Nutritional Assessment of the critically ill patient and provision of adequate nutritional support are essential parts of critical care. Protein Energy Malnutrition is common not only in childhood but also in hospitalised patients. Very often the only source of nutrition in critically ill patients is 5% glucose drip providing 100Kcal, per bottle of 500ml. The typical situation where ICU patients are likely to face nutritional problems are the post-operative period, burns, cancer, hepatic failure, renal failure, coma.
Enternal Nutrition
Enteral feeding includes both oral feeding as well as tube feeding. When oral feeding is insufficient or not feaseable, or when a current situation causing depletion is likely to be extended for a long period of time or where treatment is likely to prevent adequate oral intake or absorption for a significant time, tube feeding enables one to maintain a good nutritional status. Tube feeding may be insorted as a temporary measure or in some cases even permanently for the remainder of patients life. The tube feeding should have all nutrients in required amount and should be a liquid to enable it to pass through the tube easily by gravity flow.
Supplements can be formulated using fluid or powdered milk, powdered whole egg as concentrated protein sources. Milk is used frequently because it is one of the few liquid sources of a complete protein. Protein content of the diet can be increased at low cost by the addition of casein and lactalbumin. Milk-free or lactose free formulas can be used as nutritional supplements in the presence of lactose intolerance or milk allergy.
Situations requiring Artificial Feeding Techniques
A) Physiologic Problem
• Inability to ingest food
• Inability to digest food
• Decreased ability or inability to absorb food
• Inability to meet nutritional requirements fully with normal food
B) Clinical Situation or Disorder
• Coma
• Dental or oral surgery
• Burns
• Trauma
• Major Surgery
• Radiation Therapy
• Short Bowel Syndrome
• Cancer
• Anorexia nervosa
• Pancreatitis
C) Route of administration
• Tube
• Nasogastric
• Gastrostomy
• Jejunostomy
Types of Feeds
1. Commercial Feeds
• Commercial feeds save time in preparation, are less likely to be contaminated and are of a known composition; however they are not quite as satus fying in meeting the patient’s needs as tube feedings prepared especially for the individual. Some commercial feeds which are available in the market are :-
• Recupex
• Nutrocal and Nutrocal-DM (which is mainly for diabetic patients)
• Ensure
• Resource and Resource-DM (which is mainly for diabetic patients)
• Nestle Buildup
• Nourish
• Nutren
2. PREPARED FEEDS
Feedings may also be made from a mixture of the foods served in the normal diet, or from food or supplement combinations planned to meet specific therapeutic needs. Modular formulas are prepared from the components--- carbohydrates, fat, protein etc. Preparing a formula from modules is useful in patients with hepatic or renal failure or fluid restriction.
Factors to Consider in choosing a feeding formula
• Ability (wholeness) of the patient’s gastrointestinal system.
• The type of protein, fat, carbohydrate and fiber in the formulas as related to the patient’s digestive and absorptive capacity.
• Carbohydrate, Protein and Fat Density
• Efficiency of the formula, taken in the amounts tolerated, to meet the patient’s nutritional requirements.
• Sodium, potassium and phosphorus content of the formula, especially for patients with renal or hepatic dysfunction.
• Consultency of formula as related to feeding equipment.
• Cost of formula.
Indications and advantages :
Enteral tube feeding is the proper choice over parenteral feeding whenever the digestive and absorptive capacities of the gastrointestinal track are still functional. The cost is considerably less (one-sixth) and fewer complications are involved. Enteral feeding usually require less patient monitoring and normal gastrointestinal functions are maintained.
Complications :
A. Aspiration : The patient with poor gastric emptying and having poor swallowring due to cough is at risk for aspiration Because of effective tracheal suctioning patients tend to frequent coughs and provokes gastric regurgitation. The cuff provided on the endotrachel tube also seldom provides adequate protection against aspiration.
B. Diarrhoea : Enteral feeding often causes diarrhoea especially if absorption is poor due to bowel disease or drugs such as antibiotics. Diarrhea stimulated by enteral feeding absorbs more of water and electrolyte than other nutrients. Due to concentrated nutrients, the G.I. tract gets sensitive and results in Diarrhoea.
C. Constipation : Enteral feeding may often causes constipation, which may be because of immobility, inadequate amount of water, lack of fibre and antibiotics given to the patient. Constipation may lead to heavyness which can further lead to vomitting, indigestion of feed and inability to accept feed.
D. Infection : Enteral feeding can also cause infection in a patient, which can be because of unhygienic preparation, water infection, cleanliness of Rylestube, mishandling by the handler.
These complications should be observed and be avoided. These feeds are effective means of sustained healthy feeding if handled properly.