Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, Limerick, Ent/Ol j2010 Page 1 of 18

~.SIirtHI!!ib ,,,",,__ Enteral Feeding Guidelines (Adults) Mid-Western Regional Hospital, Limerick

Document Ent/01/2010 Document Marcella Richardson reference drafted by Senior Dietitian in number Nutrition Support

Erica Shanley, CNM2 ICU Teresa Woodland, Staff Nurse Ward 46

Revision number 02 Document

I ~laLoke~~ie:i~!jlO approved by

l~Aer fi~ L Mr E. Kavanagh 7 '"'" Consultant Surgeon

bw:L 1y30/C ?1 Gerardlne Kennedy, Nurse Practice Development cgrdinator

~"-'- ~J< , Susan Stack Senior Pharmagst

j;.)~ fl!i!i'f!.{), ~ J

P-P Geraldine ShaWl ~

Director of Nursing and Midwifery, MWRH

~- ./ Professor D. L~ on5 Consultant Ph~ sician

Approval date July 2010 Responsibility Dietitians, Nursing and for Medical Staff implementation

Revision date July 2012 Responsibility Dietitian Manager, for evaluation Nursing Practice and audit Development Coordinator

and Medical Nominee

Pages 20

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, limerick, Ent/01/2010 Page 2 of 18

TABLE OF CONTENTS PAGE

1.0 GUIDELINE STATEMENT 3

2.0 PURPOSE 3

3.0 SCOPE 3

4.0 DEFINITIONS 3

5.0 ROLES AND RESPONSIBILITIES 3 -4

6.0 PROCEDURE 4-8 6.1 Placing the Tube 4 6.2 Verifying the position of the tube using pH strips 4 6.3 Indications for enteral feeding 4 6.4 Feed Administration 4-5 6.5 Administering drugs via enteral feeding tubes 5-6 6.6 Out of Hours Feeding Regime Wards and HDU 6

Out of Hours Feeding Regime IeU ONLY 7 6.7 Re-feed ing Syndrome causes and management 8 6.8 Planned Aspiration of feed ' ·H 6.9 Monitoring required for patients receiving enteral feeding 8 6.10 Blockage of Tube 8-9

7.0 IMPLEMENTATION 9

8.0 AUDIT 9

9.0 REFERENCES 10

ApPENDICES PAGES 11-18 1. GUIDELINE TO CONFIRM CORRECT POSITION OF A NASOGASTRIC (N.G.) TUBE IN THE STOMACH

2. Tips to help aspirate gastric secretions via fine-bore nasa-gastric tube 3. LIQUID PREPARATIONS WHICH ARE NOT SUITABLE FOR ADMINISTRATION VIA ENTERAL FEEDING TUBES

4 . ENTERAL FEEDING AND DRUG INTERACTIONS

S. TABLETS WHICH SHOULD NOT BE CRUSHED AND CAPSULES WHICH SHOULD NOT BE OPENED

6 GUIDELINES FOR ASPIRATION OF ENTERAL FEEDING TUBES

7. RE-FEEDING SYNDROME

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, limerick, Ent/Ol/2010 Page 3 of 18

1.0 GUIDELINE STATEMENT

1.1 This Enteral Feeding Guideline outlines the referral system, the administration and the monitoring necessary, for all patients receiving enteral feeding.

2.0 PURPOSE

2.1 The purpose of the guideline is to assist nursing, dietetic and medical staff in the care of adult patients receiving nutritional support in the form of enteral feeding.

3.0 SCOPE

3.1 Applies to all registered general and psychiatric nurses, student nurses, clinical dietitians and medical staff, working within the Mid Western Regional Hospital Limerick.

4.0 DEFINITIONS

4.1 Enteral Feeding is defined as the administration of nutrients direct ly into the gastrointestinal tract . The route (see table 1) and amount of enteral feeding will be decided on an individual basis according to the clinical indications, treatment plan and nutritional state of the individual patient. Enteral feeding should be considered in people who are malnourished or at risk of malnutrition and have a) Inadequate or unsafe oral intake, and b) a functiona l, accessible gastrointestinal tract . For common indications for enteral tube feeding see section 6.3, table 2. 4.2 This guideline covers the following routes for enteral feeding: Ora-gastric, Naso-gastric, Naso­duodenal and Naso-jejunal . Consult the current issue of "Clinical Guidelines for the selection of patients receiving nutritional support via gastrostomy", with regard to all patients who receive nutritional support via Percutaneous Endoscopic Gastrostomy (PEG). Table l' Access routes

Gastric Access Post Pvloric Access Oro-qastric feedinq Naso-duodenal (ND) Naso-gastric feeding Naso-jejunal (N) Percutaneous endoscopic gastrostomy Surgical jejunostomy (S)

, (PEG) Surgical gastrostomy Percutaneous endoscopic jejunostomy

(PE) Radiologically inserted gastrostomy (RIG) Percutaneous endoscopic gastrostomy with

jejunal extension (PEG) (placed endoscopically or radiologically)

4.3 The Nasogastnc/nasojejunal feeding tube Is the most commonly used enteral feeding tube and is suitable for short term use. Fine bore feeding tubes should be used whenever possible as these are more comfortable for the patient than wide bore tubes. For medium and long term feeding gastrostomy/jejunostomy tubes may be more appropriate.

