Choosing the Right Enteral Nutrition Formula - Ashley DePriest, MS, RD, LD, CNSC

okay so I'm Ashley dupré some a

nutrition support dietitian at Northside

Atlanta and first I just want to say I'm

never going to look at h2 blockers and

you guys the same again so today I've

been asked to talk about choosing the

right intro formula for a Ric you

critically ill patient and they

mentioned that 7-minute talk and at

first I was like ooh that is going to be

difficult but then I thought a little

more about it and I said no I can just

say start a formula and consult your

dietitian but since I have a few more

minutes to talk I'll go ahead and go

through some of the some of the

different types of formulas today a

small shameless plug I could find me on

Twitter talking to people about the

nutrition and the nutrition in general

so check me out there and so there's

four types of main types of family

there's standard formulas there's

elemental or semi elemental formulas and

main modulating formulas and disease

first you have your standard formula

this is your workhorse type formula and

they may or may not have fiber they are

just a good formula to start for anyone

you can really just start this and any

ten twenty thirty fifties an hour most

patients are going to do okay with this

in the ICU quick just a quick

clarification here I've added some names

of formulas just for you guys to know to

kind of trigger like this is what the

FAK types formula is but this is in no

way an endorsement of any of these

specific formula so again this is your

best type of formula to just go ahead

and get started until you can consult

your dietician to talk a little bit more

about a special life on the next type of

formula is an elemental or semi

elemental formula and we also refer to

this as a hydrolyzed formula and

basically what that means is it's also

we kind of call a predigested formula

most of the most of the components of

that formula is already broken down so

for example your peptides or proteins

are broken those peptide bonds are

broken that might be

we use this typically for patients that

have maybe are experiencing a lot of

diarrhea or also how many sort of

pancreatic insufficiency and the reason

for that is because again the formulas

are already pre digested so you don't

need all of the pancreatic enzymes in

order to absorb the form and there's a

couple of examples of these next we have

immune modulating and I know I'm just

tons of words on this slide and we're

trying to avoid back but essentially

what immune modulating formulas are they

contain a little bit of extra

supplemental nutrients so most of the

time it's going to be arginine glutamine

nucleic acids Omega threes and the best

data and the best indication for this is

in your surgical trauma burn or head and

neck cancer patients we should not be

using this formula routinely though this

is not one you want to start at a triple

rate or trophic grade this is not one

you want to start routinely and then

consult a dietitian first of all is an

extremely expensive formula in most

cases but most of the time in order to

get the benefits of all these extra

added nutrients you need to be feeding

at least 60 to 80 percent of their needs

so again we try not to use this to start

or to to just trope trophy or trickle

feed patients because it's very

expensive and you're not going to see

the added benefits of those nutrients

unless you're getting at least 60 to 80

percent immune modulating formulas can

come in a standard formula or they can

also be elemental or semi elemental so

some examples of that would be pivot

impacted disease specific formulas this

is kind of one of my favorite things to

talk about because it's super easy there

is no indication for the use of disease

specific form

most studies that have looked at using

free no formulas for example have shown

no difference in electrolytes or video

ends or renal function so they really

aren't helpful in our critically ill

patients and what that really means is

that it's not usually the nutrition

that's causing that issue but with that

I will say that sometimes we do get to

that point where we're you know we had

just a super high or something we are

trying to avoid but we still want to get

that protein so it may be helpful but

certainly we're not you know this

patient oh they never you'll figure go

ahead and put them on a renal formula

that's not how that works we're really

just treating symptoms of renal failure

in that case there aren't at it formulas

that contain branched chain amino acids

again the data for those isn't super

great they're extremely expensive

formulas so we try to avoid the use of

routine use of those as well and then

finally we've got a lot of those lung

and respiratory specific formulas out

there and the newer data around those

have suggested that really it wasn't

making the composition of that formula

or the special components of that

formula that helped but it actually was

probably that we were providing patients

with more princey and that actually was

what was improving their outcomes in

that case some other considerations

quickly well go through these when

choosing a formula is is your osmolality

of the formula so the more calories you

have in a formula they typically tend to

be more concentrated and this

can certainly cause diarrhea and we've

seen that before so we know the GI tract

is about around a concentration of 300

and these are just some examples of what

the concentrations are at various

concentrations of formulas so that's

just a good slide to refer to fiber is

also another consideration so of course

we don't recommend the routine use of

fiber in the ICU and that is because

there's a risk for gut ischemia so the

fiber can kind of slow the gut down and

it can sit cause the formula to sit

there and cause a skin but we can't use

a little bit of insoluble are soluble

fiber if we need to but the important

take-home point there is just remember

there are two different types of fiber

don't you routinely use them again talk

to the dietician if you have more

questions about that and then of course

we have some extra modulars that we can

use to help meet people's crazy needs so

to kind of wrap things up the assman FCC

and guidelines again recommend just the

routine use of a standard formula for

all ICU patients specialized formulas

are not indicated most of the time but

if you ever have questions about it and

again consult your your dietitian and

nothing else you'll just make a stove