Enteral Nutrition for Adults: Administration Issues

including material from

Dietitians in Nutrition Support
A DIETETIC PRACTICE GROUP OF AMERICAN DIETETIC ASSOCIATION
Your link to nutrition and health.

Contraindications for EN
Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Expected need less than 5-7 days if

malnourished or 7-9 days if normally nourished

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

Contraindications for EN
Inadequate resuscitation or

hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed

Indicators of Adequate Fluid Resuscitation in Critically Ill Pts

Urine output should be >30 ml/hour

Heart rate <120 beats/minute; preferably

<100 beats/minute Systolic BP should be ~100 Ask staff/medical team If patient is receiving fluid boluses in addition to continuous IVF, likely they are not adequately resuscitated

Nasogastric Tubes

Nasogastric Tubes
Definition A tube inserted through the nasal passage into the stomach Indications: Short term feedings required Intact gag reflex Gastric function not compromised Low risk for aspiration

French 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

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

Nasogastric Tubes
Disadvantages: Increases risk of aspiration (maybe) Not suitable for patients with compromised gastric function May promote nasal necrosis and esophagitis Impacts patient quality of life

Nasoduodenal/Jejunal
Definition A tube inserted through the nasal passage through the stomach into the duodenum or jejunum

Indications: High risk of aspiration Gastric function compromised

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

EAL EN Tube Placement Guidelines Critical Care

Enteral Nutrition (EN) administered into the

stomach is acceptable for most critically ill patients. If your institution's policy is to measure GRV, then consider small bowel tube feeding placement in patients who have more than 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

EAL EN Guidelines (Critical Care)

Adequately-powered studies have not been

conducted to evaluate the impact of GRV on aspiration pneumonia. There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroporesis), however they were not evaluated at this phase of the analysis. Fair; conditional
ADA EAL Guidelines Critical Care accessed 8-07

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

Orogastric
Tube is placed through mouth and into

stomach Often used in premature and small infants as they are nasal breathers Not tolerated by alert patients; tubes may be damaged by teeth

GastrostomyJejunosotomy

Enterostomy Placement
Gastrostomy

Jejunostomy

Gastrostomy
Definition A feeding tube that passes into the stomach through the abdominal wall. May be placed surgically or endoscopically Indications: Long-term support planned Gastric function not compromised Intact gag reflex present

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

Gastrostomy

Jejunostomy
Definition A feeding tube that passes into the jejunum through the abdominal wall. May be placed endoscopically or surgically Indications: Long-term feeding option for patients at high risk for aspiration or with compromised gastric function

Jejunostomy
Advantages: Post-op feedings may be initiated immediately Decreased risk of aspiration Suitable option for patients with compromised gastric function Stable patients can tolerate intermittent feedings

Jejunostomy
Disadvantages: Requires stoma care Potential problems related to leakage or tube dislodgement/clogging may arise May restrict ambulation Bolus feedings inappropriate (stable patients may tolerate intermittent feedings)

Determining Method of Administration

Feeding site

Clinical status of patient

Type of formula used Availability of pump Mobility of patient

Initiation of Enteral Feedings

Dilution of enteral formulas not generally

recommended Initiate at full strength at slow rate and steadily advance Allows achievement of goal rates more quickly; less manipulation of formula

Administration
Bolus

Intermittent
Continuous

Cyclic

Bolus Feedings
Definition Infusion of up to 500 ml of enteral formula into the stomach over 5 to 20 minutes, usually by gravity or with a large-bore syringe Indications: Recommended for gastric feedings Requires intact gag reflex Normal gastric function

Bolus Feedings
Advantages: More physiologic Enteral pump not required Inexpensive and easy administration Limits feeding time so patient is free to ambulate, participate in rehabilitation, or live a more normal life in the home Makes it more likely patient will receive full amount of formula

Bolus Feeding

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

Initiation of Bolus Feedings

Adults: Initiate with full strength formula 3-

8 times per day with increases of 60-120 ml q 8-12 hours as tolerated up to goal volume; does not require dilution unless necessary to meet fluid requirements Children: Initiate with 25% of goal volume divided into the desired number of daily feedings; increase by 25% each day divided among all feedings until goal volume is reached
ASPEN Nutrition Support Practice Manual, 2005, 2nd ed, p. 78

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

Continuous Feedings
Definition Enteral formula administration into the gastrointestinal tract via pump or gravity, usually over 8 to 24 hours per day Advantages: May improve tolerance May reduce risk of aspiration Increased time for nutrient absorption

Continuous Feedings
Disadvantages: May reduce 24-hour infusion May restrict ambulation More expensive for home support Pumps are more accurate; useful for small-bore tubes and viscous feedings, but many payers have strict criteria for approval of pumps for home or LTC use

