98e

Enteral and Parenteral Nutrition

Therapy
Bruce R. Bistrian, L. John Hoffer, David F. Driscoll

APPROACH TO THE PATIENT:

Requirements for Specialized Nutritional Support
INDICATIONS FOR SPECIALIZED NUTRITIONAL SUPPORT
Approximately one-fifth to one-quarter of patients in acute-care
hospitals suffer from at least moderate protein-energy malnutrition
(PEM), the defining features of which are malnutrition-induced
weight loss and skeletal muscle atrophy. Usually, but not always,
other features further compromise clinical responses; these features
include a subnormal adipose tissue mass, with the accompanying
adverse consequences of weakness, skin thinning, and breakdown;
reduced ventilatory drive; ineffective cough; immunodeficiency;
and impaired thermoregulation. Commonly, PEM is already present at the time of hospital admission and remains unimproved or
worsens during the ensuing hospital stay. Common reasons for
PEM worsening during hospitalization are refusal of food (because
of anorexia, nausea, pain, or delirium), communication barriers, an
unmet need for hand-feeding of patients with physical or sensory
impairment, disordered or ineffective chewing or swallowing, and
prolonged periods of physician-ordered fastingall potentially

BMI (kg/m2)
>30
2529.9
2024.9
>18.5

Skeletal Muscle Mass

Normal
Normal
Normal
Decreased

>18.5
<16
<13
<11

Decreased
Decreased
Decreased
Decreased

Nutritional Status
Obese
Overweight
Normal
PEM despite adequate or
excessive adipose tissue store
Moderate PEM
Severe PEM
Lethal in men
Lethal in women

taking place in a context of caregiver unawareness and inattention.

Most patients who are suffering from in-hospital PEM do not, or
ought not, to require SNS. A large proportion of these patients
can be expected to improve with appropriate management of their
primary disease. Others have a terminal disease whose downward
course will not be altered by SNS. In yet other cases, the PEM is
sufficiently mild that the benefits of SNS are exceeded by its risks.
For patients who fall into this last category, the correct approach is
to intensify and/or modify the patients oral nutrition as directed by
the unit dietitian.
PEM is often classified as minimal, moderate, or severe on the
basis of weight for height (body mass index, BMI) and percentage of
body weight recently lost. As shown in Table 98e-1, the BMI (when
corrected for abnormal extracellular fluid accumulation) is a crude
but useful indicator of PEM severity. Note, however, that obesity
does not preclude moderate or severe PEM, especially in older or
bedridden patients; indeed, obesity can mask the presence of PEM
if the patients muscle mass is not specifically examined.
The decision to implement SNS must be based on the determinations (1) that intensified or modified oral nutrition has failed
or is impossible, impractical, or undesirable; and (2) that SNS will
increase the patients rate and likelihood of recovery, reduce the risk
of infection, improve healing, or otherwise shorten the hospital stay.
In chronic-care situations, the decision to institute SNS is based
on the likelihood that the intervention will extend the duration or
quality of the patients life. An algorithm for determining when to
use SNS is depicted in Fig. 98e-1.
The decision to enhance oral nutrition orthat attempt failing
to resort to SNS is based on the anticipated consequences of nonintervention. The mnemonic in-in-in (for inanition-inflammation-inactivity) can serve as a reminder of the three main factors
that come into play when deciding whether or not it is acceptable
to withhold SNS from a patient with PEM.
Inanition Key issues include whether normal food intake is likely
to be impossible for a prolonged period and whether the patient
can tolerate prolonged starvation. A previously well-nourished
person can tolerate ~7 days of starvation without harm, even in the
presence of a moderate systemic response to inflammation (SRI),
whereas the degree of tolerance to prolonged starvation is much less
in patients whose skeletal muscle mass is already reduced, whether
from PEM, from the muscle atrophy of old age (sarcopenia), or
from muscle atrophy due to neuromuscular disease. Excess body
fat does not exclude the possibility of coexisting muscle atrophy
from any of these causes. In general, unintentional weight loss of
>10% during the previous 6 months or a weight-to-height ratio that
is <90% of standard, when associated with physiologic impairment,
crudely predicts that the patient has moderate PEM. Weight loss
>20% of usual or <80% of standard makes severe PEM more likely.
Inflammation The anorexia that invariably accompanies the SRI
reduces the likelihood that a patients nutritional goals will be
achieved by intensifying or modifying the diet, by providing counseling, or by hand-feeding. Furthermore, the protein-catabolic

Copyright 2015 McGraw-Hill Education. All rights reserved.

98e-1

CHAPTER 98e Enteral and Parenteral Nutrition Therapy

When correctly implemented, specialized nutritional support (SNS)

plays a major and often life-saving role in medicine. SNS is used for
two main purposes: (1) to provide an appropriate nutritional substrate
in order to maintain or replenish the nutritional status of patients
unable to voluntarily ingest or absorb sufficient amounts of food, and
(2) to maintain the nutritional and metabolic status of adequately
nourished patients who are experiencing systemic hypercatabolic
effects of severe inflammation, injury, or infection in the course of
persistent critical illness. Patients with permanent major loss of intestinal length or function often require lifelong SNS. Many patients who
require treatment in chronic-care facilities receive enteral SNS, most
often because their voluntary food intake is deemed insufficient or
because impaired chewing and swallowing create a high risk of aspiration pneumonia.
Enteral SNS is the provision of liquid formula meals through a tube
placed into the gut. Parenteral SNS is the direct infusion of complete
mixtures of crystalline amino acids, dextrose, triglyceride emulsions,
and micronutrients into the bloodstream through a central venous
catheter or (rarely in adults) via a peripheral vein. The enteral route
is almost always preferred because of its relative simplicity and safety,
its low cost, and the benefits of maintaining digestive, absorptive, and
immunologic barrier functions of the gastrointestinal tract. Pliable,
small-bore feeding tubes make placement relatively easy and acceptable to patients. Constant-rate infusion pumps increase the reliability
of nutrient delivery. The chief disadvantage of enteral SNS is that many
days may be required to meet the patients nutrient requirements.
For short-term use, the feeding tube can be placed via the nose into
the stomach, duodenum, or jejunum. For long-term use, these sites
may be accessed through the abdominal wall by endoscopic or surgical
procedures. The chief disadvantage of tube feeding in acute illness is
intolerance due to gastric retention, risk of vomiting, or diarrhea. The
presence of severe coagulopathy is a relative contraindication to the
insertion of a feeding tube. In adults, parenteral nutrition (PN) almost
always requires aseptic insertion of a central venous catheter with a
dedicated port. Many circumstances can delay or slow the progression
of enteral SNS, whereas parenteral SNS can provide a complete substrate mix easily and promptly. This practical advantage is mitigated
by the need to infuse relatively large fluid volumes and the real risk of
inadvertent toxic overfeeding.

Table 98e-1 Body Mass Index (BMI), Muscle Mass, and Protein Energy
Malnutrition (PEM)

98e-2

ALGORITHM FOR IMPLEMENTATION OF SNS

Is disease process likely to cause nutritional impairment?
Yes
Does the patient have PCM or is at risk for PCM?
Yes
Would preventing or treating the malnutrition
with SNS improve the prognosis and quality of life?

