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Enteral Nutrition for
Adults: Administration Issuesincluding material from
Dietitians in Nutrition Support
A DIETETIC PRACTICE GROUP OF
AMERICAN DIETETIC ASSOCIATION
Your link to nutrition and health.
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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 ifmalnourished or 7-9 days ifnormally nourished
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143
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Contraindications for ENInadequate resuscitation or
hypotension; hemodynamic
instabilityIleus
Intestinal obstruction
Severe G.I. Bleed
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Indicators of Adequate Fluid
Resuscitation in Critically Ill PtsUrine output should be >30 ml/hour
Heart rate
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Nasogastric Tubes
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Nasogastric Tubes
Definition
A tube inserted through the nasal passageinto the stomach
Indications:
Short term feedings required
Intact gag reflex
Gastric function not compromised
Low risk for aspiration
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French UnitsTube 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
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Nasogastric Tubes
Advantages:
Ease of tube placement
Surgery not required
Easy to check gastric residuals
Accommodates various administration techniques
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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
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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
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Nasoduodenal/Jejunal
Advantages:
Allows for initiation of early enteral feeding
May decrease risk of aspiration
Surgery not required
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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
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EAL EN Guidelines (Critical Care)
Adequately-powered studies have not beenconducted to evaluate the impact of GRVon aspiration pneumonia.
There may be specific disease states orconditions that may warrant small boweltube placement (e.g., fistulas, pancreatitis,gastroporesis), however they were notevaluated at this phase of the analysis.Fair; conditional
ADA EAL Guidelines Critical Care accessed 8-07
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Nasoduodenal/Jejunal
Disadvantages:
Transpyloric tube placement may be difficult
Limited to continuous infusion
May promote nasal necrosis and esophagitis
Impacts patient quality of life
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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
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Gastrostomy-
Jejunosotomy
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Enterostomy Placement
Gastrostomy
Jejunostomy
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Gastrostomy
Definition
A feeding tube that passes into the stomach
through the abdominal wall. May be placed
surgically or endoscopicallyIndications:
Long-term support planned
Gastric function not compromised Intact gag reflex present
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Gastrostomy
Disadvantages:
May require surgery
Stoma care required
Potential problems for leakage or tube
dislodgment
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Gastrostomy
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Jejunostomy
Definition
A feeding tube that passes into the jejunum
through the abdominal wall. May be placed
endoscopically or surgicallyIndications:
Long-term feeding option for patients at high risk
for aspiration or with compromised gastricfunction
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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
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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)
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Determining Method of
Administration
Feeding site
Clinical status of patient
Type of formula used
Availability of pump
Mobility of patient
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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
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AdministrationBolus
Intermittent
ContinuousCyclic
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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 syringeIndications:
Recommended for gastric feedings
Requires intact gag reflexNormal gastric function
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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
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Bolus
Feeding
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Bolus Feeding
Disadvantages:
Increases risk for aspiration
Hypertonic, high fat, or high fiber formulas may
delay gastric emptying or result in osmoticdiarrhea
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Initiation of Bolus Feedings
Adults: Initiate with full strength formula 3-8 times per day with increases of 60-120 mlq 8-12 hours as tolerated up to goal volume;
does not require dilution unless necessary tomeet fluid requirements
Children: Initiate with 25% of goal volumedivided into the desired number of dailyfeedings; increase by 25% each day dividedamong all feedings until goal volume isreached
ASPEN Nutrition Support Practice Manual, 2005, 2nd
ed, p. 78
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Continuous Feedings
Indications:
Initiation of feedings in acutely ill patients
Promote tolerance
Compromised gastric function
Feeding into small bowel
Intolerance to other feeding techniques
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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
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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 orLTC use
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Initiation of Continuous Feedings
Adults: Initiate at full strength at 10-40ml/hour and advance to goal rate inincrements of 10 to 20 mL/hour q 8-12
hours as toleratedCan be used with isotonic or hyperosmolar
formulas
Children: Isotonic formula full strength at 1-2 mL/kg/hour and advanced by .5-1mL/kg/hour q 6-24 hours until goal rate isachieved
ASPEN Nutrition Support Practice Manual, 2005, 2nd ed, p. 78
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Intermittent Feedings
Definition Enteral formula administered at specified times
throughout the day; generally in smaller volume andat slower rate than a bolus feeding but in largervolume and faster rate than continuous drip feeding
Typically 200-300 ml is given over 30-60 minutes q4-6 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 dischargeto home or LTC facility
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005
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Intermittent Feedings
Advantages:
May enhance quality of life
Allows greater mobility between feedings
More physiologic
May be better tolerated than bolus
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Intermittent Feedings
Disadvantages:
Increased risk for aspiration
Gastric distention
Delayed gastric emptying
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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
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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
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Cyclic Feedings
Disadvantages:
May require high infusion ratesmay promote
intolerance
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Enteral Feeding Tubes
Types: pediatric vs adult; gastric vs small bowel
Sizes: smaller sizes (5-8 Fr) for commercial productsdelivered via pump; larger sizes for viscous,
blenderized, fiber-containing formulas, gravity andbolus feedings
Weighted vs. unweighted: it was once thought thatweighted tubes facilitated transpyloric passage; nowdictated by personal preference
Stylet vs. no stylet: stylet facilitates tube placementbeyond the pylorus for small, flexible tubes
Composition: silicone and polyurethane mostcomfortable
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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?
