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Enteral Nutrition During Deployment. JENNIFER GRAF, MS, RD LIEUTENANT COMMANDER, USPHS NUTRITION DEPARTMENT NATIONAL INSTITUTES OF HEALTH JUNE 21, 2012. Disclaimers. - PowerPoint PPT Presentation
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JENNIFER GRAF, MS, RDLIEUTENANT COMMANDER, USPHS
NUTRITION DEPARTMENTNATIONAL INSTITUTES OF HEALTH
JUNE 21, 2012
Enteral Nutrition During Deployment
Disclaimers
Brand name formulas are included for purposes of education and their inclusion does not
reflect bias or endorsement of a particular product or brand.
Suggestions for short-term solutions when specialized formulas are not available are often
based on my personal judgment rather than evidence. I hope to discuss others’ suggestions
as well.
Outline of Talk
Set the scene for deployment
Review enteral nutrition guidelines in the context of deployment
Assess the need for specialized formulas in various disease conditions
Walk through case studies
Subject Matter Experts
Ship Deployment CDR Kathleen Edelman CDR Pamella Vodicka
Federal Medical Station (FMS) CDR Blakeley Fitzpatrick LCDR Merel Kozlosky Coppola, Dean, CAPT, USPHS. “Leadership of a
Federal Medical Station-Special Needs Shelter” slide presentation
Ship Deployments
Challenges to Optimal Care
Space is limited for supplies and staff Replenishment of supplies can be delayed
Must keep close tabs on supply and par level Specialty items require much coordination Limited phone/email access NJ tube feed placement may be appropriate given
seasickness Must prioritize time and demand on others Plans/recommendations must be simple
CDR Vodicka meeting with an enterally fed patient in Trinidad
Reed Arena, College Station, TXHurricane Ike
Special Needs Patient
Any individual who would need assistance to evacuate and shelter due to physical or mental disabilities and/or someone who requires the level of care and resources beyond the care available in a general population shelter, yet does not require hospitalization.
Examples: behavioral health, hospice, morbid obesity, diabetes, respiratory disease, hypertension, orthopedic, gastrointestinal disease
Taken from: Coppola, Dean, CAPT, USPHS. “Leadership of a Federal Medical Station-Special Needs Shelter” slide presentation.
FMS- Hurricane Ike, College Station, TX 2008
Special Needs Category (9/16/08) 0 7% 1 16% 2 12% 3 24%4 26%***5 15%***
Provided courtesy of CAPT Dean Coppola
Hurricanes Rita, Gustav, and Ike
Types of Patients Seen Chronic diseases
Renal disease Diabetes Mellitus Degenerative neurologic disorder with dysphagia Nursing home residents
Higher acuity Burn patients on TPN/TF (accompanied by nurses and
supplies) Ventilated patient s/p GSW on TF (brought own formula)
Tube feeding patients Usually came with some formula supply, but often no
instructions
Hurricanes Rita, Gustav, and Ike
Supplies in FMS Cache Formulary of enteral formulas (not official list?)
Enfacare, liquid Milk-based Infant formula, liquid Soy-based infant formula, liquid Vanilla supplement, powdered Diabetic formula, powdered Oral rehydration packets
Tube feeding kits May not be fully stocked or substitutions may be made
Hurricanes Rita, Gustav, and Ike (cont.)
Other Challenges
At initial set up, may not have potable water or food Lab values, weights, fluid balance not readily
available Medical history may be incomplete
Dietitians’ Other Responsibilities
Securing food and potable waterScreening over 200 patients
Dysphagia, NPO, special diets
Plating/serving foodMaintaining food par levelsCleaning
Priorities at Arrival to FMS
Assess formulas and supplies in FMS cacheIdentify a local facility (university, hospital, retail store)
that could be a source of specialized or additional formula
Coordinate a contract through the Logistics TeamAssess special formula needsBecome familiar with process of pharmacy orders to IRCTIdentify how tube feeding orders are being
communicatedRecommend patient transfer if unable to safely meet
needs
**Be flexible and make do with what you have while taking the route of least harm to the patient**
Resources to Bring
Food and Nutrition Guide for DeploymentAND Nutrition Care ManualPocket product guides for Abbott, Nestle,
NutriciaAmerican Association of Kidney Patients
Nutrition Counter http://www.aakp.org/userfiles/File/NutritionCounter_English(9).pdf
If deployed to relieve rapid deployment group, contact dietitians at FMS to find out what resources may be necessary.