PART 6

Yes
What are the fluid, energy, mineral,
and vitamin requirements and can these
be provided enterally?

Nutrition and Weight Loss

Yes

Risks and discomfort of SNS

outweigh potential benefits.
Explain issue to patient or
legal surrogate. Support patient
with general comfort measures
including oral food and liquid
supplements if desired.

No

Does the patient require

total parenteral nutrition?

Can requirements be met

through oral foods and
liquid supplements?
No
Yes

No

Keep under
surveillance
with frequent
calorie counts
and clinical
assessment

No

Yes

Request CVC, PICC

or peripheral catheter
plus enteral nutrition

Request feeding tube

Needed for
several weeks

Needed for
months or years

Nasally
inserted tube

Percutaneously
inserted tube

Request
CVC or PICC

Need for
several
weeks

Need for
months
or years

Subclavian
catheter or
PICC

Tunneled
external catheter
or subcutaneous
infusion port

Figure 98e-1 Decision-making for the implementation of specialized nutritional support (SNS). CVC, central venous catheter; PICC,
peripherally inserted central catheter. (Adapted from the chapter on this topic in Harrisons Principles of Internal Medicine, 16e, by Lyn Howard, MD.)
effects of the SRI accelerate skeletal muscle wasting and substantially block normal protein-sparing adaptation to protein and
energy starvation.
Inactivity A nutritional red flag should be raised over every acutely
ill patient who remains bedridden or inactive for a prolonged
period. Such patients commonly manifest muscle atrophy (due to
nutritional deficiencies and disuse) and anorexia with inadequate
voluntary food intake.
Once it has been determined that a patient has significant
and, in particular, progressivePEM despite meaningful efforts to
reverse it by modifying the diet or the way food is provided, the
next step is to decide whether SNS will have a net positive effect on
the patients clinical outcome. The pathway to the end stage of most
severe chronic diseases leads through PEM. In most patients with
end-stage untreatable cancer or certain end-organ diseases, SNS will
neither reverse PEM nor improve the quality of life. Provision of
food and water is commonly regarded as an aspect of basic humane
care; in contrast, enteral and parenteral SNS is a therapeutic intervention that can cause discomfort and pose risks. As with other

life-support interventions, the discontinuation of enteral or parenteral SNS can be psychologically difficult for patients, their families,
and their caregivers. Indeed, the difficulty can be greater with SNS
than with other life-support interventions because the provision of
food and water is often considered equivalent to comfort care. In
such difficult, near end-of-life situations, it is prudent to explicitly
state the treatment goals at the outset of a course of SNS therapy.
Such clarity can smooth the way for subsequent appropriate discontinuation in those patients whose prognosis has become hopeless.
After the decision has been made that SNS is indeed appropriate, the next determinations are the route of delivery (enteral versus
parenteral), timing, and calculation of the patients nutritional
goals. Although enteral SNS is the default option, the choice of
optimal route depends on the degree of gut function as well as on
available technical resources.
Both the choice of route and the timing of SNS require an evaluation of the patients current nutritional status, the presence and
extent of the SRI, and the anticipated clinical course. Severe SRI is
identified on the basis of the standard clinical signs of leukocytosis,
tachycardia, tachypnea, and temperature elevation or depression.

Copyright 2015 McGraw-Hill Education. All rights reserved.

RISKS AND BENEFITS OF SPECIALIZED NUTRITIONAL SUPPORT

The risks of enteral SNS are determined primarily by the patients
state of alertness and swallowing competence, the anatomy and function of the gastrointestinal tract, and the experience of the supervising clinical team. The safest and least costly approach is to avoid
SNS by close attention to oral food intake; personal encouragement;
dietary modifications; hand-feeding, when possible; and, often, the
addition of an oral liquid supplement. For this reason, all patients
at nutritional risk should be assessed and followed by a nutritionist.
There is increasing interest in the use, under selected circumstances
and when not contraindicated, of pharmacologic doses of anabolic
steroids to stimulate appetite and promote muscle anabolism.
Nasogastric tube insertion is a bedside procedure, but many
critically ill patients have impaired gastric emptying and a high
risk of aspiration pneumonia. This risk can be reduced by placing
the tip of the feeding tube in the jejunum beyond the ligament of
Treitz, a procedure that usually requires fluoroscopic or endoscopic
guidance. When a laparotomy is planned for a patient who has
other surgical conditions likely to necessitate prolonged SNS, it is
advantageous to place a jejunal feeding tube at the time of surgery.
A major disadvantage of enteral SNS is that the amounts of protein and calories provided to critically ill patients commonly fail to
reach target goals within the first 714 days after SNS is initiated.
This problem is compounded by the lack of enteral products that
allow the provision of the recommended protein target of 1.52.0
g/kg without simultaneously inducing potentially harmful caloric
overfeeding.
Enteral SNS is often required in patients with anorexia, impaired
swallowing, or small-intestinal disease. The bowel and its associated
digestive organs derive 70% of their required nutrients directly from
nutritional substrates absorbed from the intestinal lumen. Enteral
feeding also supports gut function by stimulating splanchnic blood
flow, neuronal activity, IgA antibody release, and secretion of gastrointestinal hormones that stimulate gut trophic activity. These
factors support the gut as an immunologic barrier against enteric
pathogens. For these reasons, current evidence indicates that some
luminal nutrition should be provided, even when PN is required to

