clinical food, fluid and nutritional care policy (adults)

Clinical

Food, Fluid and Nutritional Care Policy (Adults)

SECTION 4: PROTOCOL FOR THE MANAGEMENT OF ARTIFICIAL NUTRITION SUPPORT IN HOSPITAL AND COMMUNITY (ADULTS)

4.1 ENTERAL TUBE FEEDING 4.2 PARENTERAL NUTRITION

Policy Manager

Dietetic Consultant in Public Health

Policy Group

Food, Fluid and Nutritional Care

Policy Established

September 2012

Policy Review Period/Expiry

31 January 2024

Last Updated

18 July 2022

This policy does / does not apply to Medical/Dental Staff employed by NHS Tayside (delete as appropriate)

UNCONTROLLED WHEN PRINTED

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Document: NHS Tayside FFNC Policy Section 4 Version: 7.1 Version Date: Jul 2022

Policy Manager: Dietetic Consultant in Public Health of 148 Review Date: Jan 2024

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Version Number

Purpose/Change Author Date

1.0 First Draft Janet Baxter 29/05/2012

2.0 Changes made following Expert Consultation

Janet Baxter 31/10/2012

3.0 Changes made following Universal Consultation

Janet Baxter 10/12/2012

4.0 Formatting Lorna Murray Sue Smart

24/06/2013 09/07/2013

4.1 Minor amendment Appendix 6 Janet Baxter 04/07/2014

5.0 First review Janet Baxter K Blair J Tait V Hampson

29/02/2016

6.0 Second review Janet Baxter K Blair A Campbell A Ingledew

01/12/2017

6.1 Changes made following Expert Consultation / addition of Appendices 1, 12 & 14 / formatting

Janet Baxter A Campbell Sue Smart

08/11/2018

6.2 Amendments following responses from Associate Nurse Director Sarah Dickie/ Nurse Director Gillian Costello

A Campbell 03/06/2019

6.3 Clarification to strength of preparations of Sodium Chloride & Heparin in SOPs 4.2c/4.2d & 4.2e


7.0 Addition of Appendix 6b, 8b. Updates following change in guidance for gastropexy removal timescale, addition of Chyle leak flow chart, revised enteral feeding administration chart, more explicit guidance on consent for artificial nutritional support. Update of Appendix 20 for enteral feeding guidance after abdominal surgery/ formatting Updates to Appendix 25,26 Updates to SOPs 4.2a – f Expert consultation on all changes listed. Minor amendments to Appendices 6a, 6b, 8a, 8b, 17, 18, 19, 20, 24, 25 & 26

A Campbell 28/01/2021 & 20/04/2021

7.1 Additional detail bullet point 4, page 76 (Care of surgical jejunostomy tubes)


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CONTENTS

SECTION 4 Page Number

1. PURPOSE AND SCOPE 7

2. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS 8

3. BACKGROUND 10

4. CONSENT 11

5. EDUCATION AND TRAINING 11

6. LEGAL LIABILITY 11

SECTION 4: 4.1 ENTERAL TUBE FEEDING 12

4.1.1 Insertion and care of nasogastric tubes 13

STANDARD OPERATING PROCEDURE – 4.1a Insertion of a nasogastric feeding tube

17

APPENDIX 1: Decision tree for nasogastric tube placement checks in ADULTS 19

APPENDIX 2: Competencies for insertion and care of Nasogastric (NG) tube 20

APPENDIX 3: Nasogastric (NG) tube insertion checklist 21

4.1.2 Guidance for the use of nasal retention device 22

APPENDIX 4: Information on the use of a nasal retention device 23

4.1.3 Insertion and care of jejunal tubes 24

APPENDIX 5: Post insertion care of Naso-Jejunal (NJ) tubes

25

4.1.4 Medium Change Triglyceride (MCT) diet/feed for Chyle leak – instructions for commencing on a weekend/public holiday

26

Algorithm for dietetic management of Chyle Leaks 27

4.1.5 Insertion and care of percutaneous enteral feeding tubes 28

Table 1: Gastrostomy tubes most commonly used in NHS Tayside 34

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STANDARD OPERATING PROCEDURE – 4.1b Preparing patient for insertion of a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube

35

APPENDIX 6a: Checklist for insertion of Percutaneous Endoscopic Gastrostomy (PEG) tube

36

APPENDIX 6b: Enteral feeding regimen - post PEG 37

APPENDIX 7: Guidance for the care of Percutaneous Endoscopic Gastrostomy (PEG) tube

38

STANDARD OPERATING PROCEDURE – 4.1c Preparing patient for insertion of a Radiologically Inserted Gastrostomy (RIG) enteral feeding tube

41

STANDARD OPERATING PROCEDURE – 4.1d Immediate post aftercare of a Radiologically Inserted Gastrostomy (RIG)/Percutaneous Endoscopic Gastrostomy (PEG) enteral feeding tube

42

APPENDIX 8a: Checklist for insertion of Radiological Inserted Gastrostomy (RIG) tube

43

APPENDIX 8b: Enteral feeding regimen - post RIG 45

APPENDIX 9: Guidance for the care of Radiological Inserted Gastrostomy (RIG) tube

46

APPENDIX 10: Competencies for care of PEGs and balloon gastrostomy 49

STANDARD OPERATING PROCEDURE – 4.1e Replacing the y-adaptor on a Halyard percutaneous gastrostomy tube

50

APPENDIX 11: Competencies for replacement of balloon gastrostomy 52

STANDARD OPERATING PROCEDURE – 4.1f The replacement of a balloon gastrostomy

53

STANDARD OPERATING PROCEDURE – 4.1g The replacement of a low profile ‘button’ gastrostomy tube

56

APPENDIX 12: Checking pH of gastric aspirate for gastrostomy tube

replacement 59

STANDARD OPERATING PROCEDURE – 4.1h The procedure for measuring stoma tract for a low profile gastrostomy tube

61

STANDARD OPERATING PROCEDURE – 4.1i Checking the volume of the retention balloon in a balloon gastrostomy or jejunostomy tube

64

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APPENDIX 13: Troubleshooting Guide (gastrostomy/jejunostomy enteral tube feeding)

66

APPENDIX 14: Flowchart for managing overgranulation tissue 73

4.1.6 Insertion and care of percutaneous jejunostomy tubes 75

4.1.7 Enteral tube feeding regimen 76

STANDARD OPERATING PROCEDURE – 4.1j The administration of feed using an enteral feeding pump

79

APPENDIX 15: Enteral tube feeding regimen 82

APPENDIX 16: NHS Tayside enteral feeding administration chart 84

APPENDIX 17: Enteral tube pump feeding regimen 86

APPENDIX 18: Enteral tube bolus feeding regimen 87

APPENDIX 19: Nasojejunal feeding regimen 88

APPENDIX 20: Post major abdominal surgery feeding regimen 89

STANDARD OPERATING PROCEDURE – 4.1k The administration of bolus feed

91

STANDARD OPERATING PROCEDURE – 4.1l Administration of medication via enteral feeding tube

93

APPENDIX 21: Review process for patients on oral medication who are

unable to take their medicines by mouth 96

STANDARD OPERATING PROCEDURE – 4.1m Referral procedure for Home Enteral Tube Feeding (HETF) 97

4.1.8 NHS Tayside Out of Hours (OOH) boxes for Enteral Tube Feeding 98

SECTION 4: 4.2 PARENTERAL NUTRITION (PN) 99

4.2.1 Referral for parenteral nutrition 100

4.2.2 Refeeding Syndrome 100

4.2.3 Access routes for parenteral nutrition 101

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4.2.4 Administration of parenteral nutrition 103

4.2.5 Monitoring patients on parenteral nutrition 104

4.2.6 Preventing complications associated with parenteral nutrition 105

APPENDIX 22: Tayside Artificial Nutrition Group: Identification and treatment of Refeeding Syndrome

109

APPENDIX 23: Types and indications of intravenous access for Parenteral Nutrition

110

APPENDIX 24: Parenteral Nutrition (PN) Request Form (medical staff) 112

APPENDIX 25: Aseptic Dispensing Services Parenteral Nutrition Request Form

113

APPENDIX 26: NHS Tayside - Adult TPN Administration Chart 114

APPENDIX 27: Out of hours Parenteral Nutrition regimen 118

APPENDIX 28: Protocol for laboratory monitoring of nutrition support for patients in hospital on Parenteral Nutrition

119

APPENDIX 29: Metabolic Complications 126

STANDARD OPERATING PROCEDURE – 4.2a Procedure for dressing central venous catheter exit site

127

STANDARD OPERATING PROCEDURE – 4.2b Procedure for commencing Parenteral Nutrition (PN) via central venous catheter

129

STANDARD OPERATING PROCEDURE – 4.2c Procedure for administration of medication via central venous catheter

132

STANDARD OPERATING PROCEDURE – 4.2d Procedure for disconnecting Parenteral Nutrition (PN) from a central venous catheter

134

STANDARD OPERATING PROCEDURE – 4.2e Procedure for taking blood from a central venous catheter

136

STANDARD OPERATING PROCEDURE – 4.2f Procedure for removal of a central venous catheter

139

4.2.7 Referral for Home Parenteral Nutrition (HPN) 141

STANDARD OPERATING PROCEDURE – 4.2g Referral procedure for Home Parenteral Nutrition (HPN)

143

7. REFERENCES 144

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4. PROTOCOL FOR THE MANAGEMENT OF ARTIFICIAL NUTRITION SUPPORT IN HOSPITAL AND COMMUNITY (ADULTS)

1. PURPOSE AND SCOPE

NHS Tayside recognises its duty to ensure that a patient’s individual fluid and nutritional needs are met even when normal routes of intake are compromised or not available. This section sets out NHS Tayside’s approach to the management of artificial nutrition for adults using enteral and parenteral routes within the hospital and home setting. Promote the knowledge and compliance of artificial nutritional support procedures

to enhance patient safety and ensure optimum nutritional care for patients in hospital or at home who receive artificial nutrition.

To ensure that patients requiring artificial nutrition have access to the expertise

and services of a nutrition support team responsible for the clinical aspects of artificial nutrition.

NHS Tayside will aim to ensure that adult patients in need of artificial nutrition are identified and cared for appropriately and actions are taken to maximise their nutritional intake via enteral or parenteral routes by providing: 1. Clear policy statements. 2. Clinical tools that will aid decision making. 3. Standard Operating Procedures (SOPs). 4. Competency information to ensure that NHS staff are safe and competent

practitioners. 5. Access to the necessary training to ensure staff have the necessary skills and

knowledge. 6. Artificial nutritional support equipment. 7. Patient information and support which assists patients to self manage their

artificial nutritional care. 8. Improvement, outcomes and risk monitoring frameworks which are reported on

annually and used to continuously improve artificial nutritional care. 9. A multi-disciplinary clinical nutrition support team. This policy must be adhered to by all NHS Tayside staff. This protocol excludes: 1. Ethical issues around food, fluid and artificial nutrition. 2. Paediatrics. 3. Oral Nutritional Support. 4. Specific long-term therapeutic regimens. 5. Pregnant women. 6. Patients with eating disorders.

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2. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS Senior Management (General Managers/Clinical Service Managers, Lead Nurses, AHP Leads, Associate Directors (or equivalent) are responsible for:

Distributing this policy to staff within their area/directorate ensuring that staff have the opportunity to access this complex nutritional care policy and receive training as appropriate within their level of responsibility in relation to artificial nutrition, and ensure that the necessary resources are in place to maintain equipment associated with artificial nutrition.

Ensuring that the policy and standard operating procedures within it are implemented within their areas, monitoring compliance and reporting on outcomes.

Ensuring that the local surveillance systems in place are followed and feedback of data is given to Tayside Artificial Nutrition Group on artificial nutrition complications.

Reviewing specific nutrition issues at senior management meetings, e.g. complications, incidence reports and non-adherence to best practice.

Facilitating and supporting cross-representation between hospital and home management.

Supporting healthcare workers in following this policy by ensuring access to adequate training, resources and equipment for the delivery of safe and effective artificial nutritional support.

Ensuring that resources are in place for the maintenance and replacement of artificial nutrition equipment.

Senior Charge Nurses are responsible for:

Providing leadership on artificial nutrition, ensuring they keep up to date with any subsequent alterations to this policy and ensuring that all staff are aware of any changes.

Auditing compliance with this policy.

Providing education opportunities on this policy.

Ensuring that surveillance systems are in place and monitoring cases where a patient’s artificial nutritional support is compromised within the facility and advising the Artificial Nutrition Group as necessary.

Ensuring that patient information leaflets used are the most recent versions.

Ensuring that all artificial nutrition equipment is available if needed and is fit for purpose.

Nutrition Support Teams, including Nurse Specialists in Gastroenterology are responsible for:

Providing clinical support to staff in delivering artificial nutritional support.

Supporting and reviewing patients with complex artificial nutrition including those on home parenteral nutrition.

Providing training on artificial nutrition, as required.

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Tayside Artificial Nutrition Group (TANG) is responsible for:

Updating this policy.

Providing expert advice to NHS Tayside in relation to artificial nutrition.

Developing training material.

Developing patient information material.

Establishing a monitoring framework.

Providing Tayside Nutrition MCN Board with a progress, outcomes and risk report annually.

Nutrition Support Service is responsible for:

The leadership on artificial nutrition across NHS Tayside.

Developing, and assisting with the implementation, monitoring and reporting on the service improvement programmes for nutritional support including artificial nutrition.

Supporting the TANG achieve its aims.

Ensuring best value around nutritional support is achieved for NHS Tayside.

Ensuring that artificial nutrition is patient centred and follows a defined patient pathway.

Providing leadership around improvement methodology and MCN working to ensure quality artificial nutritional care is provided throughout NHS Tayside.

Medical Staff are responsible for:

Following this policy.

Informing their manager if the policy cannot be followed.

The ultimate responsibility of ensuring patients artificial nutritional care is met.

Ensuring they provide leadership around artificial nutrition, keeping up to date with any subsequent alterations to this policy and ensuring that all staff are aware of any changes.

Qualified nursing staff are responsible for:


Informing their line manager if this policy cannot be followed.

Their own compliance with the guidance contained within this policy and with their line manager, identifying their training needs and attending appropriate training when available.

Following SOPs in relation to artificial nutrition.

Ensuring that key nutrition documentation accompanies the patient on discharge or transfer to other facilities.

Being alert to the possibility of under nutrition and nutrition complications in their patients.

Providing patients with relevant and up-to-date patient information as indicated in SOPs.

Student nurses (following training) are responsible for assisting qualified nursing staff.

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Support Grade Staff are responsible for:



Reporting clinical observations to a Registered Nurse e.g. when a patient pulls out a nasogastric tube or when an enteral feed is completed.

Dietitians are responsible for:



Adhering to TN MCN dietetic clinical standards around dietetic practice in relation to artificial nutrition and complete regular audit of their practice.

Providing leadership around artificial nutrition, ensure they keep up to date with any subsequent alterations to this policy and ensure that all staff are aware of any changes.

Auditing compliance with this policy.

Providing education opportunities on this policy as required.

Ensuring that surveillance systems are in place and monitor cases where a patient’s artificial nutritional support was compromised within a facility and advising the Tayside Artificial Nutrition Group as necessary.

Ensuring that patient information leaflets used are the most recent versions. Pharmacists are responsible for:



Providing leadership around pharmaceutical issues related to artificial nutrition.

3. BACKGROUND (Ref: NICE CG 32, 2017) People who are ill in hospital or the community may have lack of appetite and/or difficulties accessing or absorbing sufficient food and fluid to maintain an adequate nutritional status. The consequence is malnutrition. Significant deterioration of nutritional status during hospitalisation is common with between 60-100% of patients assessed at admission showing significant deterioration in nutritional status. The consequences of this include delayed wound healing, impaired respiratory and immune function, muscle weakness, depression, increased frequency and duration of hospitalisation, and premature death. The causes of malnutrition are multifactorial: poor appetite, physical disabilities, including swallowing impairments; increased metabolic demands for nutrients; and nutrient losses due to vomiting and diarrhoea, are some of the reasons. Inadequate nutritional knowledge among nursing and medical staff, partly because of the low emphasis given to nutrition education in undergraduate training, has led to a lack of awareness and recognition of malnutrition. Consequently, low referral rates to dietetic and specialist staff are not uncommon. One study reported that more than 80% of patients identified as malnourished on admission to hospital did not receive any nutrition intervention during their hospital stay.

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The type and severity of the patient’s disease, disorder or medical condition, and his or her nutritional status, will determine the choice of nutrition support (such as specially formulated nutritional fluids). Nutrition Support can be administered via 1. The Enteral Route (Section 4.1) which utilises the gastrointestinal tract. 2. The Parenteral Route (Section 4.2) – administered intravenously to bypass the

gastrointestinal tract. The options for enteral and parenteral nutrition are numerous and the criteria for choosing either option may be complex and will vary depending on the individual patient and the clinical expertise available.

4. CONSENT There is a duty for all clinical staff to provide best care to an individual, which includes assumed consent for oral feeding. However, the context of consent can take many different forms ranging from the active request by a patient for a particular treatment to the passive acceptance of a health professional’s advice. In many cases ‘seeking consent’ is better described as ‘joint decision making’: the patient and the health professional need to come to an agreement on the best way forward, based on the patient’s values and preferences and the health professional’s clinical knowledge. Issues of capacity and competence around consent for non-oral nutritional support are complex. Where an adult patient is judged to lack the mental capacity to give or withhold consent for themselves, this must be assessed under the terms of the Adults with Incapacity Scotland) Act 2000 (see Section 3.6 of NHS Tayside Informed Consent Policy 2018).

5. EDUCATION AND TRAINING Staff should have appropriate professional undergraduate and post graduate training to allow them to fulfill their professional role with regard to the management of people with feeding difficulties. This may vary from attendance at local training days, to specific post-graduate RCSLT qualifications in dysphagia assessment and management, depending on the professional and their individual role.

6. LEGAL LIABILITY NHS Tayside as an employer will assume vicarious liability for the actions of all staff, including those on honorary contracts, providing that: a. Staff have undergone any training identified as necessary. b. The member of staff is authorised by NHS Tayside to undertake the procedure. c. The provision of this Policy and the supporting procedure has been followed by the

member of staff at all times.

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SECTION 4: 4.1 4.1 ENTERAL TUBE FEEDING

Patients may require referral for artificial nutritional support when oral nutrition intake no longer sustains nutritional requirements.

Healthcare professionals should consider enteral tube feeding into the stomach or small bowel in people who are malnourished or at risk of malnutrition and cannot be supplemented orally or have an inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract.

Enteral feeding has fewer risks and is more cost effective than parenteral feeding; therefore all patients who have a functioning gut should receive enteral rather than parenteral nutrition.

Indications for enteral feeding:

Dysphagia - caused by a neurological condition, cerebral vascular accident (CVA) trauma, motor neurone disease, multiple sclerosis, head injury, demyelinating disease.

Hypermetabolism - caused by major surgery, sepsis, trauma, burns, organ transplantation, HIV/AIDS.

Gastrointestinal Disease - i.e. oesophageal dysmotility, inflammatory bowel disease, short bowel syndrome, pancreatic insufficiency (e.g. cystic fibrosis), gastrectomy, gastroparesis.

Cancer - e.g. head and neck or upper GI cancer, side effects of chemotherapy, Radiotherapy, or Surgery.

Psychiatric disease e.g. anorexia nervosa, severe depression.

Learning disability e.g. cerebral palsy. Contraindications for enteral feeding:

lower gastrointestinal obstruction

prolonged intestinal ileus

severe diarrhoea or vomiting

high enterocutaneous fistula

intestinal ischaemia Type of Enteral tube The indications for the type of enteral tube used are dependent upon a number of factors including expected duration of use, presenting problem, medical history and patient choice. The four main routes of access for enteral nutrition are as follows: 1. Nasogastric 2. Naso-jejunal 3. Gastrostomy 4. Jejunostomy To refer patients for enteral nutrition please refer to the nutrition & dietetic service.

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4.1.1 INSERTION AND CARE OF NASOGASTRIC TUBES Insertion of a naso-enteric tube Staff must ensure that they are competent to pass and care for naso-enteral feeding tubes and are aware of any patient safety alerts before passing or caring for naso-enteral tubes. A naso-enteral feeding tube refers to any feeding tube that is placed nasally into the oesophagus and beyond. Nasogastric feeding is generally considered appropriate for short-term use only. If appropriate an alternative route of tube feeding should be e.g. Percutaneous Endoscopic Gastrostomy Tube (PEG). Long term use of a nasogastric tube may cause discomfort, local nasal irritation, nose bleeds, sinusitis, and the inability to conceal the tube. However it may be appropriate for naso-enteric feeding to continue for longer periods of time. Indications for nasogastric (NG) tube insertion A nasogastric tube is recommended as follows:

For a patient with a functioning gastrointestinal system.

When access via other routes is inappropriate or unachievable. A nasogastric tube is contraindicated in the patient who has:

Vomiting not controlled by anti-emetics, or diarrhoea not responding to treatment.

Oesophageal strictures.

Fistulae (e.g. oesophageal perforation).

