2Outline Selection of the appropriate enteral access device Short-term enteral feeding tubesLong-term enteral feeding tubesDelivery systems: Open vs ClosedAdministrationCase StudyMonitoring and Documentation
3Learning ObjectivesAt the end of this presentation, the participant will be able:Determine the appropriate type of enteral access / device when assessing patients.Understand the importance of a tube feeding protocol in advancing a tube feeding to maintenance and managing complications.Inform medical team on appropriate method for medication administration via feeding tubes.
4Selection of the Appropriate Enteral Access Device Factors to consider:Functional and accessible gastrointestinal tractNormal digestion and absorptionNo gastric outlet obstructionNo intestinal strictureGastric motilityExpected length of time enteral feeds requiredShort-term (< 4 weeks)Orogastric (intubated patients only)Nasoenteric (nasogastric, nasoduodenal, nasojejunal)Long-term (> 4 weeks)GastrostomyJejunostomy
5Selection of the Appropriate Enteral Access Device Aspiration risk?Gastric vs small bowel accessSurgical intervention planned?Tube could be placed during surgery (ex.: jejunostomy)Patient and family preferences / activityPre-existing medical conditions such coagulopathy or ascitesPlan for dischargeOften rehab and long-term care facilities will only accept:Percutaneous endoscopic gastrostomy (PEG)Jejunostomy
6Short-Term Enteral Feeding Tubes (< 4 weeks) Short-term use in hospitalized patients : nasogastric,nasoduodenal,nasojejunalPediatric IBD patients may use these tubes at homeInsertion routeOral: in ICU post-op only with patient sedatedNasal: Preferred routeAccessNasogastricAble to feed larger volumesLarge bore PVC tubes (14-18 Fr.) may be used initially but should be changed to softer more flexible tubesPVC tubes may cause nose irritation, gastric and esophageal erosionsNot preferred access in hospitalized patients due to aspiration riskConfirm correct feeding tube position radiographically
7Short-Term Enteral Feeding Tubes (< 4 weeks) Nasoduodenal or nasojejunalNasoduodenal (distal to pylorus)Nasojejunal (distal to ligament of Treitz in jejunum)Used when problems with delayed gastric emptying, aspiration risk, early post-op feeding (liver transplant patients malnourished pre-op)More commonly used in non-ICU hospitalized patientsContraindicationsObstruction head, neck, esophagus or gastric outlet obstruction
8Short-Term Enteral Feeding Tubes (< 4 weeks) Tubes : nasoduodenal or nasojejunalPolyurethane or SiliconeMost nasoenteric tubes are made of polyurethaneLengthVaries: usually 36” (91 cm) to 60” (152 cm)SizeMeasured by external diameter in French size (Fr.)Usually 8-12 French in adults10-12 Fr. commonly used due to problems with tube clogging with meds
9Short-Term Enteral Feeding Tubes (< 4 weeks) Tubes : nasoduodenal or nasojejunalStylet or guidewireProvided for guiding tube insertionWater-activated lubricant coats the inner surface of tube, needs to syringe 5-10 mL into tube before removing guidewireGuidewire must never be reinserted, could cause perforationOtherTips: vary, end holes, side holes, no particular advantageWeighted vs Unweighted tip: No advantageFeeding connector: Y port
10Short-Term Enteral Feeding Tubes (< 4 weeks) Insertion : nasoduodenal or nasojejunalBedside: MD, nurse, dietitian (in certain Canadian provinces when certified)Prokinetic agent (maxeran or erythromycin) may facilitate passage into small bowelEndoscopicOften tube displaced when scope removedFluoroscopically guidedNeed to go to radiology if portable not availableUsed when bedside insertion unsucessfulSurgically-placedOften done in ENT cancer surgeries and GI surgeries where patient expected to be NPO > 1 week, malnourished pre-op, expected gastroparesis
11Short-Term Enteral Feeding Tubes (< 4 weeks) Tube position – check:All nasogastric and nasoenteric tubes needsradiographic verification before useWith a permanent marker, mark nasal exit siteSecure tube with tape to nose
12Short-Term Enteral Feeding Tubes (> 4 weeks) Complications: nasoentericInsertionEpistaxisRespiratory compromise during tube insertionMisplacement of tube in bronchopulmonary tree, often results in pneumothoraxOtherTube dislodgementInadvertentPatient pulls it outTube occlusion: Often due to medicationsTube malfunction: KinkingAspiration
13Long-Term Enteral Feeding Tubes (> 4 weeks) Google image
14Long-Term Enteral Feeding Tubes (> 4 weeks) Placement techniquesSurgically: open gastrostomy, jejunostomyEndoscopically (sedation, local anesthetic)Percutaneous endoscopic gastrostomy (PEG)Percutaneous transgastric jejunostomy (PEG/J)RadiologicallyRadiologically inserted gastrostomyRadiologically inserted transgastric jejunostomyRadiologically inserted jejunostomy – rarely done at my center.