provide most of the nutritional support. The nonessential amino

acids arginine and glutamine, short-chain fatty acids, long-chain
omega 3 fatty acids, and nucleotides are available in some specialty
enteral formulas and appear to have an important role in maintaining immune function. The addition of supplemental PN to enteral
feeding (either by mouth or as SNS by enteral tube) may hasten the
transition to full enteral feeding, which is usually successful when
>50% of requirements can be met enterally. As long as protein and
other essential nutrient requirements are met, substantial nutritional benefit can be achieved by providing ~50% of energy needs
for periods of up to 10 days. As a rule of thumb, dietary protein
provision should be increased by ~2550% when energy intake is
reduced by this amount, since negative energy balance reduces the
efficiency of dietary protein retention. For longer periods and in
patients who have a normal or increased body fat content, it may be
preferable to provide only 7580% of energy needs (together with
increased protein), as the mild energy deficit improves gastrointestinal tolerance, makes glycemic control far easier, and avoids excess
fluid administration.
The main risks of PN are related to the placement of a central
venous catheter, with its complications of thrombosis and infection, and the relatively large intravenous volumes infused. Less
often appreciated are the risks associated with the ease of inadvertently infusing excessive carbohydrate and lipid directly into the
bloodstream. These risks include hyperglycemia, inadequate lipid
clearance from the circulation, hepatic steatosis and inflammation,
and even respiratory failure in patients with borderline pulmonary
function. On the other hand, renal dysfunction does not reduce a
patients requirement for protein or amino acids. In cases in which
renal function is a limiting factor, appropriate renal replacement
therapy must be provided along with SNS.
In the past, bowel rest through PN was the cornerstone of treatment for many severe gastrointestinal disorders. However, the value
of providing even minimal amounts of enteral nutrition (EN) is now
widely accepted. Protocols to facilitate more widespread use of EN
include initiation within 24 h of ICU admission; aggressive use of
the head-upright position; use of postpyloric and nasojejunal feeding tubes; use of prokinetic agents; more rapid increases in feeding
rates; tolerance of higher gastric residuals; and adherence to nursedirected algorithms for feeding progression. Parenteral SNS alone is
generally necessary only for severe gut dysfunction due to prolonged
ileus, intestinal obstruction, or severe hemorrhagic pancreatitis.
In critically ill patients, parenteral SNS can be commenced
within the first 24 h of care, with the anticipation of a better clinical
outcome and a lower mortality risk than those following delayed or
inadequate enteral SNS; however, this point remains controversial.
Some evidence suggests that early SNS is associated with a reduced
risk of death but also with an increased risk of serious infection.
More recent data, obtained in studies of moderately critically ill
patients, suggest that early hypocaloric parenteral SNS lessens morbidity and mitigates muscle atrophy without an increased risk of
infection, but also without a detectable reduction in mortality risk.
Unfortunately, the current clinical-trial evidence fails to address
several important unknowns. It is important to note that the level
of protein substrate provided in published clinical trials generally falls well below the current recommendation, even in trials
of supplemental parenteral SNS. Much of the increase in morbidity associated with parenteral and enteral SNS can be ascribed to
hyperglycemia, which can be prevented by appropriately intensive
insulin therapy. The level of glycemia necessary to prevent complications, whether <110 mg/dL or <150 mg/dL, remains unclear.
Adequately fed surgical patients may benefit from the lower glucose
range, but studies of intensive insulin therapy alone, without full
feeding, suggest improved morbidity and mortality outcomes with
looser control of glucose at <180 mg/dL.
In the early years of its use, PN was relatively expensive, but
its components now are often less costly than specialty enteral
formulas. Percutaneous placement of a central venous catheter

Copyright 2015 McGraw-Hill Education. All rights reserved.

98e-3

CHAPTER 98e Enteral and Parenteral Nutrition Therapy

Serum albumin is a negative acute-phase protein and hence a

marker of the SRI. More severe hypoalbuminemia is a crude indicator of greater SRI severity, but this condition is almost certainly
worsened by concurrent dietary protein deficiency. Despite the
importance of adequate protein provision to patients with the SRI,
no amount of SNS will raise serum albumin levels into the normal
range as long as the SRI persists.
The SRI can be graded as mild, moderate, or severe. Examples
of a severe SRI include (1) sepsis or other major inflammatory diseases (e.g., pancreatitis) that require care in the intensive care unit;
(2) multiple trauma with an Injury Severity Score >2025 or an
Acute Physiology and Chronic Health Evaluation II (APACHE
II) score >25; (3) closed head injury with a Glasgow Coma Scale
<8; and (4) major third-degree burns of >40% of the body surface
area. A moderate SRI occurs with less severe infections, injuries,
or inflammatory conditions like pneumonia, uncomplicated major
surgery, acute hepatic or renal injury, and exacerbations of ulcerative colitis or regional enteritis requiring hospitalization.
Patients with a severe SRI require the initiation of SNS within
the first several days of care, for they are highly unlikely to consume
an adequate amount of food voluntarily over the next 7 days. On
the other hand, a moderate SRI, as is common during the period
following major uncomplicated surgery without oral intake, may
be tolerated for 57 days as long as the patient is initially well
nourished. Patients awaiting elective major surgery benefit from
preoperative nutritional repletion for 510 days but only in the
presence of significant PEM. When adequate preoperative nutrition
or SNS is impractical, early postoperative SNS is usually indicated.
Furthermore, patients with a combination of a moderate SRI and
moderate PEM are likely to benefit from early postoperative SNS.

98e-4

PART 6

into the subclavian vein or (less desirably) the internal jugular

vein with advancement into the superior vena cava can be accomplished at the bedside by trained personnel using sterile techniques.
Peripherally inserted central catheters (PICCs) can also be used,
although they are usually more appropriate for non-ICU patients.
Subclavian or internal jugular catheters carry the risks of pneumothorax or serious vascular damage but are generally well tolerated
and, rather than requiring reinsertion, can be exchanged over a wire
when catheter infection is suspected.
Although most SNS is delivered in hospitals, some patients
require it on a long-term basis. At-home SNS requires a safe home
environment, a stable clinical condition, and the patients ability
and willingness to learn appropriate self-care techniques. Other
important considerations in determining the appropriateness of athome parenteral or enteral SNS are that the patients prognosis indicates survival for longer than several months and that the therapy
enhances the patients quality of life.

Nutrition and Weight Loss

DISEASE-SPECIFIC NUTRITIONAL SUPPORT

The purpose of SNS is to correct and prevent malnutrition. Certain
conditions require special modification of the SNS regimen. Protein
intake may need to be limited in many stable patients with renal
insufficiency or borderline liver function. In renal disease, except
for brief periods, protein intakes should approach the required
level for normal adults of at least 0.8 g/kg and should aim for
1.2 g/kg as long as severe azotemia does not occur. Patients with
severe renal failure who require SNS need concurrent renal replacement therapy. In hepatic failure, protein intakes of 1.21.4 g/kg (up to
1.5 g/kg) should be provided as long as encephalopathy due to protein intolerance does not occur. In the presence of protein intolerance, formulas containing 3350% branched-chain amino acids are
available and can be provided at the 1.2- to 1.4-g/kg level. Cardiac
patients and many other severely stressed patients often benefit
from fluid and sodium restriction to 1000 mL of PN formula and
520 meq of sodium per day. In patients with severe chronic PEM
characterized by severe weight loss, it is important to initiate PN
gradually because of the profound antinatriuresis, antidiuresis, and
intracellular accumulation of potassium, magnesium, and phosphorus that develop as a consequence of the resulting high insulin
levels. This modification of parenteral SNS is usually accomplished
by limiting daily fluid intake initially to ~1000 mL; limiting carbohydrate intake to 1020% dextrose; limiting sodium intake; and
providing ample potassium, magnesium, and phosphorus, with
careful daily assessment of fluid and electrolyte status. Protein need
not be restricted.