5.0 Roles and Responsibilities 5_1 Nurses 5.1.1 Will monitor and manage the administration of feeds to patients, the hydration of patients and will liaise with the multi-disciplinary team regarding any concerns arising . 5.1.2 Will document all feeding regimes and administer same as prescribed by the medical team and in consultation with the dietitians. 5.1.3 Will bring to the attention of the medical team and Dietitian any issues concerning hydration. 5.1.4 Will consult regarding care, with the patient (and/or family with the patients consent). 5.1.5 Will monitor and support the patient. 5.2 Medical Staff 5.2.1 Will consult this guideline as appropriate. 5.2.2 Will ensure all orders are written appropriately in the medication record . 5.2.3 Will consult with the dietitians regarding feeding regimes and patient tolerance of feeds. 5.2.4 Will consult with nursing staff with regard to patient care and tolerance of feeds. 5.2.5 Will ensure that all patients who commence on enteral feeding in "out of hours" periods wIll be referred for review by the Dietitian as soon as possible. 5.2.6 Will insert fine bore nasogastric enteral feeding tubes and all nasojejunal feeding tubes. 5.3 Dietitians 5.3.1 Will review all patients known to be receiving enteral feed ing when they are on duty and advise on the most suitable regime for each patient.

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5.3.2 Will be a resource to medical and nursing staff with regard to feeding reg imes and tolerance of feeds on a regular basis. 5,4 Pharmacists SA.1 Provide pharmaceutical care to patients in line with departmental policies and procedures 5.4.1 Will provide advice on the administration of medication via enteral feeding tubes to patients made known to the pharmacist through ward based activities or by referral. 5.4.2 Will be a resource to medical and Nursing staff

6.0 Procedure 6,1 placjng the Tube 6.1.1 Discuss the rationale and obtain consent for enteral feeding with the patient and/or relatives, parents or guardians as appropriate. 6.1.2 Prepare the patient for the insertion of the tube. 6.1.3 Gather all necessary equipment. 6.1.4 Wash and clean hands in accordance with the Infection Control policy. 6.1.5 Adhere to the principles laid down in the Hospi tal Medication Policy. 6.1.6 Open all packaging and ensure an aseptic fie ld and non-toUch technique. 6.1.7 Select the appropriate tube. 6.1.8 On initial placement, the position of a NasoGastriC (NG) tube, unless placed under rad iological guidance, must be checked for all adults by x-ray assessment, to ensure It is correctly positioned. NOTE! Check time and date of the x-ray as mult iple x- rays may have been taken on the same day. 6.1.9 When the position of the tube has been confirmed, remove the guide wire (if using a fine bore feeding tube), whilst firmly holding the feeding tube at the tip of the nose. Use tape to avoid displacement. Secure to nose and cheek. 6.1.10 Prophylactic use of an appropriate dressing may be used to prevent skin damage. 6.1.11 Placement of the cartrak naso-gastric tube may be confirmed by med ical personnel using an electra-magnetic sensor and printout of tube position (www.corpakmedsystems.com. accessed 21/06/10). Wash and clean hands after the procedure. 6.1.12 Tube placement shou ld be reconfirmed following violent coughing fits, vomiting or other potential causes of displacement. 6 .2 Verifying the position of the tube using pH strips (also See Appendix 1) 6.2.1 Position of N.G. tubes should be verified following initial placement, by x-ray and before first and each subsequent daily feed using pH indicator strips. pH should be less than 5.5, (NICE 2006;NPSA 2005; Appendix 1). See section 6.7 below for guidance on planned aspiration of the tube to confirm correct position. 6.2.2 The reliability of pH strips may be compromised by commonly used medication, such as proton-pump inhibitors, antacids and H2 antagonists. Patients receiv ing these medications have higher gastric and intestinal pH, potentially Increasing the need for X-ray confirmation of tube position (Duggan 2008), (See Appendices I and 2), 6.2.3 Always apply the aspirate directly from the syringe onto the pH strip. Do not use any other surface or paper for the aspirate as this can change the pH reading . 6.204 To avoid false negative results pH strips should be kept clean during storage and the syringe with gastric aspirate should not be put back into the syringe cover, (NPSA 2007) . 6.2.5 The whoosh test and litmus paper should not be used to verify position, (NPSA 2005). 6 3 I d' t ' f t I f d' • n Ica Ions or ~D ~[iI !:!: 109 Table2: Enteral Tube Feedina for the Adult Datlent (NICE 20061 Indication Example Unconscious patient Head injury, ventilated patient. Neuromuscular swallowing disorder Post CVA, Multiple Sclerosis, Motor Neurone Disease,

Parkinson's disease. Phvsiolooical anorexia Cancer sepsis liver disease HJV. U er GI obstruction Oro-oharvnaeal or oesoohaqeal stricture or tumour. GI dysfunction or mal-absorption Dysmotility inflammatory bowel disease, reduced

bowel length (although Parenteral Nutrition may be needed),

Increased nutritional requirements CystiC fibrosis burns. Psychological problems Severe depression or anorexia nervosa. Specific treatment Inflammatory bowel disease, for short term access

during surgery Le. head and neck cancer . . 6,4 Feed AdmlOlstratlon Following confirmation of the position of the tube:

6.4.1 Use a non touch technique to connect the feeding tube to the giving set and nutrient container I feed reservoir. 604.2 Ensure nutrient container/ feed reservoir is more than 50cm above the patient's abdomen.