Nasal fractures and bleeds. Appendix 2 outlines the necessary competencies required to pass and care for a nasogastric tube. Risk assessment before insertion of nasogastric tube Decisions regarding modes of feeding will be made by the multidisciplinary team, the patient and if appropriate family and carers. The potential benefits of nutritional support and the access route will be considered, taking into account the associated risks, the clinical condition of the patient and any related ethical issues, including race, gender, age, disability and religion, (Lennard-Jones, 1999), and the rationale for any decisions is recorded in the patient’s medical notes (NPSA/2011/PSA002) (NNNG safe insertion and ongoing care of nasogastric feeding tubes in adults, 2016). Potential complications:

pulmonary intubation and pulmonary aspiration

nasal and mucosal ulceration, epistaxis

oesophageal, gastric and duodenal perforation

pneumothorax

nasal irritation with larger bore tubes (12/14 french gauge)

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Insertion of nasogastric tube A nasogastric tube may be inserted by a Registered Nurse/Allied Healthcare Professional who demonstrates competence or by a third year nursing student under direct supervision (Appendix 2). The location of the tube tip can vary i.e.:

nasogastric tube (tip within the stomach)

naso-jejunal tube (tip within the jejunum) - inserted by medical staff only Placement may be delayed if support is unavailable to accurately confirm nasogastric tube placement e.g. at night, unless clinically urgent, and that the rationale for any decisions made is recorded in the patient’s medical notes. ** For insertion technique please follow the Standard Operating Procedure for the insertion of nasogastric feeding tube (SOP 4.1a) and the checklist for passing a nasogastric tube (Appendix 3). Methods used to confirm placement of the nasogastric tube Nasogastric tubes are not flushed or any liquid/feed introduced through the tube following initial placement, until the tube tip placement is confirmed to be in the stomach by pH testing or x-ray, as per national patient safety alert 2012.

pH testing Currently the most reliable non-radiological method of checking the position of a nasogastric is aspiration of gastric acid and the use of pH indicator strips that are CE marked and intended by the manufacturer to test human gastric aspirate (NPSA 2011). pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe range, and that each test and test result is documented on a chart kept at the patient’s bedside. See Appendix 16 Enteral feeding administration chart. Patient does NOT then require an x ray. There are other non-radiological methods currently used in practice to determine tube position, unfortunately many of these methods are unreliable. The following four methods have been shown to be unreliable and therefore must never be used independently as a method of confirming tube position. 1. Auscultation of air into the stomach. 2. Observing for respiratory symptoms. 3. Visual inspection of aspirate. 4. Aspiration of stomach contents: testing with litmus paper or testing gastric

aspirate on litmus paper indicates whether it is acidic (pH < 7). N.B. Litmus paper is not able to distinguish between gastric acid that may have a pH from 1 - 6, and bronchial secretions, which in some instances may have a pH of between 5.5 and 7.

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Use of X-ray to determine placement of nasogastric tube. Current evidence suggests that routine checking by x-ray should be avoided because of the following factors: 1. The risk to the patient of frequent exposure to X-rays. 2. The potential delay in administration of nutritional support. 3. Cost and resource implications. 4. The use of radiology can only confirm the position of the tube when the X-ray is

taken. Currently it is good practice to: 1. X-ray only as a second line test when no aspirate could be obtained or pH

indicator paper has failed to confirm the position of the nasogastric tube. 2. Ensure X-ray request clearly states that the purpose of the x-ray is to establish

the position of the nasogastric tube for the purpose of feeding. 3. Ensure that the radiographer takes responsibility to ensure that the nasogastric

tube can be clearly seen on the x-ray to be used to confirm tube position. 4. Within documentation of the tube placement checking process include

confirmation that any x-ray viewed was the most current x-ray for the correct patient, how placement was interpreted, and clear instructions as to required actions.

5. Ensure any tubes identified to be in the lung are removed immediately, whether in the x-ray department or clinical area as per National Patient Safety Agency (NPSA/2011).

Care of nasogastric tubes There is always the risk that tubes become dislodged and cause bronchial aspiration. It is essential therefore that all patients who have nasogastric tubes in situ must be managed in the following way:

Before administrating anything down the NG tube including water, feed or medication the position should be confirmed by one of the above methods.

All tubes must be marked at the nostril with an indelible pen on initial successful insertion.

This mark must be checked before administering enteral feeding or medication or water via the tube.

The position of the tube must be confirmed if the pen mark is not visible at the nostril.

All tubes must be taped securely; check and replace fixation tape as necessary.

If the patient develops signs of respiratory distress, discontinue feeding immediately, manage the patient’s respiratory distress as per normal procedures and check the position of the tube.

Patients who are restless, agitated or confused are at higher risk of aspiration; in these cases the risk of aspiration must be considered and the multidisciplinary team must make the decision regarding feeding. Bolus feeding via the NG tube or other forms of feeding should be considered.

If medical condition permits, patients undergoing continuous feeding should be nursed at an angle of 30-45 degrees, to reduce the risk of aspiration from reflux.

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Complications Because of the ease in which nasogastric tubes may become displaced, it is important that measures are taken to regularly check the position of the tube in high-risk patients or if the following occurs:

After the patient has a coughing episode, retches or vomits.

After the use of oro-pharyngeal suction.

If the tube appears to have changed in length.

If the patient suddenly has signs of respiratory difficulties such as breathlessness, stridor, cyanosis or wheezing.

Considerations regarding planned nasogastric feeding at home Depending on the individual patient, a clear plan should be in place for all health professionals involved in the care of the patients in relation to the following:

Who will routinely place the nasogastric feeding tube every 6 weeks (district nurse/community hospital/carer/self trained)?

What does patient do if the tube blocks (access to Clog Zapper, unblocking information sheet in patient information booklet)

What does patient do if the tube comes out by accident or cannot be unblocked (daytime/overnight plans, fully dependent on tube for fluid, medication, acute ward/ district nurse, GP could contact on-call medical registrar in local hospital)?

What does the patient do if there are concerns about the position of the tube and unable to obtain aspirate (daytime/overnight plans, X-ray facilities, fully dependent on tube for fluid, meds, acute ward/district nurse, GP could contact medical registrar on call in local hospital)?

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4.1a STANDARD OPERATING PROCEDURE – Insertion of a nasogastric feeding tube

Policy: Food, Fluid & Nutritional Care

Policy Reference: 4.1a

Originator: Julie Fyall

Operation The insertion of a nasogastric feeding tube

Part number/name The insertion of a nasogastric feeding tube for enteral nutritional support for all adults identified as at risk of malnutrition

Safety Tools/ Clothing

Universal precautions e.g. wash hands before administration Disposable apron

Tools/Equipment Fine bore nasogastric (FG 8/10) radio-opaque throughout their length and have externally visible length markings 60ml purple enteral syringe Bowl Non-sterile gloves PH indicator strips Nasogastric tube insertion checklist Incapacity form if patient unable to provide verbal consent

No Main Operating Steps Rationale Evidence/support

1 Select appropriate FG Halyard tube to suit clinical need of patient

To provide patient with tube which meets their clinical need

2 Staff preparing the patient must introduce themselves to the patient by name and title

Patient safety and good practice

NMC. (2015) The Code

3 Staff must ensure that it is the correct patient - check name, date of birth, CHI (in-patients) or address (primary care)

Patient safety NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance NMC. (2015) The Code

4 Staff must explain the procedure to the patient and gain verbal consent if able and if not then signed consent using incapacity form


NHS Tayside (2018) Informed Consent Policy NMC. (2015) The Code

5 Assist patient to sit in semi-upright position with their head in a neutral position (if possible)

To ensure patient is in correct position for inserting nasogastric feeding tube


6 Decontaminate hands and put on gloves

Patient safety NMC. (2015) The Code NHS Tayside (2019) Infection Prevention and Control Policy

7 Measure the distance from the patient’s ear lobe to bridge of the nose to the bottom of the xiphisternum with the tube

To identify length of tube to be inserted into correct insertion site


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8 Select and note appropriate marker on the tube from the patient’s measurements

To note length of tube to be inserted in stomach

Manufacturer instructions

9 Place the end of the tube in a bowl of water and flush tube with water

To lubricate tube before insertion


10 Advise patient that procedure is about to occur and relax

Good practice NMC. (2015) The Code

11 Insert the tube into the clearer nostril in a backwards and inwards direction along the floor of the nasal cavity

To place tube correctly and does not go into or trachea


12 As the tube passes the nasopharynx encourage the patient to swallow; give the patient water to sip if permitted

To place tube correctly and to prevent going into trachea


13 Advance the tube through the pharynx until the predetermined mark has been reached

To place tube correctly and prevent it going into trachea


14 Check tube position by aspirating stomach contents with a 60ml syringe and check with the pH indicator strips that the aspirate is below pH 5.5 If it is difficult to obtain aspirate, try to manoeuvre patient into sitting position or roll on to left hand side and try again; if aspirate can NOT be obtained then as second line test please refer patient for X-ray to establish position of nasogastric tube

To check tube placement, patient safety

National Patient Safety Alert/ 2011/PSA 002: reducing the harm caused any misplaced tubes in adults, children and infants March 2011

15 Remove the guide-wire, mark the tube at the nostril with an indelible pen and secure the tube to the patient’s nostril with tape

To secure tube and mark the correct tube position


16 Ensure the patient is left comfortable and document procedure in the patients nursing notes

Patient safety NMC. (2015) The Code

17 Complete nasogastric insertion checklist and file in nursing notes


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APPENDIX 1: Decision tree for nasogastric tube placement checks in ADULTS

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APPENDIX 2: Competencies for insertion and care of Nasogastric (NG) tube

Name of Practitioner …………………………………………………... Date ………..…………………..

Knowledge All criteria must be met

Met Not met

Knows what information the patient needs before NG tube is passed.

Demonstrates knowledge of complications associated with insertion and use of NG tube.

Demonstrates knowledge of NHS Tayside’s NG insertion policy.

Lists all the equipment needed for insertion of NG tube insertion and explains why each piece of equipment is used.

Can describe how the correct position of the NG tube is confirmed and explain action to be taken if NG tube is suspected not to be in stomach.

Can discuss infection control principles in relation to NG insertion and subsequent care of tube.

Can describe the appropriate documentation needed and why the tube should be marked with an indelible pen after insertion.

Can describe when the position of NG tube should be rechecked.

Skills

Effectively discusses procedure with patient and obtains oral consent when appropriate.

Chooses appropriate equipment and prepares the environment.

Demonstrates appropriate infection control practices.

Demonstrates appropriate skills in assessing the correct position of the NG tube.

Follows hospital policy for insertion and care of NG tube.

Secures the tube and marks the tube with an indelible pen at the nostril.

Awareness/Attitude

Recognises own competency level and can explain implications of accountability when undertaking this practice.

Recognises the individual needs of the patient/client and deals with them sensitively.

Supervised practice of NG insertion

Date Comments

1

2

Formal assessment

I feel I have received sufficient theoretical knowledge and supervised practice to undertake the practice of insertion and care of nasogastric tube. Signature of Practitioner: ……………………………………………. Date: ………………….……

This practitioner has successfully met all the criteria for assessment. Name of assessor: ……………………………………………………………………………..…….. Signature of Assessor: ………………………………………………. Date: ………………………

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APPENDIX 3: Nasogastric (NG) tube insertion checklist

Equipment List

- Fine bore nasogastric tube which is radio-opaque throughout its length and has externally visible length markings.

- 60ml syringe, bowl, non sterile gloves, pH indicator strips, tape.

Initials

Introduce self to patient by name and title.

Ensure you have the correct patient, check name, DOB, CHI (in-patients) or address (primary care).

Explain procedure to patient.

Gain verbal consent.

Assist patient to sit in semi-upright position with their head in a neutral position (if possible).

Decontaminate hands.

Put on gloves.

Place exit port of tube at tip of nose. Extend tube to ear lobe, and then to xiphisternum.

Select appropriate marker on the tube from the patient’s measurements.

Place the end of the tube into a bowl of water and flush the tube with water.

Insert the tube into the clearer nostril in a backwards and inwards direction along the floor of the nasal cavity.

As the tube passes the nasopharynx encourage the patient to swallow. Give the patient water to sip if permitted.

Advance the tube through the pharynx until the predetermined mark has been reached.

Check tube position by aspirating stomach contents with a 50ml syringe.

Test with pH indicator strips pH indicator strips and confirm pH below 5.5.*

Secure tube to the nostril with tape.

Remove and retain the guide wire.

Ensure the patient is left comfortable.

Document procedure in the patient’s notes.

*A pH of 5.5 or less is a reliable indicator of gastric placement. Medications particularly H2 receptor antagonists (Ranitidine) or proton pump inhibitors (Omeprazole, Lansoprazole), reduce or inhibit gastric acid. This can elevate the pH of gastric aspirate. Elevated gastric pH can also occur in the presence of refluxing duodenal and pancreatic fluid which may occur after gastric surgery. Consider changing the time of medications. Normal bronchial fluid is 7.6, however it has been reported as low as 5.5, although it is usually greater than 6. When pH readings are inconclusive, or if aspirate is unable to be obtained, the tube will require removing and reinserting, or the use of radiology to confirm tube position may be required.

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4.1.2 GUIDANCE FOR THE USE OF NASAL RETENTION DEVICE Nasogastric tubes can become displaced for a variety of reasons and require to be repassed frequently. Many patients and families can find this distressing and it can be detrimental to their treatment and recovery. A nasal retention device, commonly known as ‘Bridal’ provides a means of securing a nasogastric feeding tube in position to prevent accidental or intentional removal by the patient. The retention device helps maintain nasogastric tube position avoiding both tube pullouts and loss of nutrition (see Appendix 4 for insertion and care of nasal retention device). Indications for use of nasal retention device (www.nnng.org.uk 2017)

Patients that have inadvertently removed at least 2/3 nasogastric tubes within a 48-72 hour period (depending on local policy).

Patients who are pulling at other types of devices, e.g. urinary catheters, intravenous cannulae and who require nasogastric tube for feeding and administration of medicines.

Elective use to retain NG/NJ tubes which are considered difficult to replace or when replacement would be a high risk or a technically difficult procedure (whether bedside placement, endoscopic or radiological).

Patients being discharged into the community with NG/NJ tube (depending on local policy).

Contraindications for use of nasal retention device

Patients with nasal, facial or skull fractures or mechanical obstructions to nasal airway.

Patients with deviated nasal septum.

Patients with any structural deformity of the nose or nasopharynx.

Retention device is used with caution for patients who are extremely confused and agitated and likely to still continue to pull at tube and cause damage.

http://www.nnng.org.uk/

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APPENDIX 4: Information on the use of a nasal retention device

Insertion of retention device

Ensure contradictions have considered prior to insertion e.g. patients who are confused, agitated, presence of any structural deformities or obstructions in the nose.

Can be placed at bedside when nasogastric tube has been inserted and its position confirmed.

Nasal retention device is passed using 2 thin plastic probes with magnets at the ends.

Probes are inserted into either nostril until contact has occurred and magnets connect in naso-pharyngeal space.

Soft gauze tape can then be drawn down and out of nostrils in loop.

Small clip is then closed around the gauze tapes and nasogastric tube to secure.

Nasal retention devices are available from PECO’s.

Stroke units throughout Tayside can provide advice and support.

Care of retention device

Check retention device loop tapes are not over tight and clip is secure.

Ensure clip is not causing undue pressure to skin underneath.

Clean and dry nasal tape, more often if excessive secretions from nose.

Nasal mucosa should be observed frequently for signs of irritation, bleeding and necrosis.

Refer to Nurse Specialists in Gastroenterology (bleep 4470, ext. 36777) if any concerns.

Removal of retention device

If patient becomes very agitated and continually pulls at tube you may have to remove retention device to prevent damage to the nasal septum. Retention device can otherwise stay in place for duration of lifespan of nasogastric tube.

When removal required cut one side of gauze tape between nose and clip and gently pull both the retention device and feeding tube out at same time.

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4.1.3 INSERTION AND CARE OF JEJUNAL TUBES Naso-jejunal feeding necessitates the provision of nutrients via a naso-enteric tube placed directly into the small intestine. There is a reduced risk of reflux and aspiration when tubes are placed post-pyloric; however the risk is not completely eliminated. This route may also be used for short term feeding, when necessary to avoid feeding into the stomach e.g. following gastric surgery or in patients with poor gastric emptying (see Appendix 5 – post insertion and care of naso-jejunal (NJ) tubes). Indications for insertion of naso-jejunal tube

gastric stasis – gastroparesis

severe gastro-oesophageal reflux disease

proximal small bowel fistulae where tube is placed distal to the fistula

obstruction of the upper gastrointestinal tract where the tube is placed distal to the obstruction

surgery involving the upper gastrointestinal tract e.g. gastrectomy, oesophagectomy or pancreatectomy

Contraindications of naso-jejunal tube

distal gastrointestinal tract obstruction

high output small bowel/large bowel fistula

intestinal dysmotility Types of naso-jejunal tubes include:

single lumen tubes – allows the infusion of fluid into the jejunum

double lumen tubes – allows the infusion of fluid into the jejunum and drainage of gastric fluid

Insertion of naso-jejunal feeding tubes Naso-jejunal tubes feeding tubes are passed via the nostril through the stomach and into the intestine. They can be placed via endoscopy or radiology. As these tubes are placed using direct view respiratory placement can be avoided. Once in situ, the tube must be marked with an indelible pen. It is acceptable to leave position testing until such times as the tube has visibly moved, or the patient shown signs of intragastric feed delivery such as vomiting or gastric distension. It is now common practise for post-pyloric tubes to be placed in endoscopy or radiology. In rare circumstances where a post-pyloric tube has been placed at bedside, an abdominal x-ray would be required to check position. Naso-jejunal tube removal Check manufacturer’s instructions regarding length of time tube can be left in-situ; this must be recorded on the insertion documentation. To remove the tube; gently withdraw through the nostril until tube is fully removed.

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APPENDIX 5: Post insertion care of Naso-Jejunal (NJ) tubes

Tube securing

After insertion the tube can be secured to the side of the face by a hypoallergenic adherent dressing and looped over the ear.

Care should be taken in securing the tube to the patient’s nostril, making sure that it is well adhered but not causing pressure on the nostril; localised cyanosis and necrosis can occur if blood flows impaired.

The tube should be marked next the nostril with an indelible pan.

The position of the tube should be checked before feeding or the administration of medications via the tube is commenced.

Aspiration Routine aspiration is not required. If the patient is nauseated or vomiting, the NJ tube should be aspirated. If an aspirate is obtained, this may indicate that the tip of the tube has migrated to the stomach.

Any feed or medication being administered through the tube at this time should be stopped and advice sought from medical staff.

Tube flushing

The person flushing the tube should wear latex-free, non-sterile, powder-free gloves whilst flushing the tube after careful hand washing.

To maintain patency, the tube should be flushed with 50ml of sterile water 6 hourly if not in use and before, between and after feed and drug administration. The water must be sterile.

Monitoring Careful monitoring of the patient is also required throughout the period after NJ tube insertion to removal.

Observe patient’s respiratory status.

Observe for signs of cyanosis, unexplained confusion, hypoxia, dyspnoea, respiratory distress, or chest infection.

Monitor for tachycardia, tachypnoea or dyspnoea and pyrexia.

Feeding The feed that is administered must be prescribed after review by the Dietitian Similarly, an authorised prescriber must prescribe any medications or flushes that are administered via the tube after assessment of the patient’s fluid and nutritional requirements.

Bacterial contamination is cumulative and directly related to the number of system manipulations and technique of the person preparing the feed.

Feed via a NJ tube should not routinely be administered as a bolus as the jejunum does not have capacity for bolus feeding. If bolus feeds are given, there is a risk of pain, diarrhoea and a dumping-like syndrome. It must therefore be given through a rate-controlled pump.

Because of the risk of pulmonary aspiration of feed the patient should be nursed at a 30° angle or higher (not contra-indicated by their medical condition.

Naso-jejunal feed may run over 24 hours. The feed and administration set should be changed every 24 hours (If the patient is maintained on a Ventilator to assist with breathing, the patient must also have a nasogastric tube to reduce the risk of pulmonary aspiration.

The tube is intended for single patient use.

Medication Medication administered via NJ tubes should be kept to a minimum, as tubes are prone to blocking due to their small bore.

All medications should be taken by mouth if medications need to be administered down the tube they must be reviewed by hospital pharmacist.

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4.1.4 MEDIUM CHANGE TRIGLYCERIDE (MCT) DIET/TUBE FEED FOR CHYLE LEAK – INSTRUCTIONS FOR COMMENCING ON A WEEKEND/PUBLIC HOLIDAY NINEWELLS ONLY Oral Diet Low fat diet (maximum of 20g/day) Ensure Plus Juce to supplement diet (Inform diet kitchen Ninewells, ext. 32754 – they will adapt meals accordingly and send Ensure Plus Juce twice daily) Tube feed If patient already fully established on a feed, change to 400ml of Peptamen HN and 3 Ensure Plus Juce (poured into a Flexitainer) daily – can run at previously established rate e.g.75ml/hr If a new tube feed, give Peptamen HN at 25ml/hr for 16hr daily until reviewed by the Dietitian (Inform diet kitchen, ext. 32754 – they will send 500ml Peptamen HN and a screwcap adaptor plus 3 Ensure Plus Juce of the same flavour, and a Flexitainer if this is required) Please ensure that you call the Ninewells Dietetic Department (ext. 33875) and leave a message so that the Dietitian can review on return. Algorithm for dietetic management of Chyle Leaks follows:

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4.1.5 INSERTION AND CARE OF PERCUTANEOUS ENTERAL FEEDING TUBES A percutaneous enteral feeding tube refers to any feeding tube that is placed through the skin into the stomach. The initial placement of these tubes requires the formation of a surgical incision to create a stoma tract, and in most cases the patient will require sedation and local anaesthetic (see Table 1). Gastrostomy feeding should be considered in people likely to need long-term (NICE 2017) enteral tube feeding such as those who are unable to swallow or absorb adequate amounts of food and/or fluid by mouth. It may be used as the sole source of nutrition or may be used to supplement an inadequate oral intake. There are various methods of gastrostomy insertion:

Percutaneous Endoscopic Gastrostomy Tube (PEG) The tube is inserted with the use of an endoscope in the endoscopy department. The patient is given sedation and local anaesthetic. The procedure takes around 20-30 minutes. The tube is held in place by a firm disc and is not easily removed accidentally. It can remain in place for 3-4 years or more.