THE DESIGN OF INDIVIDUAL REGIMENS

FLUID REQUIREMENTS
Normal adults require ~30 mL of fluid/kg of body weight from all
sources each day as well as the replacement of abnormal losses such
as those caused by diuretic therapy, nasogastric tube drainage, wound
output, high rates of perspiration (which can be several liters per
day during periods of extreme heat), and diarrhea/ostomy losses.
Electrolyte and mineral losses can be estimated or measured and need
to be replaced (Table 98e-2). Fluid restriction may be necessary in
patients with fluid overload. Total fluid input can usually be limited
to 1200 mL/d as long as urine is the only significant source of fluid
output. In severe fluid overload, a 1-L central vein PN solution of 7%
crystalline amino acids (70 g) and 21% dextrose (210 g) can temporarily provide an acceptable amount of glucose and protein substrate in
the absence of significant catabolic stress.
Patients who require PN or EN in the acute-care setting generally
have associated hormonal adaptations to their underlying disease (e.g.,
increased secretion of antidiuretic hormone, aldosterone, insulin,
glucagon, or cortisol), and these signals promote fluid retention and
hyperglycemia. In critical illness, body weight is invariably increased
due to fluid resuscitation and fluid retention. Lean-tissue accretion
is minimal in the acute phase of critical illness, no matter how much

Table 98e-2 Approximate Volume and Composition of Fluid

Secretionsa
Secretion
Saliva
Gastric juice
Hepatic bile
Pancreas
Small intestine
Diarrhea

Volume
(L/d)
12
12
0.51
0.51
13
Varies

Na
15
5090
130150
130150
120140
3050

K
30
530
510
510
1020
2030

Cl
15
90130
80120
70100
80120

HCO3
30
0
3050
90110
2040
Varies

pH
68
1.53.5
79
89
79

Concentration values are in mmol/L.

protein and or how many calories are provided. Because excess fluid
removal can be difficult, limiting fluid intake to allow for balanced
intake and output is more effective.
ENERGY REQUIREMENTS
Total energy expenditure comprises resting energy expenditure, activity energy expenditure, and the thermal effect of feeding (Chap. 97).
Resting energy expenditure accounts for two-thirds of total energy
expenditure, activity energy expenditure for one-fourth to one-third,
and the thermal effect of feeding for ~10%. For normally nourished,
healthy individuals, the total energy expenditure is ~3035 kcal/kg.
Critical illness increases resting energy expenditure, but this increase
is significant only in initially well-nourished individuals with a robust
SRI who experience, for example, severe multiple trauma, extensive
burns, sepsis, sustained high fever, or closed head injury. In these
situations, total energy expenditure can reach 4045 kcal/kg. The
chronically starved patient with adapted PEM has a reduced energy
expenditure and is inactive, with a usual total energy expenditure of
~2025 kcal/kg. Very few patients with adapted PEM require as much
as 30 kcal/kg for energy balance. Because providing ~50% of measured
energy expenditure as SNS is at least as effective as 100% for the first 10
days of critical illness, actual measurement of energy expenditure generally is not necessary in the early period of SNS. However, in patients
who remain critically ill beyond several weeks, in patients with severe
PEM for whom estimates of energy expenditure are unreliable, and
in patients who are difficult to wean from ventilators, it is reasonable
to measure energy expenditure directly when the technique is available, targeting an energy intake of 100120% of the measured energy
expenditure.
Insulin resistance due to the SRI is associated with increased
gluconeogenesis and reduced peripheral glucose utilization, with
resulting hyperglycemia. Hyperglycemia is aggravated by excessive
exogenous carbohydrate administration from SNS. In critically ill
patients receiving SNS, normalization of blood glucose levels by insulin infusion reduces morbidity and mortality risk. In mildly or moderately malnourished patients, it is reasonable to provide metabolic
support in order to improve protein synthesis and maintain metabolic
homeostasis. Hypocaloric nutrition, with provision of ~1000 kcal and
70 g protein per day for up to 10 days, requires less fluid and reduces
the likelihood of poor glycemic control, although a higher protein
intake would be optimal. During the second week of SNS, energy
and protein provision can be advanced to 2025 kcal/kg and 1.5 g/kg
per day, respectively, as metabolic conditions permit. As mentioned
above, patients with multiple trauma, closed head injury, and severe
burns often have greatly elevated energy expenditures, but there is
little evidence that providing >30 kcal/kg daily confers further benefit,
and such high caloric intake may well be harmful as it substantially
increases the risk of hyperglycemia.
As a rule, amino acids and glucose are provided in an increasing
dose until energy provision matches estimated resting energy expenditure. At this point, it becomes beneficial to add fat. A surfeit of
glucose merely stimulates de novo lipogenesisan energy-inefficient
process. Polyunsaturated long-chain triglycerides (e.g., in soybean oil)
are the chief ingredient in most parenteral fat emulsions and provide
the majority of the fat in enteral feeding formulas. These vegetable
oilbased emulsions provide essential fatty acids. The fat content of

Copyright 2015 McGraw-Hill Education. All rights reserved.

PROTEIN OR AMINO ACID REQUIREMENTS

The daily protein recommendation for healthy adults is 0.8 g/kg, but
body proteins are replenished faster with 1.5 g/kg in patients with
PEM, and net protein catabolism is reduced in critically ill patients
when 1.52.0 g/kg is provided. In patients who are not critically ill
but who require SNS in the acute-care setting, at least 1 g of protein/
kg is recommended, and larger amounts up to 1.5 g/kg are appropriate when volume, renal, and hepatic tolerances allow. The standard
parenteral and enteral formulas contain protein of high biologic value
and meet the requirements for the eight essential amino acids when
nitrogen needs are met. Parenteral amino acid mixtures and elemental
enteral mixtures consist of hydrated individual amino acids. Because
of their hydrated status, elemental amino acid solutions deliver 17%
less protein substrate than intact proteins. In protein-intolerant conditions such as renal and hepatic failure, modified amino acid formulas
may be considered. In hepatic failure, higher branched-chain, amino
acidenriched formulas appear to improve outcomes. Conditionally
essential amino acids like arginine and glutamine may also have some
benefit in supplemental amounts.
Protein (nitrogen) balance provides a measure of the efficacy of parenteral or enteral SNS. This balance is calculated as protein intake/6.25
(because proteins are, on average, 16% nitrogen) minus the 24-h urine
urea nitrogen plus 4 g of nitrogen (the latter reflecting other nitrogen
losses). In critical illness, a mild negative nitrogen balance of 24 g/d is
often achievable. A similarly mild positive nitrogen balance is observed
in the nonstressed recuperating patient. Each gram of nitrogen lost or
gained represents ~30 g of lean tissue.

Table 98e-3 Usual Daily Electrolyte Additions to Parenteral

Nutrition
Electrolyte
Sodium

Parenteral
Equivalent

Potassium
Chloride
Acetate
Calcium
Magnesium
Phosphorus

10 meq
10 meq
30 mmol

Usual Intake
12 meq/kg + replacement, but
can be as low as 540 meq/d
40100 meq/d + replacement of
unusual losses
As needed for acid-base balance,
but usually 2:1 to 1:1 with acetate
As needed for acid-base balance
1020 meq/d
816 meq/d
2040 mmol