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6.4.3 Giving sets should not be used for more than 24 hours. 6.4.4. Administer feeds at room temperature. 6.4.5 Enteral feeds are administered as a bolus or by continuous infusion over 24 hours (with or without a rest period) or by cyclical infusion over variable periods, as per dietitian's instructions. 6. 4.6 Following insertion of a nasojejunal feeding tube, feeding should only be commenced following confirmation of tube position. Commence feeding and increase as per dietitian's instructions. 6.4.7 Never force feed through a feeding tube. Bolus feeds if ordered, should be administered to adults using a SOml syringe. 6.4.8 Elevate the head of the bed to 30-45° fo r all adult patients at all times to reduce the risk of regurgitation or pulmonary aspiration of the feed (NICE 2006, Heyland 2003, BDA 2004). 6.4.9 When repositioning adult patients ensure that the feeding pump is placed on HOLD to reduce the risk of aspiration. 6.4.10 Flush the entera l feed ing tube with 50 mls of sterile water before feeding is commenced and after each change of feed, or as recommended by the dietitian and with at least 10mls sterile water after each drug administration (if administered via the tube). Administer 30 mls sterile water after the fina l medication has been administered, or as recommended by the dietitian. It is important to document all fluids in the fluid balance chart to ensure patients are managed appropriately. 6.4.11 If the feeding tube is not in use, it should be flushed daily with SOmls of water for adults. 6.4.12 Monitor the hydration of the patient. 6.4.13 Sterile feeds (ready to hang) can be hung for a maximum of 24 hours. Non-sterile feeds (including modular, diluted and modified sterile feeds) should not hang for more than 12 hours. 6 . 5 Administering Drugs Via enteral feeding tubes 6.5.1 General points to consider

a. Medicines should only be administered via an enteral feeding tube when prescribed for administration via that route. Administering medication via enteral feeding tubes generally falls outSide a drug's product authorisation Le. administration in this way is ·unlicensed'.

b. Do not add medication directly to feed c. Review the need for prescribed medications after enteral feeding tube insertion d. All routes of administration of the necessary medications should be considered. For

medications for administration via the tube consideration should be given to the use of liquid or soluble tablets. Crushing Tablets and opening capsules should be conSidered as a last resort. Pharmacist should be contacted for advice.

6.5.2 General information on administration of liquid preparations via enteral feeding tubes a. Not all liquid preparations are suitable for administration via enteral feeding tubes (see

appendix 3). Solutions with a high viscosity may adhere to the tube. liquid preparations with a high viscosity may need to be diluted prior to administration.

b. The liquid preparation may not be bioequivalent to the tablet or capsule e.g. Phenytoin 90mg in lSml may be considered to be approximately equivalent in therapeutic effect to capsules/tablets containing 100mg of phenytoin .

c. An injectable preparation may be licensed for oral administration e.g. phytomenadione (konakion) and vancomycin (generic faulding). This still does not license them for administration via enteral fceding tube, so the prescription must still specify that administration via tube is required.

d. Not all liquid preparations are listed in MIMS and/or the BNF so check with pharmacy regarding availability

e. It may be possible for pharmacy to prepare a liquid preparation if one is not commercially available, but this may have implications for continuity of supply on discharge.

f. Sometimes tablet/capsu le and liquid preparations are not bioequivalent and the dose and frequency of the liquid alternative may need to be changed.

g. Many liquid preparations contain sorbitol. Total daily doses of 7.Sg-30g may cause diarrhoea.

6.5.3 An enteral feed may interact with a drug and interfere with its absorption. Some interactions and action to be taken are in Appendix 4. As a general rule feed should be stopped for two hours before and two hours after an interacting drug is administered.

6.5.4 Inadequate flush ing is the most common cause of tube blockage. Seek advice for fluid restricted patients as flush volumes may need to be reduced .

6.5.5 Small volume syringes create high intraluminal pressures and may damage and split the enteral feeding tube. In order to reduce the risk of rupturing the fabric of the enteral feeding tube, the largest functional syringe size should be used. A SOml syringe is recommended for administering medicines and flushing the tube.

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6.5.6

6.5.7

6.5.8

6.5 .9

6.5. 10 6.5.11 6.5.12

Administration of d rugs into the jejunum (bypassing the duodenum) may lead to Incomplete adsorption and therapeutic failure. Consult pharmacist fo r advice when administering drugs directly into the jejunum Step by step guide to administering medication via enteral feeding tubes. The following are general rules. Advice may be sought from pharmacist regarding drug administration. 6.5.7.1 Put the feed on hold. 6.5.7.2 Flush the tube with at least 30mls of water 6.5 .7.3 Establish the need for a break in feeding before med ication is administered. 6.5. 7.4 Assemble medication and equipment needed. Prepare each drug separa tely. 6.5.7.5 Never mix drugs unless Instructed by a pharmacist. Administer drug appropriately seeking advice from pharmacist if necessary. 6.5.7.6 As a general guide: Soluble tablets: Dissolve soluble tablets in lO-lsm! of water . Administer down the tu be. 6.5.7.7 liquids: Shake well. Viscous liquids- dilute with equal amount of water immediately before administ ration. Admin ister down tube. Please note some viscous liquids would not be suitable for dilution . Seek advice if required. 6.5.7 .8 Tablets & capsules: Some tablets may dissolve in water and should be administered as described above. Seek advice from pharmacist. 6.5.7.9 If not dissolvable, crush uncoated and sugar-coated tablets using pestle and mortar or suitable device. Ensure that thi s device is clean and does not contain traces of other medication. 6.5 .7.9 Open capsule and tip contents into medicine pot. Do not crush enteric coated medicines, modified re lease (MR, SR, LA, XL) medicines, hormone preparations, cytotoxics or other preparations which the manufacturer has advised should not be crushed (see appendix 5). Do not open capsules containing hormonal or cytotoxic prepa ra tions or other preparations where the manufacturer has advised that the capsule may not be opened (see appendix 5). Seek advice from pharmacist . Mix the crushed tablet or contents of the capsule with lO-lsml of water and administer down the tube. Rinse tablet crusher/containers, and/or draw up rinsing water into the syringe used and flush this down the tube. This ensures that the whole dose is given. If more than one medicine is to be administered, flush between medicines with at least lOmls of water to ensure that the drug is cleared from the tube. Flush tube with at least 30ml of water following administration of the last drug. Establish whether a break is requ ired before restarting feed. See append ix 6 Restart the feed

6 .6 Out of Hours Feeding Regime 6.6.1 If a patient needs to commence feeding when a dietitian is not available please follow the regime below in Table 3. If the patient appears malnourished or has a history of poor nutrition you must be aware of the risk of the patient developing 'refeeding syndrome' . See appendix 7 to categorise the patient into 'at risk' or a 'high risk' category.