Work-up for Enteral Feeding
Identify Who Should Receive Enteral Feeds
Oral intake is inadequate Poor appetite Very high needs (trauma, burns, wounds, critical
illness, catch-up growth)
Oral intake is impossible Structural barriers (e.g. tumor, esophageal atresia)
Oral intake is unsafe Impaired swallowing function (neuromuscular disease) Risk for aspiration
AND… GI tract is functional
Absolute Contraindications for Enteral Feeding
Hypovolemia/Hypotension (poor gut perfusion) Never feed until fluid resuscitated and
hemodynamically stable
Bowel obstructionIntractable vomitingUpper GI bleedingHigh output GI fistulas
Site of Enteral Access
Nasal tubesEndoscopically placed ostomy tubes
Gastric Functional stomach Absence of significant delayed gastric emptying, vomiting,
aspiration
Post-pyloric Gastric outlet obstruction Gastroparesis Pancreatitis- Place past Ligament of Treitz Reflux/risk for aspiration- Place past Ligament of Treitz?
Estimate Needs(refer to deployment guide)
Predictive equations are weight-basedEnergy needs
Use ideal body weight if underweight or poor growth Better to under-estimate needs initially and adjust per
hunger or wtProtein needs
Higher for critically illFluid needs
Increased with hot conditions, fever, losses(diarrhea, fistula)
If no weight available Ask the patient Use reference weights for age and adjust
Recommend Feeding Schedule
Bolus-delivered by gravity via a syringe More physiologic Low concern for gastric delay or aspiration
Continuous-delivered using enteral pump at a specified rate for extended period of time Presence of delayed gastric emptying, reflux, dumping
syndrome Suspected risk for refeeding syndrome Overnight feeds Small bowel feeds
Select a Formula
Patient-related factors Nutrient requirements Electrolyte balance Digestive/absorptive
capacity Disease state Renal function Food allergies
Formula-related factors Digestibility of
nutrients Nutrient adequacy Osmolality Viscosity Ease of Use
Final Considerations Before Starting Feeds
Be sure patient is hemodynamically stable and volume replete
Replete electrolytes if at risk for refeedingStart/advance feeds extra slowly using isotonic
formula for: Critically Ill Undernourished Those who have not been enterally fed for an extended
period of timeDo not use formulas that contain fiber or arginine
for critically illProvide adequate free water
Consider all sources: IV’s, water in formula, and flushes May require extra water boluses.
Initiate Feeds
Start formula full strengthAdults: See page 21 of Deployment GuideChildren
Bolus 25% needs or 2.5-5 ml/kg divided among 6-8 boluses over
>15-20 minutes Advance by 25% per day until reach goal Condense to 4-6 boluses per day as tolerated
Continuous 1-2 ml/kg/hr (1 ml/kg/hr for kids >35 kg) Advance 0.5-1 ml/kg/hr every 6-24 hrs
Monitor Patient
WeightFluid status (Ins/Outs)Labs: electrolytes, glucoseActual delivery of formulaGI symptomsReports of hunger/thirst from patientGastric Residual Volumes
Controversial
Minimize Bacterial Contamination
Formula Preparation
Powdered formulas are not sterile; use ready-to feeds (RTF) if available Clean RTF can lids Keep opened RTF formula covered in refrigerator ; expires in 24 hr Prepare formulas in disinfected, separate area with little traffic, no cleaning
supplies and without strong air currents using disposable or heat-sterilized equipment (dishwasher to 180 degrees)
Use chilled, sterile water (can boil 1-2 minutes & cool) Use whisk (not blender) Powdered formula cans: once opened, keep lidded in clean, cool, dry place;
expires in 1 month Prepared formula: keep in sealed container in fridge; expires in 24 hr
Formula Hang times- 4 hr
Maintain Quality Control
Formula preparation Measure powders by weight
May need to use scoop provided in can if no scale available Verify formulations for accuracy and appropriateness
Labeling of prepared formulas Patient identifiers Formula name, concentration, volume Expiration date and time Check label against the order
Do you really need a specialized formula?What if you do not have one available?
