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1. EntEral nutrition
in adults
PRESENTER ; CLEMENT KIP

2. What's enteral nutrition?
• Enteral nutrition is a way of providing nutrition to
the patients who are unable to consume an
adequate oral intake but have at least a partially
functional GI tract

3. Indications of EN
 Decreased oral intake <50% for 7-10 days
 Malnourished unable to eat >5 days
 Normal nourished patients unable to eat > 5 days
 Adaptive phase of short bowel syndrome
 Following severe trauma or burns
 Inability to take oral feedings due to head or neck trauma.
 Prolonged anorexia
 Facial or oesophageal structural abnormalities
 Coma

4. Contraindications for EN
Severe acute pancreatitis
High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
peritonitis
Severe diarrhea
Inability to gain access
Ileus
Intestinal obstruction
Severe G.I. Bleed
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

7. Types of EN

9. Nasogastric Tubes
Definition
• A tube inserted through the nasal passage into the
stomach
Indications:
• Short term feedings required
• Intact gag reflex
• Gastric function not compromised
• Low risk for aspiration

10. Nasogastric Tubes
Advantages:
• Ease of tube placement
• Surgery not required
• Easy to check gastric residuals
• Accommodates various administration techniques

11. Nasogastric Tubes
Disadvantages:
• Increases risk of aspiration
• Not suitable for patients with compromised gastric
function
• May promote nasal necrosis and esophagitis
• Impacts patient quality of life

12. Nasoduodenal/Jejunal
Definition
• A tube inserted through the nasal passage through
the stomach into the duodenum or jejunum
Indications:
• High risk of aspiration
• Gastric function compromised

13. Nasoduodenal/Jejunal
Advantages:
• Allows for initiation of early enteral feeding
• May decrease risk of aspiration
• Surgery not required

14. Nasoduodenal/Jejunal
Disadvantages:
• Transpyloric tube placement may be difficult
• Limited to continuous infusion
• May promote nasal necrosis and esophagitis
• Impacts patient quality of life

15. Orogastric
• Tube is placed through mouth and into stomach
• Often used in premature and small infants as they
are nasal breathers
• Not tolerated by alert patients; tubes may be
damaged by teeth

16. Enterostomy Placement
• Gastrostomy
• Jejunostomy

17. Gastrostomy
Definition
• A feeding tube that passes into the stomach through
the abdominal wall. May be placed surgically or
endoscopically
Indications:
• Long-term support planned
• Gastric function not compromised
• Intact gag reflex present

18. Gastrostomy
Disadvantages:
• May require surgery
• Stoma care required
• Potential problems for leakage or tube dislodgment

21. Jejunostomy
Definition
• A feeding tube that passes into the jejunum through
the abdominal wall. May be placed endoscopically or
surgically
Indications:
• Long-term feeding option for patients at high risk for
aspiration or with compromised gastric function

22. Jejunostomy
Advantages:
• Post-op feedings may be initiated immediately
• Decreased risk of aspiration
• Suitable option for patients with compromised
gastric function
• Stable patients can tolerate intermittent feedings

23. Jejunostomy
Disadvantages:
• Requires stoma care
• Potential problems related to leakage or tube
dislodgement/clogging may arise
• May restrict ambulation
• Bolus feedings inappropriate (stable patients may
tolerate intermittent feedings)

25. Bolus
Feeding

26. Enteral Feeding Complications
• Mechanical
• Gastrointestinal
• Metabolic
• Infectious

27. Mechanical
• Feeding tube obstruction
• Feeding tube dislodged
• Nasal irritation
• Skin irritation/excoriation at ostomy site

28. Gastrointestinal Complications
• Diarrhea
• Constipation
• Gastric distention/bloating
• Gastric residuals/delayed gastric emptying
• Nausea/vomiting

29. Metabolic
• Fluid and Electrolyte abnormalities
• Glucose intolerance
• Ca++
, Mg++
, PO4 abnormalities
• Other

30. Infectious Complications
• Formula contamination
• Unsanitary equipment
• Failure to follow appropriate protocols re handling of
enteral feedings/changing of bags and tubing

31. Monitoring of Patients on EN
• Electrolytes
• BUN/Cr
• Albumin/prealbumin
• Ca++
, PO4, Mg++
• Weight
• Input/output
• Vital signs
• Stool frequency/consistency
• Abdominal examination

32. PARENTERAL NUTRITION
• This refers to nutrition directly into the
systemic circulation, bypassing the
gastro-intestinal tract (GIT)

33. ROUTES OF PARENTERAL NUTRITION
• Peripheral Parenteral Nutrition (PPN)
• Total/Central Parenteral Nutrition(TPN)

35. PERIPHERAL PARENTERAL NUTRITION
• This refers to use of peripheral veins to provide a
solution that meet nutrient needs for infusion. It has
lower dextrose (5% to 10% final concentration) and
amino acid (5% final concentration)
• PPN may be used in patients with mild or moderate
malnutrition to provide partial or total nutrition
support when they are not able to ingest adequate
calories orally or enterally or when central vein PN is
not feasible

36. TOTAL PARENTERAL NUTRITION
• CPN is often referred to as “Total Parenteral
Nutrition” since the entire nutrient needs of the
patient may be delivered by this route. It requires a
central venous system for long term infusions

37. INDICATIONS FOR TPN
• Gastrointestinal fistula
• Bowel obstruction
• GI non functioning
• NPO >5 days
• GI fistula
• Acute pancreatitis
• Short bowel syndrome
• Nutritional needs not met; patient refuses food

38. Complications of PN

39. Summary of Parenteral Nutrition Guidelines in
the Critical Care Unit
1. All patients receiving less than target in 3 days enterally to
receive PN within 24 to 48 hours of admission once
haemodynamically stable
2. PE requirements to be calculated at 25 kcal/kg/d and increased
to target over 2 – 3 days
3. Carbohydrate to be given at a minimum of 2g/kg/d as glucose,
monitor blood sugars (BS), BS >10mmol/l to be avoided
4. Lipids to be given at a dose of 0.7 – 1.5g/kg/d, EFA, EPA and
DHA, live oil based, fish oil added
5. Protein to be given at 1.3 –1.5g ideal body weight (IBW)
6. Amino acid solution should contain glutamine at a dose of 0.2
-.04g /kg/Bodyweight/d (0.3 – 0.6g alanyl-glutamine dipeptide)

40. 7. Daily dose of multivitamin and trace element to be adhered to
8. PN admixtures to be administered as a complete All in One
bag. If there is evidence of PEM on admission and enteral
nutrition is not feasible, it is appropriate to initiate parenteral
nutrition as soon as possible following admission and
adequate resuscitation
9. If a patient is expected to undergo major upper GI surgery
and EN is not feasible, PN should be provided under specific
conditions: If the patient is malnourished PN to be given 5-7
days preoperatively and continued into the postoperative
period
10. Wean PN gradually
11. Discontinue once the patient is able to adequately tolerate
60% of caloric requirements enterally

41. •Thank you