Radiological insertion of Gastrostomy Tube (RIG) In some patients it may not be possible or safe to place a gastrostomy tube endoscopically. Radiological placement under x-ray can provide an alternative method of insertion. A nasogastric tube is required during the procedure to inflate air and contrast medium into the stomach. Local anaesthetic is given and sedation if required. Gastropexy sutures are inserted to secure the stomach wall to the abdomen and should be removed 7 days hours post insertion. The gastrostomy tube placed radiologically should be replaced every 6 months. The gastrostomy tube is held in place by a balloon of sterile water. The sterile water should be replaced at least every 2 weeks with 5mls sterile water unless otherwise stated.

Surgical insertion of Gastrostomy Tube If placement of a gastrostomy tube cannot be carried out endoscopically or radiologically then it may be possible for it to be surgically inserted in theatre. This can happen if the stomach cannot be accessed by any of the other procedures. This can occur if the anatomical position of the stomach has changed for example following previous gastric or bowel surgery. N.B. Only devices intended for enteral tube feeding must be used. When a device is used for the purposes other than those intended by the manufacturer, it cannot be assured to be safe, suitable or effective (MHRA, 2004).

Indications for gastrostomy tubes insertion

the patient has been assessed as ethically appropriate for artificial nutrition support

the patient has an intact functioning gastrointestinal tract

the patient has been referred to a dietitian and speech and language therapist, and a decision has been made on the most appropriate method of meeting the individual’s nutritional requirements

oral supplementation or dietary modification has not met the patient’s nutritional requirements and/or the nasogastric tube feeding has been unsuccessful

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the patient is likely to require artificial nutritional support for at least four weeks

the implications of gastrostomy tube insertion and feeding has been discussed with the patient and/or relative

Contraindications for use:

prognosis is so poor that survival beyond a few weeks is unlikely

the patient refuses treatment and is legally competent to do so

the patient has lost the capacity to make a decision, but has made a valid, clear and unambiguous advance directive that artificial nutrition be withheld

the patient has lost the capacity to make a decision, but gastrostomy feeding would prolong a life and increase a patient’s pain and distress

Contraindications to placement may also occur when there is an inability to access the stomach either endoscopically or trans-abdominally. This occurs in patients:

with INR >1.4 or platelets <50 x 10/9/l

who have poor general health e.g. cardio respiratory failure

who have had a CVA within the last 2 weeks

who have had some types of previous gastric surgery

who have ascites or marked hepatomegaly

who have obstructing oesophageal lesions or gastric lesions

who are morbidly obese

who have neoplastic and infiltrated diseases of the gastric wall

who have a proximal small bowel fistula

with severe cardiac and respiratory disease

who are receiving peritoneal dialysis Consideration in Stroke NICE guidelines recommend nasogastric tube feeding within 24 hours of admission for those unable to take adequate fluids and food orally. Nasogastric tube feeding is the recommended route for those who require enteral feeding in the first few weeks after a stroke. PEG tube feeding has been shown to be associated with increased mortality and poor outcome and should be reserved for those who cannot be fed via a nasogastric tube, or where enteral feeding is prolonged. In the terminal phase of their illness the appropriateness of any the intervention should be discussed with all relevant parties and the patient’s quality of life and prognosis before deciding on the appropriateness or otherwise of either procedure. Consideration in Dementia PEG tubes are generally poorly tolerated by patients with dementia and there is some evidence that hand feeding can be as effective. Additionally PEG tube feeding does not improve overall prognosis in patients with advanced dementia or prevent aspiration, prolong survival, improve quality of life, functional status or nutritional status.

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There is an acknowledged need for palliative care provision for patients with advanced dementia. Where dietary intake is insufficient but death is not imminent, the GMC states that a second opinion must be sought from a senior clinician not directly involved in the patient's care, before the decision to withhold artificial feeding is finalised and that where significant conflicts remain, either within the healthcare team or with those close to the patient, legal advice should be sought (abstract from British Geriatric Society, 2000). In the acute setting, an initial 2–4 week trial of enteral tube feeding should be considered. Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should assess the prognosis and options for future nutrition support (see Section 6). Referral for insertion Assessment for gastrostomy tube insertion is carried out by Nurse Specialists in Gastroenterology, Consultant Physician, Consultant Surgeon or Consultant Radiologist. Patients requiring enteral tube feeding should have their tube inserted by healthcare professionals with the relevant skills and training. The healthcare professional inserting the tube will:

Assess the patient for suitability.

Inform the referring team of any outstanding issues. For PEG referral contact Nurse Specialists in Gastroenterology in Ninewells on 01382 496777, bleep 4470 internal extension 36777 or Marie Anderson, Endoscopy Nurse Specialist Perth Royal Infirmary 01738 473825, internal extension 13825 or Consultant Gastroenterologist at Perth Royal Infirmary. For RIG contact Consultant Radiologist at Ninewells X-ray department. For surgical gastrostomy contact Gastrointestinal Surgeon. Patient preparation Prior to gastrostomy insertion the staff member must follow the Standard Operating Procedure for insertion of gastrostomy tube (see SOPs 4.1b, c and d and complete associated checklists - Appendices 6a & 8a. Consent Verbal or written consent is required for the patient who is being prepared for the insertion of an enteral feeding tube. Verbal consent is required for nasogastric insertion (unless there are concerns regarding cognitive ability/capacity) and written consent is required for gastrostomy or jejunostomy tubes. Consent should involve a detailed discussion outlining what is involved in the procedure itself, the associated risks and followed up with written information. Consent should be undertaken by a member of the team involved in the procedure ideally with the patient or next of kin before the procedure is arranged.

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Complications Aspiration pneumonia The level of sedation may contribute to aspiration risk during the procedure, and rates of around one per cent of insertions resulting in peri-procedure aspiration are reported. Whilst post-procedure aspiration resulting from refluxed gastric contents and tube feedings is thought to be even higher. Colonic perforation Colonic perforation during gastrostomy placement is rare. Colonic perforation is also likely to lead to peritonitis and necessitate major surgery. Haemorrhage Haemorrhage may be primary haemorrhage (during or immediately after insertion), or secondary haemorrhage (which may occur 12-24 hours) or may occur several days after gastrostomy insertion (due to stomal necrosis). Whilst very minor external bleeding can be normal, significant external bleeding can indicate serious internal bleeding. Wound infection Localised wound infection can occur in 5 -25% of cases, despite the standard administration of prophylactic antibiotics. Given the very vulnerable nature of the patient group, some localised infections may proceed to bacteraemia. Peritonitis Peritonitis results from bacterial transmission across the stoma puncture site and complicates up to 2.3% of procedures and carries a high mortality rate. Peritonitis manifests as abdominal pain, fever, and a raised white cell count in the initial days after placement. Transient external leakage of the stomach contents from the puncture canal can indicate a likelihood that internal leakage is also occurring. There can also be chemical peritonitis if enteral feed leaks across; this can manifest as pain on feeding. Post insertion care of gastrostomy tube Staff must follow guidance for the post insertion care of gastrostomy tube and general care of a PEG/RIG (see Appendices 6a, 7 & 8a and SOP 4.1d. PEG tubes which have been placed without apparent complications can be used for enteral tube feeding 4 hours after insertion.

Observe patient for signs of acute abdominal pain or leakage from site.

The wound site should be cleaned and dried using aseptic technique for the first 2 days.

The first 24 hours are critical for development of infection around the site; therefore regular checks (3-4 times a day) for skin redness or swelling of abdomen or leaking of stomach contents are necessary.

The patient must not have an immersion bath for 2 weeks following the procedure while the tract around the inserted tube is being formed. However the patient can have a shower.

Do not release the fixation device until the tract is formed (for about 7 days).

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From day 10 post-insertion, rotate tube daily to prevent buried bumper syndrome. The tube should be rotated through 360 degrees daily thereafter.

4 weeks post insertion loosen the external fixation device, gently push tube inwards by 2/3cms (NB: PEG ONLY) then retract to maintain a healthy stoma tract. This should be undertaken weekly thereafter.

Flush the tube before and after feeds, and before and after medication with prescribed amount of water or 30ml of water if no volume stipulated.

If the tube falls out it must be replaced straight away.

Always ensure hands are adequately decontaminated before and after care as per local policy.

If peritonitis suspected:

Stop enteral feed immediately.

If patient systemically unwell (tachycardia, pyrexial, low BP, raised white cell count, raised CRP), place the tube on free drainage and request urgent surgical review.

Long term complications 1. Infection at the insertion site. 2. Oesophageal reflux resulting in aspiration pneumonia – wherever possible the

patient should be fed at an angle of at least 30° recumbent. 3. Tube occlusion. 4. Accidental removal of gastrostomy. 5. Overgranulation. Accidental or intentional removal of gastrostomy Accidentally dislodged gastrostomies must be replaced within 2-4 hours. Placement of a balloon gastrostomy tube in a mature stoma tract (>6 weeks) is a low risk procedure. Dislodged gastrostomies can be replaced in the community by staff that have undergone appropriate balloon gastrostomy placement training. Refer to Appendix 10 for competencies for care of PEGs and balloon gastrostomies. Refer to Appendix 11 for competencies required for replacement of balloon gastrostomy in adults and SOP 4.1f for replacement of a balloon gastrostomy and SOP 4.1g for replacement of a low profile gastrostomy.

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Removal of gastrostomy tube The decision to remove the tube will be made by the multi-disciplinary team including the medical, nursing, and dietetic and speech & language therapy staff. Tube removal is relatively uncomplicated, but occasionally problems arise. Bleeding or infection can occur around the tube placement site. These complications are rare, and the majority of people will have the procedure performed in a straightforward manner. Balloon gastrostomy can be removed by deflating the balloon and pulling out the tube. There is no need for sutures. Dry dressing is applied for 24 hours post procedure. If a feeding tube is no longer required then routine removal should not be undertaken until 6 weeks has lapsed since the initial feeding tube was placed. Appendix 13 is a troubleshooting guide for PEG/JEJ enteral tube feeding. PEG tubes are removed by Nurse Specialist in Gastroenterology, Gastroenterologists or Surgeon. Balloon retained gastrostomy tubes can be removed by appropriately trained dietitians, nurses or medical staff.

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Table 1: Gastrostomy tubes most commonly used in NHS Tayside

Route Indication Lifespan Method of

securing tube

Picture

Percutaneous Endoscopic Gastrostomy (PEG) Halyard

Most common route for long term feeding into stomach. Placed under sedation in the Endoscopy Unit at either Ninewells Hospital or Perth Royal Infirmary.

Several years

Small sponge device in stomach

Percutaneous Endoscopic Gastrostomy (PEG) Freka

Placed under sedation in the Endoscopy Unit at either Ninewells Hospital or Perth Royal Infirmary. Requires upper endoscopy to remove.

Several years

Small, plastic retention device in stomach

Balloon gastrostomy

May be inserted radiologically as the initial tube in patients who are unsuitable for endoscopy or may be used as a replacement tube in patients who have previously had a PEG.

4-12 months (depending on make)

Small internal balloon filled with sterile water

Low profile gastrostomy tube (LPGT) or ‘button’ gastrostomy

Replacement tubes in patients who have had either a PEG or balloon gastrostomy as their initial tube. Cosmetically more acceptable as they lie flush with the skin. Available in different shaft lengths/widths. Extension set must be attached to LPGT before administering feed, fluid or medication.

6 months

Small internal balloon filled with sterile water

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4.1b STANDARD OPERATING PROCEDURE – Preparing patient for insertion of a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube


Policy reference: 4.1b


Operation Preparing patient for insertion of a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube

Part number/name The preparation of patients for the insertion of a PEG for enteral nutritional support for all adults


Universal precautions e.g. wash hands

Tools/Equipment PEG insertion checklist





2 Staff must ensure that it is the correct patient - check name, date of birth, CHI (in-patients) and ensure patient ID wristband is attached and has been fasted for at least 6 hours pre-procedure


3 Staff complete PEG checklist (see Appendix 6a) and ensures that the patient has had their bloods checked and that a Venflon is in situ


4 Assist patient into theatre gown To ensure patient is in correct clothing for procedure


5 Send nursing and medical notes with associated informed consent to Endoscopy Department.

To ensure Endoscopy Department have necessary documentation

NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance NMC. (2015) The Code

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APPENDIX 6a: Checklist for insertion of Percutaneous Endoscopic Gastrostomy (PEG) tube

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APPENDIX 6b: Enteral feeding regimen - post PEG

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APPENDIX 7: Guidance for the care of Percutaneous Endoscopic Gastrostomy (PEG) tube

CARE OF PATIENT FOLLOWING PEG TUBE INSERTION

OBSERVATIONS

The patient will be given sedation and analgesia during procedure. Post procedure monitor TPR, BP and oxygen saturations every hour for the first 2 hours then 4 hourly for 24 hours.

WOUND

Observe the PEG site for signs of leakage. The site may be covered with a dressing, which should be removed 24hrs post procedure.

STOMA SITE

Clean stoma site with saline using aseptic technique for the first 48 hours, thereafter clean with a clean cloth, unperfumed soap and water and dry thoroughly.

TUBE

Observe the position of the tube on return to the ward and note any outward/inward movement. If there is any outward/inward movement gently move external bumper nearer to skin, leaving at least 5mm from skin surface. After 10 days the tube should be rotated 360o daily.

PAIN MANAGEMENT

A PEG site may be painful after insertion. Patients must be regularly assessed for pain and adequate analgesia given. First line analgesia is Paracetamol 1gm every 4-6 hourly to a maximum dose of 4gm. Second line Tramadol 50-100mg every 4-6 hourly to a maximum dose of 400mg.

COMMENCING FEEDING

Commence feeding via the gastrostomy tube as follows:

Flush the tube with 50ml of sterile water for the first 4 hours.

After the sterile water and before starting formula feed aspirate some gastric contents and check for a pH value of 5.5 or less. If pH value is 5.5 or less then proceed to formula feeding. If no gastric aspirate or pH above 5.5 then organise a tubogram to ensure the tube is in the correct position.

If pH 5.5 or less commence feeding with formula feed at 50ml per hour and build up slowly to full regimen observing for any adverse signs.

If patient is not NBM, oral diet can be commenced after 4 hours as tolerated.

FLUSHING

Flush the tube with 50ml of water before and after commencement of the feed and administration of medicines.

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MEDICINES

Medication given via the tube should be given in liquid form where possible. Dispersible medicines may be given if dissolved well and flushed with copious amounts of water. Unless in exceptional circumstances crushed tablets should never be given and capsules should not be opened and administered via the tube. Please refer to the medical staff, pharmacist or nurse specialist for advice. The tube is extremely narrow and will block easily.

HYGIENE

The patient should not have an immersion bath for 2 weeks following the procedure. Showers are permitted after 24 hours. Ensure that the stoma site is washed first.

TUBE DISPLACEMENT

If a displaced tube has been inserted within the last 6 weeks there is a risk that the stoma tract is not fully formed.

In this situation, the risk of disrupting the tract with leakage of feed or gastric contents into the peritoneum or abdominal wall layers could be significant particularly within the first 3 days.

Only an experienced person should attempt to gently replace the tube, tape it into place and arrange a contrast study as soon as possible.

If the tube will not easily pass into the tract, no effort should be made to force it, but a spare gastrostomy tube, fine bore NG feeding tube, or small gauge Foley catheter may be gently placed through the tract taped in place and a contrast study arranged with a view to dilating the tract to replace with a permanent tube.

If a PEG/RIG is displaced within 2 weeks of insertion, no attempt is to be made to re-insert the tube or use catheters/NG tube to maintain tract. Due to the risk of disrupting a tract which is not fully formed.

If a PEG/RIG is displaced within 2-4 weeks of insertion, re-insertion should only be attempted by an experienced practitioner and anything used to maintain the tract should only remain there for as little time as possible

Any replacement tube inserted 2-6 weeks after initial placement, should have a tubogram performed before use

If a feeding tube is no longer required then routine removal should not be undertaken until 6 weeks has lapsed since the initial feeding tube was placed.

UNDER NO CIRCUMSTANCES SHOULD THESE TEMPORARY TUBES BE USED FOR FEEDING - THEY ARE MERELY TO MAINTAIN PATENCY OF THE TRACT

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EMERGENCY ADVICE CONTACT IN HOSPITAL

Nurse Specialist in Gastroenterology on 01382 496777 or 01382 600111, bleep 4470 (during office hours)

COMMUNITY DIETITIAN: contact details

Angus: 01356 665031 Dundee: 01382 424148 Perth: 01738 473511

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4.1c STANDARD OPERATING PROCEDURE – Preparing patient for insertion of a Radiologically Inserted Gastrostomy (RIG) enteral feeding tube


Policy reference: 4.1c


Operation Preparing patient for insertion of a Radiologically Inserted Gastrostomy (RIG) enteral feeding tube

Part number/name The preparation of patients for the insertion of a RIG for enteral nutritional support for all adults


Universal precautions e.g. wash hands

Tools/Equipment RIG insertion checklist





2 Staff must ensure that it is the correct patient - check name, date of birth, CHI (in-patients) and ensure patient ID wristband is attached and patient has been fasted for at least 6 hours pre-procedure


3 Staff complete RIG checklist (see Appendix 8a) and ensure that the patient has had their bloods checked; that a Venflon is in situ and a nasogastric tube is in situ

Patient safety To ensure patient is prepared correctly for procedure


4 Assist patient into theatre gown To ensure patient is in correct clothing for procedure


5 Send nursing and medical notes with associated informed consent to Radiology Department

To ensure Radiology Department have necessary documentation


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4.1d STANDARD OPERATING PROCEDURE – Immediate post aftercare of a Radiologically Inserted Gastrostomy (RIG)/ Percutaneous Endoscopic Gastrostomy (PEG) enteral feeding tube


Policy reference: 4.1d


Operation Immediate post aftercare of a Radiologically Inserted Gastrostomy (RIG)/ Percutaneous Endoscopic Gastrostomy (PEG) enteral feeding tube

Part number/name The immediate aftercare of patients after the insertion of a RIG/PEG tube for enteral nutritional support for all adults


Universal precautions e.g. wash hands Apron & Gloves

Tools/ Equipment

RIG/PEG insertion checklist Incapacity form if patient unable to provide verbal consent required post procedure Tympanic temperature gauge Dynamap 60ml Enfit syringe Sterile water





2 Staff must ensure that it is the correct patient - check name, date of birth, CHI


3 Staff completes RIG/PEG Post Procedure checklist (see Appendices 7 / 9)


4 Staff measures patient’s vital signs – BP, pulse and temperature hourly for 2 hours then 4 hourly for 24 hours

Patient safety and to observe for signs of complications post procedure


5 Check wound site hourly for 2 hours then 4 hourly for 24 hours

Patient safety and to observe for signs of fresh bleeding or leakage of gastric contents


6 Administer 50ml of sterile water via tube hourly for 4 hours

To observe for signs of acute abdominal pain

Not Manufacturer instructions

7 If pain on feeding, flushing tube, or prolonged or severe pain, fresh bleeding or leakage of gastric contents within 72 hours post procedure then obtain senior medical advice

Patient safety and post procedural complications and early identification of complications

NMC. (2015) The Code National Patient Safety Alert (2010)

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APPENDIX 8a: Checklist for insertion of Radiological Inserted Gastrostomy (RIG) tube

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APPENDIX 8b: Enteral feeding regimen - post RIG

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APPENDIX 9: Guidance for the care of Radiological Inserted Gastrostomy (RIG) tube

CARE OF PATIENT FOLLOWING RIG TUBE INSERTION

OBSERVATIONS

The patient will be offered sedation and analgesia during procedure- monitor TPR and BP every hour for the first 2 hours then 4 hourly for 24 hours.

WOUND

Observe the RIG site for signs of leakage. The site may be covered with a dressing, which should be removed 24hrs post procedure.

STOMA SITE

Clean stoma site with saline using aseptic technique for the first 48 hours, thereafter clean with a clean cloth, unperfumed soap and water and dry thoroughly.

TUBE

Observe the position of the tube on return to the ward and note any outward/inward movement. If there is any outward/inward movement gently move external bumper nearer to skin, leaving at least 5mm from skin surface. The tube is retained by 5ml water filled balloon. After 10 days the tube should be rotated 360o daily.

PAIN MANAGEMENT

A RIG site may be painful after insertion. Patients must be regularly assessed for pain and adequate analgesia given. First line analgesia is Paracetamol 1gm every 4-6 hourly to a maximum dose of 4gm. Second line Tramadol 50-100mg every 4-6 hourly to a maximum dose of 400mg.

SUTURES

Around the stoma there will be three or four sutures that look similar to small buttons in situ. Please note the gastrostomy tube is not held in place by the sutures. The sutures secure the stomach wall to the abdominal wall to allow the stoma to be formed. Nursing staff should remove these sutures 7 days post procedure. To remove sutures, raise the fastener away from the skin surface and then cut the suture at skin level. The internal portion (T fastener in stomach) will be passed out naturally. Any remaining suture material is unlikely to cause a significant problem.

