Factors to consider when choosing an EN formula Patient Factors Past medical history and present problems Age Calorie and nutrient requirements Hydration status GI function Hepatic function Renal function Pulmonary status 2 Factors to consider when choosing an EN formula Formula factors Composition of carbohydrate, protein, and fat Electrolyte, vitamin, mineral, and trace element content Osmolality
3 Factors to consider when choosing an EN formula Formula factors Residue/fiber content Viscosity Caloric density Cost 4 5 Type of EN Formula Formulas used for enteral feeding have
been classified according to various criteria The general term "medical foods" have been used since 1989 by the Food and Drug Administration (FDA) to define enteral nutrition products 6 Type of EN Formula Essential nutrient profile Complete Incomplete Form of the nutrients Polymeric Solution (PS) (intact) Monomeric or Oligomeric Solutions (elemental, semi elemental) 7
Type of EN Formula Composition Natural foods(standard)(belenderized) Milk-Based Products Non milk-Based Products Hydration Solution Solution For Specific Metabolic Needs Branched Chain AA (BCAA) Solution Essential AA solution High Fat / Low CHO Solution or high protein solution Immune Modulating Solution Modular Solution 8 Where can you get information about enteral products? Novartis Nutrition USA
www.novartisnutrition.com/us/home Laboratories Ross Products Division, Abbott www.ross.com02122911398 Nestle Nutrition www.nestleclinicalnutrition.com B Braun www.bbraun.com02188879766 Fresenius-Kabi www.fresenius-kabi.com 02188792695 Enteral Selection Blenderized
Complete or homemade (CAUTION!) Standard Osmolite, Nutren, Isosource Added fiber Jevity, Impact with Fiber, Nutren with Fiber, Nutren Replete with Fiber, Nutren 1.5 Fiber, Fibersource, Fibersource HN, Enteral Selection Extra calories/volume restricted Osmolite 1.2, TwoCal HN, Novasource 2.0, Nutren 1.5, Nutren 2.0, Peptamen 1.5, Jevity 1.2, Jevity 1.5 High nitrogen Osmolite HN, TwoCal HN, Fibersource HN, Peptamen VHP, Isosource HN
Carbohydrate Source % Fat (g/L) Samples of Nestle formula BENECALORIE Nestle kcal/mL: 7
Caloric Distribution (% of kcal) Protein: 9% Carbohydrate: 0% Fat: 91% Protein Source: calcium caseinate (milk) Calorie and Protein Food Enhancer BENEPROTEIN Nestle A Concentrated Source of High-Quality Protein 100% high-quality whey protein Each serving provides 6 g protein Mixes instantly into a wide variety of foods and beverages without compromising taste or texture Provides protein to help maintain muscle Contains no fillers, sweeteners or artificial flavorings Caloric Distribution (% of kcal) Protein: 100% Carbohydrate0% Fat: 0% BOOST GOLUCOSE
CONTROL Nestle kcal/mL: 1.06 Caloric Distribution (% of kcal) Protein: 22% Carbohydrate: 35% Fat: 43% Protein Source: sodium and calcium caseinates (milk), L-arginine NPC:N Ratio: 89:1 n6:n3 Ratio: 2.4:1 Osmolality (mOsm/kg water): 400 Free Water: 85% Meets 100% RDI for 24 key micronutrients: 1180 Ml Fiber Content (Source): 3.5 g/237 mL (FOS, PHGG*, soy fiber) Supplemental L-Arginine: 1 g/237 mL BOOSTHIGHPROTEIN Nestle Provides 15 g of high quality protein in an 8 fl oz serving Same formulation available in retail stores
kcal/mL: 1.0 Caloric Distribution (% of kcal) Protein: 24% Carbohydrate: 55% Fat: 21% Protein Source: milk protein concentrate, calcium and sodium caseinates NPC:N Ratio: 80:1 n6:n3 Ratio: 4.9:1 Osmolality (mOsm/kg water): 650 Free Water: 85% Meets 100% RDI for 24 key micronutrients: 946 mL BOOST NUTRITIONAL PUDDING Nestle Creamy pudding provides supplement variety kcal/5 oz 240 Caloric Distribution (% of kcal) Protein 11% Carbohydrate 55% Fat 34% Protein Source milk protein concentrate, sodium and
