enteral nutrition administration issues

7/29/2019 Enteral Nutrition Administration Issues

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Enteral Nutrition for

Adults: Administration Issuesincluding material from

Dietitians in Nutrition Support

A DIETETIC PRACTICE GROUP OF

AMERICAN DIETETIC ASSOCIATION

Your link to nutrition and health.


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Contraindications for EN

Severe acute pancreatitis

High output proximal fistula

Inability to gain access

Intractable vomiting or diarrhea

Aggressive therapy not warranted

Expected need less than 5-7 days ifmalnourished or 7-9 days ifnormally nourished

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143


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Contraindications for ENInadequate resuscitation or

hypotension; hemodynamic

instabilityIleus

Intestinal obstruction

Severe G.I. Bleed


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Indicators of Adequate Fluid

Resuscitation in Critically Ill PtsUrine output should be >30 ml/hour

Heart rate


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Nasogastric Tubes


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Nasogastric Tubes

Definition

A tube inserted through the nasal passageinto the stomach

Indications:

Short term feedings required

Intact gag reflex

Gastric function not compromised

Low risk for aspiration


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French UnitsTube Size Diameter of feeding tube is measured in

French units

1F = 33 mm diameter

Feeding tube sizes differ for formula types and

administration techniques

Generally smaller tubes are more comfortable

and better suited to NG or NJ feedings

May be more likely to clog with viscous

formula or formula mixtures


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Nasogastric Tubes

Advantages:

Ease of tube placement

Surgery not required

Easy to check gastric residuals

Accommodates various administration techniques


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Nasogastric Tubes

Disadvantages:

Increases risk of aspiration (maybe)

Not suitable for patients with compromised gastric

function

May promote nasal necrosis and esophagitis

Impacts patient quality of life


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Nasoduodenal/Jejunal

Definition

A tube inserted through the nasal passage through

the stomach into the duodenum or jejunum

Indications:

High risk of aspiration

Gastric function compromised


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Advantages:

Allows for initiation of early enteral feeding

May decrease risk of aspiration

Surgery not required


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EAL EN Tube Placement Guidelines

Critical Care

Enteral Nutrition (EN) administered into the

stomach is acceptable for most critically ill

patients.

If your institution's policy is to measure GRV,then consider small bowel tube feeding placement

in patients who have more than 250ml GRV or

formula reflux in two consecutive measures.

Small bowel tube placement is associated with

reduced GRV.

ADA EAL Critical Care Guidelines accessed 8-07


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EAL EN Guidelines (Critical Care)

Adequately-powered studies have not beenconducted to evaluate the impact of GRVon aspiration pneumonia.

There may be specific disease states orconditions that may warrant small boweltube placement (e.g., fistulas, pancreatitis,gastroporesis), however they were notevaluated at this phase of the analysis.Fair; conditional

ADA EAL Guidelines Critical Care accessed 8-07


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Disadvantages:

Transpyloric tube placement may be difficult

Limited to continuous infusion

May promote nasal necrosis and esophagitis

Impacts patient quality of life


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Orogastric

Tube is placed through mouth and into

stomach

Often used in premature and small infants

as they are nasal breathers

Not tolerated by alert patients; tubes may be

damaged by teeth


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Gastrostomy-

Jejunosotomy


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Enterostomy Placement

Gastrostomy

Jejunostomy


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Gastrostomy

Definition

A feeding tube that passes into the stomach

through the abdominal wall. May be placed

surgically or endoscopicallyIndications:

Long-term support planned

Gastric function not compromised Intact gag reflex present


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Gastrostomy

Disadvantages:

May require surgery

Stoma care required

Potential problems for leakage or tube

dislodgment


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Gastrostomy


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Jejunostomy

Definition

A feeding tube that passes into the jejunum

through the abdominal wall. May be placed

endoscopically or surgicallyIndications:

Long-term feeding option for patients at high risk

for aspiration or with compromised gastricfunction


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Jejunostomy

Advantages:

Post-op feedings may be initiated immediately

Decreased risk of aspiration

Suitable option for patients with compromised

gastric function

Stable patients can tolerate intermittent feedings


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Jejunostomy

Disadvantages:

Requires stoma care

Potential problems related to leakage or tube

dislodgement/clogging may arise

May restrict ambulation

Bolus feedings inappropriate (stable patients may

tolerate intermittent feedings)


