Chapter 073. Enteral and Parenteral Nutrition (Part 12)

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Table 73-10 Enteral Formulas Composition Characteristics Clinical Indications STANDARD ENTERAL FORMULA 1. Complete dietary products (+)a Suitable for most patients requiring tube feeding; some can be a. Caloric density 1 kcal/mL used orally b. Protein ~14% cals, caseinates, soy, lactalbumin c. CHO ~60% cals, hydrolyzed corn starch, maltodextrin, sucrose d. Fat ~30% cals, corn, soy, safflower oils e. Recommended daily intake of all minerals and vitamins in 1500 kcal/d f. Osmolality (mosmol/kg): ~300 MODIFIED ENTERAL FORMULAS 1. Caloric density 1.5–2 kcal/mL (+) Fluid-restricted patients Critically ill patients 2. a. High protein ~20–25% Impaired absorption protein (+) Immune-enhancing diets ...

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Chapter 073. Enteral and Parenteral Nutrition (Part 12) Table 73-10 Enteral Formulas Composition Characteristics Clinical Indications STANDARD ENTERAL FORMULA 1. Complete dietary products (+)a Suitable for most patients requiring tube feeding; some can be a. Caloric density 1 kcal/mL used orally b. Protein ~14% cals, caseinates,
soy, lactalbumin c. CHO ~60% cals, hydrolyzed corn starch, maltodextrin, sucrose d. Fat ~30% cals, corn, soy, safflower oils e. Recommended daily intake of all minerals and vitamins in >1500 kcal/d f. Osmolality (mosmol/kg): ~300 MODIFIED ENTERAL FORMULAS 1. Caloric density 1.5–2 kcal/mL Fluid-restricted patients (+) Critically ill patients 2. a. High protein ~20–25% Impaired absorption protein (+) Immune-enhancing diets b. Hydrolyzed protein to small peptides (+) Liver failure patients intolerant of
c. Arginine, glutamine, 0.8 g/kg protein nucleotides, ω3 fat (+++) Renal failure patient for brief d. Branched-chain amino acids, periods if critically ill aromatic amino acids (+++) Fat malabsorption e. Low protein of high biologic Pulmonary failure with CO2 value retention on standard formula, limited 3. a. Low fat, partial MCT utility substitution (+) Improvement in glycemic index b. Fat >40% cals (++) control in diabetes c. Fat from MUFA (++) Improved ventilation in ARDS d. Fat from ω3 and ω6 linoleic Improved laxation acid (+++) 4. Fiber provided as soy polysaccharide (+) Cost: + inexpensive; ++ moderately expensive; +++ very expensive. Note: ARDS, acute respiratory distress syndrome; CHO, carbohydrate;
MCT, medium-chain triglyceride; MUFA, monounsaturated fatty acids; ω3 or ω6, polyunsaturated fat with first double bond at carbon 3 (fish oils) or carbon 6 (vegetable oils). Source: Adapted from chapter in Harrison's Principles of Internal Medicine, 16e, by Lyn Howard, MD. Complications Aspiration The debilitated patient with poor gastric emptying and impairment of swallowing and cough is at risk for aspiration; this is particularly true for those who are mechanically ventilated. Tracheal suctioning induces coughing and gastric regurgitation, and cuffs on endotracheal or tracheostomy tubes seldom protect against aspiration. Preventive measures include elevating the head of the bed to 30 degrees, using nurse-directed algorithms for formula advancement, combining enteral with parenteral feeding, and using post–ligament of Treitz feeding. Tube feeding should not be discontinued for gastric residuals of
bowel feeding, residuals are not assessed but abdominal pain and distention should be monitored.