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ENTERAL NUTRITION FOR CRITICALLY ILL
Enteral feeding includes both oral feeding as well as tube feeding. When oral feeding is insufficient or not feasible, or when a current situation causing depletion is likely to be extended for a long period of time or where treatment is likely to prelude adequate oral intake or absorption for a significant time, tube feeding enables one to maintain a good nutritional status. Tube feeding may be instituted as a temporary measure or in some cases even permanently for the remainder of the patient\'s life.
The tube feeding should have all nutrients in required amounts and should be a liquid with low viscosity to enable it to pass through the tube easily by gravity flow.
Enteral Feeding vs Parenteral Feeding
Studies have shown that parenteral feeding is associated with more complications, both metabolic and septic. Continuous regulated enteral nutrition with elemental diet has been suggested as an alternative to total parenteral nutrition and the effect of diet on body composition has been found to be the same in both cases. Enteral feeding is also cheaper in comparison with parenteral feeding.
Indications for Enteral Nutrition
1. Neurological or psychiatric disorders, coma, severe depression.
2. Oropharyngeal or oesophageal disorders.
3. Trauma, fractures of head and neck.
4. Gastrointestinal disorders, fistulae, short bowel syndromes.
5. Head injuries and burns.
6. Renal or liver failure.
In critically ill trauma patients, due to raised metabolism and extraneous losses in terms of haemorrhage, exudates or fistulae, a patient needs the following:
High calories: 3000-3500/day
Proteins: 100-120 g
Adequate in all nutrients especially potassium.
The tube feed can be modified according to the status of the patient, such as a diabetic, renal or hepatic tube feed.
Technique of administration of feed is:
1. Nasogastric
2. Gastrostomy
3. Oesophagostomy
4. Jejunostomy.
The feeds are of following types:
1. Blenderized: Natural foods are blenderized and made into a liquid form.
2. Polymeric: Low residue foods like proteins from whole milk (casein), polysaccharides, disaccharides like sucrose or monosaccharides like glucose and vegetable oil or medium chain triglycerides (MCT).
3. Monomeric (elemental): Hydrolysed casein or crystalline amino acid, vegetable or MCT oil, glucose and dextrins supplemented with vitamins and minerals.
The formula is selected as given below:
1. Calories: Standard formula = 1 kcal/ml; high calorie formula = 1.5 kcal/ml.
2. Proteins: 9-24% of total calories or depending upon patients\' physiological status.
3. Fats: 1- 47% of calories.
4. Carbohydrates: Carbohydrate content varies, as it affects the osmolality of the solution.
The ingredients may be:
1. Blenderized: Milk, chicken, egg, oil, sugar, vegetables, fruit, flour or any other natural food.
2. Polymeric: Milk casein, oil, lactose, sucrose.
3. Elemental: Amino acids, glucose, sucrose, oil.
Technique of formula administration is given here:
All tube feedings begin with limited quantities of the formula containing 0.5 kcal/ml to avoid diarrhoea. The first feeding is 30 ml/hr of formula, and gradually the quantity is increased to 40 ml/hr, 50 ml/hr or 60 ml/hr. Flush tube every 4 hours with 30 ml of water. The strength of feed should be 1 kcal/ml. While feeding, the head and thorax of the patient should be elevated at an angle of at least 30° for at least 30 minutes after the feeding. Continuous feeding by infusion method is more beneficial.
Other methods of formula administration:
1. Fluoroscopic placement of nasojejunal tube.
2. Nutromat system - continuous administration (battery or power operated).
3. Mobile infusion system for continuous jejunostomy feeding.
The tube feed can be modified according to the status of the patient, such as a diabetic, renal or hepatic tube feeds.
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GENERAL HEALTH
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