Se) should
be supplemented in higher dose
 For the trauma patient, it is not recommended to
routinely use immune-enhancing EN, as its use is
not associated with reduced mortality, reduced
LOS, reduced infectious complications or fewer
days on mechanical ventilation.
 Diet supplemented with arginine should not be
used for critically ill pts.

58. FORMULAS FOR IMPAIRED GI FX:
INFANT/CHILDREN
 Protein Hydrolysate
 Pregestimil
 Alimentum
 Peptide/ Elemental
 Neocate
 Peptamen Jr.
 Vivonex Pediatric
 Neocate advance

59. INITIATION OF FEEDING
 Choose full strength, isotonic formulas for initial
feeding regimen.
 Initiation and advancement of enteral formula in
pediatric patients is best done over several days
in a hospital setting using a flexible nutrition
plan.

60. INITIATION OF FEEDING- PAEDIATRIC
Continuous feeding
 Generally children are started
 isotonic formula at a rate of 1-2 mL/kg/h for smaller children
 1mL/kg/h for larger children over 35-40 kg.
 The rate is advanced based on tolerance by the child
 the goal of providing 25% of the total calorie needs on day 1.
Bolus feeding
 2.5-5 mL/kg can be given 5-8 times per day with gradual
increases in this volume to decrease the number of feedings to
closer to 5 times daily.

61. INITIATION OF FEEDING-CHILDREN
 Bolus feedings & gravity-controlled feedings
 started with 25% of the goal volume divided into the
desired number of daily feedings.
 Formula volume may be increased by 25% per day as
tolerated, divided equally between feedings
 Pump-assisted feedings
 A full-strength, isotonic formula can be started at 1-2
mL/kg/h and advanced by 0.5-1 mL/kg/h every 6-24
hrs until the goal volume is achieved

62. For preterm, critically ill, or malnourished children
 Use pump
 initial volume : 0.5-1 mL/kg/hour
 Advancing to 10-20 ml/kg/day

63. INITIATION OF FEEDING-ADULTS
 Bolus feedings & gravity-controlled feedings
 full-strength formula
 3-8 times per day
 increases of 60-120 mL every 8-12 hours as tolerated
up to the goal volume.
 Pump-assisted feedings
 initiated at full strength at 10-40 mL/h and advanced to
the goal rate in increments
of 10-20 mL/h every 8-12 hours as tolerated

64. PATIENT POSITIONING
 Elevatethe backrest to a minimum of
30º-45º, for all patients receiving EN
unless a medical contraindication exists.
 Eg.unstable supine, hemodynamic instability,
prone position
 If
necessary to lower the Head-to-bed
(HOB) for a procedure or a medical
contraindication, return the patient to
HOB elevated position as soon as feasible.

65. FLUSHES-PRACTICE RECOMMENDATIONS
 Flush feeding tubes with 30 mL of water every 4
hours during continuous feeding or before and
after intermittent feedings in an adult patient
 flushthe feeding tube with 30 mL of water
after residual volume measurements in an
adult patient
 Flushing of feeding tubes in neonatal and
pediatric patients should be accomplished with
the lowest volume necessary to clear the tube

66. MEDICATION ADMINISTRATION
 Do not add medication directly to an enteral
feeding formula.
 Avoid mixing together medications intended for
administration through an enteral feeding tube to
reduce risks of:
 physical and chemical incompatibilities,
 tube obstruction
 altered therapeutic drug responses
 Dilute
medication appropriately prior to
administration.

67. REFEEDING SYNDROME
 Severefluid and electrolyte shifts and
related metabolic complications in
malnourished patients undergoing
refeeding.
 These complications are often worsened by
overfeeding or by use of aggressive
repletion.

68. PHYSIOLOGIC CHANGES OCCUR DURING
REFEEDING
 Intracellular mineral depletion
 Hypophosphatemia
 hypomagnesemia,
 Hypokalemia
 body fluid disturbances (―refeeding edema‖)
 vitamin deficiencies (eg, thiamine)
 lifethreatening
 cardiac arrythmias
 respiratory arrest
 Congestive heart failure

69. CONSEQUENCES OF ELECTROLYTE ABNORMALITIES
Electrolytes Consequence
 PO4 Acute ventilatory failure
Arrythmias
Confusion
Congesive heart failure
Lethargy, weakness
Rhabdomyolysis
 K+ Arrythmias
Cardiac arrest
Constipation / ileus
Polyuria / polydipsia
Respiratory depression
Weakness
 Mg2+ Anorexia
Arrythmias
Confusion
Diarrhoea / constipation
Weakness

70. PATIENTS AT HIGH RISK OF REFEEDING
 Patients with any of the following:
 BMI < 16 kg/m2
 Unintentional weight loss >15% within
the last 3-6 months
 Very little or no nutrition for >10 days
 Low levels of potassium, magnesium or
phosphate prior to feeding

71.  Patients
with 2 or more of the
following:
 BMI < 18.5 kg/m2
 Unintentional weight loss >10% within
the last 3-6 months
 Very little or no nutrition for >5 days
 A history or alcohol abuse or some drugs
including insulin, chemotherapy, antacids
or diuretics

72. MONITORING FOR REFEEDING SYNDROME
 Monitoring metabolic parameters prior to the
initiation of EN feedings and periodically during
EN therapy should be based on protocols
 Prevention of refeeding syndrome is of utmost
importance
 Pxat high risk for refeeding syndrome and other
metabolic complications should be followed
closely, and depleted minerals and electrolytes
should be replaced prior to initiating feedings.

