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Dietitians in Nutrition Support A DIETETIC PRACTICE GROUP OF

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Presentation on theme: "Dietitians in Nutrition Support A DIETETIC PRACTICE GROUP OF"— Presentation transcript:

1 Enteral Nutrition for Adults: Administration Issues including material from
Dietitians in Nutrition Support A DIETETIC PRACTICE GROUP OF AMERICAN DIETETIC ASSOCIATION “Your link to nutrition and health.”

2 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 if malnourished or 7-9 days if normally nourished ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

3 Contraindications for EN
Inadequate resuscitation or hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed

4 Indicators of Adequate Fluid Resuscitation in Critically Ill Pts
Urine output should be >30 ml/hour Heart rate <120 beats/minute; preferably <100 beats/minute Systolic BP should be ~100 Ask staff/medical team If patient is receiving fluid boluses in addition to continuous IVF, likely they are not adequately resuscitated


6 Nasogastric Tubes

7 Nasogastric Tubes Definition
A tube inserted through the nasal passage into the stomach Indications: Short term feedings required Intact gag reflex Gastric function not compromised Low risk for aspiration

8 French Units—Tube 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

9 Nasogastric Tubes Advantages: Ease of tube placement
Surgery not required Easy to check gastric residuals Accommodates various administration techniques

10 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

11 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

12 Nasoduodenal/Jejunal
Advantages: Allows for initiation of early enteral feeding May decrease risk of aspiration Surgery not required

13 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

14 EAL EN Guidelines (Critical Care)
Adequately-powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroporesis), however they were not evaluated at this phase of the analysis. Fair; conditional ADA EAL Guidelines Critical Care accessed 8-07

15 Nasoduodenal/Jejunal
Disadvantages: Transpyloric tube placement may be difficult Limited to continuous infusion May promote nasal necrosis and esophagitis Impacts patient quality of life

16 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

17 Gastrostomy- Jejunosotomy

18 Enterostomy Placement
Gastrostomy Jejunostomy

19 Gastrostomy Definition
A feeding tube that passes into the stomach through the abdominal wall. May be placed surgically or endoscopically Indications: Long-term support planned Gastric function not compromised Intact gag reflex present

20 Gastrostomy Disadvantages: May require surgery Stoma care required
Potential problems for leakage or tube dislodgment

21 Gastrostomy

22 Jejunostomy Definition
A feeding tube that passes into the jejunum through the abdominal wall. May be placed endoscopically or surgically Indications: Long-term feeding option for patients at high risk for aspiration or with compromised gastric function

23 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

24 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)

25 Determining Method of Administration
Feeding site Clinical status of patient Type of formula used Availability of pump Mobility of patient

26 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

27 Administration Bolus Intermittent Continuous Cyclic

28 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 syringe Indications: Recommended for gastric feedings Requires intact gag reflex Normal gastric function

29 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

30 Bolus Feeding

31 Bolus Feeding Disadvantages: Increases risk for aspiration
Hypertonic, high fat, or high fiber formulas may delay gastric emptying or result in osmotic diarrhea

32 Initiation of Bolus Feedings
Adults: Initiate with full strength formula 3-8 times per day with increases of ml q 8-12 hours as tolerated up to goal volume; does not require dilution unless necessary to meet fluid requirements Children: Initiate with 25% of goal volume divided into the desired number of daily feedings; increase by 25% each day divided among all feedings until goal volume is reached ASPEN Nutrition Support Practice Manual, 2005, 2nd ed, p. 78

33 Continuous Feedings Indications:
Initiation of feedings in acutely ill patients Promote tolerance Compromised gastric function Feeding into small bowel Intolerance to other feeding techniques

34 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

35 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 or LTC use

36 Initiation of Continuous Feedings
Adults: Initiate at full strength at ml/hour and advance to goal rate in increments of 10 to 20 mL/hour q 8-12 hours as tolerated Can be used with isotonic or hyperosmolar formulas Children: Isotonic formula full strength at 1-2 mL/kg/hour and advanced by .5-1 mL/kg/hour q 6-24 hours until goal rate is achieved ASPEN Nutrition Support Practice Manual, 2005, 2nd ed, p. 78

37 Intermittent Feedings
Definition Enteral formula administered at specified times throughout the day; generally in smaller volume and at slower rate than a bolus feeding but in larger volume and faster rate than continuous drip feeding Typically ml is given over minutes q 4-6 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 discharge to home or LTC facility The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

38 Intermittent Feedings
Advantages: May enhance quality of life Allows greater mobility between feedings More physiologic May be better tolerated than bolus

39 Intermittent Feedings
Disadvantages: Increased risk for aspiration Gastric distention Delayed gastric emptying

40 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

41 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

42 Cyclic Feedings Disadvantages:
May require high infusion rates—may promote intolerance

43 Enteral Feeding Tubes Types: pediatric vs adult; gastric vs small bowel Sizes: smaller sizes (5-8 Fr) for commercial products delivered via pump; larger sizes for viscous, blenderized, fiber-containing formulas, gravity and bolus feedings Weighted vs. unweighted: it was once thought that weighted tubes facilitated transpyloric passage; now dictated by personal preference Stylet vs. no stylet: stylet facilitates tube placement beyond the pylorus for small, flexible tubes Composition: silicone and polyurethane most comfortable

44 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?

