Question

Enteral Nutrition

1. Rhonda is a 67yo retiree recently involved in an MVA. She’s comatose in the neuro ICU and her medical team is concerned about cerebral edema. As a result, they’ve placed her on a severe fluid restriction. Rhonda’s prognosis is sketchy; she’s been in a coma for 2d already, her O2 sats are dipping and your team has decided to intubate and place her on mechanical ventilation. The good news is that she does have bowel sounds and the dietetic intern has been asked to provide tube feed recommendations. At this point, Rhonda’s ICU doc is confident that her condition will require tube feeding for at least 8 weeks. Your intern is formulating a plan, but she needs some of your expertise.  Below are the questions she’s posing to you (6pts each):

a. Since Rhonda may come out of her coma in a couple of days, I was thinking we’d use an NG tube for her feedings. Sound good? If not, what would you do?

b. The medical team has requested a continuous (24h) tube feed. We have a lot of formulas to choose from, but I don’t see one specific for comatose patients. Do you have any suggestions based on Rhonda’s condition and treatment plan?

c. 8 weeks later: Rhonda’s been out of her coma for and off of mechanical ventilation for a week now. Her condition is stable, her fluid restriction has been lifted, and the medical team would like her to start eating a PO diet, at least a little bit. The original tube feed order (from part b) is still in place and Rhonda’s stated that she doesn’t have any appetite. Do you have any suggestions forchanges we can make to Rhonda’s tube feed order to help increase her appetite and encourage PO intake?

d. Another 2 weeks later: Rhonda’s completely off of her tube feed,but her appetite is still somewhat low and her PO intake isn’t meeting her estimated energy and protein needs. She did a great job on the tube feed, so how about we just give her some of the same enteral formula to drink in-between meals? That will help get some extra calories and protein into her system, right?  If not, what might you suggest?

Answer 1

a. Since Rhonda may come out of her coma in a couple of days, I was thinking we’d use an NG tube for her feedings. Sound good? If not, what would you do?

Since Nutrition is important at this stage ,i too suggest the use of NG tube feeding will be apt for the short term nourishment.Since doctor has cleared the presence of bowel sounds ,which given us clear indication as there is no paralytic illeus and safe to go with feeding. NG tube is safe for the feeding during her comatose condition to prevent aspiration.Moreover it helps in calculating the required calorie and fluid volume.

b. The medical team has requested a continuous (24h) tube feed. We have a lot of formulas to choose from, but I don’t see one specific for comatose patients. Do you have any suggestions based on Rhonda’s condition and treatment plan?

As Rhonda is having severe fluid restriction and no cormormidities mentioned ,i suggest a standard feed with high calorie,high protien diet with low volume .egs(Ensure or Ensure plus).As weight is not mentioned an average target of 1500 to 1700 kcal will be sufficent for the given age group(67 years).For instance an ensure feed of 45ml per hour will give around 1620 kcal.(45ml*24hours*1.5cal).

c.Do you have any suggestions forchanges we can make to Rhonda’s tube feed order to help increase her appetite and encourage PO intake?

Rhonda has recovered and poor appetite for oral intake might be due to the calorie we are meeting with tube feed ensure .Tube feed makes her the feeling of fullness or loss of appetite to take oraly.Plan is to reduce the feed volume to 30 ml per hour and encourage with oral feeding for 1st day.Therafter feeding can be holded one hour before the meal time so that the stomach will be free to accomodate the food for the second day.Thereafter continue the tube feeding in night only and encourage oral feeding in day time.it will normalize Rhondas appetite and eating pattern.

d. how about we just give her some of the same enteral formula to drink in-between meals? That will help get some extra calories and protein into her system, right?  If not, what might you suggest?

Rhonda can be given some intermittent oral nutritional supplement (ONS) with flavours to meet the missing calorie from the per oral intake due to poor appetite.Oral nutrional supplement with excess calorie and protiens can be choosed .Egs-Ensure plus (ONS) with flavour.ONS should be timed as a snack between the meal times and at bedtime before sleep.