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Monitoring Complications of Enteral Nutrition Therapy

Session 4

After completing this session, participants will be able to:

• Identify and manage complications associated with enteral nutrition therapy

Objectives

Categories of Complications Associated with Tube Feeding

Potential complicatons

Potential complicatons

Mechanical Mechanical Pulmonary aspiration Pulmonary aspiration

Metabolic Metabolic

Gastrointestinal Gastrointestinal

Nasoenteric feeding tube

Gastrostomy feeding tube

• Use tubes made with biocompatible materials

• Do not use rubber, latex or polyvinyl chloride tubes

• Use appropriate tube size Small-bore for nasoenteric tubes

• ~8-10 French size

Gavi S, et al. Ann Long-Term Care 2008;16:28-32.

Mechanical Complications Prevent Irritation/Infection at Tube Site

• Properly tape the tube to reduce risk of Formula infusion in

esophagus, pharynx, larynx, or nasal cavity

Bronchial aspiration

Pendley F, et al. Enteral Nutrition Support in Critical Care: A Practical Guide for Clinicians. Columbus, Ohio, Abbott Nutrition, Abbott Laboratories, 1994.

Seder CW, et al. Nutr Clin Pract 2008;23:651-654.

Mechanical Complications Prevent Tube Migration

Use slide 11, session 8 TNT 3.0

Mechanical Complications Properly Inflate Balloon

Use slide 12, session 8 TNT 3.0

American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.

Mechanical Complications Properly Position External Skin Disks

• Routine irrigation with clear water or saline

• Do not use fruit juice or carbonated beverages

• Always use a syringe >30 cc during tube care

Feeding tube ruptured from excessive pressure applied by small syringe

Mechanical Complications Maintain Tube Patency

• Elevate the head of the bed 30° to 45° • Provide good oral care • Regularly assess tube feeding

tolerance and tube position • Provide tight glycemic control • Correct electrolyte abnormalities • Minimize narcotic dosage • Use continuous rather than intermittent feeding • Feed beyond the ligament of Treitz

McClave SA, et al. JPEN J Parenter Enteral Nutr 2002;26(6 Suppl):S80-S85.

Pulmonary Aspiration Can Be Lethal Use Aspiration Precautions

• Do not discontinue enteral feeding for GRV <500 mL

• GRV >500 mL: Withhold feeding

• GRV >200 mL on two successive assessments: Withhold feeding

• GRV threshold >250 mL: Use a protocol-driven approach

Pulmonary Aspiration Is Monitoring Gastric Residual Volume (GRV) Helpful?

McClave SA, et al. Crit Care Clin 2010;26:451-466. McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316.

Update of the Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. www.criticalcarenutrition.com/docs/cpg/srrev.pdf.

• GI motor dysfunction • Admission diagnoses (eg, burns, head injury,

sepsis, and multiple trauma) • Age of the patient • GI conditions • Medications Sedatives, analgesics and vasopressor agents

delay gastric emptying Hyperosmolar medications such as sorbitol can cause

osmotic diarrhea

• GI disuse atrophy

Deane A, et al. World J Gastroenterol 2007;13:3909-3917. Magnuson BL, et al. Nutr Clin Pract 2005;20:618-624.

Wohlt PD, et al. Am J Health Syst Pharm 2009;66:1458-1467. Beckwith MC, et al. Hosp Pharm 2004;39:225-237.

Gastrointestinal (GI) Complications Non-formula Etiologies

McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316. Update of the Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically

Ventilated, Critically Ill Adult Patients. www.criticalcarenutrition.com/docs/cpg/srrev.pdf. Kreymann KG, et al. Clin Nutr 2006;25:210-223.

Manage Non-formula Etiologies Gastrointestinal (GI) Complications

Etiology • GI motor dysfunction • Admission diagnoses

(eg, burns, head injury, sepsis, and multiple trauma)

• Aging • GI conditions

Management • Consider prokinetic

agents and postpyloric feeding

• Consider an oligomeric, peptide-based enteral formula

Manage Non-formula Etiologies Gastrointestinal (GI) Complications

Etiology • Medications

Management • Consult with a pharmacist

Manage Non-formula Etiologies Gastrointestinal (GI) Complications

McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316.

Etiology • GI disuse atrophy

Management • Rule out C. difficile

infection, treat diarrhea • Continue to feed

enterally Consider a soluble fiber-

supplemented formula

• Consider supplemental parenteral nutrition

• Malabsorption of formula components

Fat, intact protein, lactose

• Hyperosmolar formulas

• Rapid formula delivery

• Microbiological contamination

Formula-related Etiologies Gastrointestinal (GI) Complications

Deane A, et al. World J Gastroenterol 2007;13:3909-3917.

Manage Formula-related Etiologies Gastrointestinal (GI) Complications

Etiology • Malabsorption of

formula components

Management • Consider formulas

designed to enhance tolerance

• Avoid lactose

American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.

Manage Formula-related Etiologies Gastrointestinal (GI) Complications

Etiology • Hyperosmolar

formulas

• Rapid formula delivery

Management • Use full-strength

formulas Do not dilute formula

• Reduce the formula flow rate initially and advance as tolerated

• Use an enteral feeding pump

American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.

Bankhead R, et al. JPEN J Parenter Enteral Nutr 2009;33:122-167.

