Chapt 5 Enteral Nutrition Administration Issues

8/19/2019 Chapt 5 Enteral Nutrition Administration Issues

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Enteral Nutrition for

Adults


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Contraindications for EN

♦Severe acute pancreatitis

♦Inability to gain access

♦Intractable vomiting or diarrhea

♦Aggressive therapy not warranted


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Contraindications for EN♦Inadequate resuscitation orhypotension; hemodynamic

instability♦Ileus

♦Intestinal obstruction

♦Severe GI !leed


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Indicators of Adequate "luid

#esuscitation in Critically Ill $ts♦%rine output should be &'( ml)hour ♦*eart rate +,-( beats)minute; preferably

+,(( beats)minute♦Systolic !$ should be .,((


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Nasogastric /ubes


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Nasogastric /ubes

0efinition

♦A tube inserted through the nasal passageinto the stomach

Indications1

♦Short term feedings required

♦ Intact gag refle2

♦Gastric function not compromised

♦3ow ris4 for aspiration


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"rench %nits5/ube Si6e♦0iameter of feeding tube is measured in"rench units

♦ ," 7 '' mm diameter

♦ "eeding tube si6es differ for formula types and

administration techniques

♦Generally smaller tubes are more comfortable

and better suited to NG or N8 feedings

♦9ay be more li4ely to clog with viscous

formula or formula mi2tures


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Nasogastric /ubes

Advantages1

♦ Ease of tube placement

♦ Surgery not required

♦ Easy to chec4 gastric residuals

♦ Accommodates various administration techniques


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Nasogastric /ubes

0isadvantages1

♦ Increases ris4 of aspiration :maybe

♦ Not suitable for patients with compromised gastric

function

♦ 9ay promote nasal necrosis and esophagitis

♦ Impacts patient quality of life


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Nasoduodenal)8e


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Nasoduodenal)8e


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Nasoduodenal)8e


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=rogastric

♦/ube is placed through mouth and into

stomach

♦=ften 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>

8e


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Enterostomy $lacement

♦ Gastrostomy

♦ 8e


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Gastrostomy

0efinition

♦ A feeding tube that passes into the stomach

through the abdominal wall 9ay be placed

surgically or endoscopicallyIndications1

♦ 3ong>term support planned

♦ Gastric function not compromised♦ Intact gag refle2 present


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Gastrostomy

0isadvantages1

♦ 9ay require surgery

♦ Stoma care required

♦ $otential problems for lea4age or tube

dislodgment


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Gastrostomy


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8e


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8eop feedings may be initiated immediately

♦ 0ecreased ris4 of aspiration

♦ Suitable option for patients with compromised

gastric function

♦ Stable patients can tolerate intermittent feedings


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8e


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0etermining 9ethod of

Administration

♦ "eeding site

♦ Clinical status of patient

♦ /ype of formula used

♦ Availability of pump

♦ 9obility of patient


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Initiation of Enteral "eedings