Standard Polymeric Formulas
Standard Formula
Polymeric formula – intact proteinEnergy Density
Infant formulas- 20 kcal/oz Pediatric/Adult formula- 30 kcal/oz
Micronutrients Needs generally met by 1-1.5 L of formula
Water ~80-85% free water
Renal Formulas
Varying amounts of proteinLower/Absent Electrolytes (Na, Ca, K, Mg, Phos)Fluid restricted (1.8-2 kcal/ml)
Renal Disease
Considerations: Stage of disease and access to dialysis Access to sodium polystyrene sulfonate
Acute Risks: Heart arrhythmias from high potassium (K) Pulmonary edema or congestive heart failure from
excessive fluid Acute event from hypertension
Possible short-term substitute for renal formula: ?May not be able to tolerate any volume (no formula) ?Standard formula at a reduced volume to limit Na, K and fluid Make up calories and protein with K-free modulars
Always discuss your plan with medical team! Conditions may be much more complex than perceived
Hepatic Disease
BCAA-enriched formulas not indicated Specialized formula not indicated
Formulas for Diabetes
Lower % CHO (~35% of kcal)Higher % FatComplex carbohydrates (including more fiber)
Diabetes
Acute Risk: Hyperglycemia/Increased Infection Risk
Short-term substitute for diabetes formula: ?Standard formula at appropriate kcal level Communicate with physicians and nurses about
frequent blood glucose checks and insulin coverage
Pulmonary Disease
Chronic Obstructive Pulmonary Disease Risk: Overfeeding leads to increased CO2
production Specialized formula not indicated Do not provide excess kcal
Free Amino Acid Formulas
Used for Allergies or Severely Impaired GI Function for Infants, Older Children and Adults
Allergy
Considerations Be sure that lactose intolerance is not being confused
for milk protein allergy Most formulas are lactose-free, gluten-free
Risk: AnaphylaxisGoal: To obtain a formula free of allergen
Safest choice for milk or soy allergies or multiple protein allergies is free amino acid formula
Peptide-based with MCT oil
Often selected in cases of malabsorptionPartially hydrolyzed proteinHigher % MCT oil
Impaired GI tract/Malabsorption
Considerations: Degree of GI impairment Access to pancreatic enzymes if needed
Acute Risk: Increased stool output/dehydration
Short-term substitution: ?Standard formula run continuously at slow rate with
consideration of fluid and potassium losses
If severe GI impairment, may need supplemental TPN if using standard formula
Wounds
Ensure adequate kcal, protein and vitamin/mineral status (especially Vitamins A,C,E, and Zinc)
Specialized formula not indicated
Pediatric (>1 yr old)
Considerations: Adult formulas often contain higher levels of the following:
Protein- risk for dehydration Vitamin A Iron Electrolytes (Na, K) Magnesium Folic Acid Zinc
Acute Risk: Dehydration; consider extra fluid for high protein (see deployment guide p. 6)
Note: concentrated infant formula (30 kcal/oz) may also be appropriate for toddlers
Modulars
Extra calories Vegetable oil- monitor for separation; consider giving
as bolus Cornstarch
Extra protein Powdered milk- be sure to mix very well to avoid
clogging tube Pasteurized egg whites
Case Study 1
57 yr old male with chronic renal diseaseAccompanied by his wife who is a better historian
Has a history of poor intake and has G-tube Receives bolus of 1 can Nepro, 2-3 x/day + oral snacks Usually gets hemodialysis M/W/F, but missed Fri (now Mon) Pt has small amount of urine output still Has not gotten tube feeds in 5 days; eating potato chips,
granola bars- made him thirsty to drinking 1-2 20 oz water bottles/day
Social worker trying to arrange dialysis for tomorrow
No labs availableO2 saturations are low 90’sFMS cache has Glucerna and Ensure available
Case 1
What are the major considerations? Pt has been having minimal intake for 5 days Potassium likely elevated Fluid overload Dangerously high blood pressure?
