Nutritional support should be initiated in pts with malnutrition or in those at risk for malnutrition (e.g., conditions that preclude adequate oral feeding or pts in catabolic states, such as sepsis, burns, major surgery, or trauma).
Enteral nutrition (EN) is provided through a feeding tube placed through the nose into the stomach or beyond it into the duodenum, via a mini-surgical procedure in which a feeding tube is inserted through the abdominal wall into the stomach or beyond it into the jejunum using an endoscope, or by an open surgical approach to access the stomach or small intestine. EN is the treatment of choice when optimized voluntary nutritional support is impossible or has failed. Parenteral therapy refers to the infusion of nutrient solutions into the bloodstream via a peripherally inserted central catheter (PICC), a centrally inserted externalized catheter, or a centrally inserted tunneled catheter or subcutaneous port. When feasible, EN is the preferred route because it sustains the digestive, absorptive, and immunologic functions of the GI tract, and because it minimizes the risk of fluid and electrolyte imbalance. Parenteral nutrition (PN) is often indicated in severe pancreatitis, necrotizing enterocolitis, prolonged ileus, and distal bowel obstruction.
Standard Polymeric Formulas are the most widely used sources of EN. They are available in a wide variety of formats that generally meet the nutritional requirements of a normal, healthy person. Carbohydrates provide most of the energy. The proteins (from casein, whey, or soy) are intact and require normal pancreatic enzyme function for digestion and absorption. These products are isotonic or nearly so, and provide from 1000–2000 kcal and 50–70-g protein/L. Additional formula types include Polymeric Formulas with Fiber, Elemental and Semi-elemental Formulas, and Immune-enhancing Formulas, Protein-enriched Formulas, as well as disease-specific formulas used in pts with diabetic, hepatic, renal, or pulmonary disease.
After elevation of the head of the bed and confirmation of correct tube placement, continuous infusion is initiated using a half-strength diet at a rate of 25–50 mL/h. This can be advanced to full strength as tolerated to meet the energy target. The major risks of enteral tube feeding are aspiration, diarrhea, electrolyte imbalance, glucose intolerance, sinusitis, and esophagitis.
PN delivers a complete nutritional regimen directly into the bloodstream in the form of crystalline amino acids, dextrose, triglyceride emulsions, minerals (calcium, phosphate, magnesium, and zinc), electrolytes, and micronutrients. Because of its high osmolarity (>1200 mOsm/L) and often large volume, PN is infused into a central vein in adults. Ready-to-use PN admixtures typically containing 4–7% hydrous amino acids and 20–25% dextrose (with or without electrolytes) are available in two-chamber (amino acids and dextrose) or three-chamber (amino acids, dextrose, and lipid) bags that are intermixed, and vitamins, trace minerals, and additional electrolytes added just prior to infusion. Although convenient and cost-effective, these products have fixed nutrient composition ...