DAY 1:

Day 2:

Day 3:

600MLS "NUTRISON 1KcAL" AT 30MLS /HR FOR 20 HOURS

Rest for 4 hours = 600kcals; 24g protein; 26mmols Na+, 23mmols K+

1000mls "Nutrison lKcal H at 50mls / hr for 20 hours Rest for 4 hours =1000kcals; 40g protein; 43mmols Na+; 36mmols K+

DOOmls "Nutrison 1 Kcal" at 65 mls /hr for 20 hours Rest for 4 hours*'" = 1300kcals; 52g protein; S6mmols Na+; 49mmols K+

* * If patient Is less than 50 kg do not increase rate above SOmls/hr/20hrs

For patients at risk of refeeding syndrome Including renal who are ~ of re-feeding, follow regime below: 600mls "Nutrison lKcal" at 30mls/hr over 20 hrs on days 1, 2 & 3. For 'at high risk' patients follow reg ime below: 400mls "Nutrison lKcal H at 20mls/hr over 20 hours on days 1, 2 & 3. For renal patients who are not at risk of re-feeding and who are hyperkalaemic_and/or volume restricted, follow the regimen below:

payl,2 &3 600mls "Nutrlson Concentrated" at 30mls/hr for 20 hours

420 orotein. 26mmols Na+. 26mmols K+

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TABLE 4 OUT OF HOURS FEEOING REGIME FOR ICU ONLY

DAY 1 nOmls "Nutrison IKcal" at 30mls / hr for 24 hours No Rest '" nOkcals; 29g protein; 3Immols Na+, 27mmols K+ Day 2 I200mls "Nutrison 1 Kcal" at SOmls /hr for 24 hours No Rest =1200kcalsi 48g protein; 52mmols Na+; 46mmols K+

Day 3 1S60mls "Nutrison 1 Kcal ft at 65 mls / hr for 24 hours No Rest** = 1560kcals; 62g protein; 67mmols Na+; 59mmols K+

** If patient Is less than 50 kg do not increase rate above 50mls/hr/24hrs

For patients 'at risk' of refeeding including renal, follow regime below: n Omls "Nutrison 1 Kcal " at 30mls/ hr over 24 hrs on days 1, 2 & 3.

For 'at high risk' patients follow reg ime below:

480mls "Nutrison 1 Kcal " at 20mls/ hr over 24 hours on days 1, 2 & 3.

For renal patients who are not at risk of re~feeding and who are hyperkalaemic and/or volume restricted, follow the regimen below:

Qay1.2 &3 nOmls "Nutrison Concentrated" at 30mls/hr for 24 hours

= 1440KCALS, 54G PROTEIN, 31MMOLS NA+, 32MMOLS K+

6.6.2 These regimes will not meet the fluid requirements of all patients and patients may need to continue on I.V. fluids until the dietitian can assess their requirements. 6.6.3 Check bloods daily (U&E's, Ca 2 +, magnesium, phosphate, albumin/total protein) whilst using the 'Out of Hours' Feed ing Regime until reviewed by the dietitian.

6 .7 Re-feed jng Syndrome causes and management. (see Appendix 7 also) 6.7 .1 Re~ feeding problems encompass life-threatening situations. Medical assistance should be sought urgent ly. Causes include fluid and electrolyte imbalance and disturbances of organ function and metabolic regulation that may result from over~rapid or unbalanced nutrition support. It can occur in severely malnourished individuals but are particularly common In those who have had very little or no food intake, including overweight patients who have eaten nothing for protracted periods (NICE 2006). 6.7.2 Giving over- rapid or unbalanced nutrition support to malnourished patients can precipitate acute micronutrient deficiencies and dangerous changes in fluid and electrolyte balance (NICE 2006). 6.7.3 Management Includes monitoring fluid balance accurately and carefully restore circulatory volume. 6.7.4 See "Section 6.5 above for feeding regimes/assessment when dietitians are not on duty.

6.8 Planned Aspiration of feed 6.8.1 Feeding tubes need to be aspirated, to check pH to confirm tube position or to check gastric residual volumes. Put feed on HOLD immediately before checking pH to confirm tube position or when aspirating stomach contents.

6.8.2 Aspirating nasogastric tubes to check tube position 6.8.2.1 Aspirate all fine bore nasogastric tubes to check pH before administering each feed, before giving medication, at least once daily during continuous feeds and following episodes of vomiting, retching or coughing. Note: Absence of coughing does not rule out m isplacement or migration, following evidence of tube displacement (for example loose tape or visible tube appears longer) .

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6.8.2.2 Ensure all staff report misplaced feeding tube incidents through the local risk incident system (NPSA 2005).

