1. Enteral Access and Tube Feeding Administration
Michele Port, P.Dt.
Clinical Dietitian
March 2014

2. Outline Selection of the appropriate enteral access device
Short-term enteral feeding tubes
Long-term enteral feeding tubes
Delivery systems: Open vs Closed
Administration
Case Study
Monitoring and Documentation

3. Learning Objectives
At 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.

4. Selection of the Appropriate Enteral Access Device
Factors to consider:
Functional and accessible gastrointestinal tract
Normal digestion and absorption
No gastric outlet obstruction
No intestinal stricture
Gastric motility
Expected length of time enteral feeds required
Short-term (< 4 weeks)
Orogastric (intubated patients only)
Nasoenteric (nasogastric, nasoduodenal, nasojejunal)
Long-term (> 4 weeks)
Gastrostomy
Jejunostomy

5. Selection of the Appropriate Enteral Access Device
Aspiration risk?
Gastric vs small bowel access
Surgical intervention planned?
Tube could be placed during surgery (ex.: jejunostomy)
Patient and family preferences / activity
Pre-existing medical conditions such coagulopathy or ascites
Plan for discharge
Often rehab and long-term care facilities will only accept:
Percutaneous endoscopic gastrostomy (PEG)
Jejunostomy

6. Short-Term Enteral Feeding Tubes (< 4 weeks)
Short-term use in hospitalized patients : nasogastric,nasoduodenal,nasojejunal
Pediatric IBD patients may use these tubes at home
Insertion route
Oral: in ICU post-op only with patient sedated
Nasal: Preferred route
Access
Nasogastric
Able to feed larger volumes
Large bore PVC tubes (14-18 Fr.) may be used initially but should be changed to softer more flexible tubes
PVC tubes may cause nose irritation, gastric and esophageal erosions
Not preferred access in hospitalized patients due to aspiration risk
Confirm correct feeding tube position radiographically

7. Short-Term Enteral Feeding Tubes (< 4 weeks)
Nasoduodenal or nasojejunal
Nasoduodenal (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 patients
Contraindications
Obstruction head, neck, esophagus or gastric outlet obstruction

8. Short-Term Enteral Feeding Tubes (< 4 weeks)
Tubes : nasoduodenal or nasojejunal
Polyurethane or Silicone
Most nasoenteric tubes are made of polyurethane
Length
Varies: usually 36” (91 cm) to 60” (152 cm)
Size
Measured by external diameter in French size (Fr.)
Usually 8-12 French in adults
10-12 Fr. commonly used due to problems with tube clogging with meds

9. Short-Term Enteral Feeding Tubes (< 4 weeks)
Tubes : nasoduodenal or nasojejunal
Stylet or guidewire
Provided for guiding tube insertion
Water-activated lubricant coats the inner surface of tube, needs to syringe 5-10 mL into tube before removing guidewire
Guidewire must never be reinserted, could cause perforation
Other
Tips: vary, end holes, side holes, no particular advantage
Weighted vs Unweighted tip: No advantage
Feeding connector: Y port

10. Short-Term Enteral Feeding Tubes (< 4 weeks)
Insertion : nasoduodenal or nasojejunal
Bedside: MD, nurse, dietitian (in certain Canadian provinces when certified)
Prokinetic agent (maxeran or erythromycin) may facilitate passage into small bowel
Endoscopic
Often tube displaced when scope removed
Fluoroscopically guided
Need to go to radiology if portable not available
Used when bedside insertion unsucessful
Surgically-placed
Often done in ENT cancer surgeries and GI surgeries where patient expected to be NPO > 1 week, malnourished pre-op, expected gastroparesis

11. Short-Term Enteral Feeding Tubes (< 4 weeks)
Tube position – check:
All nasogastric and nasoenteric tubes needs
radiographic verification before use
With a permanent marker, mark nasal exit site
Secure tube with tape to nose

12. Short-Term Enteral Feeding Tubes (> 4 weeks)
Complications: nasoenteric
Insertion
Epistaxis
Respiratory compromise during tube insertion
Misplacement of tube in bronchopulmonary tree, often results in pneumothorax
Other
Tube dislodgement
Inadvertent
Patient pulls it out
Tube occlusion: Often due to medications
Tube malfunction: Kinking
Aspiration

13. Long-Term Enteral Feeding Tubes (> 4 weeks)
Google image

14. Long-Term Enteral Feeding Tubes (> 4 weeks)
Placement techniques
Surgically: open gastrostomy, jejunostomy
Endoscopically (sedation, local anesthetic)
Percutaneous endoscopic gastrostomy (PEG)
Percutaneous transgastric jejunostomy (PEG/J)
Radiologically
Radiologically inserted gastrostomy
Radiologically inserted transgastric jejunostomy
Radiologically inserted jejunostomy – rarely done at my center.

