Enteral Nutrition – Enteral nutrition refers to the provision of protein, electrolytes, calories, vitamins, minerals, trace elements and fluids via intestinal routes either orally or via feeding tube. Up to 60% of hospitalized geriatric patients have malnutrition (1). Nutritional support is indicated for patients who have existing or are at risk of malnutrition. Initiate Enteral Nutrition (EN) within 48 hours of admission if no contraindications present as it is associated with decreased mortality in critically ill patients (2-4). Enteral nutrition in critically ill patient who Enteral tube feeding is indicated for patients who have a functioning gastrointestinal tract but cannot ingest enough nutrient orally because they are unable or unwilling to take oral feedings. Esicm Working Group on Gastrointestinal Function suggest using early enteral nutrition in the majority of critically ill under certain precautions. In the absence of evidence, they suggest delaying enteral nutrition in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access (5).
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Enteral tube feeding has got certain advantages to parenteral nutrition including better preservation of the structure and function of the GI tract, lower cost, low risk of infectious and other complications (6). Enteral tube feeding compared to increased oral intake and oral supplement in patients with malnutrition is shown to improve nutritional status. But is not associated to length of stay or mortality. Enteral tube tolerance is an issue in long term feeding. Oral nutritional support is likely to be cost-effective when acceptable for patient (7).
A study from Belgium showed that elderly people living in community when admitted for elective surgery are at high risk of malnutrition. According to the NRS-2002 these patients might benefit from nutritional support. However, it appears that nutritional support is not yet commonly implemented in preoperative care for this population (8).
Table no. 1 – Indications for enteral tube feeding
|
Indications for enteral tube feeding |
Example |
|
Unconscious patient |
Head injury Patient on ventilator |
|
Neuromuscular swallowing disorder |
Brain malignancy MS (multiple sclerosis) motor neurone disorder particularly involving swallowing reflux / muscles Microvascular ischemia of brain e.g. Parkinson’s disease |
|
Physiological anorexia |
Cancer Sepsis from any source Impaired liver function |
|
Upper GI obstruction |
Oro-pharyngeal or oesophageal stricture or tumour |
|
GI dysfunction or Malabsorption |
Dysmotility disorder e.g. Ehler Danlos Syndrome Inflammatory bowel disease Reduced bowel length (although PN may be needed) Gastrointestinal cancer Gastrointestinal tract surgery |
|
High protein / calorie requirement. |
Cystic fibrosis especially in children Severe burns |
|
Psychological problems |
Severe depression anorexia nervosa |
|
Specific treatment |
For short term enteral access during surgery i.e. head and neck cancer |
|
Mental health |
Patients with Dementia |
|
Other |
Switching from parenteral nutrition to enteral nutrition Pancreatitis Pre-operative to improve nutritional status of patients. |
Assessment of patient’s nutritional status and if indicated feeding should be started within 48 hours of hospital admission especially in critically ill patients (9). A recent review by Casaer suggested that in acute phase of critical illness it is reasonable to initiate some gastric feeding, while also providing micronutrients(10). Next step is to determine type of feed which depends on indication, duration and requirement of individual patients (7). Table. 2 show common types of feed and usage.
Table 2 – Types of feed and usage
|
Type of feed |
Usage |
|
Standard 1kcal/ml (with or without fibre) |
Most commonly used – suitable for most patients. Soluble and insoluble fibre added for patients on long term enteral feeding |
|
High energy 1.2-2.0 kcal/ml (with or without fibre) |
Small amount of diet will deliver high calorie for fluid restricted patients. Soluble and insoluble fibre added for patients on long term enteral feeding |
|
Low energy formulas |
Contain 0.5 – 1 kcal/ml are complete for vitamins and minerals in a lower volume. |
|
Milk free feed |
Standard 1kcal/ml feed with a soya based protein source |
|
Low Sodium feeds |
Sodium content reduced to about 10-15 mmol/litre. Patient with sodium restriction |
|
Renal feeds |
Low on sodium, phosphate and potassium |
Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract (11). Enteral tube feeding is associated with complications as detailed in table 3.
