- Lower infection risk

- More physiologic

- Less expensive

- Maintains structure and function of GI tract which directly uses such fuels as glutamine, glucose, and leucine. 

- Neoplastic disease:  Chem/Radiation with n/v, obstructive tumors, Cachexia where pt. doesn't feel like eating, TNF mediated inflammation. 

- Organ Failure:  Renal, hepatic, cardiac, respiratory

- Hypermetabolic states:  burns, trauma, sepsis, closed head injury

- GI disease:  SBS, IBD, motility disorders, pancreatitis, fistulae.

- Other:  Stroke, HIV, anorexia nervosa, transplant, severe depression, extreme prematurity

- Obstruction of the GI tract

- Pseudo-obstruction/dysmotility

- Peritonitis

- Severe diarrhea/malabsorption

- Severe GI hemorrhage

- Severe/intractable vomiting

- Nasogastric/nasojenunal

- Stamm gastrostomy/percutaneous endoscopic gastrostomy

- Gastrojenunostomy

- Jejunostomy

Continuous non-cyclic --> same rate/24h, for gastric tube feeding, post pyloric (jejunal) feeding, critically ill patients, SBS limited absorption

Continuous Cyclic --> Given over 10-14h, then break.  For gastric or post pyloric feeding, home or noctournal tube feeding, long term care

Intermittent --> 240-480ml infused 4-6x per day.  Given via pump over 20-40min or large syringe given over 0-10 min.  For Gastric (not post pyloric) feeding, LTC (stroke, rehabilitation, and/or home tube feeding, patients unable to transition to oral feeding

- Don't mix drugs together, dilute known irritants and hypertonics

- Avoid adding drugs directly to feeds unless stability and compatability information is available.

- Don't mess with slow release tabs/caps, and pay attention on whether on an empty stomach or not.

- Drug efficacy and absorption may vary based on feeding tube tip

- Flush, flush, flush the tube. 

- Fine bore tubes easily clogged with ibuprofen, metamucil, and dyazide. 

- Phenytoin should be spaced 1-2h from tube feeds, and monitor closely

- Meds to be taken without feed (empty stomach):  Penicillin, Tetracycline, Isoniazid, Rifampin, Quinolones.

- Never give cipro suspension through tube.

- Need to give higher doses or switch to IV b/c bioavailability dec. with EF (Cipro), don't give with J tube

- Watch Warfarin and soy protein/vitamin K+ content, monitor INR

- Only give antacids if tip is in stomach, Al3+ antacids should be spaced out from tube feeds, could cause clogging

- Omeprazole: Mix with apple juice, don't give with small bore tubes, give 1 hour before meals for immediate release, hold feeds 1hr before and after administration. 

- Lansoprazole: kind of same as above, do not use granules for susp (can cause clogging), give solutabs if possible, or make susp. with Na Bicarb, hold EF 1hr pre and post.

  Enteral feeds are classified depending on the complexity of the amount of hydrolysis and digestion required prior to absorption:

a) Polymeric where the molecular form of the macronutrients (carbohydrate, fat and protein) are presented intact ie. similar to normal food.

b) Partially hydrolyzed or elemental (Defined formula diets)

Carbohydrates:  simple sugars, highest osm., GI intolerance; glucose polymers are best tolerated but don't taste good, so not good for PO, most EF are lactose free

Fat - High calorie, low osmol., vehicle for FS Vits.  LCT's provide essentia FA, linolenic., MCT's don't.  Fat content varies from 2-45%.  Omega 6's are bad for you, 3's are good

Conditionally Essential AA's:  Glutamine, made in muscle, good for enterocyte, mucosal integrity, tumor stimulation?  Arginine stimulates T cells, prevents protein breakdown, improves wound/body healing

Fiber - Soy Polysaccharide 6-24g/liter (pretty soluble), broken down in intestine to short chain fatty acids, stimulates mucosal growth, used in pt.'s with diarrhea, not very effective

