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Fluid and Electrolyte Disturbances Associated with Tube Feedings

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Fluid and Electrolyte Disturbances Associated with Tube Feedings 81644_CH12_179_190_QXP6.qxd 9/14/10 11:42 AM Page 179 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chapter 12 Fluid and Electrolyte Disturbances Associated with Tube Feedings© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Clinicians generally agree with the philosophy that “When FORMULA OSMOLALITY NOT FOR SALEthe gut works,OR DISTRIBUTION use it.” That is, if gastrointestinal function isNOT FOR SALE OR DISTRIBUTION present, enteral feedings should be favored over parenteral Osmolality is an important characteristic of an enteral for- nutrition. Aside from being less expensive, enteral feedings mula; it is primarily a function of the number and size of are associated with better preservation of both immune molecular and ionic particles in a given volume. Table 12-1 function and intestinal function. Nevertheless, tube feed- shows the wide variance in osmolalities of some com- ings are not without ©problems. Jones Primarily, & Bartlett these Learning,problems merciallyLLC available tube feeding© formulas. Jones Whereas& Bartlett some Learning, LLC arise because many tube-fedNOT FORpatients SALE have preexisting OR DISTRIBUTION fluid formulas approximate the osmolalityNOT FOR of plasma SALE (300 OR DISTRIBUTION and electrolyte imbalances associated with their underlying mOsm/kg) and, therefore, are deemed isotonic, others illnesses. A multitude of enteral products are available; have considerably higher osmolalities and are referred to as some are “disease specific” and others are “standard” (suit- “hypertonic.” Isotonic formulas are generally well toler- able for most patients). It is important to review some of ated; in contrast, hypertonic formulas can slow gastric em- the© characteristics Jones & Bartlettof enteral formulasLearning, to understand LLC their ptying and cause© Jones nausea, &vomiting, Bartlett and Learning,distention. When LLC potentialNOT impactFOR onSALE fluid and OR electrolyte DISTRIBUTION balance. hypertonic formulasNOT FOR are administered SALE OR in theDISTRIBUTION small bowel, © Jones & BartlettTable 12-1 Learning,Characteristics LLC of Selected Enteral Formulas © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORContent SALE (mg) ORper 8 OuncesDISTRIBUTION of Formula Formula Cal/mL Osmolality Na K Ca P Mg Glucerna 1.0 1.0 355 220 370 170 170 67 Glucerna 1.5 1.5 875 330 600 240 240 95 Jevity 1.0 ©1.0 Jones & Bartlett300 Learning,220 LLC375 215 © Jones180 & Bartlett72 Learning, LLC Osmolite 1.0 NOT1.0 FOR SALE300 OR DISTRIBUTION220 370 180 NOT180 FOR SALE72 OR DISTRIBUTION Osmolite 1.5 1.5 525 330 425 240 240 95 Pulmocare 1.5 475 310 465 250 250 100 Two-Cal HN 2.0 725 345 580 250 250 100 Vital© HNJones & Bartlett2.0 Learning,500 LLC 170 420 © Jones200 & Bartlett200 Learning,80 LLC Notes:NOT All FORof the formulas SALE are made OR by DISTRIBUTION Abbott Laboratories, Abbott Park, Illinois. Formulations mayNOT have changed FOR since SALE this table OR was prepared;DISTRIBUTION refer to the manufacturer’s literature. 179 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 81644_CH12_179_190_QXP6.qxd 9/14/10 11:42 AM Page 180 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE180 OR CHAPTER DISTRIBUTION12 FLUID AND ELECTROLYTE DISTURBANCESNOTASSOCIATED FOR SALE WITH T UBEORFEEDINGS DISTRIBUTION they create an osmotic gradient that pulls water into the dence to the contrary, a standard formula is the product of intestine. If the fluid is not adequately absorbed, cramping choice for the majority of tube-fed patients.2 and diarrhea may result.© Jones For this & reason,Bartlett hypertonic Learning, for- LLC © Jones & Bartlett Learning, LLC mulas are introducedNOT slowly FOR until SALE the body OR has DISTRIBUTION time to Calorie-Dense Formulas NOT FOR SALE OR DISTRIBUTION adapt to them. A calorie-dense formula usually contains 2.0 kilocalories A formula’s osmolality affects the renal solute load and per milliliter of fluid and is used in patients who require thus the water requirements. Renal solute load can be fluid restriction—for example, patients with congestive defined as the sum of substances that must be excreted by heart failure, syndrome of inappropriate antidiuretic hor- the© kidneysJones (such & Bartlett as urea, potassium,Learning, sodium, LLC and chlo- mone (SIADH),© Jones or renal & failure. Bartlett For instance, Learning, for a patient LLC ride).NOT A FORhigh renal SALE solute OR load DISTRIBUTION (created