♦0ilution of enteral formulas not generally

recommended

♦ Initiate at full strength at slow rate and

steadily advance

♦Allows achievement of goal rates more

quic4ly; less manipulation of formula


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Administration♦!olus

♦ Intermittent

♦

Continuous♦Cyclic


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!olus "eedings

0efinition

♦ Infusion of up to ?(( ml of enteral formula into

the stomach over ? to -( minutes@ usually by

gravity or with a large>bore syringeIndications1

♦ #ecommended for gastric feedings

♦ #equires intact gag refle2♦ Normal gastric function


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!olus "eedings

Advantages1

♦ 9ore physiologic

♦ Enteral pump not required

♦ Ine2pensive and easy administration

♦ 3imits feeding time so patient is free to ambulate@

participate in rehabilitation@ or live a more normal

life in the home♦ 9a4es it more li4ely patient will receive full

amount of formula


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!olus

"eeding


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!olus "eeding

0isadvantages1

♦ Increases ris4 for aspiration


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Continuous "eedings

Indications1

♦ Initiation of feedings in acutely ill patients

♦ $romote tolerance

♦ Compromised gastric function

♦ "eeding into small bowel

♦ Intolerance to other feeding techniques


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Continuous "eedings

0efinition

♦ Enteral formula administration into the

gastrointestinal tract via pump or gravity@ usually

over to -B hours per day

Advantages1

♦ 9ay improve tolerance♦ 9ay reduce ris4 of aspiration

♦ Increased time for nutrient absorption


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Continuous "eedings

0isadvantages1

♦ 9ay reduce -B>hour infusion

♦ 9ay restrict ambulation

♦ 9ore e2pensive for home support

♦ $umps are more accurate; useful for small>bore

tubes and viscous feedings@ but many payers have

strict criteria for approval of pumps for home or3/C use


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Intermittent "eedings

0efinition♦ 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

♦ /ypically -((>'(( ml is given over '(>( minutes qB> hours

♦ $recede and follow with '(>ml flush of tap water

Indications1

♦ Intolerance to bolus administration

♦ Initiation of support without pump

♦ $reparation of patient for rehab services or dischargeto home or 3/C facility


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Advantages1

♦ 9ay enhance quality of life

D Allows greater mobility between feedings

D 9ore physiologic

D 9ay be better tolerated than bolus


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0isadvantages1

♦ Increased ris4 for aspiration

♦ Gastric distention

♦ 0elayed gastric emptying


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Cyclic "eedings

0efinition

♦ Administration of enteral formula via continuous drip over

a defined period of to ,- hours@ usually nocturnally

Indications1

♦ Ensure optimal nutrient inta4e when1

D /ransitioning from enteral support to oral nutrition

:enhance appetite during the day D Supplement inadequate oral inta4e

D "ree patient from enteral feedings during the day


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Cyclic "eedings

Advantages1

♦ Achieve nutrient goals with supplementation

♦ "acilitates transition of support to oral diet

♦ Allows daytime ambulation

♦ Encourages patient to eat normal meals and snac4s


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Cyclic "eedings

0isadvantages1

♦ 9ay require high infusion rates5may promote

intolerance


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Enteral "eeding Complications

♦ 9echanical

♦ Gastrointestinal

♦ 9etabolic

♦ Infectious


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9echanical

♦ "eeding tube obstruction

♦ "eeding tube dislodged

♦ Nasal irritation

♦ S4in irritation)e2coriation at ostomy site


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Causes of "eeding /ube =bstruction

♦ Concentrated@ viscous@ and fiber>containingfeeding products

♦ /ube feeding contamination

♦ Chec4ing of gastric residuals♦ Small diameter tubes

♦ $owdered or crushed medication flushed throughtubes

♦ Acidic or al4aline medications passed throughtubes

♦ /ubes not routinely flushed after feedings arestopped


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$revention of "eeding /ube

=bstruction♦"lush the feeding tube@ especially before

and after medication administration and bolus)intermittent feedings

♦%se liquid formulations of medicines where possible :but be careful of osmolarity

♦0o not mi2 medications with enteral

feedings unless shown to be compatible♦Avoid crushing enteric>coated tablets


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/reatment of

"eeding /ube =bstruction♦0eclog with irrigants :warm water or

sodium bicarbonate)pancrealipase mi2ture

or by mechanical means

♦Cola beverages@ cranberry


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Aspiration

♦#eported incidence of aspiration in tubefed

patients varies from to H? Clinically

significant aspiration ? gastric>fed pts

♦9any aspiration events are silentJ and

often involve oropharyngeal secretions

♦Symptoms include dyspnea@ tachycardia@

whee6ing@ rales@ an2iety@ agitation@ cyanosis

♦9ay lead to aspiration pneumonia


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Aspiration $revention

♦Keep head of bed elevated '(>B? degreesduring and '(>B( minutes after feedings

♦"eed post>pylorically :research mi2ed on

this♦Small@ frequent feedings or continuous drip

♦%se of promotility agents

♦9onitoring of gastric residuals may behelpful in identifying delayed gastricemptying and increased ris4 of aspiration

/he AS$EN Nutrition Support $ractice 9anual@ -nd Edition@ -((?