BALLOON

An internal water filled balloon holds the tube in place. The water volume should be checked and replaced every 2 weeks, and after the tube has been in situ for 2 weeks – NB only after 2 weeks.

Push tube in gently prior to checking balloon

Attach 5ml slip-tip (not luer lock) syringe to balloon port and withdraw all the fluid, discard liquid.

Re-inflate balloon with 5ml sterile water or as per manufacturer’s guidelines.

Never administer anything else down this balloon port.

See SOP 4.1i for checking the volume of the retention balloon on a balloon gastrostomy.

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COMMENCING FEEDING

Commence feeding via the gastrostomy tube as follows:

Never administer FEED DOWN balloon port.

Flush the tube with 50ml of sterile water for the first 4 hours.

After the sterile water and before starting formula feed aspirate some gastric contents and check for a pH value of 5.5 or less. If pH value is 5.5 or less then proceed to formula feeding. If no gastric aspirate or pH above 5.5 then organise a tubogram to ensure the tube is in the correct position.

If pH 5.5 or less commence feeding with formula feed at 50ml per hour and build up slowly to full regimen observing for any adverse signs. If patient previously established on enteral feed, commence as before.

FLUSHING

Flush the tube with 50ml of water before and after commencement of the feed and administration of medicines.

MEDICINES

Medication given via the tube should be given in liquid form where possible. Dispersible medicines may be given if dissolved well and flushed with copious amounts of water. Unless in exceptional circumstances crushed tablets should never be given and capsules should not be opened and administered via the tube. Please refer to the medical staff, pharmacist or nurse specialist for advice. The tube is extremely narrow and will block easily. Never administer medicines down the balloon port.

HYGIENE

The patient should not have an immersion bath for 2 weeks following the procedure. Showers are permitted after 24 hours. Ensure that the stoma site is washed first.

TUBE DISPLACEMENT

If a displaced tube has been inserted within the last 6 weeks there is a risk that the stoma tract is not fully formed.

In this situation, the risk of disrupting the tract with leakage of feed or gastric contents into the peritoneum or abdominal wall layers could be significant particularly within the first 7 days.

Only an experienced person should attempt to gently replace the tube, tape it into place and arrange a contrast study as soon as possible.

If the tube will not easily pass into the tract, no effort should be made to force it, but a spare gastrostomy tube, fine bore NG feeding tube, or small gauge Foley catheter may be gently placed through the tract taped in place and a contrast study arranged with a view to dilating the tract to replace with a permanent tube.

If a PEG/RIG is displaced within 2 weeks of insertion, no attempt is to be made to re-insert the tube or use catheters/NG tube to maintain tract. Due to the risk of disrupting a tract which is not fully formed.

If a PEG/RIG is displaced within 2-4 weeks of insertion, re-insertion should only be attempted by an experienced practitioner and anything used to maintain the tract should only remain there for as little time as possible

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Any replacement tube inserted 2-6 weeks after initial placement, should have a tubogram performed before use

If a feeding tube is no longer required then routine removal should not be undertaken until 6 weeks has lapsed since the initial feeding tube was placed.

UNDER NO CIRCUMSTANCES SHOULD THESE TEMPORARY TUBES BE USED FOR FEEDING - THEY ARE MERELY TO MAINTAIN PATENCY OF STOMA TRACT

EMERGENCY ADVICE CONTACT IN HOSPITAL

Nurse Specialists in Gastroenterology on 01382 496777 or 01382 600111, Bleep 4470 (during office hours)

COMMUNITY DIETITIAN: name and contact details

Angus: 01356 665031 Dundee: 01382 424148 Perth: 01738 473511

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APPENDIX 10: Competencies for care of PEGs and balloon gastrostomy

Name of Practitioner ………………………………………………………...…. Date …….………………………

Knowledge All criteria must be met

Met Not met

Can describe the difference between a Percutaneous Endoscopic Gastrostomy (PEG) tube and a balloon gastrostomy.

Can describe the parts of the tube and can identify if the tube has a retaining balloon port.

Can describe and explain action to be taken if tube is accidentally removed.

Is able to state how quickly they must respond to a displaced tube.

Can describe how to maintain patency of the tube.

Is able to state how often the tube should be rotated.

Can describe what the first line measures are if there is leakage from the tube.

Is aware of local policy for drug administration via tube.

Can discuss infection control principles in relation to care of tube.

Demonstrates knowledge of appropriate NHS Tayside policies.

Can describe current ward/unit documentation to record care of tube.

Skills

Assesses and plans interventions.


Demonstrates an ability to flush tube, commence and discontinue enteral feed.

Can effectively clean the stoma tract, rotate the tube and detect any signs of infection.

Demonstrates how to ensure balloon fully inflated and external fixator is in correct position.

Can administer drugs via tube and flush tube after use.

Demonstrates appropriate infection control practices.

Follows ward/hospital polices when dealing with the tube and disposes of used equipment appropriately.

Awareness/Attitude

Recognises own competency level and can explain implications of accountability when undertaking an advanced practice.


Supervised practice of flushing tube and caring for stoma site

Date Comments

1

2

Formal assessment

I feel I have received sufficient theoretical knowledge and supervised practice to undertake the practice of care of PEG/Gastrostomy tube. Signature of Practitioner: ………………………………………………….… Date: ………………………………

This practitioner has successfully met all the criteria for assessment. Name of assessor: ……………………………………………………… Signature of Assessor: ………………………………………………………. Date: ………………………………

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4.1e STANDARD OPERATING PROCEDURE – Replacing the Y-adaptor on a Halyard percutaneous gastrostomy tube

Policy: Food, Fluid &Nutritional Care

Policy reference: 4.1e


Operation Fitting a Halyard PEG replacement feeding adaptor

Part number/name The procedure for replacing the Y adaptor on a Halyard percutaneous gastrostomy tube for enteral nutritional support for all adults identified as at risk of malnutrition undertaken by signed competent qualified staff (only staff that have demonstrated competence and have signed record of competence)



Tools/Equipment Non-sterile, powder free gloves and apron Gallipot Y adaptor of appropriate size Sterile scissors Freshly drawn tap water 1 x 60ml Enfit syringe







3 Staff must explain the procedure to the patient and gain verbal consent



4 Assist patient to lie flat on a bed if possible/not required

To ensure patient is in correct position for procedure


5 Decontaminate hands and put on gloves and apron

Patient safety and minimise cross infection

NMC. (2015) The Code NHS Tayside (2019) Infection Prevention & Control Policy

6 Assemble equipment on a clean surface

To help the procedure run smoothly


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7 Determine whether the PEG tube is a 16 Fr or 20 Fr gauge; this information is printed on the side of the PEG tube

To ensure correct size of Y-adaptor is fitted


8 Ensure both caps on existing Y-adaptor are closed

To close ends.


9 Close clamp on PEG tube To close inflation lumen and therefore prevent accidental removal of PEG tube. To prevent leakage of gastric juices


10 Remove existing Y-Adaptor by cutting through PEG tube using sterile scissors

To allow removal of existing Y-adaptor To allow replacement Y-connector to be fitted firmly


11 Untwist skirt from replacement Y-adaptor and put PEG tube through the narrow end of the skirt

To ensure correct position for connection


12 Push PEG tube onto barbed end of Y-adaptor until tube stop is reached

To ensure Y-adaptor is firmly attached


13 Twist and push skirt on until skirt stop is reached

To prevent collapse of internal retention device

Manufacturer instructions NHS Tayside (2019) Infection Prevention & Control Policy

14 Attach syringe to syringe port on Y-adaptor and flush PEG tube with 50ml freshly drawn tap water

To check that there is no leakage from Y-adaptor



Patient safety To ensure accurate records are maintained


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APPENDIX 11: Competencies for replacement of balloon gastrostomy

Name of Practitioner: ……………………………………………………..…………….. Date ……………………….

Knowledge All criteria must be met Met Not met

Can describe the difference between a Percutaneous Endoscopic Gastrostomy (PEG) tube and a balloon gastrostomy.

Can describe and explain action to be taken if PEG or gastrostomy tube is accidentally removed.

Is able to state how quickly they must respond to a displaced gastrostomy tube.

Can describe when it would not be safe to use a replacement tube for enteral feeding.

Lists and the equipment needed for replacement of the tube and explains why each piece of equipment is used.

Is able to state why gastric aspirate should be obtained and tested and what action should be taken if pH reading is not within the recommended range or has not been obtained.

State what action they would take if they were unable to complete the procedure.

Knows what information the patient needs before replacement of tube occurs.

Can discuss infection control principles in relation to replacement of tube.

Demonstrates knowledge of appropriate NHS Tayside policies related to this procedure.

Can describe current ward/unit documentation to record change of tube.

Skills

Assesses and plans intervention when tube replacement is required.


Demonstrated appropriate infection control practices.

Demonstrated knowledge of the principles of tube replacement.

Demonstrates an ability to replace the tube, to inflate the balloon and ensure external fixator is secure and tight.

Follows ward/hospital polices when changing tube and disposes of used equipment appropriately.

Awareness/Attitude

Recognises own competency level and can explain implications of accountability when undertaking an advanced practice.


Supervised practice changing gastrostomy tube

Date Comments

1

2

Formal assessment

I feel I have received sufficient theoretical knowledge and supervised practice to undertake the replacement of gastrostomy tube. Signature of Practitioner: ………………………………………………………….. Date: ………………………….

This practitioner has successfully met all the criteria for assessment. Name of assessor: ………………………………………………………… Signature of Assessor: ……………………………………………………..……… Date: ………………………….

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4.1f STANDARD OPERATING PROCEDURE – The replacement of a balloon gastrostomy tube


Policy reference: 4.1f


Operation The replacement of a balloon gastrostomy tube

Part number/name The replacement of a balloon gastrostomy tube for enteral nutritional support for all adults


Universal precautions e.g. wash hands before administration. Disposable apron

Tools/Equipment Non-sterile, powder free gloves and apron Water soluble lubricating jelly Gallipot 10ml sterile water Balloon gastrostomy tube of relevant size 2 x 10ml luer tip syringes Gauze swabs 10ml or 60ml enteral syringe pH indicator strips


1 Select appropriate gastrostomy replacement tube to suit clinical need of patient

To provide patient with a replacement tube that meets their clinical need









5 Assist patient to lie flat on bed To ensure patient is in correct position for replacing the tube








8 Using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should

To confirm gastric position of the existing tube and provide a baseline for replacement pH checks

NNNG Good Practice Guideline Changing of a Balloon Gastrostomy tube (2016)

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be 5.5 or less If the tube change is elective and it has not been possible to obtain gastric aspirate or the pH value is above 5.5 do not proceed with the elective tube change To aid in obtaining a gastric aspirate 200mls of coloured fluid e.g. blackcurrant juice can be given via the gastrostomy tube

9 Gently roll the balloon of the replacement gastrostomy between your fingers; inflate the balloon with 5ml of sterile water; deflate the balloon

To check the balloon for possible flaws


10 Slide the external fixator towards the feeding port

To ensure that the balloon can be passed beyond the abdominal wall


11 Lubricate the tip of the new gastrostomy tube with water soluble lubricating jelly

To facilitate passage of the gastrostomy tube


12 Use a 10ml syringe to remove all fluid from the balloon of the existing gastrostomy; discard this fluid and reinsert the syringe to withdraw any remaining fluid; gently pull on the gastrostomy tube to remove and discard

To ensure that the balloon is completely empty to allow removal of the existing balloon gastrostomy tube


13 Clean the skin around the stoma with sodium chloride solution or soap and water using gauze swabs

To minimise cross infection


14 Insert the tip of the replacement gastrostomy tube into the stoma and guide it through into the stomach (this sometimes requires a twisting motion); pass the tube all the way into the stomach.

To ensure that the balloon is passed beyond the abdominal wall


15 Inflate the balloon with sterile water

5ml balloon use 5ml

To hold the tube in place internally To prevent overfilling of the balloon, which may cause obstruction


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16 Ensure that the gastrostomy tube can be freely rotated and pulled back/ pushed forward; gently pull the gastrostomy tube back until resistance is felt

To ensure correct positioning of the balloon against the gastric mucosa


17 Slide the external fixator towards the abdomen until it is approximately 5mm from the skin surface

To hold the tube in place externally

Manufacturer instructions 1.

18 Check position of the tube by checking gastric aspirate Using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should be 5.5 or less If no gastric aspirate is obtained or the pH reading is above 5.5 then a tubogram should be undertaken to ensure the tube is in the correct position

To ensure the correct positioning of the tube in the stomach



Patient safety To ensure accurate records are maintained and ensure timely replacement of the tube


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4.1g STANDARD OPERATING PROCEDURE – The replacement of a low profile ‘button’ gastrostomy tube


Policy reference: 4.1g


Operation The replacement of a low profile ‘button’ gastrostomy tube

Part number/name The replacement of a low profile gastrostomy tube for enteral nutritional support for all adults (only staff who have demonstrated competence and have signed record of competence)



Tools/Equipment Non-sterile, powder free gloves and apron Water soluble lubricating jelly Gallipot 10ml sterile water Low profile gastrostomy tube of relevant size 2 x 10ml luer tip syringes Gauze swabs 10ml or 60ml enteral syringe pH indicator strips


1 Select appropriate gastrostomy replacement tube to suit clinical need of patient

To provide patient with a replacement tube that meets their clinical need









5 Assist patient to lie flat on bed To ensure patient is in correct position for replacing the tube





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7 Assemble equipment on a clean surface To help run smoothly


8 Using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should be 5.5 or less If the tube change is elective and it has not been possible to obtain gastric aspirate or the pH value is above 5.5 do not proceed with the elective tube change To aid in obtaining a gastric aspirate 200mls of coloured fluid i.e. black current juice can be given via the gastrostomy tube


NNNG (2016) Good Practice Guideline Changing of a Balloon Gastrostomy tube

9 Gently roll the balloon of the replacement gastrostomy tube between your fingers; inflate the balloon with 5ml of sterile Deflate the balloon



10 Lubricate the tip of the new gastrostomy tube with water soluble lubricating jelly

To facilitate passage of the gastrostomy tube








13 Insert the tip of the replacement gastrostomy tube into the stoma and guide it through into the stomach (this sometimes requires a twisting motion); pass the tube all the way into the stomach



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5ml balloon use 5ml

To hold the tube in place internally To prevent overfilling of the balloon, which may cause obstruction


15 Ensure that the gastrostomy tube can be freely rotated and pulled back/ pushed forward Note that a correctly sized low profile tube should only be able to be moved a few millimetres



16 Check position of the tube by checking gastric aspirate Using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should be 5.5 or less If no gastric aspirate is obtained or the pH reading is above 5.5 then a tubogram should be undertaken to ensure the tube is in the correct position






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APPENDIX 12: Checking PH of gastric aspirate for gastrostomy tube placement

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4.1h STANDARD OPERATING PROCEDURE – The procedure for measuring stoma tract for a low profile gastrostomy tube


Policy reference: 4.1h


Operation The procedure for measuring stoma tract for a low profile gastrostomy tube

Part number/name The procedure for measuring stoma tract for a low profile gastrostomy tube for enteral nutritional support for all adults (only staff who have demonstrated competence and have signed record of competence)



Tools/ Equipment

Non-sterile, powder free gloves and apron Water soluble lubricating jelly Gallipot 10ml sterile water Stoma measuring kit 2 x 10ml luer tip syringes Gauze swabs 10ml or 60ml enteral syringe pH indicator strips










4 Assist patient to lie flat on bed To ensure patient is in correct position for procedure








7 Using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should be 5.5 or less



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If the tube change is elective and it has not been possible to obtain gastric aspirate or the pH value is above 5.5 do not proceed with the removal of the existing tube to allow the tract measurement

7 Gently roll the balloon of the stoma measuring device between your fingers; inflate the balloon with 5ml of sterile water; deflate the balloon



8 If the stoma measuring device has a plastic disc, ensure that this is at the top of the device

To ensure that the balloon can be passed beyond the abdominal wall


9 Moisten the tip of the stoma measuring device with water soluble lubricant

To facilitate the passage of the stoma measuring device








12 Insert the stoma measuring device through the stoma site well into the stomach

To ensure the balloon is passed beyond the abdominal wall


13 Inflate the balloon with 5ml of sterile water

To hold the stoma measuring device in place internally


14 Gently pull on the stoma measuring device until you can feel resistance against the inside of the stomach wall



15 If the stoma measuring device has a plastic disc, slide this down towards the stoma

To allow for accurate measuring of the stoma tract


16 Read the marking (at the top of the plastic disc if the stoma measuring device has one) and record

To obtain an accurate measure of the length of the stoma tract


17 If possible, take a further reading with the patient in the upright position. Take the average of the two readings for the desired length

To allow movement for a proper fit


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18 Deflate the balloon and remove the stoma measuring device.

To ensure removal of the stoma measuring device


19 Insert the tip of the replacement gastrostomy tube into the stoma and guide it through into the stomach (this sometimes requires a twisting motion): pass the tube all the way into the stomach




5ml balloon use 5ml

To hold the tube in place internally To prevent overfilling of the balloon as may cause obstruction.


21 Ensure that the gastrostomy tube can be freely rotated and pulled back/ pushed forward - note that a correctly sized low profile tube should only be able to be moved a few ml



22 Check position of the tube by checking gastric aspirate; using an appropriate sized enteral syringe aspirate a small amount of gastric aspirate and test the pH of the gastric secretions using pH indicator strips/paper - pH reading should be 5.5 or less If no gastric aspirate is obtained or the pH reading is above 5.5 then a tubogram should be undertaken to ensure the tube is in the correct position






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4.1i STANDARD OPERATING PROCEDURE – Checking the volume of the retention balloon in a balloon gastrostomy or jejunostomy tube

NB: NOT ALL BALLOONS IN JEJUNOSTOMIES ARE INFLATED SO SEEK GUIDANCE FROM INSERTER BEFORE USING BALLOON INFLATION PORT


Policy reference: 4.1i


Operation Checking the volume of the retention balloon in a balloon gastrostomy or jejunostomy tube

Part number/name The procedure for checking the volume of the retention balloon in a balloon gastrostomy or jejunostomy tube for enteral nutritional support for all adults (only staff who have demonstrated competence and have signed record of competence)



Tools/Equipment Non-sterile, powder free gloves and apron Gallipot 10ml sterile water 2 x 10ml luer slip syringes










4 Assist patient to lie flat on a bed To ensure patient is in correct position for replacing the tube








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7 Fill one syringe with appropriate volume of sterile water GASTROSTOMY: 5ml balloon - use 5ml JEJUNOSTOMY: 3-5ml balloon use 3ml 7-10ml balloon use 5ml

To prevent overfilling of the balloon, which may cause obstruction


8 If possible, ask patient or assistant to hold tube in place by placing fingers over external retention device

To prevent accidental removal of the tube


9 Insert second luer tip syringe into inflation valve and withdraw fluid from balloon and check volume obtained

To deflate balloon and check volume withdrawn


10 Discard this fluid into Gallipot or cup and reinsert syringe into balloon inflation valve to withdraw any remaining fluid

To ensure that the balloon is completely empty


11 Insert first luer tip syringe into balloon inflation valve and inflate the balloon to identified correct volume

To inflate balloon with correct volume


12 Gently pull the gastrostomy tube until tension is felt from the balloon contacting the stomach wall DO NOT PULL A JEJUNOSTOMY



13 Position the external fixator flush against the skin so that there is a space of less than 5mm between it and the stomach

To hold the tube in place externally


14 Ensure the patient is left comfortable and document procedure in the patients nursing notes.



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APPENDIX 13: Troubleshooting Guide (gastrostomy/jejunostomy enteral tube feeding)

Complication Possible Causes Prevention Actions

Skin sensitivity at stoma site. Indications: redness, itching, but no infection.

External fixator too tight.

Discomfort from external fixator.

Sensitivity to tube material.

Ensure external fixator is ~5mm from skin

1. Loosen external fixator until ~5mm from skin. If external fixator is digging into skin due to patient’s posture, the skin can be protected using a small thin dressing folded into a pad under the external fixator.

2. Use barrier film e.g. Cavilon spray. This will leave a clear plastic coating on the skin. Apply once daily after cleaning site. Can be applied to broken or excoriated skin. Cavilon can be obtained on prescription or over the counter.

3. Try 1% hydrocortisone cream for a week. If this is still not effective continue with steps 1 & 2.

4. If steps 1-3 not successful, discuss changing type of external fixator or type of feeding tube with dietitian or gastroenterology specialist nurse.

Over granulation tissue at gastrostomy site. Indications: overgrowth of pink, ‘cauliflower-like’ moist tissue from stoma. May be bleeding.

Excessive movement of gastrostomy tube in and out of stomach.

Ensure internal fixator (or balloon) and external fixators are in correct position. Check the position of the internal fixator by using the tube to pull gently on the abdominal wall before replacing the external fixator ~5mm from skin.

Refer to NHS Tayside Overgranulation Pathway

Developed by Julie Fyall

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Leakage from stoma around gastrostomy tube. Indications: leakage of gastric contents – tests positive to acid with universal pH indicator strips. (Note: a small amount of mucus discharge is normal).

Constipation (can cause gastric outflow obstruction therefore stomach contents will flow back through stoma).

Avoid constipation by ensuring adequate fluid intake via gastrostomy tube. Give additional water flushes as required to ensure urine is clear and straw-coloured.

Discuss fluid and fibre content of feeding regimen with dietitian.