15Long-Term Enteral Feeding Tubes (> 4 weeks) SizeGastrostomies: usually Fr., average 22 FrenchJejunostomies: Fr.Internal and external bolster or bumper (silicone or polyurethane) and/or balloon (silicone) of PEGBalloons have lifespan of 3-4 monthsPortsUsually a port for feeding and a port for medicationPEG/J: Percutaneous endoscopic gastrostomy with jejunal extension3 ports:Bal. = BalloonJejunal = FeedGastric
16Long-Term Enteral Feeding Tubes (> 4 weeks) Peristomal CareClean area with mild soap and waterDressings are not needed unless there is drainage at siteComplicationsAspiration during procedureHemorrhagePeritonitisPneumoperitoneumPeristomal infectionAccidental tube removalIf stoma tract mature put foley in to keep open until tube replacedBuried bumper syndrome: Gastric mucosa grows over internal bumperClogging
17Long-Term Enteral Feeding Tubes (> 4 weeks) Replacement as per manufacturer’s recommendation and hospital policyRemoval of PEGOnly after tract has matured, after 4 weeksIf on steroids, after 6 weeksSome contraindications to PEGAscitesExtensive gastric ulcerationGastric varicesCoagulopathyMorbid obesity
18Long-Term Enteral Feeding Tubes (> 4 weeks) Practice recommendations for long-term enteral device placement include:Document tube type, tip location and external markings in medical record and on follow-upAvoid placement of catheters or tubes not intended for use as feeding devices such as foleysEvaluation by multidisciplinary team prior to insertion of long-term feeding device
19Delivery Systems: Open vs. Closed OPEN feeding systemCLOSED feeding systemGoogle images
20Nursing practice for monitoring of enteral feeding Care of Open Feeding SystemUse disposable gloves during the administration of TF.Label each container with patient’s name, date, time of first use, and formula’s name.Wipe top of formula container with damp paper towel before opening.Do not add anything to the container other than the formula.Fill container with maximum of 4 hours of the feeding formula.Rinse container and tube well q 4 hours with water for continuous feedings or after each intermittent feedings.Change administration sets for open tube feeds every 24 hours.Discard any opened or mixed formula after 24 hours.Store unopened commercial liquid tube feeding (TF) formulas under controlled (dark, dry, cool) conditions.
21Nursing practice for monitoring of enteral feeding Care of Closed Feeding SystemUse disposable gloves during the administration of TF.Label container along with patient’s name, date, and time when container was spiked.Shake feeding bag well for 10 seconds when starting, then every 4 hours.Do not add anything to the container.Closed-system TF formulas can hang for 48 hours as per manufacturer’s guidelines.Change administration set each time formula container is changed.Discard any unused formulas and spike set after 48 hours.Refer to product information sheet for further detail.Store unopened commercial liquid tube feeding (TF) formulas under controlled (dark, dry, cool) conditions.