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Gastrointestinal Complications

♦ 0iarrhea

♦ Constipation

♦ Gastric distention)bloating

♦ Gastric residuals)delayed gastric emptying

♦ Nausea)vomiting


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0iarrhea

♦ 0efinition1 &?(( ml every hours or more than '

stools a day for at least two consecutive days

#elates more to stool consistency than frequency

♦ 0iarrhea was a common consequence of enteralfeedings when hyperosmolar feedings were

routinely delivered via syringe

♦ =ccurs in - to ' of enterally>fed pts depending

on how defined


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Causes)/reatments of 0iarrhea

♦ Intestinal atrophy due to malnutrition

D EN is the best stimulant for recovery Increase

rate slowly as tolerated

D Albumin infusion is unli4ely to be helpful;diarrhea is not caused by low albumin; it is a

mar4er of malnutrition

♦

!olus feeding in the small intestine1 resultsin dumping syndrome

D %se an infusion pump to regulate flow


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♦!acterial overgrowth of intestinal tract orcontamination of the enteral feeding D Avoid prolonged use of broad>spectrum

antibiotics D %se clean technique and closed system in

handling enteral feedings

D 3imit hang time of open system formulas to

hours :B hours for mi2tures D Change bag and tubing per protocol

D /est for C difficile and other pathogens beforeusing anti>motility agents


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♦Steatorrhea1 characteri6ed by frothy@

odiferous stools that float on water; caused

by fat intolerance

D %se lowfat enteral formula or one with higher

percentage of 9C/; pancreatic en6ymes may

help in pancreatic insufficiency


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♦3actose intolerance D 9ost enteral products are lactose free but this

may occur with initiation of full liquid diet

Eliminate mil4 and dairy products♦0rug>induced diarrhea

D 9eds may cause up to , of diarrhea intubefed pts due to hypertonicity or direct

la2ative action :magnesium@ sorbitol@ potassium 0iarrhea most common withantibiotics 0iscuss with 90)pharmacist


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♦ Infusion of hypertonic feeding solutions;

rare unless delivered at very high rate or

bolused into small bowel

D /ry a different product rather than diluting the

original feeding

♦GI disease1 such as I!S@ short gut@ celiac

disease@ AI0S D 9ay require $N or specially formulated EN


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/reatment of 0iarrhea in General

♦Add soluble fiber :such as banana fla4es or

!enefiber or insoluble fiber such as

psillium

♦Consider an enteral formula with added

fiber

♦%se an antidiarrheal agent :loperamide@

dipheno2ylate@ paregoric@ octreotide

♦Change the formula


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Nausea)Lomiting

♦ -( of patients on EN report

nausea)vomiting

♦=ften related to delayed gastric emptying

caused by hypotension@ sepsis@ stress@

anesthesia@ medications :analgesics and

anticholinergics@ surgery


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Nausea)Lomiting /reatment

♦ Consider reducing)discontinuing narcoticmedications

♦ Switch to a lowfat formula

♦ Administer feeding solution at room temperature♦ #educe rate of infusion by -(>-? ml)hr

♦ Administer pro4inetic agent :metoclopramide@erythromycin@ domperidone@ bethanechol

♦ Chec4 gastric residuals♦ Consider antiemetics


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9etabolic

♦ "luid and Electrolyte abnormalities

♦ Glucose intolerance

♦ CaMM@ 9gMM@ $=B abnormalities

♦ =ther


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"luid and Electrolyte

0isturbances♦9ay result from long term nutrition deficits@

acute stress@ medications@ medical

conditions@ improper nutrient prescription

♦Electrolytes lost via stool@ urine@ ostomy or

fistula drainage

♦0ehydration most common complication

:tube feeding syndrome especially with

high protein feeding and insufficient fluid


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9onitoring of $atients on EN

♦ Electrolytes

♦ !%N)Cr

♦ Albumin)prealbumin

♦ CaMM@ $=B@ 9gMM

♦ eight

♦ Input)output

♦

Lital signs♦ Stool frequency)consistency

♦ Abdominal e2amination

Documents

Chapt 5 Enteral Nutrition Administration Issues