calcium caseinates NPC:N Ratio 200:1 Free Water 62% COMPLEAT Nestle Formulated with real food: chicken, peas, carrots, tomatoes and cranberry juice cocktail Cranberry Juice helps support urinary tract health The fiber blend with BENEFIBER soluble fiber helps promote beneficial bacterial growth and normal bowel function COMPLEATNestle kcal/mL: 1.07 Caloric Distribution (% of kcal) Protein: 18% Carbohydrate: 48% Fat: 34% Protein Source: sodium caseinate (milk), chicken NPC:N Ratio: 114:1
n6:n3 Ratio: 3.0:1 Osmolality (mOsm/kg water): 340 Free Water: 85% Meets 100% RDI for 24 key micronutrients: 1313 mL Fiber Content (Source): 6 g/L (BENEFIBER soluble fiber, vegetables) Samples of NOVARTIS formula 29 30 31 32
33 34 Samples of B Braun formula Nutricomp Standard Balanced nutrition without fiber Caloric density: 1 ml = 1 kcal High protein quality: 60 % milk protein, 40 % soy protein Fat: as a balanced combination of soy oil, MCT and fish oil Fatty acid ratio -3:-6:-9 = 1 : 5.6 : 2.1 Carbohydrates: as maltodextrin with high proportion of polysaccharides Caloric distribution protein : fat : carbohydrates : fiber = 15 : 30 : 55 : 0
Osmolality: 244 mosmol/kg, Osmolarity: 205 mosmol/l Free of gluten, purines, cholesterol, practically free of fiber and lactose Nutricomp Standard fiber Balanced nutrition with fiber Caloric density 1 ml = 1 kcal High protein quality: 60 % milk protein, 40 % soy protein Fat: as a balanced combination of rapeseed oil, soy oil, MCT, fish oil Fatty acid ratio -3:-6:-9 = 1 : 3.3 : 3.5 Carbohydrates: as maltodextrin with high proportion polysaccharides 1.5 % fiber (1.5g/100ml) Caloric distribution protein : fat : carbohydrates : fiber= 15 : 29 : 53 : 3 Osmolality: 313 mosmol/kg, Osmolarity: 261 mosmol/l Free of gluten, purines, cholesterol, practically free of lactose Nutricomp Hepa Balanced nutrition adapted to special
metabolic conditions Advantages Specific amino acid pattern 52% of MCT (easy to digest) Indication If nutritional support is indicated in patients with liver disease and without neurological symptoms Malnutrition due to chronic liver disease Cholestasis and cirrhotic portal hypertension with consecutive fat malabsorption Liver surgery Pathologic diagnostics of liver function and clinical symptoms of impaired liver function Properties Caloric density: 1 ml = 1.3 kcal Caloric distribution: protein : fat : carbohydrates = 12 : 40 : 48 Specific amino acid pattern: branched chain amino acids and milk protein Fat: combination of 52% MCT and 48% soy oil Carbohydrates: maltodextrin with a high percentage of polysaccharides
Free of gluten, cholesterol, practically free of lactose Nutricomp Intensive Balanced nutrition adapted to special metabolic conditions Advantages High amount of protein and fat, low in carbohydrates 51% of MCT (easy to digest) Indication Metabolic conditions that require reduced carbohydrates and high fat and protein (posttraumatic metabolism, diabetes mellitus, respiratory failure) Impaired nutrient uptake Malnutrition Gastroenterological diseases Anorexia, e.g. geriatric patients and psychiatric patients Properties Caloric density: 1 ml = 1.3 kcal High in protein, low in carbohydrates