22Nursing practice for monitoring of enteral feeding Choice of system:Product availabilityPreference of patient and family
23Administration 3 METHODS Continuous drip Feeds run continuously with a pump either X 24 hr or for a specified # of hours, such as 06h00-22h00 or 06h00-24h00Necessary when have small bowel accessGenerally best tolerated especially in patients with GI disordersRate of advancement of feeds depends on whether patient fed recently or not and medical conditionIntermittentIn adults, usually 3-6 feedings per dayAdministered over minutesInitiate feeds at 150mL-200mL per feeding and increase as toleratedPump or gravity method may be usedBolusFormulas delivered via syringe over 5-20 minutesNot used in hospitals and generally not recommended unless pump failsCan result in bloating, abdominal discomfortUsed in clinically stable patients
27AdministrationPUMPSPumps needs to be calibrated periodically to assess accuracy.Small, portable with battery for 4-8 hoursPumps in back-pack for home useFeed and flush pumpsWill automatically flush tube as programmedQuantify feeding provided
28Administration Positioning: Important to GER and possible aspiration Practice recommendations: HOB to a minimum of 30⁰ (preferably 45⁰), for all patients on EN, unless medically contraindicatedUse reverse trendelenberg position if HOB can't be elevated, unless medically contraindicatedIf head of bed must be lowered for a procedure, return patient to elevated HOB positionBankhead et al. JPEN 2009, Boullata, J et al. eds. A.S.P.E.N. Enteral Nutrition handbook. ASPEN 2010Water flushesFor hydration and cleaning of tubeUse sterile water in immunocompromised and critically illMedication administration
29Administration Oral Hygiene Poor oral / dental hygiene can increase bacteria in oral secretions risk for aspiration pneumoniaNeed tooth brushing / mouth wash twice per day
30Administration of Medications Use oral route if safe / possible.Check with pharmacy if uncertain which medications can be delivered by tube and/or the appropriate delivery method.Never add medication directly to an enteral feeding formula.Never mix medications together (to avoid chemical incompatibilities, tube obstruction…)Dilute medications appropriately prior to administration:Use liquid forms when available.Grind simple compressed tablets to a fine powder and mix with 30 mL water.Dilute viscous liquids with mL water and concentrated liquids with mL water.Do not crush slow release tablets or enteric coated tablets.Open hard gelatin capsules and mix contents with water.
31Administration of Medications Prior to administering medication, stop feeding and flush the tube with 30 mL water.Administer each medication separately and flush the tube with at least 30 mL of water after each medication.Use sterile water for immunocompromised patients.Start with liquid medications, followed by those that have been diluted Keep viscous medications until the end.Rinse the tube one final time with 30 mL water.Record the volume of water given on the input/output sheets.In the case of continuous feeding, resume formula administration immediately unless contraindicated as in the case of drug-nutrient interaction.
32Administration Drug nutrient interactions Many possible drug - nutrient interactions.DrugSolutionPhenytoinHold EN formula 1-2hr before and after administration of diluted suspensionMonitor levelsCarbamazepineIf jejunal feedings, hold EN formula 2hrs before and after drug administration of diluted suspension (1:1)Warfarin(Interaction between wafarin and Vitamin K)Hold the EN formaula 1hr before and after warfarin doseFluoroquinolines (Ciprofloxacin, Levofloxacin)Forms complexes with divalent cations i.e.: CaHolds feeds 1hr before and 2hr after drugBoulatta et al
33Enteral feeding protocol After nutrition assessment, caloric and protein requirements are calculated.If Na, K, phosphorus or fluid is limited i.e.: in case of dialysis patients this must also be taken in consideration.Case study43 yo male, unwell x 1 week, admitted with PCP pneumonia. Intubated and ventilated. Had renal transplant in Has AKI on CKD. Patient will be intermittently hemodialyzed.Urine output 300mL/day. K=5.1, Phos=1.80, Cr=300Height: 170cm IBW: Minute ventilation = 12Weight: 67kg BMI: Tmax = 37.8CCalorie Requirement: Mifflin formula: 10 (67) (170) - 5 (43) + 5 = 1523Penn State (Mifflin): (.96) + 12 (31) (167) = 1935Protein Requirement: 67 X 1.2 = 80Na: 80mmoL; K: less than 60mmoL; Phos: mg; Fluid: Output plus mL = 1000mLDue to the K, phosphorus and fluid limitation, there are very few formulas to meet our requirements. Nepro would be the formula of choice Required Kcal/day = 1935 Kcal; Nepro provides 2 Kcal/mL; Kcal = 968mL of Nepro2 Kcal/mL960mL Nepro provides: 78g protein; 26 mmoL K; 670mg phosphorus; 696mL waterPatient needs 1000mL fluid: 1000mL-696mL (in formula) = 304mL
35Monitoring and Documentation of Enteral Feeding Administration Following tube placement verification by x-ray, mark exit point of tube.Confirm HOB elevation at 30o – 45o, unless medically contraindicated.Observe and document any signs of intolerance such as abdominal distension, firmness, discomfort, nausea, vomiting, or diarrhea. Notify and consult the Clinical Dietitian and MD of any of these feeding intolerances and interruptions.Ensure adequate mouth care.Document GRV for gastrically fed patients in progress notes.Verify placement of feeding tube q 8 hours, prn.Weigh patient on day 1 of tube feeding, then every 1-7 day(s). Enter data in OACIS.Document volume delivered for each tube flush.Document the volume of formula delivered each shift including the volume of any modular product also delivered (ex., protein powder) if needed.
