Overview of Enteric Feedings

Enteral nutrition is a method of getting nutrients into the body through the digestive system. This type of nutrition can be given either by eating food normally, or through a special tube that is used to deliver nutrients directly into the stomach or the small intestine. It’s considered safer and more effective than other methods of nutrient delivery like parenteral nutrition, which requires introducing nutrients directly into a vein. Using enteral nutrition also helps to keep the gut healthy and functioning well by reducing risk of infection, lowering cost and preventing the gut from shrinking. This method also helps to maintain the gut’s natural defense mechanisms.

On the other hand, artificial nutrition is another method employed when a person cannot eat by mouth, or when their food intake is not sufficient. This can be provided through two main pathways – parenteral (intravenous) or enteral (using the gut). Parenteral nutrition is given by injecting nutrients directly into a large vein near the heart.

Enteral nutrition can be delivered through a feeding tube which can be inserted through the nose (known as nasogastric and nasojejunal tubes) or the mouth (orogastric tube), mostly done at the bedside. In certain circumstances, a surgery may be required to place a feeding tube directly into the stomach or small intestine – these tubes are called a gastrostomy and jejunostomy, respectively.

Historically, the use of enteral nutrition was overlooked in favor of parenteral due to the misconception that certain diseases makes the gut unable to function normally. Today, however, we know that even people who are seriously ill and have severe disease can often tolerate enteral nutrition quite well. In fact, studies show that enteral nutrition helps prevent infections, reduce the cost, and even reduce the duration of hospital stay.

Why do People Need Enteric Feedings

Enteral tube feeding, a method where nutrients are delivered directly into the digestive system via a tube, is often used for patients who are unable to eat enough food or maintain their nutritional needs through regular eating. This is often the case for patients who have trouble swallowing their food, known as dysphagia. Swallowing problems make it difficult for such patients to get the correct amount of food needed for their bodies to work properly, even when the food is adjusted to make it easier to swallow.

For tube feeding to work, the patient’s digestive system must be functioning and reachable by the feeding tube. In cases where the digestive system cannot be reached, does not absorb nutrients well, or is releasing important nutrients too quickly, tube feeding may not be possible. In these situations, parenteral feeding, where nutrients are delivered through an injection, can be used.

There are numerous situations in which enteral tube feeding may be necessary. Some of these include:

– Patients who are unconscious or on a ventilator, or those with a severe head injury.
– Neuromuscular disorders that interfere with the swallowing reflex. Examples include Parkinson’s disease, multiple sclerosis, and stroke.
– Extreme loss of appetite due to chemotherapy, HIV, or sepsis.
– Any obstruction in the upper digestive system like a stricture (narrowing) or tumor.
– Situations where the body’s nutritional and metabolic demands are increased, such as during sepsis, cystic fibrosis, or burns.
– Mental illnesses such as dementia.

In critical illness, evidence strongly suggests that using enteral feeding is the best nutritional approach. Recommendations suggest that:

– Enteral feeding can help improve nutritional outcomes, reduce hospital stays, and lower the risk of infection.
– Patients who can’t eat normally for more than 72 hours should use specialized nutritional support.
– If deciding between enteral and parenteral feeding methods, enteral feeding is generally preferable.
– Enteral feeding should start within 48 hours of hospital admission.
– It should provide 25 to 30 calories per kilogram of the patient’s body weight each day.
– The target calorie intake should be met within 48 to 72 hours.
– If the patient is experiencing hemodynamic instability, which is when their blood circulation isn’t working properly, enteral feeding should be postponed until they stabilize.

Passing gas, bowel movements, or making noises with your stomach aren’t necessary conditions to start enteral feeding.

The number of calories a patient needs while being fed this way can be calculated using a technique called indirect calorimetry. When this is not available, a rough estimate is 25 calories for each kilogram of the patient’s body weight per day. Guidelines suggest patients on mechanical ventilation should consume about 4 grams of carbohydrates per kilogram of their body weight each day, keep their blood glucose level below 180 mg/dL, consume between 0.7 to 1.5 grams of fat per kilogram each day, and adjust their protein intake between 1 to 1.8 grams per kilogram of body weight per day.

The general advice for critically ill patients is to start enteral feeding as soon as possible. Giving fewer calories in the early stages of a severe illness can help to prevent high blood sugar, which is associated with a higher risk of death. Some experts suggest providing about 80% of the patient’s nutritional needs in the first week of illness, gradually increasing this as the patient recovers.