parenteral zinc/d (equivalent to 30 mg of oral elemental zinc) to maintain zinc balance. Excessive urinary potassium losses with amphotericin or magnesium losses with cisplatin or in renal failure necessitate
adjustments in sodium, potassium, magnesium, phosphorus, and acidbase balance. Vitamin and trace element requirements are met by the
daily provision of a complete parenteral vitamin supplement and trace
elements via PN and by the provision of adequate amounts of enteral
feeding formulas that contain these micronutrients.
Iron is a highly reactive catalyst of oxidative reactions and thus
is not included in PN mixtures. The parenteral iron requirement is
normally only ~1 mg/d. Iron deficiency occurs with considerable frequency in acutely ill hospitalized patients, especially those with PEM
and gastrointestinal tract disease, and in patients subjected to frequent
blood withdrawals. Iron deficiency is sometimes inadequately considered in hospitalized patients because there are commoner causes: the
inflammation-mediated anemia of chronic disease (with an associated
increase in serum ferritin, an acute-phase protein) and redistribution
of the intravascular fluid volume during prolonged bed rest. Iron deficiency should be considered in every patient receiving SNS. A falling
mean red cell volume, even if still in the low-normal range, together
with an intermediate serum ferritin concentration is suggestive of iron
deficiency. Intravenous iron infusions follow standard guidelines,
always with a termination order and never as a standing order because
of the risk of inadvertent iron overdosing. Major iron replacement
during critical illness is of some concern because of the possibility that
a substantial rise in the serum iron concentration may increase susceptibility to some bacterial infections.
Table 98e-4 Parenteral Multivitamin Requirements for Adults
Vitamin
Vitamin A
Thiamin (B1)
Riboflavin (B2)
Niacin (B3)
Folic acid
Pantothenic acid
Pyridoxine (B6)
Cyanocobalamin (B12)
Biotin
Ascorbic acid (C)
Vitamin D
Vitamin E
Vitamin Kb

Revised Values
3300 IU
6 mg
3.6 mg
40 mg
600 g
15 mg
6 mg
5 g
60 g
200 mg
200 IUa
10 IU
150 g

MINERAL AND VITAMIN REQUIREMENTS

Parenteral electrolyte, vitamin, and trace mineral requirements
are summarized in Tables 98e-3, 98e-4, and 98e-5, respectively.
Electrolyte modifications are necessary with substantial gastrointestinal losses from nasogastric drainage or intestinal losses from fistulas, aThe current vitamin D requirementa minimum of 600 IU/daycannot be met with
diarrhea, or ostomy outputs. Such losses also imply extra calcium, available injectable vitamin formulations. Calcitriol is not equivalent to vitamin D and is
a suitable replacement for it, since it is not a substrate for 25-hydroxyvitamin D biomagnesium, and zinc losses. Zinc losses are high in secretory diar- not
synthesis. bA product is available without vitamin K. Vitamin K supplementation is recomrhea. Secretory diarrhea contains ~12 mg of zinc/L, and patients with mended at 24 mg/week in patients not receiving oral anticoagulation therapy when the
intestinal fistulas or chronic diarrhea require an average of ~12 mg of vitamin Kfree product is used.
Copyright 2015 McGraw-Hill Education. All rights reserved.

98e-5

CHAPTER 98e Enteral and Parenteral Nutrition Therapy

enteral feeding formulas ranges from 3% to 50% of energy. Parenteral

fat is provided in separate containers as 20% and 30% emulsions
that can be infused separately or mixed in the sterile pharmacy as an
all-in-one or total nutrient admixture of amino acids, glucose, lipid,
electrolytes, vitamins, and minerals. Although parenteral fat needs to
make up only ~3% of the energy requirement in order to meet essential
fatty acid requirements, when provided daily as an all-in-one mixture
of carbohydrate, fat, and protein, the complete admixture has a fat
content of 23 g/dL and provides 2030% of the total energy requirementan acceptable level that offers the advantage of ensuring emulsion stability. When given as a separate infusion, parenteral fat should
not be provided at rates exceeding 0.11 g/kg of body mass or 100 g over
12 hequivalent to 500 mL of 20% parenteral fat.
Medium-chain triglycerides containing saturated fatty acids with
chain lengths of 6, 8, 10, or 12 carbons (>95% of which are C8 and C10)
are included in a number of enteral feeding formulas because they are
absorbed preferentially. Fish oil contains polyunsaturated fatty acids of
the omega 3 family, which improve immune function and reduce the
inflammatory response. At this time, fish oil injectable emulsions are
available in the United States as an investigational new drug.
PN formulations provide carbohydrate as hydrous glucose (3.4
kcal/g). In enteral formulas, glucose is the carbohydrate source for socalled monomeric diets. These diets provide protein as amino acids and
fat in minimal amounts (3%) to meet essential fatty acid requirements.
Monomeric formulas are designed to optimize absorption in the seriously compromised gut. These formulas, like immune-enhancing diets,
are expensive. In polymeric diets, the carbohydrate source is usually
an osmotically less active polysaccharide, the protein is usually soy or
casein protein, and fat is present at concentrations of 2550%. Such
formulas are usually well tolerated by patients with normal intestinal
length, and some are acceptable for oral consumption.

98e-6

Table 98e-5 Parenteral Trace Metal Supplementation for Adultsa

Trace Mineral
Zincb
Copper
Manganese
Chromium
Selenium

PART 6

Molybdenum
Iodine

Table 98e-6 Monitoring the Patient Receiving Parenteral Nutritiona

Clinical Data
General sense of well-being
Strength, as evidenced by getting out of bed, walking, and resistance exercise as appropriate
Vital signs, including temperature, blood pressure, pulse, and respiratory rate
Fluid balance: weight (recorded at least several times weekly); fluid intake
(parenteral and enteral) vs. fluid output (urine, stool, gastric drainage, wound,
ostomy)
Parenteral nutrition delivery equipment: tubing, pump, filter, catheter,
dressing
Nutrient solution composition
Laboratory Data
Finger-stick glucose
Three times daily until stable
Blood glucose, Na, K, Cl, HCO3, BUN
Daily until stable and fully advanced;
then twice weekly
Serum creatinine, albumin, PO4, Ca,
Baseline; then twice weekly
Mg, Hb/Hct, WBC count
INR
Baseline; then weekly
Micronutrient tests
As indicated

Intake
2.54 mg/d; an additional 1015 mg/d per L of stool or
ileostomy output
0.51.5 mg/d; possibility of retention in biliary tract
obstruction
0.10.3 mg/d; possibility of retention in biliary tract
obstruction
1015 g/d
20100 g/d; necessary for long-term PN, optional for
short term
20120 g/d; necessary for long-term PN, optional for
short term
75150 g/d; necessary for long-term PN, optional for
short term

Commercial products are available with the first four, the first five, and all seven of these
metals in recommended amounts. bThe basal IV zinc requirement is approximately onethird of the oral requirement, because only approximately one-third of orally ingested zinc
is absorbed.
a

Nutrition and Weight Loss

Abbreviation: PN, parenteral nutrition.

Parameters are assessed daily unless otherwise specified.