36Preventing Feeding Tube Blockage Possible causes include inadequate tube irrigation, administering improperly crushed medication, intraluminal accumulation of formula residue, solidification of formula, medication residue. To prevent feeding tube blockage:Immediately flush the feeding tube with a minimum of 30 mL of water after each feeding, after administration of each medication, after any interruption in feeding.Shake the enteral feeding container before hanging for 10 seconds.Shake formula every 4 hours (i.e. when flushing the tubing).Change the feeding bag and tubing used for enteral feeding every 24 hr for the open system and every 48 hr for the closed system.Use liquid formulations of medications whenever possible.Unless contraindicated, crush solid medications thoroughly.Use a syringe (60 mL) filled with 30 ml water to flush the tube before and after administering medications. Replace syringe every 24 hours.Rinse using 30 ml water after measuring gastric residual volume.Use a feeding pump.
37Unblocking of Obstructed Feeding Tubes Possible Causes:Inadequate irrigation of tube.Administration of improperly crushed medication, intraluminal accumulation of formula residue, solidification of formula or medication residue because of drug/nutrient interaction.Improperly dissolved enteral formula due to poor mixing technique
38Unblocking of Obstructed Feeding Tubes Prevention:Immediately flush the feeding tube with a minimum of 30 mL of water after each feeding, after administration of each medication, after any interruption in feeding.Shake the enteral feeding container before hanging for 10 seconds.Shake formula regularly (i.e. every 8 hours or when flushing the tubing).Change the feeding bag and tubing used for enteral feeding every 24 hr for the open system and every 48 hr for the closed system.Use liquid formulations of medications whenever possible.Unless contradicted, crush solid medications thoroughly.Use a syringe (60 mL) filled with 30 ml water to flush the tube before and after administering medications. Replace syringe very 24 hours.Rinse using 30 mL of water after measuring gastric residual volume.Use a feeding pump equipped with a flush feature. Schedule flushes q 4h.
39Unblocking of Obstructed Feeding Tubes Treatment as per MD’s orders.In order to restore tube patency, first flush with warm water.If this is ineffective:Dissolve one 500 mg crushed tablet of sodium bicarbonate in 5-10 mL sterile water (this will take about 3-5 minutes).Once dissolved, mix contents of 1 opened capsule of pancreatic enzyme, Cotazym ECS20, into the sodium bicarbonate / water mix, allow to dissolve 5 minutes, the mixture should turn a light brown color.Suspend mixture by adding 15 mL of warm water.Introduce the pancreatic enzyme solution into the feeding tube while gently massaging the tube.Clamp the tube and leave the pancreatic enzyme solution in the tube for minutes before flushing the tube.Repeat the above once if necessary. Contact MD in event of failure.
40Unblocking of Obstructed Feeding Tubes NEVER USE Cranberry juice or carbonated beverages such as cola as their acidity may aggravate the blockage.NEVER try to restore patency of a feeding tube by reinserting the stylet because of the risk of intestinal perforation.
41MonitoringMonitoring and documentation of enteral feed administration (nurse, dietitian)Monitoring by team to prevent and correct complicationsAdequacy of nutritional intakePhysical assessment ex.: check for edemaGI tolerance:Stool frequency / consistencyOstomy outputAbdominal distension / painNausea and vomitingResidual volumes: look for changeGlycemic control
42Monitoring Fluid intake and output Weight (1 x per week): look at trendLab dataMarkers of nutrition adequacy if applicable (include CRP)Review medicationsMedical procedures which require discontinuation of feeding
43ConclusionThere are many enteral access devices to choose from. It is important to communicateto the patient and family (if possible) why you recommend a specific devicei.e: PEG vs PEG/J.The best way to ensure enteral feeding safety is to implement enteral nutritionpractice guidelines such as those from ASPEN or ESPEN, educate all staff and thenaudit to see if those guidelines are being followed.
44ReferencesBankhead R, Fang J. Enteral Access Devices. In Gottschlich P, ed. in chief The A.S.P.E.N. Nutrition Support Core Curriculum, Silver Spring, MD ;Bankhead R, Boullatta J, Brantley S, et al and the A.S.P.E.N. Board of Directors, Enteral nutrition practice recommendations. JPEN 2009; 33;Boullata J, Nieman Carney L, Guenter P, eds. A.S.P.E.N. Enteral Nutrition Henadbook Silver Spring, MD. A.S.P.E.NShroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients Gut 2003; 52 (Suppl VII); vii1-vii12.MUHC Adult Sites. Interprofessional Professional protocol for the initiation and monitoring of enteral feedings