What do you recommend right now? No more fluid until dialysis Consumption of only low Na and low K foods Initiate a plan to obtain a renal formula comparable to
Nepro Discuss plan with physician
Case 1
Later that week, patient is able to start regular dialysis
What are new recommendations? Liberalize fluid and electrolyte intake somewhat, but continue to
limit them Try to provide adequate kcal and protein
Implementation Provide standard formula in amount that would provide similar
potassium as 3 cans of Nepro (his usual intake while on dialysis) Depending on oral intake, could add vegetable oil to meet kcal
goal. Skim milk powder contains K so would not be a good way to meet protein goal.
Explain/discuss rationale of plan with physician
Case Study 2
5 yr old female with baseline neurologic impairment
Per mother Wt= 34 lb (15.4 kg) Usually gets continuous feeds of Pediasure at 45 ml/hr
x 22 hr via G-tube; never eats by mouth Has been growing well on this regiment Mother brought Pediasure from home, but it went
missing at last shelter
FMS cache has only powdered infant formula or RTF Boost
Case 2
Determine needs (using deployment guide) Use usual intake as kcal goal because she grew well
on that amount 1) 45 ml/hr x 22 hr = 990 ml 2) Pediasure is 30 kcal/oz (1kcal/ml), so 990 ml = 990
kcal Determine fluid needs
50-60 ml/kg 924 ml/day (using higher end of range) Determine protein needs
RDA=0.95 g/kg 15 g/day
Case 2
What formula to use? Infant formula
Powdered- requires preparation Would provide appropriate protein, but low levels of
some vit/min Adult standard formula
RTF- safer Provides excess amount of protein and some vit/min
Choose the RTF and provide extra fluid to compensate for excess protein
Case 2
Calculate fluid needs: 1) Usual needs = 925 ml/day 2) Extra fluid to compensate for extra protein
990 ml Boost provides 41 g protein = 2.7 g/ kgExtra fluid need=[(g protein/day)–(wt x 2.5 g/kg)] x 16
ml = 40 ml extra3) Total needs = 965 ml/day
Calculate free water intake: Most 30 kcal/oz formulas are ~80-85% free water
990 ml formula x 83% =820 ml free water from formula
Fluid deficit: 965 ml-820 ml= 145 mlDivide 145 ml into 6 G-tube flushes of 25 ml
Resources
The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach- The Adult Patient, 2007
The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010 Infant Feeding: Guidelines for Preparation of Human Milk and Formula in
Health Care Facilities, 2nd Edition, Pediatric Nutrition Practice Group, American Dietetic Association, 2011
Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPEN. 33 (3), 2009 p 277-316.
Malone, A. Successful management of enteral feeding. In: Current Concepts in Adult Critical Care, E.Y. Cheng and P.K. Park, eds. Society of Critical Care Medicine: 2012.
Malone, A. Enteral Formula Selection: A review of selected product categories. Practical Gastroenterology, June, 2005.
Bankhead et al. Enteral Nutrition Practice Recommendations. JPEN 33(2), 2009.
Thank you
Category Day Organizing CommitteeCDR Kathleen EdelmanCDR Blakeley FitzpatrickLCDR Merel KozloskyCDR Pamella VodickaCDR Sara Bergerson (retired)
Addendum:Sampling of Currently Marketed
Specialized Formulas not Already Discussed
Note: Formulas within a category are not necessarily interchangeable.
Calorically Dense Pediatric Formulas
Consider extra free water needs if not volume-restricted
Isotonic w/ or w/o Fiber
Isotonic formulas may be better toleratedGood choice for initiating feeds
Immune Enhancing
Not safe for use in the critically ill
Infant Formulas- Standard
Standard dilution = 20 kcal/oz
Infant Formulas-Soy
Lactose intolerance or galactosemia or vegan
Infant Formulas- Hydrolyzed Proteins
Mild allergies? or Malabsorption
Toddler Formulas
Marketed to bridge nutrient gap during transition to table foods
Modulars