- Requires normal absorption and digestion

- PT: Usually 1-1.2 kcal/ml

- Iso-osmolar, usually unpalatable

- Formulas vary, could be high protein, fiber, or calorie (1.5-2 kcal/ml)

- Osmolite HN, Probalance, and Deliver are examples of these complex, but cheap EF's

- Partially hydrolyzed, not palatable, give PT

- Indicated for those with digestion/absorption/fat malabsorption issues

- Ex: Peptamen, Impact, Crucial; more expensive

- Estimate needs to be based on actual body weight

- If greater than 120% of IBW use:  (ABW - IBW) x 0.35 +IBW

- Fluid requirements: 25-35ml/kg BW assuming normal renal and cardiac function

- If pt. >65 y/o use 25ml/kg

How do we grade severity of weight loss compared to normal body weight?

Bonus:  How do we calculate ideal body weight in men and women?

Can fit one of two criteria, overall weight loss from normal weight, or a specified weight loss over a period of time.

10-20% - Mild

20-30% - Moderate

> 30% - Severe

Severe weight loss is defined as 2% in one week, 5% in one month, or 10% in 6 months

Women:  45.5kg + 2.3kg per inch over 5 feet, for men use 50kg

Mild stress --> 25-30kcal/kg/day, 1-1.2g/kg/protein day

Moderate - severe --> 25-35kcal/kg/day, 1.2-1.8g/kg/protein day

- Standard or partially hydrolyzed most appropriate

- No major GI problems, possibly some degree of malabsorption from prolonged STARVING, no renal disease, not immunocompromised

- Need ~1000kcal and 40g protein in 1 LITER

- To administer: Start at 25ml/hr, increase by 20ml/hr q8h as tolerated.  If we give 700ml/day, final rate would be 30ml/hr rounded, flush with steril water every 4h

- Daily profile 1 and P x 3 days?

- Fingerstick glucose every shift x 2 days, continue if glucose > 240mg/dl

- baseline cbc with differential, profile 2+Mg

- Chest X Ray

- Check residuals.  Notify MD for residual >200 mls, GI symptoms

- Weight three times per week

- Input/output daily x 7 days

- Most frequently K, P, and Mg-refeeding syndrome

- Acute is due to intracellular shifts, chronic is because of new tissue in wound healing

- Rapid refeeding with high CHO and high calories without adequate phosphate can be life threatening

- Neutraphos and Neutraphos K (the latter with more K, both with 250mg Phos.), can be used, as well as potassium products

- In hypokalemia, 80meq/day, no more than 40meq/dose

- In hypophosphotemia, 1000-1500mg/day in divided doses; if life-threatening replace IV, otherwise PO is fine

Diarrhea - Abx, hyperosmolar, Magnesium antacids, malabsorption, EF related

N/V - Bacteria, Hyperosmolar, fast infusion rate, dymotility from surgery, DM, anticholinergics

Constipation - Dehydration, drug induced, inactivity, low residue, impaction/obstruction

Cramping - Too rapid administration, too cold

Occlusion - Drug-EF intx, inadequate flushing, undisolved formula

Displacement - Self extubation, vomitting or coughing, inadequate fixation

Aspiration - Improper position, GERD, diminished GAG, malposition tube, possible aspiration pneumonia from GI contents

Peristomal excoriation - Poor skin/tube care, GI secretion leakage

  = [1.0 x 0.8] + 6.9

  = 0.8 + 6.9 = 7.7 mg/dl

  Additional calcium is needed

  K= 3.6 meq/l- give 40-80 meq/pt/day in two or three divided doses

   500 mg qid neutraphos K provides 112 meq K

  *500 mg tid neutraphos K provides 85.5 meq K

Profile 1:  Na, K, Cl-, CO2, Glucose, BUN, Creatinine

Profile 2:  Same as above, plus Albumin, ALP, AST, Bilirubin, Calcium, Total Protein

Liver Function Panel:  ALT, AST, ALP, Bilirubin total and direct, Albumin.