- High protein, volume concentrated formula (e.g., IMPACT® or equivalent). A formula with fiber would be contraindicated in patients who are at risk for bowel ischemia or are hemodynamically unstable. 1-3

Use for:

1. Major trauma patients for the first 7 days of nutrition support.
2. Moderately malnourished patients undergoing major elective procedures of the esophagus, stomach, pancreas, hepatobiliary tree or abdominal-perineal resection
3. Severely malnourished patients (pre-albumin < 10gm/dl) undergoing large bowel resection.
4. Prolonged starvation > 6 days.
5. High output distal small bowel fistula (>500 mL output).
6. Burn patients.

- Semi-elemental/elemental enteral formulas (may contain some fiber, moderate protein, and may be supplemented with Omega-3 fatty acids and/or probiotics). Semi-elemental and elemental formulas allow for ease of digestion/absorption. (E.g., Vital®, Vital 1.2 AF®, Vital 1.5®, Peptamen®, Peptamen 1.5®, Peptamen AF® are semi-elemental; Vivonex®, Vital HN®). Use for:

1. Proven intolerance to the first formula used
2. Persistent, severe diarrhea > 48hrs
3. Pancreatic or duodenal injury
4. Moderate distention > 24hrs
5. Short bowel syndrome
6. At discretion of attending physician

- Polymeric, fiber free formula (E.g., Osmolite®1.0, 1.2, 1.5; Nutren® 1.0, 1.5,)—isotonic enteral feed with long-chain proteins, carbohydrates and a normal fat content. Use for:

1. Patients with a moderate protein need, normal digestive and absorptive capacity of the GI tract.

- Polymeric with mixed fiber formula (Jevity 1.0, 1.2, 1.5, Fibersource HN, Nutren 1.0 Fiber, Nutrisource Fiber) added fiber content to promote more formed stool. Use for:

1. Stable, long term patients and those requiring a bowel regimen (e.g., paraplegics)

- Other formulas include:

1. Isosource 1.5—high protein, high calorie, fiber containing formula with 1.5 kcal/ml to limit volume.
2. Nepro— volume concentrated (1.8 kcal/mL), lower in K+, Mg, Phos therapeutic nutrition with mixed fiber for patients on dialysis
3. Promote, Replete: High protein, polymeric formula, 1.0 kcal/mL. Appropriate for use in patients who tolerate a standard formula but require additional protein and do not need a volume concentrated product.

- Additional fiber source: Use if additional fiber is needed for stool management, use the soluble variety (e.g., Nutrisource Fiber ® or equivalent.)
- Additional protein source: Use if additional protein is needed when calorie needs are already being met by the enteral formula (ex: Beneprotein®, ProMod®, ProStat®). Content of protein varies depending on protein source used.