PARENTERAL NUTRITION
INFUSION TECHNIQUE AND PATIENT MONITORING
Parenteral feeding through a peripheral vein is limited by osmolarity
and volume constraints. Solutions with an osmolarity >900 mOsm/L
(e.g., those which contain >3% amino acids and 5% glucose [290
kcal/L]) are poorly tolerated peripherally. Parenteral lipid emulsions
(20%) can be given to increase the calories delivered. The total volume
required for a marginal amino acid provision rate of 60 g (equivalent to
50 g of protein) and a total of 1680 kcal is 2.5 L. Moreover, the risk of
significant morbidity and mortality from incompatibilities of calcium
and phosphate salts is greatest in these low-osmolarity, low-glucose
regimens. For short-term infusions, calcium may be temporarily
limited or even omitted from the mixture. Parenteral feeding via a
peripheral vein is generally intended as a supplement to oral feeding;
it is not suitable for the critically ill. Peripheral PN may be enhanced by
small amounts of heparin (1000 U/L) and co-infusion with parenteral
fat to reduce osmolarity, but volume constraints still limit the value of
this therapy, especially in critical illness.
PICCs may be used to infuse solutions of 2025% dextrose and
47% amino acids, thus avoiding the traumatic complications of percutaneous central vein catheter placement. With PICC lines, however,
flow can be position-related, and the lines cannot be exchanged over
a wire for infection monitoring. It is important to withdraw blood
samples carefully and appropriately from a dual-port PICC because
intermixing of the blood sample with even tiny volumes of nutrient
infusate will falsely indicate hyperglycemia and hyperkalemia. For all
these reasons, centrally placed catheters are preferred in critical illness.
The subclavian approach is best tolerated by the patient and is the
easiest to dress. The jugular approach is less likely to cause a pneumothorax. Femoral vein catheterization is strongly discouraged because of
the risk of catheter infection. For long-term feeding at home, tunneled
catheters and implanted ports are used to reduce infection risk and are
more acceptable to patients. Tunneled catheters require placement in
the operating room.
Catheters are made of Silastic, polyurethane, or polyvinyl chloride.
Silastic catheters are less thrombogenic and are best for tunneled catheters. Polyurethane is best for temporary catheters. To avoid infection,
dressing changes with dry gauze should be performed at regular intervals by nurses skilled in catheter care. Chlorhexidine solution is more
effective than alcohol or iodine compounds. Appropriate monitoring
for patients receiving PN is summarized in Table 98e-6.
STANDARD VERSUS INDIVIDUALIZED NUTRIENT PROVISION
Even though premixed solutions of crystalline amino acids and dextrose are in common use, the future of evidence-based PN lies in computer-controlled sterile compounders that rapidly and inexpensively

Abbreviations: BUN, blood urea nitrogen; Hb, hemoglobin; Hct, hematocrit; INR, international normalized ratio; WBC, white blood cell.
Source: Adapted from the chapter on this topic in Harrisons Principles of Internal Medicine,
16e, by Lyn Howard, MD.

generate personalized solutions that meet the specific protein and

calorie goals for different patients in different clinical situations. For
example, 1 L of a standard mixture of 5% amino acids/25% dextrose
solution provides 50 g of amino acids (41.5 g of protein substrate) and
1000 kcal; the use of this solution to meet the 1.5to 2.0-g/kg protein
requirement of an acutely ill 70-kg patient requires the infusion of
2.53.4 L of fluid and a potentially excessively high energy dose of
2500-3300 kcal. When the body fat store is adequate, clinical evidence
increasingly supports the greater safety and efficacy of high-protein,
moderately hypocaloric SNS in such patients. A sterile compounder
can accurately generate an appropriate recipe for such a patient. For
example, 1 L of a solution including 600 mL of 15% amino acids, 300
mL of 50% dextrose, and 100 mL of electrolyte/micronutrient mix contains 75 g of protein substrate and 800 kcal; thus it is feasible to meet
the patients protein requirement with only 1.41.9 L of solution and a
more appropriate 11001520 kcal; any mild gap in energy provision is
easily filled by use of intravenous lipid.
COMPLICATIONS
Mechanical The insertion of a central venous catheter should be performed by trained and experienced personnel using aseptic techniques
to limit the major common complications of pneumothorax and inadvertent arterial puncture or injury. The catheters position should be
radiographically confirmed to be in the superior vena cava distal to the
junction with the jugular or subclavian vein and not directly against
the vessel wall. Thrombosis related to the catheter may occur at the
site of entry into the vein and extend to encase the catheter. Catheter
infection predisposes to thrombosis, as does the SRI. The addition
of 6000 U of heparin to the daily parenteral formula for hospitalized
patients with temporary catheters reduces the risk of fibrin sheath
formation and catheter infection. Temporary catheters that develop
a thrombus should be removed and, according to clinical findings,
treated with anticoagulants. Thrombolytic therapy can be considered for patients with permanent catheters, depending on the ease of
replacement and the presence of alternative, reasonably acceptable
venous access sites. Low-dose warfarin therapy (1 mg/d) reduces the
risk of thrombosis in permanent catheters used for at-home parenteral
SNS, but full anticoagulation may be required for patients who have
recurrent thrombosis related to permanent catheters. A recent U.S.
Food and Drug Administration mandate to reformulate parenteral
multivitamins to include vitamin K at a dose of 150 g/d may affect

Copyright 2015 McGraw-Hill Education. All rights reserved.

the efficacy of low-dose warfarin therapy. A no vitamin K version

is available for patients receiving this therapy. Catheters can become
occluded due to mechanical factors; by fibrin at the tip; or by fat, minerals, or drugs intraluminally. These occlusions can be managed with
low-dose alteplase for fibrin, with indwelling 70% alcohol for fat, with
0.1 N hydrochloric acid for mineral precipitates, and with either 0.1 N
hydrochloric acid or 0.1 N sodium hydroxide for drugs, depending on
the pH of the drug.

Table 98e-7 Selected Metabolic Disturbances Caused by PN and Their

Correction
Disturbance
Hyponatremia
Hypernatremia

Hypokalemia

Cause
Increased total body water or
decreased total body sodium
Occurs commonly with
excessive isotonic or hypertonic fluid followed by
diuretic administration with
free water clearance; can also
occur with dehydration and
normal total body sodium
Inadequate intake relative
to need
Excessive diuresis, tubular
dysfunction
Magnesium deficiency
Metabolic alkalosis
Hyperinsulinemia

Hyperkalemia

Excessive provision
Metabolic acidosis

Renal deterioration

Hypocalcemia

Hypercalcemia

Hypomagnesemia

Hypophosphatemia

Hyperphosphatemia
Azotemia

Reciprocal response to
phosphorus repletion
Critical illness effect
Severe malabsorption
Excessive administration or
pathology (cancer, hyperparathyroidism)
Increased requirements due
to diuretic use, alcoholism,
malabsorption, malnutrition
Critical illness

Corrective Action
with PN
Decrease free water
or increase sodium.
Increase free water to
produce net positive
fluid balance, maintaining sodium and
chloride balance.

Use supplements.
Use supplements.
Increase PN magnesium.
Correct alkalosis.
Maintain constant PN;
increase potassium.
Reduce supplements.
Evaluate acidosis.
Treat with PN acetate
salt, and decrease
potassium.
Evaluate patient and
adjust PN as indicated.
Increase calcium.
Increase calcium.
Supplement calcium.
Reduce or eliminate
calcium.
Supplement
magnesium.