When a Person Should Avoid Enteric Feedings

There are times when someone should not be given a certain type of treatment for various reasons. For example, if a person’s body is not stable enough (because of poor blood flow to organs), any form of digestive feeding could make things worse. Other conditions that make digestive feeding a bad idea include active bleeding in the digestive tract, problems causing complete or partial blockage in the small or large intestines, or if the intestines have stopped working due to issues such as chemical imbalances in the body or inflammation of the tissue lining the abdominal wall (peritonitis).

Some other conditions, while not completely stopping this type of treatment, would require careful consideration. This includes conditions that cause poor nutrient absorption, problems with pouches in the gut wall (diverticular disease), the presence of abnormal connection (fistula) in the small intestine, or if the person has gone through surgery to remove a large part of their bowel and is in the early stages of recovery.

In certain situations, it is actually beneficial to provide nutritional support for patients. For instance, people with acute kidney injury benefit from nutrition to avoid malnourishment. However, the type of diet would depend on whether the patient’s body is in a state of breaking down stored nutrients. If it is, then a low protein and electrolyte diet is recommended. Patients should also have their nutrient levels monitored to ensure they’re receiving enough essential nutrients like zinc, selenium, and vitamins A, C, and D.

People with liver failure face challenges because their liver no longer functions properly to produce blood clotting proteins. Therefore, feeding them through the digestive system comes with a risk of gastrointestinal bleeding. In severe cases, nutrition might be provided through a vein instead. When they consume food, it’s important that they get a balance of energy from carbohydrates and protein. Foods with enough potassium, magnesium, and zinc should also be included in their diet.

When it comes to acute lung injury or severe lung syndrome, such patients usually end up in intensive care units. Their diet should be rich in proteins but not high in fats and carbohydrates. They should also consume omega-3 fatty acids and antioxidants.

Patients who suffered multiple injuries should start being fed through the digestive system early. Their diet should contain arginine and omega fatty acids and should provide a total of about 25 to 30 calories per kilogram of body weight daily.

The dietary advice for patients who have undergone abdominal surgery is largely similar. Surgery can cause inflammation and alter metabolism. Malnourished post-surgery patients might experience slower wound healing, increased risk of infections, and cardiopulmonary issues. This could mean longer hospitals stays and a higher chance of death.

Acute pancreatitis involves inflammation of the pancreas, causing a heightened metabolic state. Traditionally, it was treated with digestive rest and nutrition provided through a vein. However, this method was associated with high sickness rates and death rates because of an intestinal barrier problem. The current advice is to commence feeding through the small intestine, preferably within 48 hours of being hospitalized.

Equipment used for Enteric Feedings

There are various types of tubes used for feeding patients who can’t eat by mouth. These tubes are generally made from materials such as polyurethane or silicone. The size of these tubes is measured in French units (Fr), where each French unit is equal to 0.33 millimeters. The types of feeding tubes are identified based on where they are placed inside the body.

Here are the various types of feeding tubes:

  • Nasogastric tube
  • Nasoduodenal tube
  • Nasojejunal tube
  • Gastrostomy tube
  • Jejunostomy tube
  • Gastrojejunal tube

Feeding tubes can be inserted in different ways including manually, through a procedure that involves a lighted flexible tube called an endoscope, surgically, or with the help of a type of medical imaging known as interventional radiology.

A nasogastric tube (abbreviated as NG) is usually used for patients who can control their vomiting and don’t suffer from gastroesophageal reflux (heartburn), poor stomach emptying, or blockages in the small or large intestine. However, they aren’t suitable for those with difficulty swallowing. For most cases, a small 5 to 8 Fr NG tube is suggested. If needed, a larger tube can be used to relieve pressure in the stomach. Trained medical staff should insert these tubes for safety reasons. After the placement, the tube’s position should be verified either by listening with a stethoscope or via x-ray. In the Intensive Care Unit or for newborns, an x-ray is recommended to confirm the tube’s placement. The acidity of the stomach content, which should be less than 5.5 before the feeding is initiated, can also be used to confirm the position.

Nasoduodenal and Nasojejunal tubes are feeding tubes that end in the second part of the small intestine (duodenum) or the central part of the small intestine (jejunum) respectively. These can be placed at the bedside or with the help of x-ray technology.

A gastrostomy tube is a feeding tube that goes through the wall of the stomach from the outside. It’s usually given to patients who need long-term feeding support. There are several ways to insert this type of tube: percutaneous endoscopic gastrostomy (PEG, which is done through endoscopy), radiologically, surgically, or via endoscopy. However, adding a jejunal extension to the PEG tube can cause the tube to dislocate and dysfunction.

A jejunostomy tube is a tube that goes from outside the body into the section of the small intestine named the jejunum. It can be placed either surgically or radiologically. An endoscope could be used to insert this tube, but its direct placement could be difficult. However, tubes placed through percutaneous endoscopic gastrojejunostomy (PEGJ) are firm and less prone to dislocation.