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Determining Method of

Administration

Feeding site

Clinical status of patient

Type of formula used

Availability of pump

Mobility of patient


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Initiation of Enteral Feedings

Dilution of enteral formulas not generally

recommended

Initiate at full strength at slow rate and

steadily advance

Allows achievement of goal rates more

quickly; less manipulation of formula


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AdministrationBolus

Intermittent

ContinuousCyclic


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Bolus Feedings

Definition

Infusion of up to 500 ml of enteral formula into

the stomach over 5 to 20 minutes, usually by

gravity or with a large-bore syringeIndications:

Recommended for gastric feedings

Requires intact gag reflexNormal gastric function


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Bolus Feedings

Advantages:

More physiologic

Enteral pump not required

Inexpensive and easy administration

Limits feeding time so patient is free to ambulate,

participate in rehabilitation, or live a more normal

life in the home Makes it more likely patient will receive full

amount of formula


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Bolus

Feeding


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Bolus Feeding

Disadvantages:

Increases risk for aspiration

Hypertonic, high fat, or high fiber formulas may

delay gastric emptying or result in osmoticdiarrhea


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Initiation of Bolus Feedings

Adults: Initiate with full strength formula 3-8 times per day with increases of 60-120 mlq 8-12 hours as tolerated up to goal volume;

does not require dilution unless necessary tomeet fluid requirements

Children: Initiate with 25% of goal volumedivided into the desired number of dailyfeedings; increase by 25% each day dividedamong all feedings until goal volume isreached

ASPEN Nutrition Support Practice Manual, 2005, 2nd

ed, p. 78


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Continuous Feedings

Indications:

Initiation of feedings in acutely ill patients

Promote tolerance

Compromised gastric function

Feeding into small bowel

Intolerance to other feeding techniques


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Continuous Feedings

Definition

Enteral formula administration into the

gastrointestinal tract via pump or gravity, usually

over 8 to 24 hours per day

Advantages:

May improve tolerance May reduce risk of aspiration

Increased time for nutrient absorption


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Continuous Feedings

Disadvantages:

May reduce 24-hour infusion

May restrict ambulation

More expensive for home support

Pumps are more accurate; useful for small-bore

tubes and viscous feedings, but many payers have

strict criteria for approval of pumps for home orLTC use


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Initiation of Continuous Feedings

Adults: Initiate at full strength at 10-40ml/hour and advance to goal rate inincrements of 10 to 20 mL/hour q 8-12

hours as toleratedCan be used with isotonic or hyperosmolar

formulas

Children: Isotonic formula full strength at 1-2 mL/kg/hour and advanced by .5-1mL/kg/hour q 6-24 hours until goal rate isachieved

ASPEN Nutrition Support Practice Manual, 2005, 2nd ed, p. 78


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Intermittent Feedings

Definition Enteral formula administered at specified times

throughout the day; generally in smaller volume andat slower rate than a bolus feeding but in largervolume and faster rate than continuous drip feeding

Typically 200-300 ml is given over 30-60 minutes q4-6 hours

Precede and follow with 30-ml flush of tap water

Indications:

Intolerance to bolus administration Initiation of support without pump

Preparation of patient for rehab services or dischargeto home or LTC facility

The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005


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Advantages:

May enhance quality of life

Allows greater mobility between feedings

More physiologic

May be better tolerated than bolus


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Disadvantages:

Increased risk for aspiration

Gastric distention

Delayed gastric emptying


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Cyclic Feedings

Definition

Administration of enteral formula via continuous drip over

a defined period of 8 to 12 hours, usually nocturnally

Indications:

Ensure optimal nutrient intake when:

Transitioning from enteral support to oral nutrition

(enhance appetite during the day) Supplement inadequate oral intake

Free patient from enteral feedings during the day


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Cyclic Feedings

Advantages:

Achieve nutrient goals with supplementation

Facilitates transition of support to oral diet

Allows daytime ambulation

Encourages patient to eat normal meals and snacks


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Cyclic Feedings

Disadvantages:

May require high infusion ratesmay promote

intolerance


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Enteral Feeding Tubes

Types: pediatric vs adult; gastric vs small bowel

Sizes: smaller sizes (5-8 Fr) for commercial productsdelivered via pump; larger sizes for viscous,

blenderized, fiber-containing formulas, gravity andbolus feedings

Weighted vs. unweighted: it was once thought thatweighted tubes facilitated transpyloric passage; nowdictated by personal preference

Stylet vs. no stylet: stylet facilitates tube placementbeyond the pylorus for small, flexible tubes

Composition: silicone and polyurethane mostcomfortable


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Factors Affecting Tube Selection

Will the patient be fed into the stomach or

small bowel?