Supplement
magnesium.
Inadequate intake relative to Supplement
needs related to malnutrition, phosphorus.
alcohol use
Increased calcium intake
Use supplements.
Excessive administration or
Reduce phosphorus.
worsening renal function
Excessive amino acid infusion Reduce amino acid
or worsening renal function
level if feasible, but
use renal replacement therapy if 1 g
of protein/kg cannot
be provided for prolonged periods.

Abbreviation: PN, parenteral nutrition.

Infectious Infections of the central access catheter rarely occur in the

first 72 h. Fever during this period is usually attributable to infection
elsewhere or another cause. Fever that develops during parenteral SNS
can be addressed by checking the catheter site and, if the site looks
clean, exchanging the catheter over a wire, with cultures taken through
the catheter and at the catheter tip. If these cultures are negative, as
they usually are, the new catheter can continue to be used. If a culture
is positive for a relatively nonpathogenic bacterium like Staphylococcus
epidermidis, a second exchange over a wire with repeat cultures or
replacement of the catheter can be considered in light of the clinical
circumstances. If cultures are positive for more pathogenic bacteria or
for fungi like Candida albicans, it is generally best to replace the catheter at a new site. Whether antibiotic treatment is required is a clinical
decision, but C. albicans grown from the blood culture in a patient
receiving PN should always be treated with an antifungal drug because
the consequences of failure to treat can be dire.
Catheter infections can be minimized by dedicating the feeding
catheter to TPN, without blood sampling or medication administration. Central catheter infections are a serious complication, with an
attributed mortality rate of 1225%. Fewer than three infections per
1000 catheter-days should occur in central venous catheters dedicated
to feeding. At-home TPN catheter infections may be treated through

Copyright 2015 McGraw-Hill Education. All rights reserved.

98e-7

CHAPTER 98e Enteral and Parenteral Nutrition Therapy

Metabolic The most common problems caused by parenteral SNS

are fluid overload and hyperglycemia (Table 98e-7). Hypertonic
dextrose stimulates a much higher insulin level than meal feeding.
Because insulin is a potent antinatriuretic and antidiuretic hormone,

hyperinsulinemia leads to sodium and fluid retention. Consequently,

in the absence of gastrointestinal losses or renal dysfunction, net fluid
retention is likely when total fluid intake exceeds 2000 mL/d. Close
monitoring of body mass as well as of fluid intake and output is necessary to prevent this complication. In the absence of significant renal
impairment, the sodium content of the urine is likely to be <10 meq/L.
Provision of sodium in limited amounts (40 meq/d) and the use of
both glucose and fat in the PN mixture will reduce serum glucose
levels and help reduce fluid retention. The elevated insulin level also
increases the intracellular transport of potassium, magnesium, and
phosphorus, which can precipitate a dangerous re-feeding syndrome
if the total glucose content of the PN solution is advanced too quickly
in severely malnourished patients. To assess glucose tolerance, it is
generally best to start PN with <200 g of glucose/d. Regular insulin
can be added to the PN formula to establish glycemic control, and the
insulin doses can be increased proportionately as the glucose content is
advanced. As a general rule, patients with insulin-dependent diabetes
require about twice their usual at-home insulin dose when receiving
PN at 2025 kcal/kg, largely as a consequence of parenteral glucose
administration and some loss of insulin to the formulas container.
As a rough estimate, the amount of insulin provided can be proportionately similar to the number of calories provided as total parenteral
nutrition (TPN) relative to full feeding, and the insulin can be placed
in the TPN formula. Subcutaneous regular insulin can be provided to
improve glucose control as assessed by measurements of blood glucose
every 6 h. About two-thirds of the total 24-h amount can be added to
the next days order, with SC insulin supplements as needed. Advances
in the TPN glucose concentration should be made when reasonable
glucose control is established, and the insulin dose can be adjusted
proportionately to the calories added as glucose and amino acids.
These are general rules, and they are conservative. Given the adverse
clinical impact of hyperglycemia, it may be necessary to use intensive
insulin therapy as a separate infusion with a standard protocol to initially establish control. Once control is established, this insulin dose
can be added to the PN formula. Acid-base imbalance is also common during parenteral SNS. Amino acid formulas are buffered, but
critically ill patients are prone to metabolic acidosis, often due to renal
tubular impairment. The use of sodium and potassium acetate salts in
the PN formula may address this problem. Bicarbonate salts should
not be used because they are incompatible with TPN formulations.
Nasogastric drainage produces hypochloremic alkalosis that can be
managed by attention to chloride balance. Occasionally, hydrochloric acid may be required for a more rapid response or when diuretic
therapy limits the ability to provide substantial sodium chloride. Up
to 100 meq/L and up to 150 meq of hydrochloric acid per day may be
placed in a fat-free TPN formula.

98e-8

the catheter without its removal, particularly if the offending organism

is S. epidermidis. Clearing of the biofilm and fibrin sheath by local treatment of the catheter with indwelling alteplase may increase the likelihood of eradication. Antibiotic lock therapy with high concentrations
of antibiotic, with or without heparin in addition to systemic therapy,
may improve efficacy. Sepsis with hypotension should precipitate catheter removal in either the temporary or the permanent TPN setting.

Table 98e-9 Enteral Formulas

Composition Characteristics
Standard Enteral Formula
Complete dietary products (+)a
1. Caloric density: 1 kcal/mL
2.Protein: ~14% cals (caseinates, soy,
lactalbumin)
3.Carbohydrate: ~60% cals (hydrolyzed corn starch, maltodextrin,
sucrose)
4.Fat: ~30% cals (corn, soy, safflower
oils)
5.Recommended daily intake of
all minerals and vitamins in
>1500 kcal/d
6. Osmolality: ~300 mosmol/kg
Modified Enteral Formulas
1.Caloric density: 1.52 kcal/mL (+)
2.Protein
a.High protein (~2025%
protein) (+)
b.Hydrolyzed protein to small
peptides (+)
c.
Arginine, glutamine,
nucleotides, 3 fat (+++)
d.
Branched-chain amino acids,
aromatic amino acids (+++)
e.Low protein of high biologic
value
3.Fat
a.Low-fat partial MCT
substitution (+)
b. Fat (>40% cals) (++)

ENTERAL NUTRITION

PART 6
Nutrition and Weight Loss

TUBE PLACEMENT AND PATIENT MONITORING

The types of enteral feeding tubes, methods of insertion, their clinical
uses, and potential complications are outlined in Table 98e-8. The
different types of enteral formulas are listed in Table 98e-9. Patients
receiving EN are at risk for many of the same metabolic complications
as those who receive PN and should be monitored in the same manner.
EN can be a source of similar problems, but not to the same degree,
because the insulin response to EN is about half of that to PN. Enteral
feeding formulas have fixed electrolyte compositions that are generally modest in sodium and somewhat higher in potassium. Acid-base
disturbances can be addressed to a more limited extent with EN.
Table 98e-8 Enteral Feeding Tubes
Type/Insertion
Technique
Nasogastric Tube
External measurement:
nostril, ear, xiphisternum; tube stiffened by
ice water or stylet; position verified by air injection and auscultation or
by x-ray
Nasoduodenal Tube
External measurement:
nostril, ear, anterior
superior iliac spine; tube
stiffened by stylet and
passed through pylorus
under fluoroscopy or
with endoscopic loop
Gastrostomy Tube
Percutaneous placement endoscopically,
radiologically, or surgically; after track is established, can be converted
to a gastric button
Jejunostomy Tube
Percutaneous placement endoscopically or
radiologically via pylorus
or endoscopically or
surgically directly into
the jejunum