Initiation of Continuous Feedings

Adults: Initiate at full strength at 10-40

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

Intermittent Feedings
Definition Enteral formula administered at specified times throughout the day; generally in smaller volume and at slower rate than a bolus feeding but in larger volume and faster rate than continuous drip feeding Typically 200-300 ml is given over 30-60 minutes q 4-6 hours Precede and follow with 30-ml flush of tap water Indications: Intolerance to bolus administration Initiation of support without pump Preparation of patient for rehab services or discharge to home or LTC facility
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

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

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

Cyclic Feedings
Definition Administration of enteral formula via continuous drip over a defined period of 8 to 12 hours, usually nocturnally Indications: Ensure optimal nutrient intake when: Transitioning from enteral support to oral nutrition (enhance appetite during the day) Supplement inadequate oral intake Free patient from enteral feedings during the day

Cyclic Feedings
Advantages: Achieve nutrient goals with supplementation Facilitates transition of support to oral diet Allows daytime ambulation Encourages patient to eat normal meals and snacks

Cyclic Feedings
Disadvantages: May require high infusion ratesmay promote intolerance

Enteral Feeding Tubes

Types: pediatric vs adult; gastric vs small bowel Sizes: smaller sizes (5-8 Fr) for commercial products

delivered via pump; larger sizes for viscous, blenderized, fiber-containing formulas, gravity and bolus feedings Weighted vs. unweighted: it was once thought that weighted tubes facilitated transpyloric passage; now dictated by personal preference Stylet vs. no stylet: stylet facilitates tube placement beyond the pylorus for small, flexible tubes Composition: silicone and polyurethane most comfortable

Factors Affecting Tube Selection

Will the patient be fed into the stomach or

small bowel? How long will the patient need tube feedings? Is the patient expected to resume adequate oral feedings? Who can insert feeding tubes at my institution?

Enteral Feeding Containers

May be rigid or

flexible Sterile or non-sterile Unbreakable, leakproof, and disposable

Considerations in Choosing Enteral Feeding Containers

Easy to fill, close and hang

Easy to read calibrations and directions

Appropriate size

Adaptable tubing port

Compatible with pump Requires minimal storage space

Adapted from ASPEN. The science and practice of nutrition support. A casebased core curriculum. 2001; 179

Closed Systems

Enteral Feeding Pumps

Factors in Pump Selection

Simple to use Dose function

(intuitive) Alarm system Lightweight Long battery life Portable Volume infused indicator

Flow rate accurate to

within 10% Approved for age range in which it will be used Permanently attached cord

Enteral Feeding Complications

Mechanical

Gastrointestinal
Metabolic Infectious

Mechanical
Feeding tube obstruction

Feeding tube dislodged

Nasal irritation Skin irritation/excoriation at ostomy site

Causes of Feeding Tube Obstruction

Concentrated, viscous, and fiber-containing

feeding products Tube feeding contamination Checking of gastric residuals Small diameter tubes Powdered or crushed medication flushed through tubes Acidic or alkaline medications passed through tubes Tubes not routinely flushed after feedings are stopped

Prevention of Feeding Tube Obstruction

Flush the feeding tube, especially before

and after medication administration and bolus/intermittent feedings Use liquid formulations of medicines where possible (but be careful of osmolarity) Do not mix medications with enteral feedings unless shown to be compatible Avoid crushing sustained-release or entericcoated tablets

Treatment of Feeding Tube Obstruction

Declog with irrigants (warm water) or

sodium bicarbonate/pancrealipase mixture or by mechanical means Cola beverages, cranberry juice, and tea not recommended

The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

Aspiration
Reported incidence of aspiration in tubefed

patients varies from .8% to 95%. Clinically significant aspiration 5% gastric-fed pts Many aspiration events are silent and often involve oropharyngeal secretions Symptoms include dyspnea, tachycardia, wheezing, rales, anxiety, agitation, cyanosis May lead to aspiration pneumonia

Aspiration
Focus has been on detection of aspiration through

use of coloring agents in enteral feedings or glucose testing of respiratory secretions These methods have low sensitivity and questionable specificity; they do not prevent aspiration but at best detect it after it has occurred Blue food coloring used for this purpose has been associated with morbidity/mortality in septic patients

Aspiration Prevention
Keep head of bed elevated 30-45 degrees

during and 30-40 minutes after feedings Feed post-pylorically (research mixed on this) Small, frequent feedings or continuous drip Use of promotility agents Monitoring of gastric residuals may be helpful in identifying delayed gastric emptying and increased risk of aspiration
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