6,8.3 Aspirating nasogastric tubes to check gastrjc residual volumes 6.8.3 The stomach contents should be aspirated in order to check gastric residual volumes, if impaired gastric emptying is suspected. 6.B.4 Aspirate nasogastric tubes every 4 hours until feeding is established 6.B.s Aspirate orogastric and nasogastric tubes every 4 hours in the Critical Care setting or when indicated. Monitor and report findings . 6.8.6 Routine aspiration from a single lumen nasojejunal tube is not necessary. 6.8 .7 The stomach contents may still need to be aspirated or drained regularly in nasojejunal feeding where the nasojejunal tube position has been confirmed but the patient shows signs of abdominal distension, or nausea and vomiting. 6.8.8 If less than 200mls is aspirated from an orogastric or a nasogastric tube, replace aspirate and continue as per enteral feeding regimen. Record volume of aspirate. If however the aspirate Is very curdled it may be discarded. 6.8.9 A single high residual volume (i.e . greater than 200mls for orogastric or nasogastric feeding) should not serve as an absolute contraindication to further feed ing. Replace 200m ls and maintain rate, as per reg imen. Continue to aspirate every 4 hours. Record volume aspirated and volume replaced back via the enteral feeding tube. 6.B.10 If subsequent aspirates remain greater than 200mls for orogastric or nasogastric feeding, replace 200mls and reduce the feeding rate to the rate previously tolerated and contact the medical team regarding the prescribing of prokinetic agents to stimulate gastric emptying. 6.8.11 Record volume aspirated and volume replaced via the enteral feeding tube. Contact the dietitian . 6.B. 12 If high residuals persist when feeding Into the stomach, post pyloric tube placement may need to be conSidered. 6.B.13 If there is abdominal distension and / or abdominal pain then feeding should be stopped and the medical or surgical team contacted. 6.8.14 If feeding is stopped, increase LV fluids accordingly. Monitor electrolytes carefully. (See APPENDIX 2) 6.8.15 All Adult patients receiving enteral feeding must be assessed by the dietitian as soon as possible to assess their nutritional requirements. Once the dietitian indicates that a patient is meeting their nutritional requirements, aspiration to confirm tolerance of feed is no longer necessary. This may not apply to ICU and HDU patients.

6.9 Monitoring required for patients receiving enteral feeding 6.9.1 Weigh the patient prior to commencing enteral feeding and weekly thereafter if possible. Hoist scales are available on a number of wards. 6.9.2 Monitor and record daily records of fluid intake and output. 6.9.3 Record bowel movements and stool consistency. 6.9.4 Observe for possible Intolerance to feed e.g. vomiting or abdominal pain. 6.9.5 Record additional dietary intake if requested by the dietitian. 6.9.6 Carry out full serum biochemistry, including albumin, LFT's and FBe at commencement of feed and daily until established on the feed. Weekly, thereafter for adults or as requested by the dietitian, 6.9.7 More regular monitoring may be necessary for some patients e.g., 4-6 hourly glucometer readings for patients with diabetes, Discuss timing of insulin and oral hypoglycaemics with the dietitian and medical team and where relevant the Diabetes Clinical Nurse SpeCialist. 6.9.B For patients with a orogastric nasogastric or nasojejunal feeding tube in situ, nursing care should include mouth care, keeping nostrils clean and replacing nasogastric/ nasojejunal tape as necessary. 6.9.9 Monitor skin condition to ensure it is not excoriated and to prevent skin damage from the pressure of the tube especially on the nostril.

6.10 Blockage of Tube 6.10.1 Blockage of the tube may be caused by coagulation of feed/medication, or inadequate flushing . 6,10,2 If blockage occurs flush tube with tep id previously boiled water using a 50ml syringe and leave fo r 20 minutes. Then flush again. Tepid water can assist the removal of the blockage. Avoid using excessive force. Milk the tube if necessary, (Crest 2004). Freshly opened fizzy soda water may also be effective. If this does not work use a 5% sodium bicarbonate solution and flush as above, (5%= 30mls previously boiled tepid water to half a teaspoon of bread soda, and administer through a 50ml. syringe). 6.10.3 When tube Is unblocked flush again with 50 mls of sterile water. 6.10.4 Never attempt to unblock any tube with a guide wire.

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7.0 IMPLEMENTATION

7.1 The Dietetics Department and Nursing Practice Development Unit will oversee the roll out of this rev ised guideline. Dedicated education sessions will be held prior to/during the Introduction of the Guideline to staff. All staff will be welcome to attend. Ward managers and Discipline heads will be responsible to ensure that staff in their remit are aware of the guideline.

8.0 AuolT 8.1 This guideline will be aud ited by the Multi -Disciplinary team where possible. Nursing Pract ice Development Unit and the Dietetics Department will oversee th is audit in collaboration with medical colleagues.

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9.0 REFERENCES

• Brooks MJ, Melnik G (1995) The re- feeding syndrome: an approach to understanding Its complications and preventing its occurrence. Pharmacotherapy 15(6), 713-26

• Clinical Resource Efficiency Support Team (CREST). Guidelines for the management of enteral tube feeding in adults . April 2004.

• Doherty WL. And Winter, B. Prokinetics agents in Critical Care. Critical Care 2003 7: 206-208 Duggan, SN, Smyth, NO Egan SM, Roddy M and Conlon KC. An assessment of the validity of enteral aspirate Ph strips. E-SPEN, The European e-journal of Clinical Nutrition and Metabolism 2008; 1·6.

• Heyland, Ohaliwal R, Drover JW, Gramlich L, Dodek P, and the Canadian Critical Care Clinical Practice Guidelines Committee Canadian Clinical Practice Guidelines for nut rition support in mechanically ventilated, critica lly ill adult patients. Journal of Parenteral and Enteral Nutrition, Journal of Parenteral and Enteral Nutrition 2003; 25 (5) :355-373.

• INDI: Nutrition Support Reference Guide (2010) • Joseph I Boullata, Drug Administration Through an Enteral Feeding Tube, American Journal of

Nursing, October 2009, Vol 109, No. 10, pp 34-4 • Methany, Norma A. (2008) ReSidual Volume Measurement Should be Retained in Enteral

feeding Protocols, American Journal of Critical care, 2008: 17: 62-64 • National Institute for Health and Clinical Excellence (NICE) Nutrition Support in Adults.

Clinical guideline 32. London: NICE 2006. • National Patient Safety Association (NPSA) Alert 21st February 2005, UK; The medicines and

Healthcare Products Regulatory agency (June 2004) UK. • National Patient Safety Association (NPSA, 2005) How to confirm the correct position of

nasogastric feeding tubes in infants, children and adults, interim advice for healthcare staff -February 2005, www.npsa.uk/advice.

