Total parenteral nutrition (TPN) is provided through infusion in a vein. Intravenous (IV) solutions are more expensive than formulas used for enteral nutrition (EN). Enteral nutrition is administered through the mouth, a gastric tube, or a tube placed directly in the small bowel; so, it requires a functioning gut, which most, but not all, patients have.

Juan Ochoa, MD, medical and scientific director, Nestlé HealthCare Nutrition, offered a little background information on the issue of TPN versus EN: "TPN was first successfully implemented in 1968 and was initially endorsed as being equivalent over that of EN. There is no doubt that TPN has saved countless numbers of patients; however, like any treatment, further research tempered this wave of enthusiasm as clinicians realized that TPN is not devoid of significant complications. It is now clear that TPN is not a substitute for EN and should be used only when it is not possible to maintain the patient’s proper nutrition through the enteral route. The great majority of patients do have a functional gastrointestinal tract to be used as the preferred route of delivering nutrition."

Ochoa briefly outlined some important advantages of EN over TPN: "EN is significantly less expensive and, when adequately used, is associated with significant benefits when compared to TPN. These include decreased infection rates, improved glucose management, and easier-to-manage electrolyte replacement. In addition, the preferential use of EN may be associated with decreased mortality. Widespread consensus thus has been achieved at establishing EN as the ‘golden’ route for nutrition intervention and is recommended as the route of choice by the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN)."

A recent study¹ reiterates Ochoa’s position, outlining some distinct health advantages of EN over TPN: "Compared to PN, EN reduces the risk of major, potentially life-threatening infections ... , the risk of major, potentially life-threatening non-infection events ... , and suggests a reduction in mortality ...". Economic advantages were noted as well: "EN also reduces inpatient length of stay, time in the ICU, and length of nutritional treatment. Compared to PN, EN savings from reduced adverse event risks average nearly $1,500 per patient; savings from reduced hospital length of stay amount to nearly $2,500 per patient. Shifting 10% of parenterally treated adult patients in the U.S. to EN would save $35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays." The study concluded that "The evidence of both clinical and economic gains from EN is consistent with ASPEN guidelines recommending use of EN in critically ill hospital patients when possible."

Despite recommendations by SCCM and ASPEN, proper prescribing of EN or TPN remains a challenge, noted Ochoa: "Interestingly, educating physicians to order TPN appropriately remains a significant challenge. In a recent study, for example, misuse of TPN remained a significant problem, with inappropriate prescription by physicians being a highly relevant issue. This behavior is similar to that observed with other medications, such as the inappropriate use of antibiotics for viral upper respiratory tract infections."

NeoMed’s oral/enteral dispensers and sterile syringes

As is often the case, more research is in order. "The mechanisms as to why EN is a better option than TPN are currently being studied," explained Ochoa. "It appears clear that the provision of nutrients directly into the gastrointestinal tract is essential for its overall health and normal function. In addition, the types and amounts of nutrients that are delivered through TPN are limited, and concerns as to the appropriateness of some of the delivery of some of these nutrients during illness has been raised."

Nutritional products vary according to the needs of the patient. One patient segment whose needs have become the subject of closer scrutiny as of late is the obese patient. The growing obesity epidemic coupled with the growing popularity of bariatric surgery led Nestlé HealthCare Nutrition to launch a product designed specifically for the critically ill obese patient. The release of PEPTAMEN BARIATRIC Formula was announced at ASPEN’s Clinical Nutrition Week meeting, early in the year, where a panel of experts had gathered to discuss the issue of obesity in the critical-care setting and the unmet nutritional needs of this particular patient population. At that time, Ochoa released this statement: "More than one in four ICU patients are now obese. As obesity rates increase across the country and around the world, it is vital to provide clinicians with the information and tools they need to serve this patient population with the best care possible."

It was brought out during this meeting that nutritional needs of the obese patient are unique and resources are not necessarily adequate or even available. Some of the formulas do not contain adequate protein or micronutrients. Consensus was that new formulas, protocols, and training should be developed to address the nutritional needs of the critically ill obese patient so that they are neither underfed nor overfed.

PEPTAMEN BARIATRIC tube-feeding formula helps meet the protein requirements for the critically ill obese patient, identified in the 2009 Critical Care Nutrition Guidelines.² A recent press release provided detailed information on the formula: "PEPTAMEN is the only family of peptide formulas with over 50 clinical studies and more than 23 years of clinical experience. For tube feeding of the critically ill obese patient, PEPTAMEN BARIATRIC formula provides 37 percent of calories from 100 percent whey protein, enzymatically hydrolyzed to produce peptides. The lipid blend in PEPTAMEN BARIATRIC contains 50 percent medium-chain triglycerides (MCT) to support improved formula tolerance and successful enteral feeding."

Medline Industries Inc., also offers nutritional products. Their Active product line includes liquid protein in 1-oz/30-mL servings, which can be administered orally, via tube feeds, or mixed with hot or cold beverages. Active high-efficiency liquid proteins and protein powders come in Citrus Berry Punch and Orange Crème flavors. The products are available in sugar-free versions.

"Active Liquid Protein provides the necessary protein and amino acids that are necessary to fill the nutritional gaps of the patient," explained Madhulika Chikkerur, product manager for Medline’s OTC drugs and nutritional supplements. "It also has a very high-protein–
digestibility corrected amino-acid score (PDCAAS). The PDCAAS method for accounting for protein digestibility is the preferred method recommended by the Food and Drug Administration (FDA) and the World Health Organization."