15. Long-Term Enteral Feeding Tubes (> 4 weeks)
Size
Gastrostomies: usually Fr., average 22 French
Jejunostomies: Fr.
Internal and external bolster or bumper (silicone or polyurethane) and/or balloon (silicone) of PEG
Balloons have lifespan of 3-4 months
Ports
Usually a port for feeding and a port for medication
PEG/J: Percutaneous endoscopic gastrostomy with jejunal extension
3 ports:
Bal. = Balloon
Jejunal = Feed
Gastric

16. Long-Term Enteral Feeding Tubes (> 4 weeks)
Peristomal Care
Clean area with mild soap and water
Dressings are not needed unless there is drainage at site
Complications
Aspiration during procedure
Hemorrhage
Peritonitis
Pneumoperitoneum
Peristomal infection
Accidental tube removal
If stoma tract mature put foley in to keep open until tube replaced
Buried bumper syndrome: Gastric mucosa grows over internal bumper
Clogging

17. Long-Term Enteral Feeding Tubes (> 4 weeks)
Replacement as per manufacturer’s recommendation and hospital policy
Removal of PEG
Only after tract has matured, after 4 weeks
If on steroids, after 6 weeks
Some contraindications to PEG
Ascites
Extensive gastric ulceration
Gastric varices
Coagulopathy
Morbid obesity

18. Long-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-up
Avoid placement of catheters or tubes not intended for use as feeding devices such as foleys
Evaluation by multidisciplinary team prior to insertion of long-term feeding device

19. Delivery Systems: Open vs. Closed
OPEN feeding system
CLOSED feeding system
Google images

20. Nursing practice for monitoring of enteral feeding
Care of Open Feeding System
Use 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.

21. Nursing practice for monitoring of enteral feeding
Care of Closed Feeding System
Use 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.

22. Nursing practice for monitoring of enteral feeding
Choice of system:
Product availability
Preference of patient and family

23. Administration 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 06h00-24h00
Necessary when have small bowel access
Generally best tolerated especially in patients with GI disorders
Rate of advancement of feeds depends on whether patient fed recently or not and medical condition
Intermittent
In adults, usually 3-6 feedings per day
Administered over minutes
Initiate feeds at 150mL-200mL per feeding and increase as tolerated
Pump or gravity method may be used
Bolus
Formulas delivered via syringe over 5-20 minutes
Not used in hospitals and generally not recommended unless pump fails
Can result in bloating, abdominal discomfort
Used in clinically stable patients

24. Protocol for Enterally Fed Patients

26. Initiation and Monitoring of Enteral Feeding

27. Administration
PUMPS
Pumps needs to be calibrated periodically to assess accuracy.
Small, portable with battery for 4-8 hours
Pumps in back-pack for home use
Feed and flush pumps
Will automatically flush tube as programmed
Quantify feeding provided

28. Administration Positioning: Important to  GER and possible aspiration
Practice recommendations:
 HOB to a minimum of 30⁰ (preferably 45⁰), for all patients on EN, unless medically contraindicated
Use reverse trendelenberg position if HOB can't be elevated, unless medically contraindicated
If head of bed must be lowered for a procedure, return patient to elevated HOB position
Bankhead et al. JPEN 2009, Boullata, J et al. eds. A.S.P.E.N. Enteral Nutrition handbook. ASPEN 2010
Water flushes
For hydration and cleaning of tube
Use sterile water in immunocompromised and critically ill
Medication administration

29. Administration Oral Hygiene
Poor oral / dental hygiene can increase bacteria in oral secretions risk for aspiration pneumonia
Need tooth brushing / mouth wash twice per day

30. Administration 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.

31. Administration 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.

32. Administration Drug nutrient interactions
Many possible drug - nutrient interactions.
Drug
Solution
Phenytoin
Hold EN formula 1-2hr before and after administration of diluted suspension
Monitor levels
Carbamazepine
If 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 dose
Fluoroquinolines (Ciprofloxacin, Levofloxacin)
Forms complexes with divalent cations i.e.: Ca
Holds feeds 1hr before and 2hr after drug
Boulatta et al

33. Enteral 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 study
43 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=300
Height: 170cm IBW: Minute ventilation = 12
Weight: 67kg BMI: Tmax = 37.8C
Calorie Requirement: Mifflin formula: 10 (67) (170) - 5 (43) + 5 = 1523
Penn State (Mifflin): (.96) + 12 (31) (167) = 1935
Protein Requirement: 67 X 1.2 = 80
Na: 80mmoL; K: less than 60mmoL; Phos: mg; Fluid: Output plus mL = 1000mL
Due 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 Nepro
2 Kcal/mL
960mL Nepro provides: 78g protein; 26 mmoL K; 670mg phosphorus; 696mL water
Patient needs 1000mL fluid: 1000mL-696mL (in formula) = 304mL

35. Monitoring 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.

36. Preventing 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.

37. Unblocking 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

38. Unblocking 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.

39. Unblocking 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.

40. Unblocking 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.

41. Monitoring
Monitoring and documentation of enteral feed administration (nurse, dietitian)
Monitoring by team to prevent and correct complications
Adequacy of nutritional intake
Physical assessment ex.: check for edema
GI tolerance:
Stool frequency / consistency
Ostomy output
Abdominal distension / pain
Nausea and vomiting
Residual volumes: look for change
Glycemic control

42. Monitoring Fluid intake and output
Weight (1 x per week): look at trend
Lab data
Markers of nutrition adequacy if applicable (include CRP)
Review medications
Medical procedures which require discontinuation of feeding

43. Conclusion
There are many enteral access devices to choose from. It is important to communicate
to the patient and family (if possible) why you recommend a specific device
i.e: PEG vs PEG/J.
The best way to ensure enteral feeding safety is to implement enteral nutrition
practice guidelines such as those from ASPEN or ESPEN, educate all staff and then
audit to see if those guidelines are being followed.

44. References
Bankhead 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.N
Shroud 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

45. THANK YOU