High protein quality: 60% milk protein, 40% soy protein Carbohydrates: maltodextrin Fat: a balanced combination of 51% MCT and about 47% soy oil Caloric distribution: Protein : fat : carbohydrates : fiber = 20 : 40 : 40 : 0 Osmolality: 378 mosmol/kg, Osmolarity: 334 mosmol/l Free of gluten, purines, cholesterol, practically free of fiber and lactose Nutricomp Immun Balanced nutrition adapted to special metabolic conditions Advantages High amount of protein, low amount of fat Rich in glutamine Fortified with antioxidants Properties Caloric density: 1 ml = 1.3 kcal High in protein, low in fat, with a special amino acid pattern (wheat protein
hydrolysate rich in glutamine, milk protein hydrolysate) Rich in glutamine: 30 g per 2000 kcal (1500 ml) Fatty acid ratio -3:-6:-9 = 1 : 3.3 : 4.5 Carbohydrates: maltodextrin with high percentage of polysaccharides Fortified with antioxidants 1.33 % fiber: 1.3 g/100 ml Caloric distribution Protein : fat : carbohydrates : fiber = 20 : 24 : 54 : 2 Free of purines, cholesterol, gluten and lactose Osmolality: 481 mosmol/kg , Osmolarity: 375 mosmol/l Nutricomp Peptid Balanced nutrition adapted to special metabolic conditions Advantages Protein as defined oligopeptides Low amount of fat 47% of MCT (easy to digest)
Properties Caloric density 1 ml = 1 kcal Protein as defined oligopeptides and free amino acids Fat: combination of about 50 % MCT and about 50 % soy oil Carbohydrates: maltodextrin with high percentage of polysaccharides Caloric distribution: protein : fat : carbohydrates : fiber = 14 : 12 : 74 : 0 Osmolality: 381 mosmol/kg, Osmolarity: 332 mosmol/l Free of gluten, purines, cholesterol, practically free of fiber Samples of Fresinus-kabi formula Fresubin jucy DRINK Recommended daily intake for all vitamins and essential trace elements are covered within 400-600 ml Suitable for supplementary oral nutrition Energy density: 1.5 kcal/ml
Energy distribution: Protein: 11 % Fat: 0 % Carbohydrate: 89 % fiber 0% Water content: 76 ml / 100ml Flavours: Apple, Orange, Pineapple, Cherry, Blackcurrant Intestamin Low volume supplement for early enteral supply of high glutamine, high antioxidants Providing the key substrates for gut protection: 500 ml daily dosage contain: glutamine 30 g antioxidants 1500 mg vitamin C 500 mg vitamin E 10 mg (Regular control of coagulation is recommended) -carotene 20 mg zinc 300 g selenium
Caloric density 0.5 kcal / ml fiber free Osmolarity 490 mosmol/l Flavors: Unflavored Not suitable for children < 10 years Diben DRINK / Crme Nutritionally complete High in MUFA Contains fish oil Energy density: 1.5 kcal/ml Energy distribution: Protein: 20 % Fat: 42 % Carbohydrates: 35 % fiber 3 % Water: 79ml/100ml product (DRINK), 67.5ml/100g product (Crme) Flavors: Vanilla, Cappuccino, Forest Berries
Crme: Cappuccino, Pralin, Wild Strawberry, Vanilla Indication: Insulin resistance Diabetes mellitus Diben Crme is in particular suitable for patients with dysphagia. Fresubin hepa Nutritionally complete tube feed and sip feed, rich in branched chain amino acids (44%). Low in aromatic acids and methionine High in branched chain amino acids Rich in MCT (35% of fat) Energy density: 1,3 kcal/ml Energy distribution: Protein: 12 % Fat: 33 % Carbohydrate: 55 % fiber: 1 g / 100 ml Water (100 ml product): 78 ml
Supportan Enriched in medium chain triglycerides Recommended daily dosage of antioxidants (Vit. A, C, E, -carotene and selenium) With prebiotic fiber EPA content from fish oil: 2 g EPA/400 ml sip feed or 500 ml tube feed Energy density: 1.5 kcal/ml Energy distribution: Protein: 27 % Fat: 40 % Carbohydrates: 33 % Water (100 ml product): 76 ml Flavors tube feed: Unflavored Flavors sip feed: Cappuccino, Tropical Fruits, Pineapple-Coconut Reconvan Nutritionally complete tube feed