Consider use of laxatives as necessary.

Delayed gastric emptying due to clinical condition or as a side effect of some medication.

Consider use of gastric motility drug e.g. Metoclopramide or Domperidone to promote gastric emptying.

Consider use of jejunal feeding.

Internal and external fixators wrongly positioned. Gastrostomy site too large (can be caused by excessive tension on tube).

Ensure internal fixator (or balloon) is in correct position. Check the position of the internal fixator by using the tube to pull gently on the abdominal wall before replacing the external fixator. When the external fixator is in place, the tube should be able to be moved in and out by about 5mm.

Step 1 Ensure external fixator is ~5mm from skin.

Step 2

If skin is excoriated, use a barrier film e.g. Cavilon spray. This will leave a clear plastic coating on the skin. Apply once daily after cleaning site. Cavilon can be obtained on prescription or over the counter.

Step 3 If a heavy exudate is present, use an absorbent dressing. Foam dressing rather than gauze e.g. Permafoam, Lyofoam, Mepilex border – see formulary dressings for guidance. If this is not effective, try a barrier cream such as Orabase or a hydrogel dressing.

Step 4 If steps 1, 2 & 3 are not successful, discuss changing size/type of tube with dietitian or gastroenterology specialist nurse.

‘Buried bumper’ syndrome – internal fixator becomes buried in stomach lining.

Rotate gastrostomy tube daily through 360 degrees and on a weekly basis advance tube in and out by 2-3cms.

Some PEG tubes may be removed by external traction, however others may require endoscopic or surgical removal. Contact Endoscopy Unit for advice.

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Infected gastrostomy or jejunostomy site. Indications: red, inflamed, hot, pus, exudate, sometimes unpleasant smell.

Poor hygiene practices.

Observe NHS Tayside Infection Control Hand Hygiene Guidance before dealing with any aspect of feeding or tube care. Clean stoma site daily with soap and water, dry thoroughly. Avoid the use of creams and talcum powder on the site unless clinically indicated.

Avoid the use of dressings on the stoma site unless there is heavy discharge or leakage as they tend to accumulate moisture and possibly predispose to infection. If a dressing is required, use a loose, thin, absorbent foam dressing.

Step 1 Take a swab for culture and sensitivity. Unless symptomatic (e.g. pyrexial or raised CRP) do not treat until result of swab known. Apply loose foam dressing rather than gauze keyhole dressing only if exudate present. Change this frequently. Actisorb Silver 220 has been shown to be safe and effective in controlling infection and malodour around gastrostomy sites.

Step 2 Administer systemic antibiotics if indicated by results of swab taken. If found to be MRSA, discuss best treatment with medical staff or microbiologist. Fungal infections may require topical and systemic treatment.

May be necessary to discuss best treatment with microbiologist.

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Dislodged gastrostomy tube.

Accidental removal or, in case of balloon gastrostomies, deflation of internal retention balloon.

Secure gastrostomy tube under clothing to prevent accidental removal by patient. Check volume of retention balloon regularly (SOP 4.1i) and replace gastrostomy at regular intervals (SOP 4.1f, 4.1g). See manufacturer’s guidance re: frequency.

Less than 6 weeks since tube insertion.

Seek advice from GI Nurse Specialist if tube dislodged within six weeks of placement. If the tube is dislodged within the first few weeks after insertion, i.e. before the stoma tract is properly formed, it can result in peritonitis.

If a PEG/RIG is displaced within 2 weeks of insertion, no attempt is to be made to re-insert the tube or use catheters/NG tube to maintain tract. Due to the risk of disrupting a tract which is not fully formed. If a PEG/RIG is displaced within 2-6 weeks of insertion, re-insertion should only be attempted by an experienced practitioner and anything used to maintain the tract should only remain there for as little time as possible Any replacement tube inserted 2-6 weeks after initial placement, should have a tubogram performed before use

More than 6 weeks since tube insertion.

Tube must be replaced with a balloon gastrostomy of the same gauge within two hours to maintain stoma tract. If no spare tube immediately available wash displaced tube with soap and water, rinse and dry then insert the tube through stoma and secure it onto the skin with tape. Note that urgent action is required, as the stoma will close within minutes to hours of the tube coming out.

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Blocked gastrostomy/ jejunostomy tube. Indications: unable to administer feed or water through tube. Connectors are pushed out of tube when attempting feeding or flushing.

Inadequate flushing of tube with water. Crushed tablets not well dispersed in water. Medications mixed with feed. Multiple medications not given one at a time and flushed in between. Retention balloon on balloon gastrostomy has burst and is blocking end of tube. Breakdown of internal fixator on PEG tube.

Flush tube with water before and after administering feed and medication and also at regular intervals if necessary. Ensure medication is administered in appropriate form. See Section 2.9 Administering medication in patients with an enteral feeding tube.

Step 1 Using a 50ml syringe, attempt to flush with warm water. Use a gentle pumping action to withdraw and insert tube contents.

Step 2 If area of blockage can be seen, massage tube gently by rolling between fingers. If the blockage is close to feeding adaptor on PEG, clamp the tube below the blockage, remove the feeding adaptor and rub the tube between the thumb and forefinger towards the end to dislodge blockage. Replace feeding adaptor and flush with warm water.

Step 3 If steps 1 & 2 unsuccessful, try flushing tube with soda water or a solution of sodium bicarbonate (1 teaspoon sodium bicarbonate mixed in 25ml warm water), leave in tube for 20-30 minutes then try flushing with warm water.

Step 4 If unsuccessful try Clog Zapper (commercial declogging agent).

Step 5 If balloon gastrostomy in situ, remove and replace with new tube.

Step 6 If PEG tube or jejunostomy in situ and blockage cannot be cleared, make arrangements to have tube replaced.

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Damaged feeding adaptor or extension set.

Wear and tear. Ensure feeding adaptors and extension sets are changed at regular intervals. Extension sets for balloon gastrostomy and low profile gastrostomy tubes can be reused for several weeks. They should be removed and cleaned after each feed by washing in warm soapy water, rinsed and air dried.

PEG feeding adaptors can be readily replaced without having to replace the complete tube. Balloon gastrostomy and low profile gastrostomy tubes do not have a separate feeding adaptor so if any part of the main tube is damaged the whole tube will need to be replaced. Extension sets are easily replaced; see 4.1.8 for availability of equipment.

Blocked feeding adaptor.

Inadequate flushing with water.

Ensure tube is flushed before and after administering feed or medication.

Step 1 Soak feeding adaptor in a bowl of warm water for a few minutes before attempting to flush with water to clear blockage.

Inadequate cleaning of end of feeding adaptor.

After each feed, rinse the end of the feeding adaptor in warm water.

Step 2 If step 1 not successful, remove and replace PEG feeding adaptor.

Giving set stuck in feeding adaptor.

Giving set screwed in too tightly.

Ensure giving set is not over tightened (half-turn only) when setting up feed.

Step 1 Wear vinyl gloves to enhance grip when unscrewing giving set from feeding adaptor.

Residue of feed and medication in feeding adaptor.

After each feed, rinse the end of the feeding adaptor in warm water.

Step 2 Soak area of connection in a bowl of warm water for a few minutes to enable easier disconnection of giving set.

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Excessive vomiting and site leakage in the absence of other symptoms of gastroenteritis.

Peristalsis can cause internal fixator of gastrostomy tube to migrate through pyloric sphincter thus preventing gastric emptying. This would be indicated by external proportion of tube being shorter than usual.

Ensure internal fixator (or balloon) is in correct position. Check the position of the internal fixator by using the tube to pull gently on the abdominal wall before replacing the external fixator. When the external fixator is in place, the tube should be able to be moved in and out by about 5mm.

Use tube to gently pull on stomach wall, thus ensuring internal fixator is in correct position. Secure in place with external fixator (approx. 5mm from skin).

If balloon gastrostomy or LPGT in situ, ensure balloon is not over-inflated (SOP 4.1f and

SOP 4.1g.

5ml balloon – use 5ml sterile water.

If balloon gastrostomy, deflate balloon and re-inflate with appropriate volume of sterile water. Gently pull tube until balloon is positioned against abdominal wall. Secure in place with external fixator (approx. 5mm from skin).

If persistent problem, discuss replacement with a LPGT with dietitian or gastroenterology specialist nurse.

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APPENDIX 14: Flowchart for managing overgranulation tissue

CAUSATIVE FACTORS 1. Excessive moisture/leakage from stoma site

Checklist: abdominal distension, gut motility, constipation, flatus, feed intolerance, tube blockage, poor stoma hygiene, recent body weight changes, poor general health, systemic infection.

2. Friction/pressure excessive tube movement Checklist: fixation plate correct position 0.5cm from exit site, giving sets etc not pulling on tube, patients limb position putting pressure on tube.

3. Infection Checklist: obtain swab to identify causative organisms, treat appropriately and refer to formulary for dressings of infected wounds.

4. Presence of foreign materials or allergy to tube components Checklist: consider allergy testing, consider replacement of tube or components.

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FLOWCHART FOR MANAGING OVERGRANULATION TISSUE Home Enteral Nutrition Dietitians August 2018 1st Line Treatment 2nd Line Treatment 3rd Line Treatment 4th Line Treatment 5th Line Treatment

Use foam or absorbent dressing

If issue remains unresolved then refer to

specialist nurse to discuss referral for

biopsy, cauterisation or surgical debridement or

tube re-siting

Address causative factors

Consider swabbing the site

Stoma and tube components to be

cleaned daily with soap and water

Apply barrier cream to protect surrounding area

Apply foam dressing to compress overgranulation tissue, reduce moisture

levels and oedema at exit site

Review effectiveness in 7-14 days

Revisit causative factors

Consider the use of antimicrobial cleanser or saline water as an alternative to soap

and water


Apply microbial dressing as per

formulary guidelines

Monitor daily to ensure no adverse reactions from

silver dressings. Consider other factors

which may delay or interfere with tissue repair

i.e. anaemia, diabetes, systemic infection


Re-swab site for both bacterial and fungal

infection

Clean and monitor site daily with antimicrobial

cleanser

If no colonisations then use topical corticosteroid cream or tape. If colonisation is confirmed consider using

antimicrobial/steroid preparation e.g. Otomize

spray. Use as per guidelines for a maximum

or 2weeks

Review effectiveness in 7-14 days


Consider changing gastrostomy tube

If issue remains unresolved then refer to dermatology to discuss

referral for biopsy, cauterisation or surgical

debridement or tube re-siting

6th Line Treatment

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4.1.6 INSERTION AND CARE OF PERCUTANEOUS JEJUNOSTOMY TUBES (J-Tube) A jejunostomy tube is inserted into the proximal jejunum primarily to administer nutrition over a prolonged period of time. It creates a tract between the jejunum and abdominal surface. The J-Tube is implanted in the upper section of the small intestine called the jejunum, which is just below the stomach. The tube will be located lower and more towards the centre of the abdomen, when comparing it to the location of a Gastrostomy Tube. Types of tubes

Surgical jejunostomy - feeding into the small bowel is required when the stomach cannot be used for feeding, usually as a result of surgery. It can often be inserted during routine GI surgery. The tube can be in place for several months and is held in place by a balloon of water or sutures.

Radiological jejunostomy - in some cases a jejunostomy can be inserted into the stomach and guided through the pylorus into the jejunum under radiological guidance. The tube can be in place for several months and is held in place by a balloon of water, commonly known as a gastrojejunostomy tube.

Indications for insertion

gastric stasis

severe gastro-oesophageal reflux disease

obstruction of upper GI tract where tube is placed distal to the obstruction

surgery involving upper GI tract e.g. gastrectomy, oesophagectomy Contraindications

distal gastrointestinal tract obstruction

previous small bowel surgery

severe diarrhoea

intestinal dysmotility

Ascites

high output small bowel/large bowel fistula

Crohn’s disease (if segment of bowel to be used is diseased) Care of surgical jejunostomy tubes

Observe NHS Tayside Infection Control Hand Hygiene Guidance before dealing with any aspects of tube care.

Sterile water from a freshly opened container (in hospital) or cooled, freshly boiled water (in the community) should be used to flush the jejunostomy at regular intervals as stated in the patient’s feeding regimen.

The jejunostomy site should not be covered with a dressing unless there is a heavy discharge or leakage from the stoma site.

If a dressing is required, use a loose, thin, absorbent dressing.

Avoid the use of creams and talcum powder on the site as they can irritate the skin and give rise to infection. Creams can also affect the tube material itself.

Until the stoma is fully healed (usually within 28 days), do not immerse the site in water. During this period, the patient should take showers or shallow baths.

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Clean the stoma site daily using unperfumed soap and water. It is important that the area is dried gently but thoroughly.

Where tubes have a clamp, the position of the clamp on the tube should be changed regularly to prevent damaging the tube.

Unlike gastrostomy tubes, jejunostomy tubes MUST NOT be rotated.

The Vygon MIC Jejunal Feeding Tube has an inflation port which can be inflated with 3ml sterile water. This tube can also be stitched in place. On the main surgical ward where these tubes are routinely used either balloon inflation or stitching can be used to hold the tube in place. The managing dietitian on the ward can determine which method is best for the patient and record this on any discharge paperwork. Where the balloon has been inflated the water volume should be checked and replaced every 2 weeks, and after the tube has been in situ for 2 weeks. If the balloon on the jejunostomy tube has been inflated, see SOP 4.1i for checking the volume of the retention balloon on a jejunostomy tube.

If the sutures become dislodged, it may be necessary to replace them. Contact person who placed tube or dietitian for advice.

If the tube is accidentally removed, place a clean dressing over the site to stop the leakage of any fluid and contact medical staff or dietitian for advice.

Inspect site daily for leakage, swelling, irritation, redness, skin breakdown or tenderness.

Jejunostomy tubes can be safely removed in the community but ensure a 6 week time period has lapsed before routine removal is undertaken.

4.1.7 ENTERAL TUBE FEEDING REGIMEN

Patients requiring enteral feeding must be referred to the Nutrition and Dietetic Service. If commencing enteral tube feeding in an adult out of hours, the Starter Feeding Regimen can be used as a guide (see Appendix 15 Starter feeding regimen). It is important to note that the starter feeding regimen is an interim measure and referral to dietetics should be made as soon as possible. The type of feed used will vary depending on patient need, tolerance and clinical condition and it is vital that the correct feed is administered as per enteral feeding regimen to minimise complications including abdominal discomfort, diarrhoea, fluid overload, biochemical abnormalities and aspiration pneumonia minimised. Administered feed should be documented (see Appendix 16). Individualised Enteral feeding regimen will be documented on either Enteral Pump Tube Feeding Regimen or Enteral Bolus Tube Feeding Regimen (see Appendices 17 and 18). Dietetics must be informed as soon as possible for a review of nutritional care plan. Reasons for variance from the feeding regimen must be documented. Patients who have had major abdominal surgery and had an enteral tube placed should be fed according to Appendix 20. Patients who require Nasojejunal feeding see Appendix 19 for a starter regime and immediately refer to dietetics. For further guidance on newly inserted RIG or PEG tubes see Appendices 8a and 6a. If it is felt that a patient will require ongoing enteral feeding at home, this may be considered. Follow SOP 4.1m for referral procedure for Home Enteral Nutrition (HEN).

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Types of Administering Enteral Tube Feeding There are two ways of giving feed through an enteral feeding tube: 1. Pump-controlled feeding – a pump is used to deliver the feed at a constant rate

over a set number of hours. Follow SOP 4.1j for pump-controlled feeding. 2. Bolus feeding – bolus feeds are given at regular intervals throughout the day

using a syringe. Follow SOP 4.1k for bolus feeding. Use of Syringes with Enteral Feeding Tubes Only oral/enteral Enfit syringes which are purple in colour (that are not compatible with intravenous and other parenteral devices) must be used to administer ALL oral/enteral medicines, feeds and flushes. Flushing Enteral Feeding Tubes Enteral feeding tubes must be flushed with water before and after administration of feed and medication and also at regular intervals to prevent tube blockage. (Van den Bemt, 2006). In nasogastric tube feeding fluid must not be administered until confirmation of placement has been made by aspirating stomach contents with a 60ml syringe and check with the pH indicator strips that the aspirate is below pH 5.5. If difficulties arise obtaining gastric aspirate try: - Wait 30 minutes and try again - Try using a smaller syringe - If possible move patient onto left hand side - Flush tube with 5-10mls of air, if clinically safe, ask patient to drink a small amount

of fluid that is easily identified and aspirated again. If aspirate can NOT be obtained after all of the above methods have been tried then please refer patient for X-ray to establish position of nasogastric tube (see SOP 4.1a). Freshly drawn drinking water should be used for flushing the gastric feeding tubes except where in immunocompromised patients where sterile water should be used. Sterile water or cooled boiled water for jejunal tubes. Administering medication in patients with an enteral feeding tube Patients with an enteral feeding tube in situ who are able to take oral medications by mouth should continue to do so. Patients who are unable to take oral medications by mouth must have their medication reviewed by hospital pharmacist. Review process for patients on oral medication who are unable to take their medicines by mouth. 1. Review whether any medications can be stopped. If swallowing difficulties are

likely to be short-term only, some drugs may be suspended for short periods without causing significant harm.

2. Where there is a need for medication, consider whether current oral medication can be administered by an alternative route e.g. rectal, parenteral, transdermal, sublingual/ buccal tablets.

3. Consider whether current oral medication can be changed to another medication

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that has a more suitable method of administration e.g. buccal prochlorperazine instead of oral metoclopramide.

4. Check whether drug is available as a dispersible/soluble tablet. Some tablets that are not marketed as soluble will nevertheless disperse in water. Dispersible tablets are low in osmolality and therefore will not cause diarrhoea. Most dispersible and effervescent formulations contain sodium, which may need to be considered in sodium restricted patients.

5. Check whether drug is available as a liquid. Generally, elixirs or suspensions rather than syrups should be used. Many sugar-free liquids contain sorbitol, an artificial sweetener, which is a laxative and can result in abdominal cramping and diarrhoea (Madigan et al., 2002). Sorbitol has an accumulative effect and it is therefore important to minimise its intake where possible.

6. Check whether patient has a gastric tube or a jejunal tube. Drugs administered via gastric tube will be absorbed from the stomach in a similar way as they would if they were given orally. Drugs administered via a jejunal tube bypass the stomach and enter the jejunum directly. If jejunal tube in situ, checks that the drug is sufficiently well absorbed from the jejunum to reach therapeutic levels and monitor patient for signs of drug therapy failure. Liquid drug formulations are more likely to cause diarrhoea when administered via a jejunal tube rather than a gastric tube.

7. Consider whether dose or frequency of administration requires to be changed as a result of changing form of drug.

8. If there is no alternative but to crush some medications, ensure person administering drugs is aware of guidelines for crushing medication.

For administration of medication see Appendix 21.

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4.1j STANDARD OPERATING PROCEDURE – The administration of feed using an enteral feeding pump


Policy reference: 4.1j

Originator: Cathryn Hall

Operation The administration of feed using an enteral feeding pump

Part number/name Administration of enteral feeds



Tools/Equipment Feeding pump and drip stand Bottle of feed Administration/giving set 60ml purple Enfit syringe Water (see feeding regimen for volume and type) Feeding regimen (see Appendix 15)


1 Staff must ensure that it is the correct patient - check name, date of birth, CHI (in-patients) or address (primary care).


