Key concepts

EN is the preferred route if the gut can be used safely in a patient who cannot meet nutritional requirements by oral intake.

EN is associated with fewer infectious complications than PN.

For patients intolerant of gastric feedings or in whom the risk of aspiration is high, feedings delivered with the tip of the tube past the pylorus into the duodenum or, preferably, the jejunum are preferred.

Standard EN formulas are polymeric formulas; these are appropriate for most patients.

When choosing an EN formula, the patient's fluid status should dictate the caloric density selected.

Clinical trial data supporting the use of specialty formulas in niche populations typically are unconvincing in terms of patient outcomes.

The role of enteral immunonutrition in clinical practice remains controversial.

© GI complications are the most common complications of EN limiting the amount of feeding patients receive.

An important practice to help prevent medication-related occlusion is adequate water flushing of the tube before, between, and after each medication is given through the tube.

© Compatibility of medications with an EN formula and, conversely, an EN formula with administered medications is of concern when administering medications through feeding tubes.

Enteral nutrition (EN) is broadly defined as delivery of nutrients via the GI tract. This includes normal oral feeding as well as delivery of nutrients in a liquid form by tube. Sometimes when the term enteral nutrition is used, only tube feedings are included; hence the terms enteral nutrition and tube feedings are often used synonymously. The bulk of this chapter will include information regarding delivery of feedings via tubes. Formulas for EN usually are delivered in the form of commercially prepared liquid preparations, although some products are produced as powders for reconstitution.

It might be expected that EN via tubes would have been used widely before development of parenteral nutrition (PN); however, this was not the case. Modern techniques for enteral access, both placement of the tubes and the materials for making pliable, comfortable tubes, were not developed until the 1960s and 1970s. The National Aeronautics and Space Administration effort in the 1960s led to development of low-residue (monomelic) diets for astronauts. These were adapted for use in sick patients requiring EN. Nonvolitional feedings in patients who cannot meet nutritional requirements by oral intake include EN and PN, which are collectively known as specialized nutrition support (SNS).

Several organizations have issued clinical guidelines on the use of EN. These include the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the

European Society for Clinical Nutrition and Metabolism (ESPEN), and the Canadian team known as Critical Care Nutrition.1-4 A.S.P.E.N. has recently teamed with the Society for Critical Care Medicine (SCCM) to release guidelines for SNS in critically ill patients.5

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