• National Patient Safety Agency, (NPSA August 2008), Incidents related to nasogastric tubes, extracted from Quarterly Data Summary, Issue 9, www.npsa.nhs.uk/patient-safety/quarterly­data-reports.

• National Collaborating Centre for Acute Care, February 2006. Nice Guidelines. Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition.

• PENG: A pocket guide to Clinica l Nutrition 3r<1 Edition (2004) • Rajaraman Durai, Ramaya Venkatraman, Phillp C.H. Ng Nasogastric tubes 2: risks and

guidance on avoiding and dealing with complications in Nursing times. net, 28 April, 2009 • The Parenteral and Enteral Nutrition Group of the BDA (2004). A pocket Guide to Clinical

Nutrition. British Dietetic Association . • Thomas B & Bishop J (ed). Manual of Dietetic Practice, 4th Ed, 2007, pp 102.

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, Limerick, Ent/Ol/2010 Page 11 of 18

Appendix 1: GUIOEUNE TO CONFIRM CORRECT POSITION OF AN OROGASTRIC OR NASOGASTRIC (N.G.) TUBE IN THE

STOMACH

Note: X-ray should be used to confirm correct positioning of orogastric /nasogastric feeding tubes following initial insertion or where aspirate cannot be obtained. Rechecking the position of the tube requires testing the Gastric Aspirate with pH Indicator strips .. 00 not use Blue Litmus paper for this test. (National Patient Safety Association(NPSA) Alert 21" February 2005 UK' The Medicines and Hea/thcare Products Requ/atory Aqency (June 2004) UK).

1. How to use PH indicator strips? a. Inject 10-20mls of air into the tube to clear secretions b. Aspirate 0.5-1 mL, using a SOml. syringe. c. Dip the pH graded strip into the aspirate for 10 seconds. Never put aspirate onto any

other surface except directly onto the pH strip as other surfaces (paper etc) can alter the pH.

d. Using the colour codes on the box, identify the pH of the aspirate. e. Aspirates testing pH 5.5 or less indicate that feeding can commence (NPSA, U.K.200S). f. Enteral feeding should not be commenced if the pH aspIrate Is greater than 5 .5.

Aspirate pH of 6 or higher may indicate displacement but would still register acidity on Blue Litmus. A bronchial placement with a pH of 6 will indicate acidity on litmus paper leading to the possible use of an Incorrectly placed nasogastric tube with disastrous consequences, ( "Caring for the patient with a nasogastr ic tube, Best, c., 2005). Therefore it is dangerous to use litmus, (see NPSA 200S below).

g. Acid-inhibiting drugs may increase the pH, but feeding cannot commence until further investigation. Discuss with medical team.

h. The pH Indicator strips provided In this hospital register up to 6. If the pH is greater than 5.5, wait for 1 hour and retest using a freshly aspirated sample. If the value is still over 5.5 seek medical assistance and document accordingly.

i. Document all actions, results and find ings In the patients nursing notes and all communications.

i. Reassure the patient. 2.0 Interpretation of results: If you find it difficult to get an aspirate take the following steps

a. Inject 10 mls of air through the tube before attempting to withdraw fluid to push the port away from the gastric mucosa, (Best, 2005).

b. Lay the patient on thei r left side for 20 minutes and try again. c. Seek medical advice if the above fails to produce aspirate. Document all care and

findings . d. The 'whoosh' test (insufflation of air into the nasogastric tube while listening with a

stethoscope over the abdomen for a whoosh sound) is considered unreliable because the sound emi t ted is generalised over the abdomen, (Manual of Clinical Nursing Procedures, The Royal Marsden Hospital, 2008; "HQw tQ 'Qnfirm the cor[e.ct QQs.itiQn Qf nasogastric fe.e.ging rul2e.s. in infants.. ,h{lgre.n and'adu/ts' NPSA 2005 www.nosa.nhs.uk/advice). 3.0 When to recheck uosition of the tube using the UH striU following the initialulaccment x-ra~ Note: The initial x-ray only confirms the position of the tube at the time it was taken.

a. Before the administration of feed following a break or if bolus feeding. b. Before the administration of drugs if the tube is not used for any other purpose. c. After episodes of coughing, retching or vomiting. d. After the use of oropharyngeal suction . e. The position marking of the tube should be documented at Initial insertion and

rechecked where indicated. However this is not reliable without pH testing as the lower end of the tube can move without displacement at the nose.

f. At least once daily during continuous feeding. g. If the patient complains of discomfort or feed reflux into the throat or mouth. h. If the patient suddenly has signs of respiratory difficulties, including breathlessness,

strider, cyanosis or wheezing. i. If the patient is transferred from one clinical area to another, the receiving clinical area

must verify tube position before commencing a feed. j. Document all care and findlnes.

Developed and revised with Department of clinical Nutntlon & DietetiCs In collaboration with NPDU, MWRH, Reviewed June 2010.

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, Limerick, Ent/Ol/2010 Page 12 of 18

APPENDIX 2

Corflo FineBore Feeding Tubes accessed from http://www.merckgastroenterology.com

Adult Vygon NGT

~7' Transparent Polyurethane tube with X-ray opaque line. Closed tip. 4 lateral eyes. Lateral branch with cap. Markings at 45, 55, 65 and 75 cm. This tube is used to prevent the accumulation of gastric secretions and air, thus allowing decompression of the stomach by continuous aspiration without trauma to the gastric mucosa.

