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Nutritional support is the provision of nutrients with therapeutic intent by either the enteral or the parenteral route. Technically, the term enteral nutrition includes oral supplements as well as tube feeding, but in practice, clinicians use the term to refer strictly to tube feeding. Enteral and parenteral nutrition are important in the management of many medical conditions. Safe and effective nutritional therapy depends on careful selection of patients and a thorough understanding of the complications that can occur.

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If the gut works, use it. This simple adage is the guiding principle of nutritional support. Clinical practice guidelines consistently endorse the use of enteral nutrition for patients who have a functional GI tract but cannot take enough nutrients orally to maintain adequate nutritional status. Enteral nutrition has the following physiologic and practical benefits that make tube feeding superior to parenteral nutrition:

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Advantages of Enteral Nutrition
  • Maintains normal metabolic pathways
  • Allows delivery of a full range of nutrients
  • Triggers the release of cholecystokinin
  • Preserves hepatic lipid metabolism
  • Maintains normal intestinal pH and flora
  • Supports the GI tract as an organ of the immune system
  • Promotes wound healing
  • Lowers costs
  • Reduces infectious complications
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Technological advances in enteral access techniques have increased the numbers of patients who can safely receive tube feeding. The indications for enteral nutrition are as follows:

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Indications for Enteral Nutrition
Poor Oral Intake (Won’t Eat)
  • Anorexia
  • Depression
  • Disabilities
  • Eating disorders
  • Early satiety
  • Nausea
  • Painful swallowing
Unsafe Oral Intake (Can’t Eat)
  • Altered level of consciousness
  • Dysphagia
  • Endotracheal intubation
  • Gastroparesis
  • Impaired sucking and swallowing
  • Proximal intestinal obstruction
Elevated Needs (Can’t Eat Enough)
  • Burns
  • Open wounds
  • Pressure ulcers
  • Sepsis
  • Trauma
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Principles of Enteral Tube Feeding

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Timing:

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The optimal time for initiating enteral nutrition depends on the patient’s baseline nutritional status and clinical condition. Well-nourished patients in stable condition can tolerate suboptimal nutritional intake for 7–14 d without harmful effects. On the other hand, a convincing body of evidence has shown that early enteral feeding improves clinical outcome among critically ill patients. Many ICUs have established protocols calling for initiation of tube feeding within 24–36 h of admission to the unit.

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Delivery Site:

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The fundamental decision in planning tube feeding is to determine whether nutrients should be delivered to the stomach or the small intestine. The factors involved in choosing the appropriate location for enteral nutrition include gastric function and risk of aspiration. In general, the gastric route is preferred because feeding into the stomach is better tolerated than intestinal feeding and is technically easier. Although high risk of aspiration is the primary reason for intestinal feeding, other conditions, such as delayed gastric emptying, gastric outlet obstruction, and the presence of a tumor, also limit use of the stomach as a ...

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