Rich in glutamine: 15 g Rich in arginine: 10 g Rich in w-3-fatty acids from fish oil (w-3/w-6-ratio = 1:2) Rich in protein: 22 energy % Rich in MCT: 58 % of fat fiber-free Energy density: 1 kcal/ml Energy distribution: Protein: 22 energy % Fat: 30 energy % Carbohydrates: 48 energy % Osmolarity: 270 mosmol/l Water (100 ml product): 84 ml Flavor tube feed: Unflavored Survimed OPD Fully absorbable, oligopeptide diet for tube-feeding Rich in MCT (54% of fat) Rich in oligopeptides (80% of protein)
EPA and DHA from fish oil w-3/w-6-ratio = 1:3.6 Energy density: 1 kcal/ml Energy distribution: Protein: 18 energy % Fat: 22 energy % Carbohydrate: 60 energy % Water (100 ml product): 84 ml Flavors tube feed: Unflavored Indications Maldigestion and malabsorption After long-term parenteral feeding Chronic inflammatory bowel diseases (acute phase) Short bowel syndrome Pancreatic insufficiency Chemotherapy Radiation-induced enteritis
Fresubin Crme suitable for supplemental or complete nutrition Energy density: 1.8 kcal/g = 225kcal per cup Protein content: 10g / 100g = 12.4g per cup Energy distribution: Protein: 22 % Fat: 36 % Carbohydrate: 42 % Water content: 59ml / 100g fiber content: 2g / 2.3*g (Inulin) per 100g Flavors: Vanilla, Chocolate, Cappuccino, Pralin, Wild Strawberry Packaging: 125g cup for patients with dysphagia Fresubin 5 kcal SHOT Based on fat with medium chain triglycerides Suitable for supplemental oral nutrition Energy density: 5 kcal/ml
Energy distribution: Protein: 0 % Fat: 96.8 % Carbohydrate: 3.2 % fiber 0% Water content: 40 ml / 100ml Flavors: Lemon, Neutral Packaging: 120 ml Bottle Indication: Elderly patients Patients with chronic wasting diseases such as cancer Peri-operative patients Patients with renal or liver disease Calshake Energy dense, powdered nutritional supplement Easy to mix One serving in whole milk (240 ml, 3.5% milk fat) supplies 585 kcal, 11.9 g protein Kcal/cc)
Protein: 3.4 % Fat: 44. 2 % Carbohydrates: 52. 4 % Water: 210 g/ serving Flavors sachets: Chocolate, Vanilla, Strawberry, Banana, Neutral For patients with increased energy needs such as: Cystic fibrosis Cancer HIV/AIDS During the pre- and postoperative period (2.4 Glutamine Plus Oral powder supplement High in glutamine (10 g / sachet) Fat free Energy density: 80* / 78** / 79*** kcal per sachet (22.4g) (Ready to use product: 1 sachet + 200 ml water).
Energy distribution: Protein: 50%* / 52%** / 51%*** Fat: 0% Carbohydrates: 50%* / 48%** / 49%*** flavor Neutral; ** flavor Orange; *** flavor Mango Cancer patients Inflammatory bowel HIV / AIDS Burn patients After surgery Samples of Abbott formulas Ensure Enlive Clear liquid nutrition drink High-quality protein and essential nutrients
Use under medical supervision. Jevity 1 Cal Fiber-fortified tube-feeding formula. Glucerna Glucerna shakes are a delicious choice as a supplement, snack, or meal. Reduced-carbohydrate Modified-fat Fiber-containing formula Nepro Mixed Berry Nepro is a great-tasting nutritional supplement thats specifically designed to give your body what it needs while on dialysis. Optimental Vanilla Therapeutic nutrition for the dietary management of