2 Explain the procedure to the patient To relieve anxiety and promote cooperation


3 Ensure feed issued to ward matches feeding regimen

To ensure correct feed is provided to patient


4 Check expiry date on feed bottle To ensure that patient receives feed which is not out of date

NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance NMC. (2015) The Code NHS Tayside (2019) Infection Prevention & Control Policy

5 Ensure patient is comfortable and positioned correctly for feeding i.e. sitting upright or at an angle of 30o if in bed

To minimise the risk of aspiration pneumonia

NHS Tayside (2011) Artificial Nutrition Group Handbook

6 Wash and dry hands To minimise cross infection

NHS Tayside (2019) Infection Prevention & Control Policy

7 Gently shake bottle of feed To mix contents Abbott FreeGo Pump Training Manual (2011)

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8 Unscrew white cap from feed bottle Do not touch or pierce aluminium foil, as this will be done automatically by the giving set Remove giving set from plastic bag

To minimise the risk of infection

Abbott FreeGo Pump Training Manual (2011)

9 Screw giving set onto top of feed bottle; ensure that giving set is tightly secured

To prevent leakage of feed from bottle


10 Turn feed bottle upside down and hang on drip stand or insert in carry case

To allow feed to flow through giving set


11 Prime the giving set with feed as per relevant pump instruction booklet

To remove air from the giving set


12 Low Profile Gastrostomy Tube (LPGT) or ‘button gastrostomy’ requires an extension set; extension sets should be reused – washed with warm soapy water and air dried

To aid administration of feed


13 If patient has nasogastric tube, ensure placement confirmed with pH indicator strips (see Appendix 3)



14 Draw up water in syringe. See feeding regimen for type and volume of water

To ensure that the patient receives the correct amount of fluid and to flush the tube


15 If the tube or extension set has a clamp, ensure it is in the closed position

To prevent leakage of gastric juices


16 Open the cap on the feeding port of the tube or extension set and attach syringe; open the clamp and gently flush the feeding tube with the water Repeat until desired volume of water has been given; remove syringe

To ensure patency of the feeding tube To ensure that the patient receives the correct amount of fluid


17 Attach giving set to the feeding port of tube


Abbott FreeGo Pump Training Manual

18 Set pump at rate advised by dietitian (see feeding regimen)

To ensure feed is delivered at appropriate rate


19 Ensure clamp on the feeding tube or extension set (if present) is open and set pump to run


20 Wash and dry hands according to NHS Tayside Hand Hygiene Guidance



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21 Complete the appropriate documentation, including enteral feeding administration chart (Appendix 16)

To ensure accurate records are maintained


22 Use guide on side of pump or in pump instruction booklet to manage any problems

To trouble shoot any pump problems


23 Once desired volume of feed has been delivered, switch off the pump and close clamp on feeding tube

To prevent leakage from feeding tube


24 Disconnect giving set from pump and feeding tube and discard

To complete feed administration and ensure giving set is not re-used


25 Flush tube with desired volume of water as in step 14

To ensure patency of the feeding tube to ensure patient receives correct amount of fluid


26 If appropriate, remove extension set from feeding tube; rinse feeding port of tube in clean water and close cap on feeding port

To prevent blockage of feeding port To minimise the risk of infection

27 Complete the appropriate documentation. Including Enteral feeding administration chart (Appendix 16)



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This protocol should only be used to commence enteral feeding when the dietitian is not available. Please contact the Dietetic Department (tel. ……………………………………) for an individualised feeding regimen immediately. 1. Assess the patient’s risk of refeeding syndrome. Patients are at risk of developing refeeding syndrome if:

Patient has one or more of the following: OR Patient has two or more of the following:

BMI less than 16kg/m2 BMI less than 18.5kg/m

2

Unintentional weight loss of more than 15% within the previous 3-6 months

Unintentional weight loss of more than 10% within the previous 3-6 months

Very little or no nutritional intake for more than 5 days Very little or no nutritional intake for more than 5 days

Low levels of potassium, phosphate or magnesium prior to feeding (see below)

A history of alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics (NICE, 2006)

2. Is patient at risk of refeeding syndrome?

3. Fluid requirements Total fluid input: volume of feed + total volume of flushes + intravenous or subcutaneous fluids + medications As a guide, maintenance requirements per 24 hours can be estimated as: 18-60 years = 35ml/kg or over 60 years = 30ml/kg. However, certain clinical conditions may increase fluid requirements or necessitate a fluid restriction. 4. To minimise risk of tube blockage, flush feeding tube with:

50ml water before and after each bottle of feed

50ml water before and after administering medication via the feeding tube. Medicines should be administered separately and the feeding tube should be flushed with 10-20ml water between each different medication.

YES NO

Before commencing feeding regimen, ensure medical staff monitor biochemistry and administer supplementation as flow chart below.

Please consult surgeon if patient is immediately post op.

Regimen for patients at risk of refeeding syndrome Regimen for patients NOT at risk of refeeding syndrome

Feed Rate Feeding time Rest time Total Volume Feed Rate Feeding time Rest time Total Volume

Jevity 25ml/hour 20 hours 4 hours 500ml Jevity 50ml/hour 20 hours 4 hours 1000ml

Continue with this regimen until the dietitian reviews the patient. Continue with this regimen until the dietitian reviews the patient.

APPENDIX 15: Enteral tube feeding regimen

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Patient identified as at risk of refeeding syndrome

Check patient’s full biochemistry including PO4, Mg2+, K+ and Ca2+

If K+ < 3.3mmol/L If PO4 < 0.75mmol/L If Mg2+ < 0.7mmol/L If within normal

Infuse 500m Dextrose 5% & 40mmol KCl or 500ml Sodium Chloride 0.9% & 40mmol KCl over 6 hours *

Infuse 250ml or 500ml Phosphate Polyfusor 50mmol/500ml over 8-24 hours

Contains K+ 9.5mmol, Na+ 81mmol

Alternative products for use in ITU and HDU are available *

Infuse 20mmol of MgSO4 added to 500ml Dextrose 5% over 6 hours *

Give Pabrinex vials I + II twice daily for 3 days. Thereafter, give Pabrinex vials I + II once daily if patient unable to swallow oral medication or change to 300mg oral thiamine daily (in single or divided doses) if patient able to swallow oral medication. In addition, if patient able to swallow oral medication, give a multi-vitamin and mineral supplement such as Forceval once daily. Continue vitamin supplementation until dietitian advises to stop, usually around ten days. Monitor PO4, Mg2+, K+ & Ca2+ daily until stable - may drop sharply in response to feeding due to intracellular depletion. Repeat above infusions as necessary. Once stable monitor weekly. Consult the Clinical Pharmacist or Dietetic Department for further advice. * For advice regarding administering these products at different rates/volumes or in alternative solutions please discuss with your clinical pharmacist.

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APPENDIX 16: NHS Tayside enteral feeding administration chart

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APPENDIX 17: Enteral tube pump feeding regimen

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APPENDIX 18: Enteral tube bolus feeding regimen

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APPENDIX 19: Nasojejunal feeding regimen

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APPENDIX 20: Post major abdominal surgery feeding regimen

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4.1k STANDARD OPERATING PROCEDURE – The administration of bolus feed


Policy reference: 4.1k

Originator:

Operation The administration of bolus

Part number/name


Tools/Equipment Bottle or carton of feed 60ml purple enteral syringe A jug of water (see feeding regimen for volume and type) Clean jug for feed Feeding regimen (see Appendix 20)




2 Explain the procedure to the patient To relieve anxiety and promote co-operation


3 Ensure feed issued to ward matches feeding regimen

To ensure correct feed is provided to patient


4 Check expiry date on feed bottle To ensure that patient receives feed which is not out of date

NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance NMC. (2015) The Code NHS Tayside (2019) Infection Prevention & Control Policy

5 Ensure patient is positioned correctly for feeding i.e. sitting upright or at an angle of 30º if in bed and that the patient is comfortable

To minimise the risk of aspiration pneumonia





7 Low Profile Gastrostomy Tube (LPGT) or ‘button gastrostomy’ requires an extension set

To allow feeding to take place


8 Gently shake bottle or carton of feed To mix contents Manufacturer’s instructions

9 Decant required volume of feed into clean jug (see feeding regimen for type and volume) Check pH if nasogastric

To ensure that the patient receives the correct type and volume of feed

NHS Tayside (2019) Infection Prevention & Control Policy NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance

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10 If the tube or extension set has a clamp, ensure it is in the closed position



11 Open the cap on the feeding port of the tube and attach the syringe to the end of the feeding tube; open the clamp and flush required volume of water as per feeding regimen; close the clamp and remove the syringe

To ensure patency of feeding tube


12 Draw desired amount of feed into syringe; reattach syringe and open clamp and slowly push plunger and allow feed to flow into tube; repeat until required volume of feed has been administered See feeding regimen for volume of feed to be used. Close clamp and remove syringe

To ensure that the patient receives the correct amount of feed


13 Open the clamp and attach the syringe to the feeding tube and flush tube with desired volume of water as in step 10


14 Close the clamp on the tube or extension set; remove the syringe from the feeding port of the tube



15 If appropriate, remove extension set from feeding tube; rinse feeding port of tube in clean water and close cap on feeding port Store any excess feed in the fridge for a maximum of 24 hours

To maintain a safe environment

NHS Tayside (2019) Infection Prevention & Control Policy Manufacturer’s instructions.




17 Complete the appropriate documentation



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4.1l STANDARD OPERATING PROCEDURE – Administration of medication via enteral feeding tube

NB: EACH MEDICINE NEEDS TO BE GIVEN SEPARATELY WITH A WATER FLUSH BETWEEN


Policy reference: 4.1l

Originator:

Operation Administration of medication via enteral feeding tube

Part number/name


Enfit syringes Oral dose syringe for measuring small volumes Medication Water

Tools/Equipment


1 Consult pharmacist regarding the best way to administer each medicine via an enteral feeding tube

Patient safety NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance



3 Obtain consent for administration of medication and explain the procedure to the patient



4 Wash hands; apply gloves and apron



5 If enteral feed in progress, stop feed. Some drugs require feed to be stopped in advance, (see Appendix 21 for guidance)


NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance

6 Flush the feeding tube with water (see feeding regimen for volume and type)

7 FOR TABLETS THAT CAN BE DISPERSED IN WATER

remove the plunger from a 60ml Enfit syringe

transfer tablet to syringe barrel

replace the plunger and draw up 10-15ml of water

cap the syringe

allow the tablet to disintegrate over 5-10 minutes, gently shaking the syringe occasionally



7.1 Shake well; measure dose of drug with syringe of appropriate size* Draw up an equal volume of water to dilute the liquid



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For drug volumes 10ml, use a syringe of appropriate size. A luer lock syringe may not fit in bottle cap adaptors (bungs) if used. Is the dose measured in a small syringe and then transferred to a big syringe for administration? The textbooks recommend using the biggest syringe that can be used while maintaining accuracy to reduce the pressure on tubes and reduce the risk of rupture. Very small volumes (<2ml) are not big enough to form enough pressure to damage a tube.

For drug volumes >10ml, use a 60ml Enfit syringe

7.2 If capsule contains powder, open capsule and tip powder into a medicine pot

Mix capsule contents with 10-15ml of water and draw up the mixture into a 60ml Enfit syringe. For other forms e.g. dispersible tablets or sachets contact pharmacist.



7.3 Appropriately crush each medication separately to a fine powder Dilute with 10-15ml of water and draw up the mixture into a 60ml Enfit syringe



8 If the feeding tube has a clamp, ensure it is in the closed position

To prevent leakage

9 Attach the syringe to the feeding port of the tube; open the clamp and gently depress the plunger on the syringe to administer the dose via the feeding tube

To instil medicines


10 Remove syringe from feeding tube and use to draw up 10-15ml water; cap the syringe and shake well to dislodge the remaining particles

To instil medicines


11 Attach the syringe to the feeding port of the tube; open the clamp and gently depress the plunger on the syringe to administer the water via the feeding tube

To instil medicines


12 When several drugs are to be administered at the same time, repeat steps 5-11 until all medications have been given

To instil medicines


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13 Flush the feeding tube with water (see feeding regimen for volume and type)

To ensure all medicine administered


14 Close clamp on feeding tube (if present)

To prevent leakage

15 If appropriate, reconnect the giving set and resume feeding Some drugs require feed to be withheld for some time after drug administration (see Appendix 21 for guidance)



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APPENDIX 21: Review process for patients on oral medication who are unable to take their medicines by mouth

Ask prescriber to review whether any medication can be safely stopped until swallowing difficulties resolve.

Can current oral medication be administered by an alternative route e.g. rectal, parenteral, transdermal, sub lingual/buccal tablets?

Can current oral medication be changed to another medication that has a more suitable method of administration?

Is the drug available as a dispersible/soluble?

Contact pharmacist

Discontinue non-essential medicines or hazardous cytotoxics e.g. document decision and review as appropriate.

Provide medication in appropriate form for administration via alternative route.

Provide alternative medication.

Provide medication in alternative form.

Check whether dose or frequency of administration requires to be changed as a result of changing form of drug and advise appropriately. Check whether timing of drug administration requires adjustment and discuss feeding regimen with dietitian if necessary.

Yes

Yes

Yes

Yes

Yes

No

No

No

No

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4.1m STANDARD OPERATING PROCEDURE – Referral procedure for Home Enteral Tube Feeding (HETF)


Policy reference: 4.1m

Originator:

Operation Referral procedure for HETF

Part number/name Referral for adults requiring HETF


None

Tools/Equipment Referral to dietetics using referral system. Patient information on HETF


1 Patient assessed by multi-disciplinary team (including Dietitian – refer to dietetic department if not already known) for suitability for HETF

To ensure patient is suitable for HETF and referred to dietetics in a timely manner. Please note dietetics require a minimum of 48hrs is required for safe discharge

NICE (2017) Nutritional Support in Adults TN MCN Commencing Enteral Nutrition in adults at home standard (2018)

2 If enteral feeding tube not already in situ then the clinical team will undertake/refer to ensure that the appropriate enteral feeding tube is in place

To ensure appropriate enteral feeding tube placed

NICE (2017) Nutritional Support in Adults TN MCN (2010) Dietetic Management of Adults Requiring Nutritional Support

3 Once the patient’s enteral feeding tube is in place and they are considered to be stable, the Dietitian will arrange for the patient/carer to be trained in feeding and tube care and provide the necessary patient information

To provide the patient with the appropriate training and information on HETF to allow self-care at home

NICE (2017) Nutritional Support in Adults TN MCN (2010) Commencing Enteral Nutrition in adults at home standard

4 Once the Dietitian and ward nursing staff are confident that the patient/carer is competent in feeding then arrangements will be made for discharge home on HETF

To ensure patient/carer is competent to manage enteral feeding techniques in home/community environment


5 The Dietitian will supply one week’s feed and equipment for discharge; they will also arrange delivery of a feeding pump and subsequent feed and equipment to the patient’s home via the GP and contracted feed company

To ensure the correct HEN feed and equipment are arranged


6 The Dietitian will arrange for follow up in the community with the appropriate Dietitian, and complete the relevant transfer forms - Ward Nurse to contact District Nurse if required

To ensure ongoing care is provided once patient at home


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4.1.8 NHS TAYSIDE OUT OF HOURS (OOH) BOXES FOR ENTERAL TUBE FEEDING The sites below each hold an Out of Hours box of supplies for Enteral Tube Feeding:

Dundee

Ward 2, Ninewells Hospital OOH cupboard at Kings Cross Health and Community Care Centre

Angus

Stroke Ward, Stracathro Hospital District Nurse Cupboard, Links Health Centre, Montrose Clova Ward, Whitehills, Forfar Minor Injuries Unit, Arbroath Infirmary Kinloch Care Centre, Carnoustie

Perth & Kinross

Blairgowrie Community Hospital - (District nurse store in the old building) Pitlochry Community Hospital - (GP unit) St Margaret’s Community Hospital - (treatment room is cupboard on wall Crieff Community Hospital - (disposal cupboard at back of clinic rooms) OOH district nurses base - (Orthopaedic Out patients) Ward 4 PRI - (treatment room) Loch Leven Health Centre Kinross - ( DN store in locked cupboard) Upper Springland, Perth Bridge of Earn Surgery (DN office)

Each box contains the following:

BALLOON GASTROSTOMY TUBES 2 x 12fr Balloon Gastrostomy 2 x 14fr Balloon Gastrostomy 2 x 16fr Balloon Gastrostomy

Y-ADAPTORS FOR PEG TUBES 5 x 16fr PEG Adaptor repair kit CLAMPS 5 x Side loading clamps for Gastrostomy tubes

EXTENSION SETS 1 x Enteral Y Extension set (optional to use with Balloon Gastrostomy tube) 2 x MIC-Key Extension set (for use with Low Profile Gastrostomy tube – button)

FOR UNBLOCKING ENTERAL FEEDING TUBES 2 x Clog Zapper

PROCEDURES AND GUIDELINES - taken from the Food, Fluid and Nutritional Care Policy (see details below for further information) Enteral Feeding Tubes most commonly used in NHS Tayside Guide Management of Dislodged Gastrostomy Tubes Photographic guide and Policy for replacement of a Balloon Gastrostomy tube Photographic guide and Policy for replacement of a Button Gastrostomy tube Management of Dislodged Jejunostomy Tubes Replacing the adaptor on a Corflo PEG Troubleshooting Guide The Food, Fluid and Nutritional Care Policy which includes all standard operating procedures (SOPS) and protocols can now be found by visiting: NHS Tayside internet Home page\Our Services\Our Services A-Z: F\Food, Fluid and Nutritional Care Policy Please see Section 4: Protocol for the Management of Artificial Nutrition Support in Hospital and Community (Adults)

http://www.nhstayside.scot.nhs.uk/OurServicesA-Z/FoodFluidandNutritionalCarePolicy/index.htm




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SECTION 4: 4.2 4.2 PARENTERAL NUTRITION (PN)

Parenteral nutrition (PN) is the administration of nutrients by the intravenous route. It is indicated when artificial nutritional support is required but nutritional needs cannot be met by the enteral route. PN can be used either as the sole source of nutrition or in conjunction with oral and/or enteral tube feeding. PN is generally administered to patients with a non-functional, inaccessible or perforated gastrointestinal tract. It may also used to improve or maintain the nutritional status of severely malnourished patients who are being prepared for surgery, radiotherapy, or chemotherapy for cancer. The routes for access for parenteral nutrition are: 1. Peripheral line. 2. Central line. PN is a complex process, requiring placement of an appropriate feeding line, care of the line, accurate calculation and administration of nutritional requirements, monitoring of electrolytes and blood chemistry. It has the potential for many serious complications, both metabolic and non-metabolic. National standards (NHS QIS, 2003, NHS QIS 2015) and guidelines (NICE, 2006) recognise that the management of PN is best facilitated by the presence of a multi-disciplinary Nutrition Support Team (NST). The aim of a NST is to ensure that specialised nutrition support is given safely and effectively to those patients who need it. Before using most parenteral nutrition products, micronutrients and trace elements should be added and additional electrolytes and other nutrients may also be needed. Additions should be made under appropriate pharmaceutically controlled environmental conditions before administration. Indications for parenteral nutrition NICE Guidelines (2006) recommend considering parenteral nutrition in people who are malnourished or at risk of malnutrition and have a non-functional, non-accessible or perforated (leaking) gastrointestinal tract or have inadequate or unsafe oral and/or enteral intake as a result of:

Inability to absorb nutrients via the GI tract: i.e. extensive small bowel resection (short bowel syndrome), diseases of the small intestine and radiation enteritis.

Prolonged post op ileus.

Enteric cutaneous fistulae.

Inflammatory diseases such as Crohn’s disease.

Chronic intestinal pseudo-obstruction syndromes.

Motility disorders.

Severe diarrhoea or intractable vomiting.

Treatment with high-dose chemotherapy, radiation and bone marrow transplant.

Severe pancreatitis, where bowel rest is anticipated beyond 5-7 days.

Moderate malnutrition in patients who require intensive medical or surgical intervention.

Patients on intensive cancer chemotherapy.

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For severe malnutrition and non-functioning GI tract, parenteral nutrition should be established within 1-3 days or if it is expected that the GI tract will not be usable for 5-7 days. In normally nourished patients PN should be established if the recovery is not expected within 5-7 days or after major surgery if resumption of adequate diet is not expected within 7-10 days. Contraindications for parenteral nutrition

Patients with a functional and useable GI tract, capable to absorb adequate nutrients.

Patients whose prognosis does not warrant aggressive nutritional support.

When the risks of PN exceed the potential benefits e.g. sepsis.

4.2.1 REFERRAL FOR PARENTERAL NUTRITION Assessment prior to commencing PN A consultant or registrar identifies that PN is indicated, the indication should be documented in the medical notes. Prior to starting a new patient it is necessary to have a full assessment carried out and documented. This will include:

Weight and height and BMI.

PN biochemistry screen (U + E, Mg + P04, LFTs).

Re-feeding risk (see Appendix 22).

Renal function, hydration status and water/electrolyte balance.

Venous access available – blue venflon/PICC/CVC/Hickman (see Appendix 23).

4.2.2 REFEEDING SYNDROME (Appendix 22) Refeeding syndrome is a potentially life-threatening disorder of electrolyte metabolism that may occur in a malnourished patient who has been starving for a prolonged period. It is precipitated by large amount of nutrients (particularly carbohydrates). The hallmark of the refeeding syndrome is hypophosphataemia, hypomagnesaemia and hypokalaemia also occur. Cardiac arrhythmias may occur. A patient is at a high risk of refeeding syndrome if: 1. the BMI is less than 16 kg/m2 2. there is unintentional weight loss >15% within the last 3-6 months 3. there was little or no nutritional intake for more than 10 days 4. hypokalaemia, hypophosphataemia or hypomagnesaemia is present prior to

commencement of feeding or if two of the following criteria are fulfilled: 5. BMI less than 18.5 kg/m2 6. unintentional weight loss >10% within the last 3-6 months 7. little or no nutritional intake for more than 5 days 8. history of alcohol abuse, chemotherapy or treatment with insulin, antacids and

diuretics

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A full PN Biochemistry screen should be carried out before the PN is started and on a daily basis until the patient is stable (7-10 days). Peripheral supplementation of fluid & electrolytes will be required and should be tailored to individual patient requirements. All patients should be prescribed Pabrinex twice daily for 3 days, if the patient is at high risk of refeeding, then daily thereafter up to 10. Assessment An NHS Tayside PN Request Form (Appendix 24) should be completed, noting the need for a full biochemical screen as well as medical details and nutritional history; this will allow a full assessment of the patient’s suitability for PN. During normal hours the ward’s Clinical Dietitian should then be contacted and given form. Out of hours see guidance below. The ward dietitian and pharmacist will provide a full nutritional assessment and liaise with the ward Multi-Disciplinary Team (MDT) and if required the NST to create a management plan for the patient ensuring that the most appropriate feeding route and regimen is prescribed for the patient and that risks associated with PN are identified and minimised. Parenteral nutrition should be introduced progressively and closely monitored, usually starting at no more than 50% of estimated requirements for the first 24-48 hours. Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. Withdrawal should be planned in a step wise way according to oral/enteral intake.