by nutrient use) requiring 1800NOT kcal/day, FOR the SALE amount OR of waterDISTRIBUTION delivered in requires a large water volume for excretion. If enough water the formula could be reduced by 900 mL merely by convert- is not provided, the patient will become dehydrated. There- ing from a 1.0 calorie per milliliter formula to a 2.0 calories fore, the renal solute load imposed by a formula should be per milliliter formula.3 considered in patients with impaired renal function and in © Jones & Bartlettthose with Learning, increased losses LLC of body fluids (such as from© JonesFiber-Containing & Bartlett FormulasLearning, LLC NOT FOR SALEfever or OR diarrhea). DISTRIBUTION NOT Fiber-containingFOR SALE ORformulas DISTRIBUTION may be helpful in patients with A number of liquid medications administered via feeding diarrhea or constipation. The fiber added to the formula tubes are hyperosmolar and can cause osmotic diarrhea if increases stool bulk and helps to regulate bowel transit given undiluted, especially into the small intestine. Among time.4 Recall that the colon is the final site of water and elec- these products are acetaminophen, potassium chloride, and trolyte absorption and ultimately determines fecal composi- phosphosoda. For example,© Jones the osmolality & Bartlett of an Learning,acetamino- LLCtion. In patients who can tolerate© Jones high-residue & Bartlett formulas, Learning, LLC phen solution can rangeNOT between FOR 3000 SALE and 6000OR mOsm/kg.DISTRIBUTIONuse of a high-fiber formula NOTis thought FOR to SALE increase OR the DISTRIBUTION The delivery of hyperosmolar preparations should be lim- sodium and water absorptive ability of the colon, thereby ited to the stomach; even then, the medications should be minimizing fecal fluid loss. For example, in a study of a diluted before administration and water flushes given group of 20 critically ill patients randomized to either a sol- through the tube before and after delivery. This action not uble fiber formula or a fiber-free formula, the number of only© Jones dilutes the & medication,Bartlett Learning,but also enhances LLC its absorp- liquid stools© was Jones significantly & Bartlett lower in Learning,the fiber group. LLC5 It tion.NOT Of FORcourse, SALEit is important OR DISTRIBUTIONto keep any fluid restrictions has been recommendedNOT FOR that SALE this type OR of formulaDISTRIBUTION be consid- in mind. At times, the parenteral route may be necessary for ered in patients for whom tube feedings will be the sole electrolyte supplements when they are not tolerated by the source of nutrition for a long period of time, especially if GI tract. intestinal disease is present.6 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TYPES OF FORMULAS NOT FOR SALE OR DISTRIBUTION NOT ElementalFOR SALE Formulas OR DISTRIBUTION Commercial sources supply standardized as well as special- An elemental formula contains hydrolyzed protein and sim- ized products targeted to patients with specific problems, ple sugars; further, it has a low fat content.7 This type of for- such as renal, hepatic, and respiratory failure. Because mula is administered to patients with severe malabsorption, numerous enteral formula products are available, it is such as may be seen with intestinal atrophy or loss of absorp- important to read the© literatureJones supplied& Bartlett by manufacturers. Learning, LLCtive surface associated with profound© Jones malnutrition, & Bartlett critical Learning, LLC Enteral formulas areNOT classified FOR as standard, SALE elemental, OR DISTRIBUTION or spe- illness, and acquired immune deficiencyNOT FOR syndrome SALE (AIDS). OR DISTRIBUTION cialized, with multiple formulas available in each category.1 Research reports focusing on the efficacy of elemental diets provide mixed findings. For example, several studies have indicated that peptide-based formulas are helpful in Standard Formulas avoiding diarrhea in hypoalbuminemic, critically ill A© standard Jones formula & Bartlett contains Learning,intact protein andLLC is similar to patients.8,9 ©In Jonescontrast, a& larger Bartlett prospective Learning, study did LLC not anNOT average FOR diet SALEfor healthy OR individuals; DISTRIBUTION it can be adminis- demonstrateNOT any advantage FOR SALE in a peptide-based OR DISTRIBUTION formula over tered to patients with normal digestion. These formulas are a standard, polymeric formula.10 Further, a meta-analysis of available with and without added fiber. Unless there is evi- 10 trials involving a total of 334 patients found no significant © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR
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