Crohn's disease and mal absorptive conditions Pulmocare High-calorie Low-carbohydrate formula designed for people with COPD Suplena Low-protein Therapeutic nutrition designed specifically for patients with reduced kidney function Vital jr. Unflavored Peptide-based formula for the nutritional needs of children ages 1-13 years with mal absorption, mal digestion, and other GI conditions when hydrolyzed protein is indicated For oral or tube feeding Not intended for infants under 1 year of age unless specified by a physician
Vital HN Vanilla Partially hydrolyzed Low-residue feeding intended as a source of complete Balanced nutrition for patients with chronically impaired gastrointestinal function PediaSure Chocolate For kids who are growing fine, but could use some extra nutrients to fill nutritional gaps Enteral Nutrition & Nutritional supplement L GLUTAMIN Burned patients Trauma patients There are not sufficient data to support glutamine supplementation in surgical or heterogeneous
critically ill patients L-ARGININE Standard formula contain 1-2 g/L Ar Arg-enriched formula contain 14-15 g/L Ar Both of them increase immune function Ar semi essential, conditionally essential BCAAs:Valine, Leucine, Isoleucin Standard formula contain 20% BCAAs BCAAs enriched formula contain 45% BCAAs benefical for short time : : :
Inulin Meeting Nutrient Needs 1- Calculate kcal, protein, fluid, and nutrient needs according to age, sex, medical status 2- Select appropriate formula based on nutritional needs, feeding route, and GI function LUQ 77 Two main forms of PN Peripheral Parenteral Nutrition (PPN) Central Parenteral Nutrition (CPN)
Available solution sample DEXTROSE-SALINE DEXTROSE 5% IN NA CHLORIDE 0.9% (500cc) Each 1000 cc contains: Dextrose: 50 g Na: CL: 154 meq/ L 154 meq/ L
Osmolality: 560 mosm/ L caloric value: 170 kcal DEXTROSE-SALINE DEXTROSE 3.33% IN NA CHLORIDE 0.3% (500cc) Each 1000 cc contains: Dextrose: Na: CL: 33.3 g 51.3 meq/ L 51.3 meq/ L Osmolality: 603 msm/ L caloric value: 113.22 kcal DEXTROSE
DEXTROSE 5% (I lit) Each 1000 cc contains: dextrose: 50 g osmolality: 252 mosm/ L caloric value: 170 kcal DEXTROSE 10% (500 cc) Each 1000 cc contains: dextrose: 100 g osmolality:
500 mosm/ L caloric value: 340 kcal DEXTROSE DEXTROSE 20% (50cc) Each 1000 cc contains: dextrose: 200 g osmolality: 1110.12mosm/ L caloric value: 680 kcal DEXTROSE 50% (50cc)
Each 1000 cc contains: dextrose: 500 g osmolality: 2775.31mosm/ L caloric value: 1700 kcal AMINO PLASMAL AMINO PLASMAL- 10% Each 1000 cc contains: Total am inoacid: 100
g/L Total nitrogen: 16 g/L Caloric value: 400 kcal/L Osm olality: 1030 mosm/L Electrolites: Na:
l- malate 7.5 mmol/L mmol/L LIPOFUNDIN LIPOFUNDIN MCT/LCT 20% Each 1000 cc contains: soya bean oil: 100
g MCT: 100 g egg lecithin: 12 g glycerol: 25
g - tocopherol 170 40 mg Na oleate caloric value: 1908 kcal/L osmolarity: 380 mosm/L Standard electrolytes solution Na 35
K 28.8 Ca 5 Phos 4.5 Cl 35 Acetate 29.5 meq/L meq/L meq/L mmol/L meq/L meq/L Standard trace elements solution MTE-6 per cc have:
Zn 1 mg Cu 0.4 mg Mn 0.1 mg Cr 4 mcg Se 20 mcg I 25 mcg PN Vitamins Give 1 ampoule MultiVit per bag of TPN
MultiVit does not include vit K Vit K Can give 1 mg/day or 5 - 10 mg/wk most institutes have a standard vitamin/mineral solution but can also order special formulations based on biochemical assessment and special needs Standard vitamins solution MVI-2 include 2 ampoule Ampoule 1 per cc have:
Vit Vit Vit Vit Vit Vit Vit A E B2 B6 C D B1 660 2 0.72
0.8 20 40 0.6 IU IU mg mg mg IU mg Standard vitamins solution Vit B3 Vit B5 8 mg 3 mg
Ampoule 2 per cc have: Vit B9 80 g Vit B12 1 g Vit B8 12 g Prescribed dose MVI-12: 10 CC/L 02/09/20 102
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