Gastrointestinal Complications
Diarrhea

Constipation
Gastric distention/bloating Gastric residuals/delayed gastric emptying Nausea/vomiting

Diarrhea
Definition: >500 ml every 8 hours or more than 3

stools a day for at least two consecutive days. Relates more to stool consistency than frequency Diarrhea was a common consequence of enteral feedings when hyperosmolar feedings were routinely delivered via syringe Occurs in 2 to 63% of enterally-fed pts depending on how defined

Causes/Treatments of Diarrhea
Intestinal atrophy due to malnutrition EN is the best stimulant for recovery. Increase rate slowly as tolerated Albumin infusion is unlikely to be helpful; diarrhea is not caused by low albumin; it is a marker of malnutrition Bolus feeding in the small intestine: results

in dumping syndrome.
Use an infusion pump to regulate flow
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

Causes/Treatments of Diarrhea
Bacterial overgrowth of intestinal tract or

contamination of the enteral feeding

Avoid prolonged use of broad-spectrum antibiotics Use clean technique and closed system in handling enteral feedings Limit hang time of open system formulas to 8 hours (4 hours for mixtures) Change bag and tubing per protocol Test for C difficile and other pathogens before using anti-motility agents

Causes/Treatments of Diarrhea
Steatorrhea: characterized by frothy,

odiferous stools that float on water; caused by fat intolerance

Use lowfat enteral formula or one with higher percentage of MCT; pancreatic enzymes may help in pancreatic insufficiency

Causes/Treatments of Diarrhea
Lactose intolerance Most enteral products are lactose free but this may occur with initiation of full liquid diet. Eliminate milk and dairy products Drug-induced diarrhea Meds may cause up to 61% of diarrhea in tubefed pts due to hypertonicity or direct laxative action (magnesium, sorbitol, potassium). Diarrhea most common with antibiotics. Discuss with MD/pharmacist
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

Causes/Treatments of Diarrhea
Infusion of hypertonic feeding solutions;

rare unless delivered at very high rate or bolused into small bowel
Try a different product rather than diluting the original feeding

GI disease: such as IBS, short gut, celiac

disease, AIDS
May require PN or specially formulated EN

Treatment of Diarrhea in General

Add soluble fiber (such as banana flakes or

Benefiber) or insoluble fiber such as psillium Consider an enteral formula with added fiber Use an antidiarrheal agent (loperamide, diphenoxylate, paregoric, octreotide) Change the formula

Nausea/Vomiting
20% of patients on EN report

nausea/vomiting Often related to delayed gastric emptying caused by hypotension, sepsis, stress, anesthesia, medications (analgesics and anticholinergics), surgery

Nausea/Vomiting Treatment
Consider reducing/discontinuing narcotic

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

Metabolic
Fluid and Electrolyte abnormalities

Glucose intolerance
Ca++, Mg++, PO4 abnormalities Other

Fluid and Electrolyte Disturbances

May result from long term nutrition deficits,

acute stress, medications, medical conditions, improper nutrient prescription Electrolytes lost via stool, urine, ostomy or fistula drainage Dehydration most common complication (tube feeding syndrome) especially with high protein feeding and insufficient fluid

Hyperglycemia
Often reflects acute stress, infection, medications

(especially steroids) or latent diabetes Macronutrient distribution: is generally not the primary issue; most enteral feeding formulas fall within established guidelines; could try formula lower in carbohydrate Insulin management

Refeeding Syndrome
At risk: when refeeding those with marginal

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

Refeeding Syndrome
Correct electrolyte abnormalities (via oral,

enteral, parenteral route) before initiating nutrition support Administer volume and energy slowly Monitor pulse rate, intake and output, and electrolyte levels Provide appropriate vitamin supplementation Avoid overfeeding

Infectious Complications
Formula contamination

Unsanitary equipment
Failure to follow appropriate protocols re handling

of enteral feedings/changing of bags and tubing

Monitoring of Patients on EN

Electrolytes BUN/Cr Albumin/prealbumin Ca++, PO4, Mg++ Weight Input/output Vital signs Stool frequency/consistency Abdominal examination

Evaluating Adequacy of Support

Is and Os (what % of prescribed feeding did

patient receive?) Indirect calorimetry Nitrogen balance Weight Visceral proteins Other

Home Support
Discharge planning May work with DME company to identify whether patient is a candidate for home EN, assure availability of product; complete CMN form in conjunction with physician Patient education Patients going home on enteral feedings will need education on food safety, feeding administration, and self-monitoring Reimbursement

Enteral Support Summary

Preferred method of nutrition support

Technology exists to facilitate

implementation Can be successfully employed with careful patient and formula selection