How long will the patient need tube

feedings?

Is the patient expected to resume adequate

oral feedings?

Who can insert feeding tubes at my

institution?


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Enteral Feeding Containers

May be rigid or

flexible

Sterile or non-sterile

Unbreakable,leakproof, and

disposable


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Considerations in Choosing

Enteral Feeding ContainersEasy to fill, close and hang

Easy to read calibrations and directions

Appropriate size

Adaptable tubing port

Compatible with pump

Requires minimal storage space

Adapted from ASPEN. The science and practice of nutrition support. A case-

based core curriculum. 2001; 179


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Closed Systems


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Enteral Feeding Pumps


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Factors in Pump Selection

Simple to use

(intuitive)

Alarm system

Lightweight Long battery life

Portable

Volume infusedindicator

Dose function

Flow rate accurate to

within 10%

Approved for agerange in which it will

be used

Permanently attached

cord


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Enteral Feeding Complications

Mechanical

Gastrointestinal

Metabolic

Infectious


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Mechanical

Feeding tube obstruction

Feeding tube dislodged

Nasal irritation

Skin irritation/excoriation at ostomy site


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Causes of Feeding Tube Obstruction

Concentrated, viscous, and fiber-containingfeeding products

Tube feeding contamination

Checking of gastric residuals Small diameter tubes

Powdered or crushed medication flushed throughtubes

Acidic or alkaline medications passed throughtubes

Tubes not routinely flushed after feedings arestopped


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Prevention of Feeding Tube

Obstruction

Flush the feeding tube, especially beforeand after medication administration andbolus/intermittent feedings

Use liquid formulations of medicines wherepossible (but be careful of osmolarity)

Do not mix medications with enteralfeedings unless shown to be compatible

Avoid crushing sustained-release or enteric-coated tablets

f


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Treatment of

Feeding Tube Obstruction

Declog with irrigants (warm water) or

sodium bicarbonate/pancrealipase mixture

or by mechanical means

Cola beverages, cranberry juice, and tea not

recommended



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Aspiration

Reported incidence of aspiration in tubefed

patients varies from .8% to 95%. Clinically

significant aspiration 5% gastric-fed pts

Many aspiration events are silent and

often involve oropharyngeal secretions

Symptoms include dyspnea, tachycardia,

wheezing, rales, anxiety, agitation, cyanosis

May lead to aspiration pneumonia


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Aspiration

Focus has been on detection of aspiration through

use of coloring agents in enteral feedings or

glucose testing of respiratory secretions

These methods have low sensitivity andquestionable specificity; they do not prevent

aspiration but at best detect it after it has occurred

Blue food coloring used for this purpose has been

associated with morbidity/mortality in septicpatients


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Aspiration Prevention

Keep head of bed elevated 30-45 degreesduring and 30-40 minutes after feedings

Feed post-pylorically (research mixed on

this)Small, frequent feedings or continuous drip

Use of promotility agents

Monitoring of gastric residuals may behelpful in identifying delayed gastricemptying and increased risk of aspiration



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Gastrointestinal Complications

Diarrhea

Constipation

Gastric distention/bloating

Gastric residuals/delayed gastric emptying

Nausea/vomiting


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Diarrhea

Definition: >500 ml every 8 hours or more than 3

stools a day for at least two consecutive days.

Relates more to stool consistency than frequency

Diarrhea was a common consequence of enteralfeedings when hyperosmolar feedings were

routinely delivered via syringe

Occurs in 2 to 63% of enterally-fed pts depending

on how defined


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Causes/Treatments of Diarrhea

Intestinal atrophy due to malnutrition

EN is the best stimulant for recovery. Increase

rate slowly as tolerated

Albumin infusion is unlikely to be helpful;diarrhea is not caused by low albumin; it is a

marker of malnutrition

Bolus feeding in the small intestine: resultsin dumping syndrome.

