Enteral Formulation 營養室主任. HY. Su 1

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1 Enteral Formulation 台北醫學大學附設醫院 營養室主任 蘇秀悅營養師 HY. Su 1

2 The effective practice of nutrition support Efficiently and effectively determine who needs medical nutrition therapy. Determine the best time to initiate nutrition support. Establish which route of nutrient delivery. To develop an effective plan for nutrition therapy. HY. Su 2

3 Malnutrition Marasmus - a long-term deprivation of nutrients and a wasted, cachectic appearance. Kwashiorkor - a deficit of protein and develop over a shorter period. These individuals develop edema and hypoalbuminemia. Combination of Marasmus/Kwashiorkor - metabolic stress imposed on an individual with preexisting malnutrition. HY. Su 3

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5 Enteral nutrition: indications, options, and formulations HY. Su 5

6 Evaluation of bowel function Successful EN appropriate patient selection is the first step. If the gut works, use it. Whenever an ileus is thought to be present, a physical exam should be performed to determine if enteral feeding is feasible. The absence of bowel sounds does not preclude safe EN. HY. Su 6

7 Contraindications ti to enteral nutrition support Malnourished patient expected to eat within 5-7 days Severe acute pancreatitis High output proximal fistula Intractable vomiting or diarrhea Aggressive therapy not warranted Expected need < 5-7 days if malnourished or < 7-9 days if normally nourished HY. Su 7

8 Routes to deliver nutrition support in adults Nutrition assessment Decision to initiate specialized nutrition support Functional GI tract Yes No (obstruction, peritonitis, intractable vomiting, acute pancreatitis, short-bowel syndrome, ileus) Enteral nutrition Parenteral nutrition Short-term Long-term Nasogastric Gastrostomy, jejunostromy Nasoduodenal GI function Short-term Long-term Nasojejunal or fluid restriction Normal Compromised Peripheral PN Central PN Yes No Intact nutrients Defined formula GI function returns Adequate Progress to oral feedings Inadequate PN supplementation Progress to total Enteral feedings Adequate Progress to more Complex diet and oral feedings as tolerated HY. Su 8

9 Choosing appropriate formulas Categories of enteral formulas Polymeric diets whole protein nitrogen source, for use in patients with normal or near normal gastrointestinal function Monomeric diets predigested nutrients; most have a low fat content or a high percentage of medium chain triglycerides; gy for use in patients with severely impaired gastrointestinal function Fiber containing diets polymeric diets containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients Disease specific diets, modular formula formulas designed for feeding patients with specific disease states. HY. Su 9

10 Formula Selection Impaired digestion/ absorption? No Liver/kidney dysfunction? No yes yes Nondialyzed acute renal failure? No Liver failure with hepatic encephalothy Predigested formula yes yes Renal formula Hepatic formula Fluid restriction or high metabolic requirements No Low residue? No Fiber-containing formula yes yes High kcal/protein formula Standard 1.0 kcal/ml formula HY. Su 10

11 Enteral Formulations HY. Su 11

12 Blenderized formulas Prepared by the institution or caregiver or purchased in cans. The advantage of blenderized formulas contain flavonoids dietary fibers other phytochemicals Disadvantages: labor costs, increased risk of bacterial contamination, and homemade blenderized mixtures are also more likely to occlude feeding tubes. HY. Su 12

13 諾沛 Compleat Modified HY. Su 13

14 Defined formulas Defined formulas are nutritionally complete mixtures of carbohydrate, protein, fat, micronutrients, and water. Standard formulas are made with polymeric macronutrients: intact proteins, large carbohydrate polymers, and triglycerides. More specialized formulas with partially or completely hydrolyzed macronutrients are also available. There are some formulas which include certain amino acids and fatty acids, antioxidants, dietary fibers, and nucleotides. HY. Su 14

15 Standard enteral formulas The least expensive products Meet the needs of most patients HY. Su 15

16 管灌食營養品 一般管灌配方 管灌安素 Osmolite 稍高蛋白質配方 愛美力 Osmolite HN 含纖維質配方 健力體 Jevity HY. Su 16