Who is needed to perform Enteric Feedings?

When it comes to managing patients who need to be fed through a tube, a team of various health professionals works together using the latest advice and rules. This nutritional support team includes a doctor, a nurse, a pharmacist who specializes in direct patient care, and a diet specialist.

One of their main goals is to ensure the patient receives the best possible food and nutrients through the feeding tube. Here’s how they do just that:

  • They identify which patients may not be getting enough nutrients.
  • They take a detailed look at the patient’s nutrition needs.
  • They make sure that the feeding tube provides safe, enough, and effective nutrition support.

The nutrition support team can offer several services such as:

  • Advising other medical professionals on nutrition support matters.
  • Creating feeding plans for both medical and nursing staff to follow.
  • Carrying out research and making improvements in the nutrition field.
  • Helping other staff members learn and grow in their roles.

How is Enteric Feedings performed

Food can be delivered straight to your stomach or small intestine in several ways. These methods typically start around 12 to 24 hours after a tube has been placed in your stomach, though some studies suggest that feeding can begin as soon as 3 to 4 hours after the tube has been placed.

Bolus Intermittent Feeding with a Bulb or Syringe

This method delivers food in liquid form, around 100 to 400 milliliters at a time, over the course of 5 to 10 minutes. It’s often used when patients can move around, but there’s a risk that food might unintentionally enter the airway (aspiration).

Cyclic Intermittent Feeding

This method delivers food over a period of 8 to 16 hours using gravity or a pump. It’s used for patients who can sit halfway up.

Intermittent Drip

This method is often used for feeding at home. It can deliver around 1.5 to 2 liters of food overnight over a period of 8 to 16 hours using gravity or a pump.

Constant Infusion

This method is mostly used for patients who are confined to a bed. Food is delivered continuously through a pump or using gravity. To lessen the chance of food mistakenly entering the airway or coming back up (regurgitation), the patient’s head is raised at a 45-degree angle.

There are also several ways to place a feeding tube into the small intestine (jejunostomy). The choice of method depends on the patient’s situation and the doctor’s expertise, but less-invasive techniques are generally preferred.

Open Surgical Technique

In this method, the surgeon creates a small cut and carefully puts the tube into the small intestine while ensuring that the tube’s length is adequate to prevent food from flowing back up. A technique called the Witzel technique is performed, which prevents leakage at the point where the tube exits from the small intestine. Afterward, the intestine is attached to the abdominal wall using stitches.

Laparoscopic Technique

This is a less-invasive method using small cuts and a camera. The doctor finds an area in the intestine that can be attached to the abdominal wall, makes a cut there and guides a tube into the correct position using a wire. After the tube is in place, the doctor removes the guide wire and inflates a small balloon on the tube to secure it in place. Finally, the small cuts on the abdomen are closed with stitches and a type of medical adhesive.

Needle Catheter Technique

This technique is often used when major surgery on the digestive system is performed. A tube is guided into a created path in the intestine, and then the intestine is attached to the lining of the abdominal cavity using stitches. You can start receiving food through the tube soon after surgery, usually within 6-12 hours.

Percutaneous Technique

In this method, a tube is placed into the small intestine through the abdominal wall by using the guidance of an endoscope, a long, thin tube with a light and camera at the tip. A wire is guided through the intestine, a pathway for the feeding tube is created, and then the tube is positioned and secured in place.

Possible Complications of Enteric Feedings

For some patients, doctors insert a feeding tube to provide essential nutrients directly to the stomach or intestines. This process, called enteral feeding, can unfortunately lead to various complications. These can be broken down into mechanical, infectious, and gastrointestinal complications, along with some more specific issues.

Mechanical complications can occur due to the tube’s placement and can include the tube being positioned wrongly, getting blocked, coming out accidentally, breaking, leaking, or causing erosion and ulceration near the insertion site. In rare cases, it can also cause intestinal obstruction or bleeding. Nasoenteral insertion, where the tube is inserted through the nose, can sometimes cause the tube to end up in the wrong place, such as the lungs. This can lead to serious conditions like a lung abscess or a collapsed lung. To ensure proper tube placement, doctors usually confirm with an X-ray.

Infectious complications can arise due to the tube introducing bacteria into the body, leading to infections at the insertion site, lung infection caused by aspirating or breathing in food or stomach acid, ear and throat infection, infectious diarrhea, or infection in the lining of the abdomen (peritonitis). The size, material, and diameter of the tube can also affect the chances of complications.

Gastrointestinal complications include nausea and vomiting, diarrhea, consticpation, cramps and bloating, or regurgitation and aspiration, where stomach contents flow back into the throat and can be inhaled into the lungs. These complications can occur due to various factors, including medication and the body’s reaction to the feeding technique.