45 Enteral Feeding Containers
May be rigid or flexible Sterile or non-sterile Unbreakable, leakproof, and disposable

46 Considerations in Choosing Enteral Feeding Containers
Easy 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

47 Closed Systems

48 Enteral Feeding Pumps

49 Factors in Pump Selection
Simple to use (intuitive) Alarm system Lightweight Long battery life Portable Volume infused indicator Dose function Flow rate accurate to within 10% Approved for age range in which it will be used Permanently attached cord

50 Enteral Feeding Complications
Mechanical Gastrointestinal Metabolic Infectious

51 Mechanical Feeding tube obstruction Feeding tube dislodged
Nasal irritation Skin irritation/excoriation at ostomy site

52 Causes of Feeding Tube Obstruction
Concentrated, viscous, and fiber-containing feeding products Tube feeding contamination Checking of gastric residuals Small diameter tubes Powdered or crushed medication flushed through tubes Acidic or alkaline medications passed through tubes Tubes not routinely flushed after feedings are stopped

53 Prevention of Feeding Tube Obstruction
Flush the feeding tube, especially before and after medication administration and bolus/intermittent feedings Use liquid formulations of medicines where possible (but be careful of osmolarity) Do not mix medications with enteral feedings unless shown to be compatible Avoid crushing sustained-release or enteric-coated tablets

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

55 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

56 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 and questionable 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 septic patients

57 Aspiration Prevention
Keep head of bed elevated degrees during and 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 be helpful in identifying delayed gastric emptying and increased risk of aspiration The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

58 Gastrointestinal Complications
Diarrhea Constipation Gastric distention/bloating Gastric residuals/delayed gastric emptying Nausea/vomiting

59 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 enteral feedings when hyperosmolar feedings were routinely delivered via syringe Occurs in 2 to 63% of enterally-fed pts depending on how defined

60 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: results in dumping syndrome. Use an infusion pump to regulate flow The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

61 Causes/Treatments of Diarrhea
Bacterial overgrowth of intestinal tract or contamination of the enteral feeding Avoid prolonged use of broad-spectrum antibiotics Use 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 before using anti-motility agents

62 Causes/Treatments of Diarrhea
Steatorrhea: characterized by frothy, odiferous stools that float on water; caused by fat intolerance Use lowfat enteral formula or one with higher percentage of MCT; pancreatic enzymes may help in pancreatic insufficiency

63 Causes/Treatments of Diarrhea
Lactose intolerance Most 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 in tubefed pts due to hypertonicity or direct laxative action (magnesium, sorbitol, potassium). Diarrhea most common with antibiotics. Discuss with MD/pharmacist The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

64 Causes/Treatments of Diarrhea
Infusion of hypertonic feeding solutions; rare unless delivered at very high rate or bolused into small bowel Try a different product rather than diluting the original feeding GI disease: such as IBS, short gut, celiac disease, AIDS May require PN or specially formulated EN

65 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

66 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

67 Nausea/Vomiting Treatment
Consider reducing/discontinuing narcotic medications Switch to a lowfat formula Administer feeding solution at room temperature Reduce rate of infusion by ml/hr Administer prokinetic agent (metoclopramide, erythromycin, domperidone, bethanechol) Check gastric residuals Consider antiemetics

68 Metabolic Fluid and Electrolyte abnormalities Glucose intolerance
Ca++, Mg++, PO4 abnormalities Other

69 Fluid and Electrolyte Disturbances
May result from long term nutrition deficits, acute stress, medications, medical conditions, improper nutrient prescription Electrolytes lost via stool, urine, ostomy or fistula drainage Dehydration most common complication (tube feeding syndrome) especially with high protein feeding and insufficient fluid

70 Hyperglycemia Often reflects acute stress, infection, medications (especially steroids) or latent diabetes Macronutrient distribution: is generally not the primary issue; most enteral feeding formulas fall within established guidelines; could try formula lower in carbohydrate Insulin management

71 Refeeding Syndrome At risk: when refeeding those with marginal body nutrient stores, stressed, depleted patients, 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; acute respiratory failure

72 Refeeding Syndrome Correct electrolyte abnormalities (via oral, enteral, parenteral route) before initiating nutrition support Administer volume and energy slowly Monitor pulse rate, intake and output, and electrolyte levels Provide appropriate vitamin supplementation Avoid overfeeding

73 Infectious Complications
Formula contamination Unsanitary equipment Failure to follow appropriate protocols re handling of enteral feedings/changing of bags and tubing

74 Monitoring of Patients on EN
Electrolytes BUN/Cr Albumin/prealbumin Ca++, PO4, Mg++ Weight Input/output Vital signs Stool frequency/consistency Abdominal examination

75 Evaluating Adequacy of Support
I’s and O’s (what % of prescribed feeding did patient receive?) Indirect calorimetry Nitrogen balance Weight Visceral proteins Other

76 Home Support Discharge planning Patient education Reimbursement
May work with DME company to identify whether patient is a candidate for home EN, assure availability of product; complete CMN form in conjunction with physician Patient education Patients going home on enteral feedings will need education on food safety, feeding administration, and self-monitoring Reimbursement

77 Enteral Support Summary
Preferred method of nutrition support Technology exists to facilitate implementation Can be successfully employed with careful patient and formula selection

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