Table 3- Complications of enteral feeding.
|
Complication |
|
|
Insertion |
Nasal damage, intra-cranial insertion, pharyngeal/oesophageal pouch perforation, bronchial placement, precipitate variceal bleeding. PEG/PEJ insertions – bleeding, intestinal/colonic perforation. |
|
Post insertion trauma |
Discomfort, erosions, fistulae and strictures. |
|
Mechanical |
Unable to pass a tube, blockage, oesophageal stricture, hoarseness, laryngeal ulceration, tracheeo-esophageal fistula, variceal bleeding, |
|
Reflux |
Aspiration, oesophagitis, |
|
GI intolerance |
diarrhoea, nausea, , pain, bloating |
|
Metabolic |
fluid overload, electrolyte disturbance, vitamin, mineral, trace element, Refeeding syndrome fatty acids deficiency, hyper-glycaemia |
|
Displacement |
Tube falls out, |
|
Miscellaneous |
Abnormal liver function tests Feed contamination and resulting infection |
Contraindications of Enteral Tube Feeding.
Bowel obstruction: Small or large bowel obstruction will worsen with enteral feeding. As bowel is obstructed increased enteral intake will increase distension which can lead to perforation of bowel. It is more common in case of mechanical bowel obstruction e.g. tumor or adhesions.
Ileus: Ileus when there is no obvious cause of bowel obstruction and decreased motility as a result of surgery or electrolyte abnormality. It behaves just like bowel obstruction and managed with bowel rest and parenteral nutrition.
High output small bowel fistula: Small bowel fistula is a condition in which there is abnormal communication between bowel and abdominal wall with more than 1000 ml/day bowel contents. It is treated with bowel rest and medications to reduce enteric endogenous secretions. Enteral feeding can delay spontaneous closure of small bowel fistula.
High dose inotropic agents: Patients who are Haemodynamically unstable and on high dose inotropic / vasopressor may not benefit from enteral nutrition because of poor perfusion pressure. The available data indicate that enteral nutrition restores splanchnic perfusion and oxygenation in the hemodynamically unstable patient (12).
References:
1.Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: a narrative review. Maturitas. 2013;76(4):296-302.
2.Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. American journal of critical care : an official publication, American Association of Critical-Care Nurses. 2010;19(3):261-8.
3.Marik PE. Enteral nutrition in the critically ill: myths and misconceptions. Critical care medicine. 2014;42(4):962-9.
4.McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN Journal of parenteral and enteral nutrition. 2016;40(2):159-211.
5.Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, et al. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive care medicine. 2017;43(3):380-98.
6.Seres DS, Valcarcel M, Guillaume A. Advantages of enteral nutrition over parenteral nutrition. Therapeutic advances in gastroenterology. 2013;6(2):157-67.
7. Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Institute for Health and Clinical Excellence: Guidance. London2006.
8.Geurden B, Franck E, Weyler J, Ysebaert D. The Risk of Malnutrition in Community-Living Elderly on Admission to Hospital for Major Surgery. Acta chirurgica Belgica. 2015;115(5):341-7.
9.Patel V, Romano M, Corkins MR, DiMaria-Ghalili RA, Earthman C, Malone A, et al. Nutrition Screening and Assessment in Hospitalized Patients: A Survey of Current Practice in the United States. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2014;29(4):483-90.
10.Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. The New England journal of medicine. 2014;370(13):1227-36.
11.Stroud M, Duncan H, Nightingale J, British Society of G. Guidelines for enteral feeding in adult hospital patients. Gut. 2003;52 Suppl 7:vii1-vii12.
12.Zaloga GP, Roberts PR, Marik P. Feeding the hemodynamically unstable patient: a critical evaluation of the evidence. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2003;18(4):285-93.
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