73.  Patientsat risk of developing refeeding syndrome
should be identified, electrolyte abnormalities should
be corrected prior to the initiation of nutrition
support.
 Nutrition
support should be initiated at
approximately 25% of the estimated goal and
advanced over 3-5 days to the goal rate.
 Serumelectrolytes and vital signs should be
monitored carefully after nutrition support is started

74. CHALLENGES IN NUTRITIONAL SUPPORT
1. Caloric requirement not met
 Under ordering by physician
 Reduced delivery
 Slow advancements
2. Gut dysfunction
 High residual volume (GRV)
 Nausea
 Vommiting
 Absent of bowel sound
 Diarrhea
 Aspiration

75. 3. Procedure and diagnostic test  require
fasting
4. Lack of enthusiasm, personal bias and
individual practice

76. THE RISK FACTORS FOR ASPIRATION
 Sedation
 supine patient positioning
 the presence and size of a nasogastric tube
 malposition of the feeding tube
 mechanical ventilation,
 vomiting
 bolus feeding delivery methods
 poor oral health
 nursing
 staffing level
 advanced patient age

77. STRATEGIES TO OPTIMIZED DELIVERY
& MINIMIZED RISK
1. Use feeding protocol
2. Motility agent (eg. Prokinetic)
3. Small bowel vs gastric feeding
4. Body position
5. Nutrition support practice

78. FEEDING PROTOCOL
e.g.Prospective evaluation before and
after evidence based protocol
introduction of EN in surgical pt..
Within 24 – 48 hr
 With the protocol:
Inceased delivery of nutirents
Shortened duration of mechanical ventilation
Decrease mortality

79. PROKINETIC AGENT: METOCLOPRAMIDE
 IVadministration of metoclopramide
or erythromycin should be consider in
pt with intolerance to EF
 E.g with high gastric volume

80. LEVELS OF GRV
Severity Definition Treatment
Mild <200 ml •Return GRV
•Continue feeding
Moderate 200 – 500 ml •1st episode continue
•2nd episode start prokinetic agent
• 3rd episode reduce EN by half
• 4th episode:
•Stop feeding
•Place NJ tube
•Start EN protocol again
Severe > 500 ml •Stop gastric feeding
•Place NJ tube
•Start EN protocol
Refer MNT pg 10 other assessment of tolerance

81. SMALL BOWEL FEEDING
Small bowel fed pt have improved
energy delivery in some studies
Duodenal vs gastric feeding in
ventilated blunt trauma pt
 Improved tolerance ofEN and
consequent faster achievement of
desired calories
Kortbreek JB J Trauma

82.  Small bowel vs gastric feeding
 Maybe associated with a reduction in
pneumonia in critically ill pt
 No different in mortality or ventilation
days
 Small bowel feeding improves cal & prot
intake and is associated with less time
taken to reach target rate of enteral
nutrition.

83. NUTRITION SUPPORT PRACTICES
How should pt be tube fed after
surgery?
 TF should be initiated within 24 hr after
surgery
 Sholud satrt with low flow rate (e.g 10 -
20 (max) ml/hr)due to limited intestinal
tolerance
 May take 5 – 7 days to reach the target
intake
 Not consider harmful

84. NUTRITION SUPPORT PRACTICES
 DO NOT…………..:
1. Assemble feeding system on the pt’s bed
2. Top up fresh formula until the formula
hanging in the feeding bag has finished
3. Overfed patients:
 High calorie density formula
 1.3 kcal/ml  Perative
 1.5 kcal/ml  Pulmocare
 2.0 kcal/ml  nepro/enercal plus

85. OPEN VS CLOSED SYSTEM
 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

86.  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

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

88. CONCLUSION
o Practice early enteral feeding
o Use strict protocols
o Modify preoperative preparation
o Identify & rectify tube displacement
o Consider tube placement post pyloric
o Alter method of feeding (routine cycling, smaller
o volume, concentrated feeds)
o Works as Nutrition Support Team
o Continuous Nutrition Education

89. THANK YOU….
Q???

90. TUTORIAL
1. Male, age 39, 189 cm tall. 91 kg body weight,
confined to bed and having burn of 40% TBSA
and body temp is 39°. Calculate calorie req and
plan a EN regimen.
2. Female, age 41, 160 cm tall. 67 kg body wt.
confined to bed and ventilated. Diagnosed with
COPD. Calculate cal req and plan for EN
regimen through pump feeding
3. Pt with TPN, Patient on Nutriflex (peripheral)
for three days after operation (75 ml/hr)
1. Calculate the calorie from the TPN
2. How to manage the pt if dr plan to change to EN