Metabolic complications can occur when a person recommences normal feeding after being starved or malnourished – this is known as ‘refeeding syndrome’. Refeeding syndrome can lead to a sudden drop in phosphorus levels in the blood, which can result in severe physical illness like muscle weakness, heart problems and in some instances, can be fatal. This syndrome is considerably more common in enteral feeding. Patients at risk include those with chronic alcoholism, severe and prolonged malnutrition, postoperative patients, elderly patients, and those with certain other chronic diseases.

Overall, it’s important that the patient’s cardiovascular status and electrolyte levels are carefully monitored during enteral feeding to lessen the risk of complications.

What Else Should I Know About Enteric Feedings?

The importance of using the gut to provide nutrients is something that cannot be overstated. Feeding your body through your gut, rather than through other methods, plays a crucial role in keeping your gut healthy and functioning well. It also helps stimulate and regulate the immune system responses within your gastrointestinal tract, which is the part of your body responsible for digestion.

Frequently asked questions

1. What type of feeding tube is best for my condition and why? 2. How will the feeding tube be inserted and what are the risks or complications associated with the procedure? 3. What is the recommended method of delivering the food through the feeding tube (bolus intermittent feeding, cyclic intermittent feeding, intermittent drip, constant infusion) and why? 4. How will my nutritional needs be determined and what specific nutrients should I be receiving through the feeding tube? 5. Are there any potential side effects or complications I should be aware of while receiving enteric feedings?

Enteric feedings refer to the administration of nutrients directly into the gastrointestinal tract through a feeding tube. This method is commonly used for individuals who are unable to consume food orally or have difficulty with digestion. Enteric feedings can help provide necessary nutrition and hydration, but it is important to follow medical guidance and monitor for any potential complications.

There are several reasons why someone may need enteric feedings. Some of these reasons include poor blood flow to organs, active bleeding in the digestive tract, blockage in the intestines, inflammation of the abdominal wall, poor nutrient absorption, diverticular disease, abnormal connections in the small intestine, recovery from bowel surgery, acute kidney injury, liver failure, acute lung injury or severe lung syndrome, multiple injuries, abdominal surgery, and acute pancreatitis. Enteric feedings can provide necessary nutrition and support for individuals with these conditions.

Someone should not get enteric feedings if their body is not stable enough, if they have active bleeding in the digestive tract, if they have problems causing blockage in the intestines, if their intestines have stopped working, or if they have certain conditions such as poor nutrient absorption or diverticular disease.

The text does not provide specific information about the recovery time for Enteric Feedings.

To prepare for enteric feedings, the patient should ensure that their digestive system is functioning and reachable by the feeding tube. They should also follow the recommendations for enteral feeding, which include starting within 48 hours of hospital admission, providing the recommended calorie intake per kilogram of body weight, and postponing enteral feeding if experiencing hemodynamic instability. Additionally, the patient should work with a nutrition support team to ensure safe and effective nutrition support through the feeding tube.

The complications of enteric feedings can be categorized into mechanical, infectious, gastrointestinal, and metabolic complications. Mechanical complications include issues with the tube's placement, such as being positioned wrongly, blocked, accidentally coming out, breaking, leaking, or causing erosion and ulceration near the insertion site. It can also lead to intestinal obstruction or bleeding in rare cases. Nasoenteral insertion can result in the tube ending up in the wrong place, such as the lungs, causing serious conditions like a lung abscess or collapsed lung. Infectious complications can arise from the introduction of bacteria into the body, leading to infections at the insertion site, lung infection, ear and throat infection, infectious diarrhea, or peritonitis. Gastrointestinal complications include nausea, vomiting, diarrhea, constipation, cramps, bloating, and regurgitation and aspiration. Metabolic complications can occur when a person recommences normal feeding after being starved or malnourished, known as refeeding syndrome, which can lead to a sudden drop in phosphorus levels in the blood and severe physical illness. It is important to monitor the patient's cardiovascular status and electrolyte levels during enteral feeding to reduce the risk of complications.

Symptoms that require enteric feedings include unconsciousness or being on a ventilator, severe head injury, neuromuscular disorders that interfere with swallowing, extreme loss of appetite due to chemotherapy or other illnesses, obstruction in the upper digestive system, increased nutritional and metabolic demands, and mental illnesses such as dementia.

Based on the provided information, there is no specific mention of the safety of enteric feedings in pregnancy. The information focuses on the use of enteral nutrition in critically ill patients and those with various medical conditions. It is recommended to consult with a healthcare professional for specific advice regarding enteric feedings during pregnancy.

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