Manage Formula-related Etiologies Gastrointestinal (GI) Complications

Etiology • Microbiological

contamination

Management • Safely handle formula

during preparation and administration

• Maintain safe formula hangtime 8 hours for open systems ≤4 hours for reconstituted powder formulas 24–48 hours for prefilled containers

• Avoid excessive handling and formula manipulation

• Do not add substances to formula

Manage Formula-related Etiologies Gastrointestinal (GI) Complications

Bankhead R, et al. JPEN J Parenter Enteral Nutr 2009;33:122-167.

• Serum electrolytes • Blood glucose • Blood urea nitrogen • Serum creatinine • Calcium • Phosphorus

• Magnesium • Liver enzymes • Vital signs • Body weight • Feeding tolerance

Metabolic Monitoring Metabolic Complications

Russell MK. Monitoring complications of enteral feedings. In Charney P, Malone A (eds.). ADA Pocket Guide To Enteral Nutrition. Chicago, The American Dietetic Assoication, 2006. pp. 155-192.

• Provide antioxidant vitamins and trace elements to all patients receiving specialized nutrition therapy

• Aggressively replete phosphorus, magnesium, and potassium to prevent refeeding syndrome

McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316. Boateng AA, et al. Nutrition 2010;26:156-167.

Ensure Adequate Provision of Vitamins and Minerals Metabolic Complications

• Caused by rapidly advancing feeding in malnourished patients

• Characterized by Hypophosphatemia Hypokalemia Hypomagnesemia Fluid overload

• Anticipate it and correct fluid and electrolyte deficiencies before starting feeding

• Slowly advance feeding rate

Prevent Refeeding Syndrome

• Anticipation is key Correct pre-existing electrolyte abnormalities

• Initiate nutrition repletion slowly Initiate hypocaloric feeds

• (10-20 kcal/kg actual weight) Gradually increase feeding rate

over first week

Prevent Refeeding Syndrome

Boateng AA, et al. Nutrition 2010;26:156-167.

Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR)

• Intensive glucose control (81-108 mg/dL; 4.5-6.0 mmol/L)

Increased mortality

Increased risk of hypoglycemia

Glycemic control to ~150 mg/dL (8.3 mmol/L) is safer for critically ill patients

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297. Reeds D. Curr Opin Gastroenterol 2010;26:152-155.

Hyperglycemia is Common in Critically Ill Patients Metabolic Complications

“Sliding-scale insulin as monotherapy generally is ineffective and may be harmful.”

Thompson CL et al. Diabetes Spectrum 2005;18:20-27.

Intensive Insulin Therapy Sliding-scale Insulin (Basal Low-frequency dose)

6 am 12 pm 6 pm 12 pm

Hypo

Sliding-scale Insulin By Itself is Not Effective Therapy

• Insulin is the most appropriate agent • Use continuous IV infusion for critically

ill patients • Use scheduled subcutaneous

basal-bolus insulin regimens for non-critically ill patients

• Avoid hypoglycemia • Insulin analogs are preferred • Sliding-scale insulin regimens are not

effective

Moghissi ES. Curr Med Res Opin 2010;26:589-598.

Best Use of Insulin for Glycemic Management

• Initiate insulin therapy for persistent hyperglycemia, starting at a threshold of not >180 mg/dL (10.0 mmol/L)

• Maintain blood glucose 140 – 180 mg/dL (7.8 – 10.0 mmol/L)

• Lower targets may be appropriate in select patients, but not <110 mg/dL

• IV insulin infusion adjusted according to validated protocols with demonstrated safety and efficacy is preferred

• Monitor glucose frequently to achieve optimal glucose control

Moghissi ET, et al. Diabetes Care 2009;32:1119-1131.

Recommendations for Optimal Glucose Control for Critically Ill Patients

Variable CRS IIT

Insulin (P <0.05)

2 units daily

52 units of regular insulin daily

Median blood glucose

(P <0.05)

144 mg/dL (8 mmol/L)

133.6 mg/dL (7.4 mmol/L)

Hypoglycemia (P <0.001)

6 (3.5%) 27 (16%)

de Azevedo JRA et al. J Crit Care 2010;25:84-85.

Comparison of Intensive Insulin Therapy (IIT) to Carbohydrate-Restrictive Strategy (CRS)

Nutritional Complications

Research Objective: Describe the prognostic impact of nutritional status on 6-month mortality

Subjects: 165 older-adult patients hospitalized for an acute event

Results: Nutritional status is associated with 6-month mortality and persists after adjusting for sex, age, comorbidity, and functional status

Clinical Application: Strategic nutrition therapy during hospitalization and following discharge can positively affect long-term outcomes.

Expaulella J, et al. Age Ageing 2007;30:407-413.

Increased Mortality Seen in Spanish Study

“FASTHUG” Clinical Checklist Focusing On: • Feeding • Analgesia • Sedation • Thromboembolic prophylaxis • Head-of-the-bed elevation • Stress ulcer prophylaxis • Glycemic control

Johns RH, et al. Postgrad Med J 2010:86:541-551. Vincent JL. Crit Care Med 2005;33:1225-1229.

Provide Strategic Nutrition Therapy

• Enteral nutrition therapy is associated with complications, but they are largely preventable and can be managed

• Complications associated with enteral nutrition therapy are categorized as mechanical, gastrointestinal, and metabolic

• Appropriate and strategic nutrition therapy is key to improving long-term outcomes for patients

Key Concepts