Medline’s Active line of products combines great taste and nutritional value.

"Medline’s Active liquid proteins make it easier for the healthcare provider to administer the recommended amount, per the patient’s charted dietary needs, fewer times a day," continued Chikkerur. "This could greatly enhance the chances of the patient’s compliance to receive their protein supplementation. Active liquid protein is made with dual sources of protein: collagen and whey. When compared to casein, whey appears to offer more benefits to the immune system, is digested and absorbed faster, and is a higher quality protein."

Misconnection of infusion products can be a serious adverse event. It’s caused by human error, and unfortunately it can happen too easily. NeoMed Inc.’s mission is to eliminate misconnection errors caused by using IV product to deliver EN to the patient. Tony Lair, president, stated: "NeoMed is an enteral-products company whose core vision is to improve patient safety by eliminating dangerous misconnection errors caused when IV products are used to deliver EN. Our Enteral Safety System is not compatible with IV or Luer devices. Our design improves patient safety and protects institutions by eliminating wrong-route administration of enteral feeds. Our Enteral Safety System complies with recommendations set forth by the FDA, Joint Commission, and ASPEN.^3,4

Lair went on to explain why caregivers can be confident that using NeoMed products can prevent catastrophe: "A majority of our competitors use adapted Luer syringes. Adapted syringes are both expensive and noncompliant with the FDA, Joint Commission, and ASPEN recommendations.^3,4 NeoMed manufactures a one-piece, molded-barrel design with a true oral tip. Our Enteral Safety System is orange color-coded, non-IV compatible, and does not rely on adaptors."

NeoMed collaborated with B. Braun and Medfusion (a Smiths Medical brand) to decrease the incidence of misconnections by caregivers’ inadvertently using IV products to deliver EN. "In the neonatal intensive care unit or pediatric intensive care unit, the caregiver can confidently use our pump-compatible oral/enteral syringes, recognized by Medfusion 3500 V5 series pumps and B. Braun Space Perfusor pumps. Through the use of smart-pump technology, NeoMed’s Oral/Enteral Syringes are identified as enteral devices, preventing the caregiver from delivering feeds using an IV profile. Our cooperation with leading pump manufacturers sets a new standard for enteral safety. NeoMed is the market-leading enteral-device manufacturer and has successfully partnered with B. Braun and Medfusion to offer seamless pump delivery from our full line of syringe sizes. I strongly believe that this coordinated effort between different device manufacturers–B. Braun, Medfusion, and NeoMed–is a great example of how industry can work together to bring positive change to the market."

"This level of safety further protects the patient from dosing errors. Mitigation of misconnection errors is ultimately achieved through design incompatibility, which prevents our enteral devices from connecting to IV Luer devices."

Lair noted that NeoMed’s approach to patient safety extends to their SafeBaby Breast Milk Tracking technology. "This system uses 2-D barcode technology to track NeoMed bottles and syringes to ensure safe delivery of the right feed to the right patient at the right time. Hospitals too often rely on manual verification. SafeBaby knows whether the breast milk is fresh, frozen, or thawed and tracks location, fortification, and volume delivered to the patient. This data is crucial to integration with common electronic medical record systems."

Patients with certain conditions have particular concerns with food. They may have difficulty chewing, swallowing, keeping food down, or digesting food. AliMed Inc. specializes in food solutions for those cases.

Alan Bingham, senior product manager, AliMed Inc. went into detail: "A particular issue facing many postsurgery patients can be swallowing and keeping the food down. We address this specifically for dysphagia patients and those who have had severe facial and brain injury, as well as postsurgery bariatric patients, with specially pureed foods. These are pureed to a high standard that includes making even meat smooth, to address the intolerance many patients have to digesting meat. One of the issues that always presents is the intolerance bariatric-surgery patients may have to keeping meats down. They tend to be stringy and, given the limits of being able to ingest following surgery, this is important, as the meats are protein-rich and these patients need protein. These products are easier to ingest, overcome the meat-intolerance issue, and are simpler to prepare."

AliMed’s pureed foods could not be simpler to use, noted Bingham: "Open the can and use hot or cold. Opening the can is far simpler than having to sterilize equipment, puree the food, and then clean up after. All directions are included. With the bariatric pureed food packs, we include a portion control tray that enables both measurement of volume and refrigeration of food after the can is opened. Portion control enables accurate supplementation by dieticians where necessary. AliMed’s pureed foods are available in 7- or 21-day packs, "with a variety ranging from meats and vegetables through comfort foods such as French toast," said Bingham.

In addition to convenience, ease of use, and being time-efficient, AliMed’s pureed foods are economical, noted Bingham. "Domestic puree techniques and equipment require additional water to be added, and this brings a lack of clear nutritional value by volume. For people recovering from surgery, the cost of buying pre-pureed food is less than the cost of buying the equipment, and it yields superior food intake results. The product is more consistent and stable than home-pureed foods."

References

1. Cangelosi MJ, Auerbach HR, Cohen JT. A clinical and economic evaluation of enteral nutrition. Curr Med Res Opin 2011;27:413-22. Epub 2010 Dec 30.

2. Hogue CW Jr, Stearns JD, Colantuoni E, Robinson KA, Stierer T, Mitter N, et al. The impact of obesity on outcomes after critical illness: a meta-analysis. Intensive Care Med 2009;35:1152-1170. Epub 2009 Feb 3.

3. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr 2009;33:122-167. Epub 2009 Jan 26.