Monitoring Complications of Enteral Nutrition Therapy
Session 4
After completing this session, participants will be able to:
• Identify and manage complications associated with enteral nutrition therapy
Objectives
Categories of Complications Associated with Tube Feeding
Potential complicatons
Potential complicatons
Mechanical Mechanical Pulmonary aspiration Pulmonary aspiration
Metabolic Metabolic
Gastrointestinal Gastrointestinal
Nasoenteric feeding tube
Gastrostomy feeding tube
• Use tubes made with biocompatible materials
• Do not use rubber, latex or polyvinyl chloride tubes
• Use appropriate tube size Small-bore for nasoenteric tubes
• ~8-10 French size
Gavi S, et al. Ann Long-Term Care 2008;16:28-32.
Mechanical Complications Prevent Irritation/Infection at Tube Site
• Properly tape the tube to reduce risk of Formula infusion in
esophagus, pharynx, larynx, or nasal cavity
Bronchial aspiration
Pendley F, et al. Enteral Nutrition Support in Critical Care: A Practical Guide for Clinicians. Columbus, Ohio, Abbott Nutrition, Abbott Laboratories, 1994.
Seder CW, et al. Nutr Clin Pract 2008;23:651-654.
Mechanical Complications Prevent Tube Migration
Use slide 11, session 8 TNT 3.0
Mechanical Complications Properly Inflate Balloon
Use slide 12, session 8 TNT 3.0
American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.
Mechanical Complications Properly Position External Skin Disks
• Routine irrigation with clear water or saline
• Do not use fruit juice or carbonated beverages
• Always use a syringe >30 cc during tube care
Feeding tube ruptured from excessive pressure applied by small syringe
Mechanical Complications Maintain Tube Patency
• Elevate the head of the bed 30° to 45° • Provide good oral care • Regularly assess tube feeding
tolerance and tube position • Provide tight glycemic control • Correct electrolyte abnormalities • Minimize narcotic dosage • Use continuous rather than intermittent feeding • Feed beyond the ligament of Treitz
McClave SA, et al. JPEN J Parenter Enteral Nutr 2002;26(6 Suppl):S80-S85.
Pulmonary Aspiration Can Be Lethal Use Aspiration Precautions
• Do not discontinue enteral feeding for GRV <500 mL
• GRV >500 mL: Withhold feeding
• GRV >200 mL on two successive assessments: Withhold feeding
• GRV threshold >250 mL: Use a protocol-driven approach
Pulmonary Aspiration Is Monitoring Gastric Residual Volume (GRV) Helpful?
McClave SA, et al. Crit Care Clin 2010;26:451-466. McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316.
Update of the Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. www.criticalcarenutrition.com/docs/cpg/srrev.pdf.
• GI motor dysfunction • Admission diagnoses (eg, burns, head injury,
sepsis, and multiple trauma) • Age of the patient • GI conditions • Medications Sedatives, analgesics and vasopressor agents
delay gastric emptying Hyperosmolar medications such as sorbitol can cause
osmotic diarrhea
• GI disuse atrophy
Deane A, et al. World J Gastroenterol 2007;13:3909-3917. Magnuson BL, et al. Nutr Clin Pract 2005;20:618-624.
Wohlt PD, et al. Am J Health Syst Pharm 2009;66:1458-1467. Beckwith MC, et al. Hosp Pharm 2004;39:225-237.
Gastrointestinal (GI) Complications Non-formula Etiologies
McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316. Update of the Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically
Ventilated, Critically Ill Adult Patients. www.criticalcarenutrition.com/docs/cpg/srrev.pdf. Kreymann KG, et al. Clin Nutr 2006;25:210-223.
Manage Non-formula Etiologies Gastrointestinal (GI) Complications
Etiology • GI motor dysfunction • Admission diagnoses
(eg, burns, head injury, sepsis, and multiple trauma)
• Aging • GI conditions
Management • Consider prokinetic
agents and postpyloric feeding
• Consider an oligomeric, peptide-based enteral formula
Manage Non-formula Etiologies Gastrointestinal (GI) Complications
Etiology • Medications
Management • Consult with a pharmacist
Manage Non-formula Etiologies Gastrointestinal (GI) Complications
McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316.
Etiology • GI disuse atrophy
Management • Rule out C. difficile
infection, treat diarrhea • Continue to feed
enterally Consider a soluble fiber-
supplemented formula
• Consider supplemental parenteral nutrition
• Malabsorption of formula components
Fat, intact protein, lactose
• Hyperosmolar formulas
• Rapid formula delivery
• Microbiological contamination
Formula-related Etiologies Gastrointestinal (GI) Complications
Deane A, et al. World J Gastroenterol 2007;13:3909-3917.
Manage Formula-related Etiologies Gastrointestinal (GI) Complications
Etiology • Malabsorption of
formula components
Management • Consider formulas
designed to enhance tolerance
• Avoid lactose
American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.
Manage Formula-related Etiologies Gastrointestinal (GI) Complications
Etiology • Hyperosmolar
formulas
• Rapid formula delivery
Management • Use full-strength
formulas Do not dilute formula
• Reduce the formula flow rate initially and advance as tolerated
• Use an enteral feeding pump
American Gastroenterological Association. Gastroenterology 1995;108:1280-1281.
Bankhead R, et al. JPEN J Parenter Enteral Nutr 2009;33:122-167.