Use an infusion pump to regulate flow



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Bacterial overgrowth of intestinal tract orcontamination of the enteral feeding

Avoid prolonged use of broad-spectrum

antibioticsUse clean technique and closed system in

handling enteral feedings

Limit hang time of open system formulas to 8

hours (4 hours for mixtures)Change bag and tubing per protocol

Test for C difficile and other pathogens beforeusing anti-motility agents


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Steatorrhea: characterized by frothy,

odiferous stools that float on water; caused

by fat intolerance

Use lowfat enteral formula or one with higherpercentage of MCT; pancreatic enzymes may

help in pancreatic insufficiency


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Lactose intoleranceMost enteral products are lactose free but this

may occur with initiation of full liquid diet.Eliminate milk and dairy products

Drug-induced diarrhea

Meds may cause up to 61% of diarrhea intubefed pts due to hypertonicity or direct

laxative action (magnesium, sorbitol,potassium). Diarrhea most common withantibiotics. Discuss with MD/pharmacist



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Infusion of hypertonic feeding solutions;

rare unless delivered at very high rate or

bolused into small bowel

Try a different product rather than diluting theoriginal feeding

GI disease: such as IBS, short gut, celiac

disease, AIDSMay require PN or specially formulated EN


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Treatment of Diarrhea in General

Add soluble fiber (such as banana flakes or

Benefiber) or insoluble fiber such as

psillium

Consider an enteral formula with added

fiber

Use an antidiarrheal agent (loperamide,

diphenoxylate, paregoric, octreotide)

Change the formula


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Nausea/Vomiting

20% of patients on EN report

nausea/vomiting

Often related to delayed gastric emptying

caused by hypotension, sepsis, stress,

anesthesia, medications (analgesics and

anticholinergics), surgery


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Nausea/Vomiting Treatment

Consider reducing/discontinuing narcoticmedications

Switch to a lowfat formula

Administer feeding solution at roomtemperature

Reduce rate of infusion by 20-25 ml/hr

Administer prokinetic agent (metoclopramide,

erythromycin, domperidone, bethanechol) Check gastric residuals

Consider antiemetics


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Metabolic

Fluid and Electrolyte abnormalities

Glucose intolerance

Ca++, Mg++, PO4 abnormalities

Other

Fluid and Electrolyte


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Fluid and Electrolyte

DisturbancesMay result from long term nutrition deficits,

acute stress, medications, medical

conditions, improper nutrient prescription

Electrolytes lost via stool, urine, ostomy orfistula drainage

Dehydration most common complication

(tube feeding syndrome) especially withhigh protein feeding and insufficient fluid


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Hyperglycemia

Often reflects acute stress, infection, medications

(especially steroids) or latent diabetes

Macronutrient distribution: is generally not the

primary issue; most enteral feeding formulas fallwithin established guidelines; could try formula

lower in carbohydrate

Insulin management


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Refeeding Syndrome

At risk: when refeeding those with marginalbody nutrient stores, stressed, depletedpatients, those who have been unfed for 7-

10 days, persons with anorexia nervosa,chronic alcoholism, weight loss

Symptoms: Hypokalemia,hypophosphatemia and hypomagnesemia;

cardiac arrhythmias, heart failure; acuterespiratory failure


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Refeeding Syndrome

Correct electrolyte abnormalities (via oral,enteral, parenteral route) before initiatingnutrition support

Administer volume and energy slowlyMonitor pulse rate, intake and output, and

electrolyte levels

Provide appropriate vitaminsupplementation

Avoid overfeeding


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Infectious Complications

Formula contamination

Unsanitary equipment

Failure to follow appropriate protocols re handling

of enteral feedings/changing of bags and tubing


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Monitoring of Patients on EN

Electrolytes

BUN/Cr

Albumin/prealbumin

Ca++

, PO4, Mg++

Weight

Input/output

Vital signs

Stool frequency/consistency

Abdominal examination


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Evaluating Adequacy of Support

Is and Os (what % of prescribed feeding did

patient receive?)

Indirect calorimetry

Nitrogen balance Weight

Visceral proteins

Other


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Home Support

Discharge planning

May work with DME company to identifywhether patient is a candidate for home EN,

assure availability of product; completeCMN form in conjunction with physician

Patient education

Patients going home on enteral feedings

will need education on food safety, feedingadministration, and self-monitoring

Reimbursement


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Enteral Support Summary

Preferred method of nutrition support

Technology exists to facilitate

implementation

Can be successfully employed with careful

patient and formula selection

enteral nutrition administration issues

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