Enteral Nutrition Support Therapy for AdultsManual of Clinical Nutrition Management B- 41 Copyright © 2013 Compass Group, Inc.
been developed. These formulas contain less carbohydrate (34% to 40%), more modified fat (40% to
49%), and 10 to 15 g/L of fiber (15). Outcomes data regarding these formulas are limited in their context
and their applicability to persons with diabetes mellitus (15). A prospective study that compared a
diabetic formula to a standard fiber-containing formula in long-term care patients did not demonstrate
any clinically significant benefit from the diabetic formula, with the exception of improved high-density
lipoprotein cholesterol levels (45). A study of hospitalized diabetes patients concluded that diabetic
formulations had no effect on glycemic control (46). According to The Academy of Nutrition and Dietetics
Evidence Analysis Project for Diabetes, there is insufficient evidence to determine whether the nutrient
composition of enteral formulations has an impact on medical costs, mortality rates, infectious
complications, and length of hospital stay in patients with diabetes (Grade V) (46,47). Diabetic formulas may
be appropriately used in patients with blood glucose levels that are difficult to control with traditional
methods (15). The American Diabetes Association suggests that either a standard (50% carbohydrate) or
a lower carbohydrate content (33% to 40%) formula be used for tube-fed patients (47). It is generally
recommended that diabetic patients receive a standard formula with close monitoring of blood glucose
levels and that insulin be used as needed for glycemic control. The total grams of CHO provided in the
formulation has the greatest impact on blood glucose response. Monitoring the total grams of CHO
remains a key strategy in achieving glycemic control and is more important than the source or type of
CHO. (15,48). Formulas containing immune modulating nutrients: Formulas have been designed with increased
amounts of immune-enhancing nutrients (eg, arginine, glutamine, nucleotides, omega-3 fatty acids or fish
oil) and antioxidant vitamins and minerals. Use of immune-modulating enteral formulas (an enteral
formula that contains pharmacological doses of nutrients intended to impact the immune system) should
be carefully evaluated for ICU patients depending on primary diagnosis (Grade II) (3). For ICU patients with
acute respiratory distress syndrome (ARDS) or acute lung injury, the Registered Dietitian may consider
using immune-modulating formulas with fish oil, borage and antioxidants (Grade II) (3). Use of immune-
modulating enteral formulas is not associated with reductions in infectious complications, length of
hospital stay, cost of medical care, days on mechanical ventilation, or mortality in moderately to less
severely ill ICU patients (Grade II) (3). These formulas may be associated with increased mortality in
severely ill ICU patients, although adequately powered trials evaluating this finding have not been
conducted (3). ASPEN guidelines state that immune-modulating enteral formulations be used only for the
appropriate patient population, which includes patients who undergo major elective gastrointestinal
surgery, patients who have abdominal trauma, patients who have burns on more than 30% of their
bodies, head and neck cancer patients, and critically ill patients on mechanical ventilation who are not
severely septic; immune-modulating enteral formulations should be used with caution in patients who
have severe sepsis (5). Patients in the ICU who do not meet these criteria should receive standard enteral
formulations (5). These guidelines also suggest the provision of at least 50% to 65% of goal energy
requirements from the immune-modulating formulations to receive optimal therapeutic benefits (5).
Water/Fluid Requirements
The National Research Council recommends 1 mL of fluid per 1 kcal of energy expenditure for adults with
average energy expenditure who live under average environmental conditions (50). Medical conditions that
may reduce fluid requirements include heart failure, acute respiratory failure, renal failure, ascites, syndrome
of inappropriate antidiuretic hormone, and malignant hypertension. Fluid requirements may be increased
for pregnant patients; patients with fever, burns, diarrhea, vomiting, or high-output fistulas or ostomies; and
patients receiving ventilatory support (51). Patients with pressure ulcers and patients medically managed on
air-fluidized beds also have additional fluid needs. (Refer to Section IA: Nutrition Management of Fluid Intake
and Hydration.)
There are several methods to determine fluid requirements (50). There is no evidence that compares the
effectiveness of these methods for estimating the fluid needs of adults (Grade V) (51). The methods include (51):
Method 1: Holliday-Segar Methoda^
Body Weight (actual) Water Requirement
≤ 10 kg 100 mL/kg
between 10 kg and 20 kg 1,000 mL + 50 mL/kg for each kg > 10 kg
> 20 kg 1,500 mL + 20 mL/kg for each kg > 20 kgMethod 2: Recommended Daily Allowances Methodb^
1 mL per kilocalorie of energy expenditure