Enteral Nutrition for Adults Administration Issues including material

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. ”

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

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

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

Nasogastric Tubes

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

French Units—Tube Size ¨ Diameter of feeding tube is measured in French units ¨ 1 F = 33 mm diameter ¨ Feeding tube sizes differ 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

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

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

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

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

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 250 ml 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

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

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

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

Gastrostomy. Jejunosotomy

Enterostomy Placement ¨ Gastrostomy ¨ Jejunostomy

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

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

Gastrostomy

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

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

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)

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

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

Administration ¨ Bolus ¨ Intermittent ¨ Continuous ¨ Cyclic

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

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

Bolus Feeding

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

Initiation of Bolus Feedings ¨ Adults: Initiate with full strength formula 3 - 8 times per day with increases of 60 -120 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, 2 nd ed, p. 78

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

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

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

Initiation of Continuous Feedings ¨ Adults: Initiate at full strength at 10 -40 ml/hour and advance to goal rate in increments of 10 to 20 m. L/hour q 8 -12 hours as tolerated ¨ Can be used with isotonic or hyperosmolar formulas ¨ Children: Isotonic formula full strength at 12 m. L/kg/hour and advanced by. 5 -1 m. L/kg/hour q 6 -24 hours until goal rate is achieved ASPEN Nutrition Support Practice Manual, 2005, 2 nd ed, p. 78

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 200 -300 ml is given over 30 -60 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, 2 nd Edition, 2005

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

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

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

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

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

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

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?

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

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 casebased core curriculum. 2001; 179

Closed Systems

Enteral Feeding Pumps

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

Enteral Feeding Complications ¨ Mechanical ¨ Gastrointestinal ¨ Metabolic ¨ Infectious

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

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

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 entericcoated tablets

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, 2 nd Edition, 2005

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

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

Aspiration Prevention ¨ Keep head of bed elevated 30 -45 degrees during 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 be helpful in identifying delayed gastric emptying and increased risk of aspiration The A. S. P. E. N. Nutrition Support Practice Manual, 2 nd Edition, 2005

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

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

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, 2 nd Edition, 2005

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

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

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, 2 nd Edition, 2005

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

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

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

Nausea/Vomiting Treatment ¨ Consider reducing/discontinuing narcotic medications ¨ Switch to a lowfat formula ¨ Administer feeding solution at room temperature ¨ Reduce rate of infusion by 20 -25 ml/hr ¨ Administer prokinetic agent (metoclopramide, erythromycin, domperidone, bethanechol) ¨ Check gastric residuals ¨ Consider antiemetics

Metabolic ¨ Fluid and Electrolyte abnormalities ¨ Glucose intolerance ¨ Ca++, Mg++, PO 4 abnormalities ¨ Other

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

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

Refeeding Syndrome ¨ At risk: when refeeding those with marginal body nutrient stores, stressed, depleted patients, those who have been unfed for 710 days, persons with anorexia nervosa, chronic alcoholism, weight loss ¨ Symptoms: Hypokalemia, hypophosphatemia and hypomagnesemia; cardiac arrhythmias, heart failure; acute respiratory failure

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

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

Monitoring of Patients on EN ¨ Electrolytes ¨ BUN/Cr ¨ Albumin/prealbumin ¨ Ca++, PO 4, Mg++ ¨ Weight ¨ Input/output ¨ Vital signs ¨ Stool frequency/consistency ¨ Abdominal examination

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

Home Support ¨ Discharge planning – 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

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