1. Implementing Enteral Nutrition Therapy: Enteral Access

2. Objectives To describe the benefits of enteral nutrition therapy To review indications and contraindications of enteral nutrition To describe access routes for enteral nutrition infusion To describe the advantages and disadvantages of various enteral access routes

3. Enteral Nutrition Therapy: Benefits Maintains gastrointestinal structure and function Reduces translocation of toxins and possibly bacteria Less expensive than parenteral nutrition therapy Fewer complications

4. “If the gut works, use it.”

5. Enteral Nutrition: Indications Patients unable or unwilling to consume adequate nutrition to meet metabolic requirements alone or with assistance Complement insufficient intake or increased demand

6. Enteral Nutrition: Indications Requires total or partial GI tract function Anorexia Apoplexy Coma Sepsis Trauma/surgery Transition from parenteral nutrition

7. Enteral Nutrition: Contraindications Absolute Complete bowel obstruction Severe small bowel ileus with abdominal distention Complete inability to absorb nutrients through the GI tract

8. Enteral Nutrition: Contraindications Relative Severe postprandial pain Short bowel syndrome Intractable vomiting Severe diarrhea

9. Gastric Access Gastric Route Preferred Adequate gastric motility Minimum risk of aspiration Gastric Route Contraindicated Delayed gastric emptying (gastroparesis) High risk for aspiration

10. Gastric Access Gastric Route Advantages Normal reservoir for food Easy access Tolerates high osmotic loads Tolerates intermittent feedings Gastric acid destroys contaminants Can be placed by nurses

11. Gastric Feeding Techniques Nasogastric Tube Short term Manual or radiologic placement Gastrostomy Long term Endoscopic, radiologic, or surgical placement Rugeles S, et al. Universitas Medica 1993;34(I):19-23

12. Nasogastric Tubes 8 Fr, stylet, opaque bolus, 45" 12 Fr, opaque, 36" 12 Fr, clear, 36"

13. Nasogastric Tube: Disadvantages Short-term use only Higher risk for aspiration Difficult to confirm position Small bore Nasopharyngeal trauma/irritation Accidental tube displacement

14. Percutaneous Endoscopic Gastrostomy: PEG Tubes Rigid Flexible Minard G. Nutr Clin Prac 1994;9:172-182

15. Percutaneous Endoscopic Gastrostomy: Advantages The same as for surgical gastrostomy No surgery / less invasive Minimal sedation Direct visualization < 30 minutes to place tube Lower costs

16. Percutaneous Endoscopic Gastrostomy: Placement Criteria Adequate passage for endoscope Ease in identifying safe site Ease in determining a safe tract Functioning GI tract Absence of ascites / morbid obesity Stellato TA, et al. Ann Surg 1984;200:46-50 Lee M, et al. Clin Radiol 1991;44:332-334

17. Surgical Gastrostomy Performed in operating room Indicated when PEG is contraindicated or during other surgical procedures Requires general anesthesia and full surgical team In observation during recovery More expensive than PEG

18. Gastrostomy: Low-Profile Tube

19. Post-pyloric Access Indications for post-pyloric route Patient at risk for bronchial aspiration, gastric reflux Gastric feeding contraindicated – Gastric motility disorders; e.g., gastroparesis – Upper GI tract condition; e.g., carcinoma, stricture, fistula

20. Post-pyloric Access Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387 Advantages  Allows earlier post-op feeding  Lower risk of aspiration Disadvantages  Small bore tubes, prone to obstruction  Tubes can be dislodged into stomach  Difficult to maintain long term  Potential for dumping syndrome  Requires infusion pump

21. Post-pyloric Feeding Techniques Gauderer MW, et al. J Pediatr Surg 1980;15:872-875 Short Term Nasoenteric – Nasoduodenal – Nasojejunal Long Term Jejunostomy – Percutaneous endoscopic jejunostomy or through the PEG tube – Surgical jejunostomy

22. Nasal Access: Tubes NasogastricNasoduodenal / Jejunal  Easy  Short term  Y-Port  Small bore  Weighted tip  Metal guidewire

23. Post-pyloric Enteral Nutrition: Indications History / risk of reflux or aspiration Gastric motility disorders Upper GI tract fistulae Acute pancreatitis

24. Post-pyloric Enteral Nutrition: Advantages Easily accessible Less invasive Lower risk of aspiration Manual, fluoroscopic, or endoscopic placement

25. Post-pyloric Enteral Nutrition: Disadvantages Placement can be difficult to achieve and maintain Requires x-ray confirmation Short term use only Nasopharyngeal trauma / irritation Small bore tube

26. Jejunostomy Feeding: Indications Feeding contraindicated for upper GI tract Gastric motility disorders History / risk of reflux or aspiration

27. Nutrition by Jejunostomy: Disadvantages Small bore tube Placement can be difficult to achieve and maintain Difficult to maintain for long term

28. Percutaneous Endoscopic Jejunostomy Tube placed with or without existing PEG Requires endoscopy Placed distal to Ligament of Treitz Bumpers HL, et al. Surg Endosc 1994;8:121-123

29. Nasal Access: Multilumen Tubes

30. Choosing the Feeding Site Can the GI tract be used? NoYes Tube feeding for more than 6 weeks? NoYes Nasoenteric Tube Risk for pulmonary aspiration? YesNoYesNo Nasogastric TubeJejunostomy Parenteral Nutrition Enterostomy Tube Nasoduodenal or nasojejunal tube Gastrostomy

31. Summary Enteral nutrition should always be the first option considered Gastric access is the first choice Use post-pyloric route if gastric access not possible Nasogastric route should be used for short term feedings Surgical or percutaneous enterostomies should be the choice for long term cases and for laparotomy patients