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Enteral Feeding Containers
May be rigid or
flexible
Sterile or non-sterile
Unbreakable,leakproof, and
disposable
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Considerations in Choosing
Enteral Feeding ContainersEasy 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
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Closed Systems
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Enteral Feeding Pumps
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Factors in Pump Selection
Simple to use
(intuitive)
Alarm system
Lightweight Long battery life
Portable
Volume infusedindicator
Dose function
Flow rate accurate to
within 10%
Approved for agerange in which it will
be used
Permanently attached
cord
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Enteral Feeding Complications
Mechanical
Gastrointestinal
Metabolic
Infectious
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Mechanical
Feeding tube obstruction
Feeding tube dislodged
Nasal irritation
Skin irritation/excoriation at ostomy site
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Causes of Feeding Tube Obstruction
Concentrated, viscous, and fiber-containingfeeding products
Tube feeding contamination
Checking of gastric residuals Small diameter tubes
Powdered or crushed medication flushed throughtubes
Acidic or alkaline medications passed throughtubes
Tubes not routinely flushed after feedings arestopped
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Prevention of Feeding Tube
Obstruction
Flush the feeding tube, especially beforeand after medication administration andbolus/intermittent feedings
Use liquid formulations of medicines wherepossible (but be careful of osmolarity)
Do not mix medications with enteralfeedings unless shown to be compatible
Avoid crushing sustained-release or enteric-coated tablets
f
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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
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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
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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 andquestionable 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 septicpatients
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Aspiration Prevention
Keep head of bed elevated 30-45 degreesduring 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 behelpful in identifying delayed gastricemptying and increased risk of aspiration
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005
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Gastrointestinal Complications
Diarrhea
Constipation
Gastric distention/bloating
Gastric residuals/delayed gastric emptying
Nausea/vomiting
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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 enteralfeedings when hyperosmolar feedings were
routinely delivered via syringe
Occurs in 2 to 63% of enterally-fed pts depending
on how defined
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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: resultsin dumping syndrome.
Use an infusion pump to regulate flow
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005
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Causes/Treatments of Diarrhea
Bacterial overgrowth of intestinal tract orcontamination of the enteral feeding
Avoid prolonged use of broad-spectrum
antibioticsUse 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 beforeusing anti-motility agents
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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 higherpercentage of MCT; pancreatic enzymes may
help in pancreatic insufficiency
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Causes/Treatments of Diarrhea
Lactose intoleranceMost 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 intubefed pts due to hypertonicity or direct
laxative action (magnesium, sorbitol,potassium). Diarrhea most common withantibiotics. Discuss with MD/pharmacist
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005
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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 theoriginal feeding
GI disease: such as IBS, short gut, celiac
disease, AIDSMay require PN or specially formulated EN
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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
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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
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Nausea/Vomiting Treatment
Consider reducing/discontinuing narcoticmedications
Switch to a lowfat formula
Administer feeding solution at roomtemperature
Reduce rate of infusion by 20-25 ml/hr
Administer prokinetic agent (metoclopramide,
erythromycin, domperidone, bethanechol) Check gastric residuals
Consider antiemetics
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Metabolic
Fluid and Electrolyte abnormalities
Glucose intolerance
Ca++, Mg++, PO4 abnormalities
Other
Fluid and Electrolyte
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Fluid and Electrolyte
DisturbancesMay result from long term nutrition deficits,
acute stress, medications, medical
conditions, improper nutrient prescription
Electrolytes lost via stool, urine, ostomy orfistula drainage
Dehydration most common complication
(tube feeding syndrome) especially withhigh protein feeding and insufficient fluid
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Hyperglycemia
Often reflects acute stress, infection, medications
(especially steroids) or latent diabetes
Macronutrient distribution: is generally not the
primary issue; most enteral feeding formulas fallwithin established guidelines; could try formula
lower in carbohydrate
Insulin management
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Refeeding Syndrome
At risk: when refeeding those with marginalbody nutrient stores, stressed, depletedpatients, 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; acuterespiratory failure
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Refeeding Syndrome
Correct electrolyte abnormalities (via oral,enteral, parenteral route) before initiatingnutrition support
Administer volume and energy slowlyMonitor pulse rate, intake and output, and
electrolyte levels
Provide appropriate vitaminsupplementation
Avoid overfeeding
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Infectious Complications
Formula contamination
Unsanitary equipment
Failure to follow appropriate protocols re handling
of enteral feedings/changing of bags and tubing
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Monitoring of Patients on EN
Electrolytes
BUN/Cr
Albumin/prealbumin
Ca++
, PO4, Mg++
Weight
Input/output
Vital signs
Stool frequency/consistency
Abdominal examination
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Evaluating Adequacy of Support
Is and Os (what % of prescribed feeding did
patient receive?)
Indirect calorimetry
Nitrogen balance Weight
Visceral proteins
Other
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Home Support
Discharge planning
May work with DME company to identifywhether patient is a candidate for home EN,
assure availability of product; completeCMN form in conjunction with physician
Patient education
Patients going home on enteral feedings
will need education on food safety, feedingadministration, and self-monitoring
Reimbursement
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Enteral Support Summary
Preferred method of nutrition support
Technology exists to facilitate
implementation
Can be successfully employed with careful
patient and formula selection