Potential
Complications

Clinical Uses
Short-term clinical situation (weeks) or longer
periods with intermittent insertion; bolus
feeding is simpler, but
continuous drip with
pump is better tolerated

Aspiration; ulceration
of nasal and esophageal tissues, leading to
stricture

Short-term clinical
situations where gastric
emptying is impaired
or proximal leak is
suspected; requires continuous drip with pump

Spontaneous pulling
back into stomach
(position verified by
aspirating content, pH
>6); diarrhea common,
fiber-containing formulas may help

Long-term clinical
situations, swallowing
disorders, or impaired
small-bowel absorption
requiring continuous
drip

Long-term clinical
situations where gastric
emptying is impaired;
requires continuous drip
with pump; direct endoscopic placement (PEJ)
is most comfortable for
patient
Combined Gastrojejunostomy Tube
Percutaneous placeUsed for patients with
ment endoscopically,
impaired gastric emptyradiologically, or surgiing and high risk for
cally; intragastric arm
aspiration or patients
for continuous or inter- with acute pancreatitis
mittent gastric suction; or proximal leaks
jejunal arm for enteral
feeding

Aspiration; irritation
around tube exit site;
peritoneal leak; balloon
migration and obstruction of pylorus

c. Fat from MUFA (++)

Fat from 3 and fat from
d.
6 linoleic acid (+++)
4.Fiber: provided as soy
polysaccharide (+)

Clinical Indications
Suitable for most patients requiring
tube feeding; some standard formulas can be used orally

Fluid-restricted patients
Critically ill patients
Impaired absorption
Immune-enhancing diets
Liver failure patients intolerant of
0.8 g of protein/kg
Renal failure patients for brief periods
if critically ill
Fat malabsorption
Pulmonary failure with CO2 retention
on standard formula, limited utility
Improvement in glycemic index
control in diabetes
Improved ventilation in ARDS
Improved laxation

Cost: +, inexpensive; ++, moderately expensive; +++, very expensive.

Note: ARDS, acute respiratory distress syndrome; MCT, medium-chain triglyceride; MUFA,
monounsaturated fatty acids; 3 or 6, polyunsaturated fat with first double bond at
carbon 3 (fish oils) or carbon 6 (vegetable oils).
Source: Adapted from the chapter on this topic in Harrisons Principles of Internal Medicine,
16e, by Lyn Howard, MD.

Clogging or displacement of tube; jejunal

fistula if large-bore tube
is used; diarrhea from
dumping; irritation
of surgical anchoring
suture

Clogging, especially of
small-bore jejunal tube

Abbreviation: PEJ, percutaneous endoscopic jejunostomy.

Note: All small tubes are at risk for clogging, especially if used for crushed medications. In
long-term enteral nutrition patients, gastrostomy and jejunostomy tubes can be
exchanged for a low-profile button once the track is established.
Source: Adapted from the chapter on this topic in Harrisons Principles of Internal Medicine,
16e, by Lyn Howard, MD.

Acetate salts can be added to the formula to treat chronic metabolic

acidosis. Calcium chloride can be added to treat mild chronic metabolic alkalosis. Medications and other additives to enteral feeding
formulas can clog the tubes (e.g., calcium chloride may interact with
casein-based formulas to form insoluble calcium caseinate products)
and may reduce the efficacy of some drugs (e.g., phenytoin). Since
small-bore tubes are easily displaced, tube position should be checked
at intervals by aspirating and measuring the pH of the gut fluid (normal: <4 in the stomach, >6 in the jejunum).
COMPLICATIONS
Aspiration The debilitated patient with poor gastric emptying and
impairment of swallowing and cough is at risk for aspiration; this complication is particularly common among patients who are mechanically ventilated. Tracheal suctioning induces coughing and gastric
regurgitation, and cuffs on endotracheal or tracheostomy tubes seldom
protect against aspiration. Preventive measures include elevating the
head of the bed to 30, using nurse-directed algorithms for formula
advancement, combining enteral with parenteral feeding, and using

Copyright 2015 McGraw-Hill Education. All rights reserved.

postligament of Treitz feeding. Tube feeding should not be discontinued for gastric residuals of <300 mL unless there are other signs
of gastrointestinal intolerance, such as nausea, vomiting, or abdominal distention. Continuous feeding using pumps is better tolerated
intragastrically than bolus feeding and is essential for feeding into
the jejunum. For small-bowel feeding, residuals are not assessed, but
abdominal pain and distention should be monitored.

98e-9

GLOBAL CONSIDERATIONS
In the United States, the only parenteral lipid emulsion available is made with soybean oil, whose constituent fatty acids
have been suggested to be immunosuppressive under certain
circumstances. In Europe and Japan, a number of other lipid emulsions are available, including those containing fish oil only; mixtures of
fish oil, medium-chain triglycerides, and long-chain triglycerides as
olive oil and/or soybean oil; mixtures of medium-chain triglycerides
and long-chain triglycerides as soybean oil; and long-chain triglyceride
mixtures as olive oil and soybean oil, which may be more beneficial in
terms of metabolism and hepatic and immune function. Furthermore,
a glutamine-containing dipeptide for inclusion in TPN formulas is
available in Europe and may be helpful in terms of immune function
and resistance to infection, although a recent study using a largerthan-recommended dose was associated with net harm.
Acknowledgment
The authors acknowledge the contributions of Lyn Howard, MD, the
author in earlier editions of HPIM, to material in this chapter.

Copyright 2015 McGraw-Hill Education. All rights reserved.

CHAPTER 98e Enteral and Parenteral Nutrition Therapy

Diarrhea Enteral feeding often leads to diarrhea, especially if bowel

function is compromised by disease or drugs (most often, broadspectrum antibiotics). Sorbitol used to flavor some medications
can also cause diarrhea. Diarrhea may be controlled by the use of a
continuous drip, with a fiber-containing formula, or by the addition
of an antidiarrheal agent to the formula. However, Clostridium difficile, which is a common cause of diarrhea in patients being tube-fed,
should be ruled out as the etiology before antidiarrheal agents are
used. H2 blockers may help reduce the net volume of fluid presented
to the colon. Diarrhea associated with enteral feeding does not necessarily imply inadequate absorption of nutrients other than water and
electrolytes. Amino acids and glucose are particularly well absorbed in
the upper small bowel except in the most diseased or shortest bowel.
Since luminal nutrients exert trophic effects on the gut mucosa, it is
often appropriate to persist with tube feeding despite diarrhea, even
when this course necessitates supplemental parenteral fluid support.

Apart from conditions with drastically diminished small-intestinal

absorptive function, there are no established indications for short
peptidebased or elemental formulas.