4.2.3 ACCESS ROUTES FOR PARENTERAL NUTRITION Dedicated intravenous catheter It is essential that dedicated intravenous access is obtained prior to commencing PN. It is preferable to administer PN via a central catheter or a PICC line to aid safe administration. There are PN formulations that can be administered via either a peripheral or central vein. However in general it is preferable to ensure that robust, dedicated central venous access is in place at the start of PN delivery. Peripheral parenteral nutrition may be used for short-term nutritional support for example:

in early postoperative phase

severe pancreatitis

pre-operative support of the malnourished patient Patients requiring longer term PN require this to be administered via a central catheter for example:

intestinal artresia

inflammatory bowel disease

radiation enteritis

intestinal pseudo-obstruction

Scleroderma

short bowel of any aetiology

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Additionally, central catheters are required where there are no adequate peripheral veins and for delivery of hyper-osmolar solutions. Types of PN access Catheters are described in terms of:

the type of vein used (i.e. peripheral venous or central venous)

the site of insertion (i.e. subclavian, femoral, internal jugular)

entry into the vein (i.e. percutaneous, tunnelled, non-tunnelled) The type of catheter required and the vein into which it is inserted are determined by the anticipated duration of treatment, and the composition of the feed required by the patient (see Appendix 23). Care should be taken in catheter choice and in attention to pH, tonicity and long-term compatibility of the parenteral nutrition formulations in order to avoid administration or stability problems. Ordering Parenteral Nutrition from Pharmacy Compounded bags (with vitamins and minerals) of PN can only be ordered during standard working hours. This can be done by any member of the MDT following above assessment. Complete the Aseptic Dispensing Services PN Request Form (see Appendix 25) and email it to Pharmacy Aseptic [email protected] . Out of Hours see below. Advance ordering of PN is encouraged as this helps Aseptic plan their workload and staffing requirements. PN requests that require manipulation or addition of vitamins and trace elements need to be ordered before 9.30 am on the day they are required. Orders for bags requiring no additions can be made up to 3.00 pm on the day they are required. Prescribing of Parenteral Nutrition In line with NHS Tayside Safe and Secure Handling of Medicines Policy, as a medicine, PN must be prescribed by an appropriate person prior to administration noting the desired infusion rate and the regimen of PN being administered. As PN is a parenteral infusion, it must be prescribed in several locations.

The Regular Medication section of the TPAR, stating PN, as directed with all times circled.

NHS Tayside adult PN administration chart (Appendix 26).

mailto:[email protected]

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4.2.4 ADMINISTRATION OF PARENTERAL NUTRITION Management of catheters Only healthcare professionals who are competent in catheter insertion will be responsible for the placement of catheters and only health care professionals competent in caring for Vascular Access Devices will be involved in the delivery of PN. There is no formal assessment for these practices but they may be aspects of care that require a period of supervised, guided practice. Administration of PN is considered an advanced practice. Staff that undertake the procedure must be assessed as competent using the competency assessment tools. Within acute services the practitioner must have completed competencies for administration of intravenous medications and fluids, and other relevant mandatory training. All staff must be aware of the importance of monitoring and managing these devices and be able to prevent, detect and treat complications promptly. Please refer to standard operating procedures: Procedure for dressing Central Venous Catheter exit site (4.2a) Procedure for commencing PN via central Venous Catheter (4.2b) Procedure for administration of medication via central Venous Catheter (4.2c) Procedure for flushing central Venous Catheter (4.2d) Procedure for taking blood from a central venous Catheter (4.2e) Procedure for removal of a Central Venous Catheter (4.2f) Administration PN can be administered as a continuous infusion (up to 48 hours providing the bag is still in date) or cyclically (intermittently over shorter periods e.g. 10-18 hours). Continuous administration of PN should be offered as the preferred method of infusion as this will minimise manipulations of the line and reduces risk of line sepsis. Cyclical delivery of PN should be reserved for specific patients, where assessed as appropriate by the NST. Continuous administration of parenteral nutrition should be offered as the preferred method of infusion in severely ill people who require parenteral nutrition. Formulations and Stability of Parenteral Nutrition All in One (AIO) PN bags of various sizes and concentrations are used to meet patients’ requirements in most scenarios. AIO bags are stored at room temperature and have a long expiry when not activated. On activation (mixing of the different chambers) they are stable for 48 hours at room temperature or 72 hours if stored in a fridge. The stability of patient specific bags varies and advice on this should be sought from your clinical pharmacist or Aseptic Services. Specialist aseptic manufacturers are sometimes used to make PN bags. These specials are mainly used in the HPN service and for large quantities of simple

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formulations and require fridge storage. The stability of these special bags varies and advice on this should be sought, your clinical pharmacist or Aseptic Services. Parenteral Nutrition out of hours If PN is required out of hours, PN is never an emergency. The following should be referred to and completed:

NHS Tayside Artificial Nutrition Group identification and treatment of refeeding syndrome (Appendix 22).

Types and indications of intravenous access for PN (Appendix 23).

NHS Tayside PN request form (medical staff) (Appendix 24).

NHS Tayside out of hours Parental Nutrition regimen (Appendix 27).

NHS Tayside adult PN administration chart (Appendix 26). A small supply of uncompounded bags can be obtained from wards 2, 10 (HDU) or 20 at Ninewells. To ensure ongoing supply of PN which is then compounded with vitamins and minerals the patient MUST be referred to the ward dietitian or pharmacist on their return.

4.2.5 MONITORING PATIENTS ON PARENTERAL NUTRITION Prevention of complications requires careful monitoring. Biochemical (Appendix 29), clinical, nutritional, and anthropometric parameters should be monitored. Additionally the indications, route, risks, benefits and goals of PN should be reviewed at regular intervals. The time between reviews may increase as the patient is stabilised on PN. Daily checks to include: 1. status of the central line entry site/Venflon site 2. temperature, blood pressure and pulse 3. fluid balance 4. blood sugar levels and insulin requirement 5. oral intake (solid foods and fluids) 6. bowels - presence of bowel sounds, stoma function, diarrhoea, constipation,

abdominal distension 7. venous bloods as per protocol (Appendix 28) Roles and responsibilities of health care professionals Referring team:

discuss need for PN with patient and or relatives

decision to commence PN made by consultant or registrar, documented in the patients notes

complete referral form and contact ward pharmacist or member of nutrition team.

arrange appropriate baseline blood and urine tests

establish PN access whether peripheral or central

correct electrolyte abnormalities

ensure all patients should be prescribed Pabrinex vials 1 and 2, two times a day for 3 days then daily thereafter until day 10

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Ward pharmacist/dietitian:

monitor (Monday to Friday) the patient in conjunction with the ward MDT

update NST to allow for discussion at weekly MDT and the NST (weekly in Ninewells)

tailor the PN for each patient, updating the NHS Tayside adult PN administration chart (Appendix 26) on a regular basis

Nutrition Support Team (NST):

advise on the continued administration of PN to the patient

liaise with dietetics and pharmacy regarding supply of further patient specific PN bags

assess the patient and advise on appropriate methods of feeding

advise on central access issues

calculate and monitor nutritional requirements

the patient will be discussed by the NST once a week and reviewed on the ward as necessary

assess patient’s ability to progress to an enteral/oral diet so that PN can be discontinued

Ward medical staff:

PN prescribed on patient’s administration chart

a full PN biochemistry screen should be carried out daily during this initiation phase, with additional fluids and supplements as per the patient’s requirements

monitor blood results and treat abnormalities accordingly

liaise with nutrition team over changes in the patient’s management plan

assess patient’s ability to progress to an enteral/oral diet so that PN can be discontinued

Ward nursing staff:

ensure the PN has been prescribed on patient’s administration chart

keep accurate fluid balance chart

reconstitute the PN as instructed and label using the blank PN label supplied with each bag

commence the PN using aseptic technique through a dedicated line at the rate prescribed on the administration sheet

monitor the infusion and catheter site Discontinuing Parenteral nutrition PN can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. Withdrawal should be planned and stepwise with a daily review of the patient’s progress (NICE, 2006).

4.2.6 PREVENTING COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION Parenteral nutrition has a high risk of associated technical, metabolic, haemodynamic and septic complications. Therefore, when administering PN, special care must be taken to prevent and detect complications. Catheter related infections can be life threatening and are the most common reason for the cessation of PN. They also interrupt feeding, are expensive to treat and can cause discomfort if the catheter is to be replaced.

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Catheter related complications include:

catheter sepsis

catheter blockage

central venous obstruction Metabolic complications include:

refeeding syndrome

Hypoglycaemia

Hyperglycaemia

Hyperkalaemia Catheter related insertion complications There are several risks associated with the insertion of a central venous catheter. These may occur during the procedure i.e. arterial puncture, carotid artery air embolism, pneumothorax or misplacement of the catheter. A misplaced catheter can pass into the internal jugular vein or too distally in the right ventricle. Use of misplaced catheter may cause cardiac dysrythmia and/or cardiac tamponade. The gold standard for catheter placement is under direct radiological guidance. If this does not occur a chest X-ray is mandatory prior to commencing feeding. Catheter related infection Prevention of catheter infection and sepsis is an essential part of PN and adherence to strict aseptic technique in handling catheters, the use of administration sets and PN bags. Single lumen PN catheters should not be used for routine blood sampling, drug administration and blood transfusion. 1. Exit site infection: semi-occlusive dressings are used to cover exit sites to allow

exit site to be visible at all times. If the exit site is dry these dressings can be changed weekly. If there are any signs of exudate or blood staining, the dressing requires to be changed daily or when needed. Infection at the exit site results in tenderness and inflammation around the site and usually responds to systemic antibiotics, provided the cuff is not involved.

2. Catheter related septicaemia can be fatal. Symptoms include sudden pyrexial and tachycardia with accompanying with headache and/or rigors during PN infusion. It is important to exclude other sources of infection, e.g. chest and urinary infection. Depending on the organism cultured, it may be possible to avoid removal of the line.

3. Tunnel infection results in pain and tenderness along the tunnel. This may result in line removal; however careful assessment should be carried out.

Common pathogens infecting lines are staff aureus, staph epidermidis or E Coli and Candida. Treatment options include: 1. removal of the catheter 2. removal of the catheter and provision of broad spectrum antimicrobial cover of

staph aureus 3. leave the catheter in situ and prescribe antibiotics pending results of blood culture

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The decision will depend on the availability of venous access, the need for continuation of treatment and the general health of the patient. Seek advice and guidance from Microbiologist. Other potential complications Catheter blockage - a catheter can become blocked due to thrombus or lipid deposits. It can occur if blood backtracks during procedures. On completion of PN it is essential that lines are flushed immediately and a heparin lock instilled. Failure to do this, particularly with lipid infusions, can lead to blockage. Cracked or leaking catheter - the catheter should be clamped on the patient side of the fracture to prevent bleeding or air embolism and medical assistance sought urgently. For Hickman lines, a catheter repair kit can be obtained from the hospital stores. Central vein thrombosis - subclavian vein thrombosis may be silent but commonly presents with a swollen, painful arm. The diagnosis is confirmed using Doppler ultrasound or upper limb venography. The catheter must be removed and the patient treated with fibrinolytic drugs. Metabolic complications of parenteral nutrition (see Appendix 29) Patients may experience metabolic problems associated with their PN including the following:

refeeding syndrome (characterised by low K, Mg or PO4)

Hypoglycaemia – stopping PN too quickly, give 10% dextrose infusion for 24 hours with blood glucose monitoring

Hyperglycaemia – PN infused too rapidly or patient diabetic without adequate control. Reduce rate of PN, and/or start sliding scale

Hyperkalaemia – can be life threatening, slow down or stop PN until corrected. PN can be re-formulated to contain less K

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Use of parenteral nutrition in oncology/haematology Approximately 50% of patients with cancer develop cancer cachexia syndrome that can result in potentially life threatening malnutrition. There is currently no evidence that supports the routine use of PN in cancer patients, as with other groups PN should be restricted to those who cannot receive their nutritional requirements via the enteral route and are at risk of malnutrition. Oncology Local Guidelines for Parenteral Nutrition

As per palliative care guidelines some patients with a physical bowel obstruction or non functioning bowel in the context of advanced cancer may benefit from PN.

PN can be associated with many complications and therefore it should only be considered if all other methods of feeding have failed.

Consider if referral is appropriate for nutritional support within 48hrs of admission.

If appropriate for nutritional support and/or NBM for 24hrs refer to Oncology team dietitian and team consultant to decide if PN is most suitable method of nutritional support.

If Oncology Consultant decides PN would be appropriate refer to Adult Parenteral Nutritional Guidelines in folder at nursing station. Team consultant or Registrar to contact Nutrition team to commence process following completion of PN request form.

Daily Bloods must be taken and reviewed when patient receives PN.

If a consultant decides for PN to be administered if bloods out with the parameters stated in the Parenteral Nutrition guidelines then this must be risk assessed and the reasons for this decision fully documented in the medical notes after liaison with the PN team.

Ward team to arrange for PICC line insertion as an urgent request to radiology. Commencement of PN should not be delayed waiting for PICC access and appropriate IV access using a blue Venflon should be established. Team Consultant or registrar to make this decision.

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APPENDIX 22: Tayside Artificial Nutrition Group: identification and treatment of Refeeding Syndrome

Patients are at high risk of developing refeeding syndrome if: Patient has one or more of the following:

OR

Patient has two or more of the following:

BMI less than 16 kg/m2

BMI less than 18.5 kg/m2

Unintentional weight loss of more than 15% within the previous 3-6 months Unintentional weight loss of more than 10% within the previous 3-6 months

Very little or no nutritional intake for more than 5 days Very little or no nutritional intake for more than 5 days Low levels of potassium, phosphate or magnesium prior to feeding (see below)

A history of alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics (NICE, 2006)

HIGH MEDIUM LOW (10 Kcal/Kg/Day) (15 Kcal/Kg/Day) (25 Kcal/Kg/Day)

A full PN Biochemistry screen should be carried out before the Artificial Nutrition is started and on a daily basis until the patient is stable. (U&E, LFT, Bone, Glu, Pho, Mg, Trig). It is advisable to commence replacing deficiencies in K, Mg or PO4 prior to starting any parenteral nutrition, to prevent problems with refeeding syndrome. Prescribed Pabrinex twice daily for 3 days then until day 10 if high risk of re feeding. Monitor fluid balance and Na

+ administration closely.

Monitor BM’s every 4 hours until stable, hourly in diabetics who may require sliding scale insulin, PN can be used as the fluid source to reduce the risk of fluid overload.

Hypokalaemia (K

+ < 3.3mmol/l)

Parenteral Supplementation 500ml Dextrose 5% & 40mmol KCl

or

500ml Sodium Chloride 0.9% & 40mmol KCl over 6 hours, repeated as necessary.

ITU and HDUs

As above/or

Addition of strong KCl to infusion bags as prescribed by physician/surgeon.

Oral supplementation

Not suitable for patients on PN or with refeeding syndrome. Reserved for long-term small dose K

+ replacement

only.

MgSO4 is compatible with pre-made K

+ infusions.

Hypophosphataemia (PO4 < 0.75mmol/l)

Parenteral Supplementation Moderate (PO4-0.5-0.7mmol/l) Phosphate Polyfusor (50mmol/500ml) 250ml infused via peripheral or central line over 8-24 hours. Severe (PO4 < 0.5mmol/l) Phosphate Polyfusor (50mmol/500ml) 500ml infused via peripheral or central line over 8-24 hours. A maximum dose of 50mmol per infusion should not be exceeded. Repeat doses may be required over subsequent days, dependant on serum phosphate determinations to correct any underlying deficiency state. Outside of ITU not more than 6mmol/hour phosphate should be given. Elderly The dosage of phosphates solution may need to be reduced in the elderly, particularly in patients with impaired renal function. ITU and HDUs Intensive Care, Coronary Care and High Dependency Units may wish to give high rates of phosphate replacement but in a smaller volume, in patients who are continuously monitored. Addiphos or Glycophos are available to be made up on the ward for this patient group. Oral supplementation Not suitable for patients on PN or with refeeding syndrome. Reserved for long-term small dose PO4 replacement only.

Parenteral Phosphate preparations are NOT compatible with other solutions

Hypomagnesaemia (Mg < 0.70mmol/L)

Parenteral Supplementation MgSO4 - 20mmol added to 500ml Dextrose 5% infused over 6 hours MgSO4 is compatible with pre-made K

+ infusions.

ITU and HDUs

As above. Oral supplementation

Not suitable for patients on PN or with refeeding syndrome. Reserved for long-term small dose Mg replacement only.

Magnesium Glycerophosphate is available on a named patient basis. Diarrhoea limits the dose patients can tolerate (usually 8mmol 4 x Day).

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APPENDIX 23: Types and indications of intravenous access for Parenteral Nutrition

CVC DEVICE TYPE FEATURES ADVANTAGES DISADVANTAGES

Peripheral 22Ga cannula (Blue)

Inserted into veins of forearm. Indicated for short-term feeding (<5 days). Smallest gauge cannula should be inserted into the largest available vein to reduce incidence/risk of thrombophlebitis.

Can be used while longer term IV access is being planned.

Restrictions on type of PN that can be administered.

Peripheral inserted central venous catheter (PICC) Can be inserted on the ward by appropriately trained staff. If no suitable vein identified then radiology can insert a PICC using imaging-guidance.

One and two lumen devices available. Insertion by cannulation of peripheral vein. Occlusive dressing required, changed weekly. Removal at bedside by gentle traction.

Quick and easy to insert with minimal discomfort. Ease of removal. Reduced insertion associated complications.

Occlusion/kinking problems. Possibility of increased risk of Enfit misplacement.

Non tunnelled central venous catheter Usually inserted on the ward or in theatre for pressure monitoring.

One, two, three or four lumen devices available. Requires sutures to secure catheter. Suitable for short term only. Removal at bedside by gentle traction.

Can be inserted during emergency period. Relative ease of insertion. Meets the needs of most patients who need PN for less than 7 days. Higher risk of catheter related blood stream infections than tunnelled catheters – particularly internal jugular and femoral (latter should be avoided). Can only be used for PN if a lumen can be dedicated for PN use only and other access options have been ruled out.

Requires an aseptic dressing. Requires sutures to anchor catheter to skin.

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CVC DEVICE TYPE FEATURES ADVANTAGES DISADVANTAGES

Tunnelled central venous catheter

Usually inserted in radiology using imaging-guidance. Some inserted in theatre by surgery.

One, two or three lumen devices available. Insertion technique either surgical cutdown or percutaneous approach. Local anaesthetic (+/- sedation). Removal by surgical cut down.

Long catheter survival (up to 3-4 years). No long term external sutures required. Catheter exits through a skin tunnel on the anterior chest or abdominal wall. Indicated for mid to long term feeding (>30 days). Can be used for PN if the patient has the catheter already and a lumen can be dedicated for PN use only.

Limitations on patient’s lifestyle – bathing, swimming, sports. Body image issues. Scarring from tunnel and insertion site.

Implantable Portacath Inserted in radiology using imaging-guidance.

One or two lumen devices available. Insertion technique requires surgical cut down. Local anaesthetic (+/- sedation) or general anaesthetic. Removal by surgical cut down. Dressing only required to secure needle when infusion running.

No dressing required. Suitable for patients requiring intermittent venous access. Reduces risk of exit site infections. Allows the patient to bathe and swim.

Possibility of local discomfort during use. Possibility of skin ulceration around site. Unsuitable for patients who are needle phobic.

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APPENDIX 24: Parenteral Nutrition (PN) Request Form (medical staff)

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APPENDIX 25: Aseptic Dispensing Services Parenteral Nutrition Request Form

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APPENDIX 26: NHS Tayside - Adult TPN Administration Chart

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APPENDIX 27: Out of hours Parenteral Nutrition regimen

This protocol should be used to commence Parenteral Nutrition (PN) out of hours. Please complete the PN Request Form (Appendix 24) and inform the ward dietitian or pharmacist as soon as possible.

A full PN Biochemistry screen should be carried out before the PN is started (urea & electrolytes including Mg and PO4) and on a daily basis until the patient is stable (7-10 days). If electrolytes are particularly abnormal it may be appropriate to delay starting PN until full assessment can be carried out by dietetics. Peripheral supplementation of fluid & electrolytes will be required and should be tailored to individual patient requirements. All patients should be prescribed Pabrinex twice daily for 3 days then daily thereafter until day 10.

Low risk of refeeding Regimen: Lipoflex Peri 1250ml/24hr (52ml/hr) Continuous Peripheral Infusion (stock in Ninewells Wards 2, 11 & 9HDU)

Volume 1250ml Sodium 50mmol

Nitrogen 5.7g Potassium 30mmol

Calories (Glucose) 320Kcal Calcium 3mmol

Calories (Fat) 500Kcal Magnesium 3mmol

Total Calories (inc Nitrogen) 955Kcal Phosphate 7.5mmol

High risk of refeeding Regimen: Lipoflex Peri 1250ml/24hr (25ml/hr) Continuous Peripheral Infusion (stock in Ninewells Wards 2, 11 & 9HDU.) Note a 1250ml bag can be run for 48hrs below indicates amounts patient will get in 24hrs

Volume 625ml Sodium 25mmol

Nitrogen 2.85g Potassium 15mmol

Calories (Glucose) 160Kcal Calcium 1.5mmol

Calories (Fat) 250Kcal Magnesium 1.5mmol

Total Calories (inc Nitrogen) 477.5Kcal Phosphate 3.75mmol

PN must also be prescribed on the patient’s PN administration chart (Appendix 26) & TPAR prior to administration.

The rate of the PN must not be increased until reviewed by ward dietitian or pharmacist who may refer to member of the Nutrition Support Team for further advice.

Refeeding Syndrome – High Risk One or more of the following: BMI <16, unintentional weight loss > 15% in last 3 –6 months, little or no intake > 10 days. Two or more of the following: BMI < 18.5, unintentional weight loss >10% in last 3 –6 months, little or no intake > 5 days, history of alcohol, or drugs including insulin, chemo, antacids or diuretics.