Tips to help aspirate gastric secretions via flne-bore naso-gastrlc tube

>- Common problems associated with not being able to obtain aspirate include: (a) one of the tube's ports remains open (b) the tube Is not situated in a pocket

);> ensure the side port is closed );> turn the patient onto their side to allow the tip of the naso-gastric tube to enter the gastric fluid

pool );> use a half drawn back 50ml syringe, and pull back on it gently to gain aspirate );> air but no aspirate: try inserting tube slightly further then aspirating. Inject 10mls (Adults

only) of air into tube. If the patient belches the tubes is in the oesophagus. NOTE: This is NOT a testing procedure. Do NOT carry out auscultation of air (,whoosh test') to test tube position (NHS, 2005)

);> cannot obtain air or aspirate: try pulling the tube back slightly and then aspirating );> the tip of the tube may be silting against the gastric mucosa. Inject 1 Omls (Adults only) of

air into the stomach to push the port away from the gastric mucosa. Repeat the aspirate test.

Reference: NHS, (2005) National Patient Safety Agency. How to confirm the correct position

of nasogastric feeding tubes in infants, children and adults, www.npsa.nhs.ukJadvice.

Enteral Feeding (Adults) Guidelines, Mid·Western Regional Hospital, Limerick, Ent/Olj2010 Page 13 of 18

APPENDIX 3

Liquid preparations which are not suitable for administration via enteral fceding tubes Preparations included on this list are not suitable for administration via a gastrostomy tube however exclusion from the list should not be taken as meaning that a preparation is suitable for administration via gastrostomy tube.

Generic Name Proprietary brand name or Reason company if generic brand

Lansoprazole Zoton Suspension has a high viscosity and dilution will cause the lansoprazole to come out of solution.

Colestyramine Questran Product difficult to administer and may block the tube. Interferes with the absorption of nutrients and other drugs

Sulcralfate Antepsin Sulcralfate is a frequent cause of tu he obstruction as it forms insoluble complexes with enteral feeds. Consider alternative therapy.

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital , Limerick, Ent/01/2010 Page 14 of 18

API'ENDIX 4

Enteral feeding and drug interactions

Drug Type of interaction Suggestion Antacids e.g. maalox Protein aluminium complex Do not use antacids with high

formed when aluminium protein feeds. Consider an containing antacids are given alternative preparation to with high protein enteral treat the problem feeds

Antimicrobial agents where Absorption reduced by the Stop feed for one hour before absorption is affected by the presence of food and one hour after dose. presence of food e.g. rifampicin, flucloxacillin , metronidazole suspension Bisphosphonates e.g. Bisphosphonates bind bi and Stop the feed for two hours Alendronate (Fosarnax), tri-valent cations e.g. before and two hours after Etidronate ( Didroncl), calcium, magnesium, the administration of the Clodronate -(Boncfos i ~tc aluminium etc bisphosphonatc Carbamazepine Conflicting evidence for Monitor patient and

reduced bioavailability with carbamazepine level if enteral feed necessary. Stop feed for 2

hours before and after dose if necessary.

Cipro fioxacin (Ciproxin) Binds cations e.g. Calcium Stop enteral feed for one present in the feed or in the hour before and two hours water added to the feed after dose or administer

higher oral doses or use IV route.

Penicillin V or Unpredictable absorption Stop enteral feed for one phenoxymethylpenicillin hour before or two hours (calvepen) after dose. Administer higher

doses or use amoxicillin if appropriate.

Phenytoin (epanutin) Binding of liquid to feeding Give phenytoin as a single tubes. Inadequate dissolution daily dose_ Stop enteral feed of phenytoin. Inadequate for 2 hours before and after absorption. dose. Dilute suspension with

equal parts water. Flush tube after administration. Monitor levels.

Sulcralfate (Antepsin) Binds to protein in feed Use alternative product Tetracycline Binds cations e.g. calcium Use alternative agent if oxytetracycline iron etc. possible or stop feed for two

hours before and after dose. Theophylline (Uniphyllin) Absorption decreased by 60- Stop feed for two hours

70% before and one hour after dose and monitor levels

Warfarin May interact with vitamin K Monitor INR. content offeed and bind to

I protein in feed.

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, limerick, Entj01/2010 Page 15 of 18

APPENDIX 5 Tablets which should not be crushed and capsules which should not be opened or crushed.

Tablets included on this list should not be crushed. Capsules included on this li st should not be crushed or opened. Exclusion from the list should not be taken as meaning that a preparation is suitable for crushing or opening.

Proprietary brand name or Generic name Reason for not crushing company if generic brand Adalat Retard Tablets Nifedipine Slow Release Adalat LA Tablets Alkeran Tablets Melphalan Cytotoxic Asacolon Tablets Mesalazine Resin Coated Arthtrotec Tablets Diclofenac with misoprostol Manufacturer recommends to

swallow whole Aspirin Nuseals Tablet Aspirin Enteric coated Asasant in Retard Tablet Dipyridamole/aspirin Sustained release Brufen Retard Tablet Ibuprofen Sustained Release Cameolit Tablet Lithium Sustained Release Cardura XL Tablet Doxazosin Sustained release CECNU Capsules Lomustine cytotoxic Clonazine Chlorpromazine Risk of contact sensitivity.

A void direct contact including liquid preparation

Codafen Continus Tablet lbuprofenlcodeine Sustained release Cyclophosphamide Tablet Cyclophosphamide cytotoxic Deltacortril Tablet Prednisolone Enteric coated Diamox SR Tablets Acetazolamide Sustained Release Diumide K continues Tab Frusemide with potassium Sustained release Duleolax Tablets Bisacodyl Enteric coated Elantan Tablets Isosorbide mononitrate Manufacturer recommends to

swallow whole Epilim Enteric Coated Tab Sodium Valproatc Enteric coated Epilim chrono Tablet Sodium valproate Sustained release Fosamax once weekly Tablet Aledronate Sustained release Fludara oral Fludarabine cytotoxic Gastrobid Continus Tablet Metoclopramide Sustained release lmdur Tablet Isosorbide mononitrale Sustained release Isoptin SR Tablet Verapamil Sustained release Isordil subl ingual Tablet Isosorbide Dinitrate For sublingual use Diclac Retard Tablet Diclofenac Sustained release Diamicron MR Tablet Gliclazide Sustained release

Klacid LA Tablet Clarithromycin Sustained release Largacti l Chlorpromazine Risk of contact sensitivity.