Manage Formula-related Etiologies Gastrointestinal (GI) Complications
Etiology • Microbiological
contamination
Management • Safely handle formula
during preparation and administration
• Maintain safe formula hangtime 8 hours for open systems ≤4 hours for reconstituted powder formulas 24–48 hours for prefilled containers
• Avoid excessive handling and formula manipulation
• Do not add substances to formula
Manage Formula-related Etiologies Gastrointestinal (GI) Complications
Bankhead R, et al. JPEN J Parenter Enteral Nutr 2009;33:122-167.
• Serum electrolytes • Blood glucose • Blood urea nitrogen • Serum creatinine • Calcium • Phosphorus
• Magnesium • Liver enzymes • Vital signs • Body weight • Feeding tolerance
Metabolic Monitoring Metabolic Complications
Russell MK. Monitoring complications of enteral feedings. In Charney P, Malone A (eds.). ADA Pocket Guide To Enteral Nutrition. Chicago, The American Dietetic Assoication, 2006. pp. 155-192.
• Provide antioxidant vitamins and trace elements to all patients receiving specialized nutrition therapy
• Aggressively replete phosphorus, magnesium, and potassium to prevent refeeding syndrome
McClave SA, et al. JPEN J Parenter Enteral Nutr 2009;33:277-316. Boateng AA, et al. Nutrition 2010;26:156-167.
Ensure Adequate Provision of Vitamins and Minerals Metabolic Complications
• Caused by rapidly advancing feeding in malnourished patients
• Characterized by Hypophosphatemia Hypokalemia Hypomagnesemia Fluid overload
• Anticipate it and correct fluid and electrolyte deficiencies before starting feeding
• Slowly advance feeding rate
Prevent Refeeding Syndrome
• Anticipation is key Correct pre-existing electrolyte abnormalities
• Initiate nutrition repletion slowly Initiate hypocaloric feeds
• (10-20 kcal/kg actual weight) Gradually increase feeding rate
over first week
Prevent Refeeding Syndrome
Boateng AA, et al. Nutrition 2010;26:156-167.
Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR)
• Intensive glucose control (81-108 mg/dL; 4.5-6.0 mmol/L)
Increased mortality
Increased risk of hypoglycemia
Glycemic control to ~150 mg/dL (8.3 mmol/L) is safer for critically ill patients
The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297. Reeds D. Curr Opin Gastroenterol 2010;26:152-155.
Hyperglycemia is Common in Critically Ill Patients Metabolic Complications
“Sliding-scale insulin as monotherapy generally is ineffective and may be harmful.”
Thompson CL et al. Diabetes Spectrum 2005;18:20-27.
Intensive Insulin Therapy Sliding-scale Insulin (Basal Low-frequency dose)
6 am 12 pm 6 pm 12 pm
Hypo
Sliding-scale Insulin By Itself is Not Effective Therapy
• Insulin is the most appropriate agent • Use continuous IV infusion for critically
ill patients • Use scheduled subcutaneous
basal-bolus insulin regimens for non-critically ill patients
• Avoid hypoglycemia • Insulin analogs are preferred • Sliding-scale insulin regimens are not
effective
Moghissi ES. Curr Med Res Opin 2010;26:589-598.
Best Use of Insulin for Glycemic Management
• Initiate insulin therapy for persistent hyperglycemia, starting at a threshold of not >180 mg/dL (10.0 mmol/L)
• Maintain blood glucose 140 – 180 mg/dL (7.8 – 10.0 mmol/L)
• Lower targets may be appropriate in select patients, but not <110 mg/dL
• IV insulin infusion adjusted according to validated protocols with demonstrated safety and efficacy is preferred
• Monitor glucose frequently to achieve optimal glucose control
Moghissi ET, et al. Diabetes Care 2009;32:1119-1131.
Recommendations for Optimal Glucose Control for Critically Ill Patients
Variable CRS IIT
Insulin (P <0.05)
2 units daily
52 units of regular insulin daily
Median blood glucose
(P <0.05)
144 mg/dL (8 mmol/L)
133.6 mg/dL (7.4 mmol/L)
Hypoglycemia (P <0.001)
6 (3.5%) 27 (16%)
de Azevedo JRA et al. J Crit Care 2010;25:84-85.
Comparison of Intensive Insulin Therapy (IIT) to Carbohydrate-Restrictive Strategy (CRS)
Nutritional Complications
Research Objective: Describe the prognostic impact of nutritional status on 6-month mortality
Subjects: 165 older-adult patients hospitalized for an acute event
Results: Nutritional status is associated with 6-month mortality and persists after adjusting for sex, age, comorbidity, and functional status
Clinical Application: Strategic nutrition therapy during hospitalization and following discharge can positively affect long-term outcomes.
Expaulella J, et al. Age Ageing 2007;30:407-413.
Increased Mortality Seen in Spanish Study
“FASTHUG” Clinical Checklist Focusing On: • Feeding • Analgesia • Sedation • Thromboembolic prophylaxis • Head-of-the-bed elevation • Stress ulcer prophylaxis • Glycemic control
Johns RH, et al. Postgrad Med J 2010:86:541-551. Vincent JL. Crit Care Med 2005;33:1225-1229.
Provide Strategic Nutrition Therapy
• Enteral nutrition therapy is associated with complications, but they are largely preventable and can be managed
• Complications associated with enteral nutrition therapy are categorized as mechanical, gastrointestinal, and metabolic
• Appropriate and strategic nutrition therapy is key to improving long-term outcomes for patients
Key Concepts