17 Water and caloric density Enteral formulas can be divided into 3 categories 1 kcal/ml (about 85% water) The 1 kcal/ml formulas are appropriate p for patients with no fluid restrictions. 1.2 to 1.5 kcal/ml (78% to 82% water) The most concentrated t formulas may be necessary for patients with renal failure, pulmonary edema, liver failure, congestive heart failure, or other conditions where fluid intake must be restricted. t 2 kcal/ml (71% water) HY. Su 17

18 雀巢保健營養品 HY. Su 18

19 雙卡 HN 熱量分布圖 碳水化合物 43. 7% 蛋白質 16.8% 酪蛋白鈉 95% 酪蛋白鈣 5% 麥芽糊精 83.3% 蔗糖 12.5% 果寡醣 42% 4.2% 脂肪 39.5% 玉米油 79% MCT oil 19% 卵磷脂 2% 熱量密度 :2.0 20Kcal/mL 滲透壓 : 690 mosm/kg H2O 948 ml 可達 100% DRI 對 Vitamins & Minerals 每日建議攝取量 HY. Su 19

20 水解配方選擇 % of total cals AlitraQ 創快復 Vital HN 偉他 Protein Free amino acids Partially hydrolyzed 47 % 42 % 19.5 % 80.5 % Fat CHO Others Glutamine( 5.6%) Arginine( 1.2%) HY. Su 20

21 佳易得 -- 特殊元素完整均衡營養品 營養密度 : 1 大卡 / 毫升 (1.5, 2 大卡 / 毫升 ) 16% 蛋白質 : 100% 水解乳清蛋白 90% 由 small peptide 組成 33% 脂質 : 70% MCT oil 足量必須脂肪酸 ( 佔熱量 4%) 51% 碳水化合物 : 不含乳糖 添加抗氧化微量元素 : 增加抵抗力 等張滲透壓 : 315 mosm/l 1500 毫升即可滿足 100% US RDA HY. Su 21

22 糖尿病產品比較 NUTREN Diabetes Glucerna SR Glucerna Choice dm Resource Diabetes Protein 15% 20% 16.7% 17% 24% Fat 40% 32.6% 49% 43% 40% MUFA (% T.E.I) 27.2% 24% 35% 27.4% 26.8% CHO 45% 47.4% 34.3% 40% 36% Sucrose (% Fructose: 0 TEI) T.E.I) 23.3% 3% Frutcose: 18.9% 0 Frucose: 10% Dietary fiber (g/1000ml) 滲透壓 HY. Su 22

23 肺部疾病專用營養品 益肺佳 Pulmocare HY. Su 23

24 腎臟疾病專用營養品 HY. Su 24

25 Modular formula( 單素配方 ) HY. Su 25

26 產品英文 熱量密度 Osmolarity Product (kcal/ml) (mosm/kg English H2O) P-%kcal F-%kcal C-%kcal Fiber- Volume g/1000kc to meet al 100% US RDA for VIT/MIN (ml) Osmolite _ 1892 Osmolite _ 1320 HN Jevity Ensure _ 946 CBF CBF with fiber Isocal Isocal HN Ultracal Nutrison HY. Su 26

27 產品英文 Product English Vivonex Plus Vivonex Pediatric Osmolarity (mosm/kg H2O) P-%kcal F-%kcal C-%kcal Peptides: Amino Acid MCT/tota lfat Volume to meet 100% US RDA for VIT/MIN (ml) : : ~ 1170 Nu-pep :0 50 AlitraQ : Vital HN : Amin- Renal AMIN- HEPA Pepti- Junior Pregesti mil HY. Su 27

28 Choosing an appropriate delivery schedule It is not necessary to dilute enteral formulas when osmolality < mosm/kg. HY. Su 28

29 Conclusion Choosing the appropriate enteral formulation for a patient should begin with a complete assessment of the patient's nutritional status and requirements, medical condition, and gastrointestinal function. A comparison of this information with the properties of the various formulas available will help identify the product that most closely meets the patient's nutritional needs. HY. Su 29

30 Thank you for your attentions! HY. Su 30

31 HY. Su 31