A void direct contact including liquid preparation

Enteral Feeding (Adults) Guidelines, Mid -Western Regional Hospital , LImerick, Ent/Ol/201D Page 16 of 18

Proprietary brand name or Generic name Reason for not crushing company if ~eneric brand Losec Mups Tablets Omeprazole Protective coating Losamel Tablet Omenrazole Gastro resistant Tablet Leukeran Tablets Chlorambucil Cytotoxic Methotrexate Tablet methotrexate Cytotoxic MST Tablet Morphine Sulphate Sustained release Mvlcran Tablet Busulfanlbusulohan cytotoxic

Natulan Capsules Procarbazine cytotoxic Nanmel EC Tablet Naproxen Enteric coated Natril ix SR Tablet Indanamide Sustained release Nuclin SA Tablet Theonhvlline Sustained release Oxvcontin Tablct oXVcodone Sustained Release Pentasa Tablets Mesalazine Sustained Release Phyllocontin continues Aminophylline Sustained release Tablet Plendil Tablets FelodlPIne Sustained Release Priadel Tablets Lithium Sustained Release Proscar Tablets Finasteride Crushed tablets should not be

handled by women who are or may become oregnant

Rvihmodan Retard Tablet DisODvramide Sustained release Salazopyrin EN Tablet Sulfasalazine Enteric coated Sinemet CR Tablet Levodonalcarbidopa Sustained release Slow-sodium Tablet Sodium Chloride Sustained release Slow Trasicor Tablet Oxercnolol Sustained release Slow K Tablet Potassium Sustained release Suscard Buccal tablet Glvcervl trinitrate For buccal use onlv Teerctol Retard Tablet CarbamazeDine Sustained release Uninhvllin continuous Tablet TheoPhvlline Sustained Release Veoesid CaDsules Etoposide cytotoxic Xeloda Tablets Capecitabine Prodru" of 5 fluorouracil Xatral XL Tablet Alfuzosin Sustained release Zavedos Capsules Idarubicin Cytotoxic ZYdol SR Tablets Tramadol Sustained Release

Enteral Feed ing (Adults) Guidelines, Mid-Western Regional Hospital , Limerick, Ent/ Ol/2010 Page 17 of 18

Appendix 6

Department of Nutrition & Dietetics Mid Western Regional Hospital, Limerick

GUIDELINES FOR ASPIRATION OF ENTERAL FEEDING TUBES

Do not aspirate nasoduodenal, jejunostomy or nasojcjunal tubes.

Aspirate Nasogastric! Orogastric! Gastrostomy! PEG tubes every 4 hours until established on feeding regimen as per dieticians' instructions.

If aspirates are <200mls, replace aspirate and continue as per enteral feeding regimen. Continue to aspirate every 4 hours until established on feed

If aspirate is >200mls replace 200mls and maintain rate as per regimen

If subsequent aspirate is >200mls replace 200mls and recommence at rate previously tolerated

If aspirates >200mls persist, discuss with the patients' doctors

Enteral Feeding (Adults) GUidelines, Mid·Western Regional Hospital, Limerick, Ent/Cl/2C 1C Page 18 of 18

APPENDIX 7 Re-feeding Syndrome

• Re -feeding problems encompasses life threatening acute micronutrient deficiencies, fluid and electrolyte imbalance, and disturbances of organ function and metabolic regulation that may result from over-rapid or unbalanced nutritional support.

• nRe· Feeding Syndrome" occurs on feeding when a range of life-threa tening clinical and biochemical abnormalities arise: - cardiac failure, pulmonary oedema and dysrhythmias - acute circulatory fluid overload or circulatory fluid depletion - hypophosphataemia - hypokalaemia - hypomagnesaemia and occasional ly hypocalcaemia - hyperglycaemia.

Identifying patients at risk of "Re-feeding syndrome"

6.6.6 Determining patients at risk of developing re-feeding problems:

Any patient who has one or more of the following: • very little food intake for >5 days • unintentional weight I~ss greater than 10% within the previous 3 - 6 months

BMJ less than IB.s kQ/m2

2) Determining patients at high r isk of developing re- feeding problems:

Patient has one or more of the following: • BMI less than 16kg/m2 • Unintentional weight loss greater than 15% within the last 3-6 months • Little or no nutritional intake for more than 10 days • Low levels of potaSSium, phosphate or magnesium prior to feeding

Or patient has two or more of the following: • BMI less than 18.skg/m2 • Unintentional weight loss greater than 10% within the last 3-6 months • Little or no nutritional intake for more than 5 days • A history of alcohol abuse or drugs Including Insulin, chemotherapy, antacids or diuretics

In addition to startmg nutritional support cautiously m patients at high nsk of developing re-feedmg problems, consider: 1) Providing immediately before and during the first 10 days of feeding: oral thiamine 200-300mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) along with a balanced multi-vitamin and trace element supplement. 2) Providing oral, enteral or intravenous supplements of potassium, phosphate and magnesium unless pre­feeding plasma levels are high. (Check U&Es, Ca 2+, Mg 2+, Po4l., daily). 3) Restoring circulatory volume and monitoring fluid balance and overall clinical status closely. Reference: INDI: Nutrition Support Reference Guide (2002)

Enteral Feeding (Adults) Guidelines, Mid-Western Regional Hospital, Limerick, Ent/Ol/20tO

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