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Policy Manager: Dietetic Consultant in Public Health of 148 Review Date: June 2022

APPENDIX 28: Protocol for laboratory monitoring of nutrition support for patients in hospital on Parenteral Nutrition (PN)

ANALYTE FREQUENCY RATIONALE

Na/K/Urea/Creatinine Baseline, daily until stable Assessment of fluid balance, K status

ALT/AP/Bili/Albumin Baseline, daily until stable Assessment of PN associated liver dysfunction

Capillary Blood Glucose Baseline, twice daily, more if uncontrolled

Management of glucose intolerance

Magnesium/Phosphate Baseline, daily until stable Prevention of refeeding

CRP Baseline, dependent on clinical situation (likely daily if in hospital)

Assessment of presence of sepsis/acute phase response

Calcium Baseline, weekly Assess for deficiency/excess

Vitamin D Once yearly Assess for deficiency

Accurate measurement of fluid balance and the patient’s ECF volume is essential for interpretation of electrolyte biochemistry. Sodium Sodium requirements will be different for each patient e.g. patients with high NG aspirates, diarrhoea and fistulae will have increased requirements and patients with renal failure/cirrhosis will likely have decreased requirements. Mild hyponatraemia is common in patients receiving PN. This is usually multi-factorial and is not on its own an indication for increasing the amount of sodium in the feed. Causes include increased secretion of ADH due to the stress of acute illness and/or opiate painkillers. Sodium depletion can be indicated by a low urinary sodium concentration (<20 mmol/L) but this is dependent on the patient having normal renal function. It is also usually impossible to interpret if the patient has received IV saline. Hyponatraemia in patients with an increased serum osmolality (>295 mmol/kg) may be due to hyperglycaemia. Hyperglycaemia increases serum osmolality and causes water to shift out of cells. Correction of hyperglycaemia should restore the serum sodium concentration to normal. Clinical (orthostatic hypotension, decreased skin turgor, tachycardia) and biochemical (elevated urea and creatinine) indicators of hypovolaemia in a patient who is hyponatraemic with a low serum osmolality indicate sodium depletion. Euvolaemia and hypervolaemia in the context of hyponatraemia (and low serum osmolality) indicate water excess/water and sodium excess respectively. Spurious hyponatraemia (psuedohyponatraemia) can occur if the lipid is not being cleared adequately. The sample will appear lipaemic and triglycerides will be high. Hypernatraemia is less common than hyponatraemia. It is most commonly caused by loss of water from the skin/urine/GIT. Loss of access to water (e.g. in patients who are NBM) is required to maintain the hypernatraemic state. The addition of hypertonic fluids (such as PN) in combination with water loss can result in hypernatraemia. Glucose intolerance can be exacerbated by sepsis (due to increased insulin resistance) which may then cause an

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osmotic diuresis, thus resulting in further water loss. Parenteral administration of excessive nitrogen will result in increased formation of urea, which will contribute further to an osmotic diuresis. Increased insensible losses such as occurs in sepsis will further cause water depletion and have the potential to cause hypernatraemia, if losses are not matched. Potassium Potassium balance is usually negative in patients who are catabolic but becomes positive when patients become anabolic. Hypokalaemia in patients on PN can be indicative of ‘refeeding syndrome’. This phenomenon occurs in particular in patients whose nutritional status has been poor prior to commencing PN. There is rapid uptake of potassium into cells primarily due to the increase in insulin secretion - a response to the high glucose load from the PN. Hypokalaemia can also occur due to insufficient intake (particularly if there is increased loss such as from diarrhoea, NG aspirates or diuretics), low magnesium, metabolic alkalosis and Prescription with steroids. Hyperkalaemia can occur when there is a reduction in renal function, there is excess amount of potassium in the feed and the kidneys are not able to excrete this, if the patient has a metabolic acidosis or if potassium sparing diuretics are prescribed. Insulin deficiency may also result in hyperkalaemia. Urea Patients who are receiving PN may have an increased urea due to the excess protein intake. Other causes of high urea are listed below. More than 90% of urea is excreted through the kidneys and therefore an increased urea can occur in patients on PN whose renal function is poor or has deteriorated. Serum urea is also increased by: increased protein catabolism, reabsorption of blood proteins after GI haemorrhage, treatment with cortisol or its synthetic analogues, dehydration and decreased renal perfusion (e.g. in heart failure). In these situations, serum creatinine may be normal. In obstructive postrenal conditions, e.g. malignancy, prostatism and nephrolithiasis - urea and creatinine will be increased. Dehydration and pre-renal states should therefore be avoided. Modern PN feeds are mainly comprised of synthetically processed amino acids. Metabolism of cationic acids results in the production of both urea and hydrogen ions. If the patient is not able to excrete or neutralise the urea/hydrogen ions, a metabolic acidosis can develop. A high urea can also therefore be indicative of a metabolic acidosis. Hypophosphataemia contributes significantly to the maintenance of a metabolic acidosis. High urea on PN: 1. AKI/CKD? 2. Dry? 3. GI haemorrhage? 4. Is there decreased renal perfusion e.g. CCF? 5. Is the patient on cortisol/cortisol analogues?

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6. Does the patient have a metabolic acidosis? 7. PN? Creatinine Creatinine is primarily used as an indicator of renal function and is the waste product of creatine/phosphocreatine. In health, the concentration of creatinine in the blood stream is relatively constant although can be affected by diet, race, gender, age and muscle mass. Creatinine is freely filtered at the glomerulus with little tubular reabsorption. There is a small but significant amount of tubular secretion. Several drugs in particular inhibit the tubular secretion of creatinine, thus increasing the serum creatinine without a decline in GFR- examples include cimetidine, trimethoprim, salicylates, corticosteroids and vitamin D derivatives. Increased serum creatinine is mainly due to a decrease in eGFR. Causes can be classified as pre-renal/renal/post renal: 1. Pre-renal: hypotension/volume depletion/renal artery stenosis/renal artery or vein

thrombosis/traumatic renal infarction/multiple cholesterol emboli syndrome/congestive heart failure/hepatorenal syndrome/ACEi or ARBs/cardiac surgery

2. Renal: - Glomerular: diabetic nephropathy/hypertension/post-infectious/

cryoglobinlinaemia/drugs(NSAIDs/ciclosporin) - Tubulointerstitial: Acute interstitial nephritis/acute tubular necrosis

3. Post-renal: Obstructive uropathy LFTs Abnormal LFTs are common in patients receiving PN, both in the short and long term. In general, these can be mild and often normalise if PN continues. Furthermore, the abnormalities usually resolve on stopping the PN. Many patients often have abnormal LFTs prior to starting PN and LFTs although still abnormal, are not always made worse by the addition of PN. Abnormal LFTs in patients on PN are strongly influenced by the underlying disease process, particularly sepsis. The aetiology of abnormal LFTs in patients receiving PN is often multi-factorial. There are four main possible causes: 1. Lack of enteral nutrition is associated with an increased risk of abnormal LFTs. It is

difficult to know if this is directly due to the effects of the PN or due to fasting. The reduction in gut hormones may reduce GI motility, promoting bacterial overgrowth and may predispose to biliary stasis.

2. Nutrient deficiency: deficiencies of several methionine metabolites (carnitine, choline, taurine) may be responsible for the steatosis and cholestatic pictures seen in patients on PN. Studies have failed to show any benefit in carnitine supplementation in patients on PN. Plasma choline concentrations are low in most patients on PN and deficiency causes impaired hepatic TAG secretion with resultant steatosis. Choline deficiency in patients on PN has been shown to correlate with increased transaminases and steatosis. These abnormalities have been shown to reverse when choline supplementation is given, although these studies were small. Intervention studies have not shown benefit of choline supplementation in adults.

3. Nutrient toxicity:

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a. Glucose infusion rates of >5mg/kg/min result in steatosis by stimulating insulin release and inhibiting fatty acid oxidation. Cyclical PN (>8h/day each day without parenteral glucose infusion) has been shown to lower insulin levels and improve LFTs.

b. Excess lipid may increase hepatic complications, with proposed mechanisms including impaired phospholipid excretion, inhibition of hepatic TAG release or accumulation of phytosterols. Second or third generation lipid emulsions are associated with fewer hepatic complications.

c. Others: manganese and copper are both excreted in biliary route and can accumulate in cholestasis, exacerbating hepatic dysfunction.

4. Patient dependent factors (sepsis, intestinal anatomy, other liver disease, cholelithiasis, bacterial overgrowth, decreased hepatobiliary circulation). a. Sepsis in particular is a precipitant of abnormal LFTs in adults receiving short term

PN. In addition, bacterial overgrowth can cause cholestasis. b. Small intestinal length- patients with shortened small bowel are more likely to develop

abnormal LFTs whilst on PN although the exact mechanism is unclear. Management of abnormal LFTs whilst on PN: 1. Treatment of underlying causes e.g. sepsis. 2. Minimise hepatotoxic medication. 3. Could there be other causes for abnormal LFTs (including prescription antibiotics)? 4. Is the patient being overfed? 5. Is the patient on a second or third generation feed? 6. Has cyclical PN been considered (8 hour break minimum- NB need to monitor blood

glucose more closely)? Glucose Hyperglycaemia in patients admitted to hospital is complex and multifactorial. There is increased hepatic glucose production and decreased utilisation by the peripheral tissues. Acute illness, surgery and trauma all increase stress mediators which alter carbohydrate metabolism and result in hyperglycaemia. Peripheral insulin resistance is common and bed rest itself has been shown to reduce peripheral glucose uptake. Increases in catecholamines, cortisol and glucagon cause significantly increased insulin resistance in patients who have undergone surgery. Excess nutrition and PN can also result in hyperglycaemia. Patients with hyperglycaemia are at higher risk of complications and mortality. Hyperglycaemia is a common complication of enteral and parenteral feeding in patients with and without diabetes. Excessive glucose administration from PN may have side effects other than hyperglycaemia. These include increased lipogenesis in the liver and fat tissue, increase thermogenesis, and a higher oxidation of the glucose to CO2 resulting in an increased work of breathing. In patients receiving PN, hyperglycaemia should therefore be prevented and treated quickly. It is considered that dextrose administration rate in PN above 4 mg/kg/min is a significant predictor of hyperglycemia in non diabetic critically ill patients. Insulin is the treatment of choice if a patient on PN develops consistent hyperglycaemia. If patients consistently have capillary blood glucose >10 mmol/L, referral to the DSN for consideration of long acting insulin should be considered.

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Rebound hypoglycaemia may occur when feed is stopped suddenly. Magnesium Magnesium is the fourth most abundant cation in the body; about 1% of this is extracellular. It is a cofactor for more than 300 enzymes, is required for enzyme substrate formation and is an allosteric activator of many enzyme systems. Reduction in serum magnesium concentration results in increased neuromuscular excitability because the magnesium competitively inhibits the entry of calcium into neurons. Hypomagnesaemia is common in hospitalised patients. In many cases, this seems to be reflective of a shift into cells as it can resolve without magnesium replacement. Moderate or severe deficiency is usually due to losses from the GI tract/kidneys. Magnesium is commonly associated with losses from the lower intestine in diarrhoea. Magnesium is most effectively absorbed from the distal small bowel; malabsorption and gastric bypass surgery are associated with magnesium malabsorption. NG suction or vomiting may reduce magnesium. Some magnesium is bound to albumin, and patients with hypoalbuminaemia may therefore also have a low plasma magnesium. Hypocalcaemia (due to decreased PTH secretion) is an important consequence of hypomagnesaemia. Magnesium is often reduced as part of a refeeding syndrome. Patients are at higher risk if magnesium is low prior to starting treatment. Magnesium should be monitored prior to starting treatment and then daily until the patient is stable. Hypomagnesaemia should be corrected with IV replacement: MgSO4 - 20mmol added to 500mL Dextrose 5% infused over 4 hours. Excessive urinary losses may occur in alcoholism, DM, loop diuretics and treatment with aminoglycoside antibiotics. Phosphate Mild phosphate deficiency may be asymptomatic and in patients receiving PN, hypophosphataemia is most commonly due to refeeding syndrome, where the phosphate is shifted into cells. Other causes include respiratory alkalosis, increased GI loss (e.g. in diarrhoea and vomiting) and decreased absorption (vitamin D deficiency, malabsorption) - most phosphate is absorbed in the proximal small intestine. Clinical manifestations are generally seen at <0.48 mmol/L, Glycolysis and cellular function is impaired by low intracellular phosphate. Other signs/symptoms include muscle weakness, acute respiratory failure, decreased cardiac output, rabdomyolysis. If severe, haemolysis and a reduction in GCS may occur due to tissue hypoxia. If chronic, osteomalacia may develop. Hyperphosphataemia is most commonly caused by renal insufficiency. Other causes include increased tissue catabolism and excess intake PN. Most patients with hyperphosphataemia are asymptomatic although may report hypocalcaemic symptoms.

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Hypophosphataemia should be managed with a phosphate polyfuser with the dose dependent on the degree of deficiency. Doses should be decreased in patients with reduced renal function. Hypocalcaemia can occur if phosphate is high. Calcium Hypocalcaemia can occur in patients with hypoparathyroidism, hypomagnesaemia, hyperphosphataemia, vitamin D deficiency and acute pancreatitis. Hypercalcaemia can occur in increased bone resorption as seen in malignancy, hyperparathyroidism, immobilisation and hyperthyroidism. CRP CRP is an acute phase reactant with a half life of ~18 hours. Should be measured in assessing for sepsis and if measurement of trace elements is being considered, as inflammation may invalidate the results. Abnormal LFTs in patients on PN are often due to sepsis and CRP may be useful for further assessment. Thiamine In a well nourished individual, there is only sufficient reserve of thiamine for only 21 days. For a patient who is malnourished, reserves may be completely deplete. In starvation, only small amounts of thiamine are used. Once feeding is introduced e.g. with PN, thiamine is used up and can result in thiamine deficiency. This can then cause the onset of Wernicke-Korsakov syndrome. A sensory polyneuropathy and cardiac failure are other signs of thiamine deficiency. Thiamine should therefore be replaced at the beginning of feeding and then again at 21 days if the patient is still on PN. Vitamin D The referral laboratory (GRI) will not routinely analyse vitamin D requests made within 340 days of the previous request i.e. only request once a year. It is recommended that patients in the following groups are at greater risk of deficiency and should take a daily vitamin D supplement: • all people aged 65 years and over • all pregnant and breastfeeding women, especially teenagers and young women • children under five years of age • people who are not exposed to much sunlight, for example, those who cover their skin for

cultural reasons, are housebound or who stay indoors for long periods • people who have darker skin and, therefore, need to spend a longer time in the sun to

produce vitamin D For management of vitamin D deficiency and treatment please see: http://www.nhstaysideadtc.scot.nhs.uk/TAPG%20html/pdf%20docs/Management%20of%20Vitamin%20D%20deficiency%20in%20Adults%20Dec%2012.pdf Patients with CKD stage 4 and 5 may not respond to cholecalciferol and should be referred. These patients may require the hydroxylated derivatives (alfacalcidol or calcitriol) but usually only in severe renal impairment (CKD stage 5).

http://www.nhstaysideadtc.scot.nhs.uk/TAPG%20html/pdf%20docs/Management%20of%20Vitamin%20D%20deficiency%20in%20Adults%20Dec%2012.pdf


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Fultium D3 contains peanut oil- check for allergy before prescribing. It is not suitable for vegetarians as the gelatin is of bovine origin but it is Halal certified. Vegetarians should be prescribed cholecalciferol 3000 IU/ml made by Tayside Pharmaceuticals, please indicate supplier on the prescription.

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APPENDIX 29: Metabolic Complications

Dehydration or over-hydration

A fluid-chart is essential to prevent these. If severe electrolyte disturbances are present (such as, for instance sodium concentration above 150mmol/l or below 125mmol/l) rectify these abnormalities by treatment with crystalloids and delaying the commencement of PN until electrolyte balance is under control.

Hypokalaemia

Hypokalaemia is a frequent complication of PN. The potassium content of bags is adjusted according to the serum level and monitoring serum potassium is essential. The patient may require potassium supplementation over and above of the amount given with PN.

Hyperkalaemia

If serum potassium concentration in a patient on PN exceeds 5.5mmol/l, the PN should be discontinued and a member of the Nutrition Team contacted to adjust the potassium content of PN solution.

Hyponatraemia

It is a common complication of PN. If a patient becomes hyponatraemic and needs crystalloids, give saline only, not dextrose. Volume restriction or sodium supplementation may be required.

Hypernatraemia

Mostly related to dehydration. If crystalloids are required give dextrose only, no saline (except severe dehydration, where saline might be initially required to expand the extracellular fluid).

Hypomagnesaemia

May occur in presence of large losses of intestinal fluid. Both hypokalaemia and hypocalcemia may occur on the background of Hypomagnesaemia. Measure magnesium in hypokalaemic patients.

Hypo- and hyperphosphataemia

Hypophosphataemia may follow the introduction of nutritional support due to movement of phosphate into the cells. Hyperphosphataemia is common in renal failure (refer to section on refeeding system).

Glucose intolerance and diabetes

Commencing PN may result in hyperglycaemia, particularly in patients with glucose intolerance and diabetes mellitus. It is therefore good practice to monitor glucose regularly. Patients with diabetes may require the sliding scale insulin treatment during PN. PN can be used as the fluid for sliding scale.

Hypoglycaemia Hypoglycaemia is rare in patients on PN who do not require additional insulin. Glucose needs to be closely monitored when insulin is administered, particularly during changes in PN regimen.

Abnormal liver function

A mild increase of alkaline phosphatase and/or transaminases may be a normal finding after a few days of PN. If levels continue to rise and infection is excluded, we would consider decreasing or changing the type of fat in the PN, or stopping PN. If LFT disturbance is a consequence of PN, a cholestatic pattern is likely.

Dyslipidaemia

Fat metabolism may be impaired in renal insufficiency, uncontrolled diabetes mellitus and liver disease. Triglyceride levels should be monitored to ensure that an infused lipid emulsion is cleared from the bloodstream.

Trace metal and vitamin deficiencies

Deficiencies of zinc or copper or vitamins may rarely become apparent during long-term PN.

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4.2a STANDARD OPERATING PROCEDURE – Procedure for dressing central venous catheter exit site


Policy reference: 4.2a

Originator: Alison Ingledew

Operation Procedure for dressing central venous catheter exit site

Part number/name The procedure for dressing central venous catheter exit site


All aseptic technique precautions e.g. antiseptic hand wash Disposable apron

Tools/Equipment Antiseptic hand wash e.g. Hibiscrub Alcohol hand gel e.g. Hibisol Apron, non sterile and sterile gloves 2 x Sterile drapes ChloraPrep antiseptic stick Sterile dressing e.g. IV3000 or Mepore 2 x Alcohol wipes Appropriate size of Biopatch Protective Disc Disposal bag

No Main Operating Steps

Rationale Evidence/support









4 The procedure should be carried out using the ANTT

This is an evidence based technique which prevents infection

Nursing Times 2011

5 Put on apron and wash hands using standard hand wash, dry with paper towels; clean trolley surface with an alcohol wipe Open drape pack, drop on to trolley surface



6 Wash hands using antiseptic handwash, dry with paper towels; open sterile drape, touching corners only, place on to trolley surface and under catheter

To prevent contamination of sterile drape


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7 Place sterile gloves, dressing, Biopatch and ChloraPrep on to sterile field

To minimise contamination NHS Tayside (2019) Infection Prevention & Control Policy

8 Put on non sterile gloves, remove existing dressing from the exit site, taking care not to disturb the catheter and preventing movement If the exit site is encrusted or appears infected take a swab for culture

To prepare site for new dressing without disturbing catheter


9 Remove non sterile gloves, apply alcohol hand gel, allow to dry; put on sterile gloves

To decontaminate hands before applying sterile gloves


10 Clean the catheter exit site with ChloraPrep from inside outwards and downwards, limiting movement of the catheter

To clean site in a way that prevents contamination of exit site


11 Allow antiseptic to dry

To maximise antiseptic action


12 Apply Biopatch to line exit site, then apply dressing:

if using sterile gauze (Mepore) dressing change every 24 to 48 hours

if using IV 3000 change every 7 days, do not use IV 3000 dressing if exit site moist or leaking

To cover and protect exit site

13 Tape catheter to secure position i.e. to patients’ body

To prevent movement of catheter

14 Dispose of waste according to NHS Tayside policy





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4.2b STANDARD OPERATING PROCEDURE – Procedure for commencing Parenteral Nutrition (PN) via central venous catheter


Policy reference: 4.2b


Operation Procedure for commencing PN via central venous catheter

Part number/name Procedure for commencing PN via central venous catheter



Tools/Equipment Antiseptic hand wash e.g. Hibiscrub Alcohol hand gel e.g. Hibisol Apron and sterile gloves 2 x sterile drapes 8 x alcohol wipes Administration set IV fluid bag/PN bag (prescribed) Disposal bag

No Main Operating Steps

Rationale Evidence/support

1 Introduce themselves to the patient by name and title





3 Obtain prescribed IV fluids/PN Bag checking patient details match







Nursing Times 2011




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8 Place sterile gloves, administration set and alcohol wipes on to sterile field

To minimise contamination


9 Apply alcohol gel and allow to dry To decontaminate hands NHS Tayside (2019) Infection Prevention & Control Policy

10 Open out administration set; do not touch either end of the administration set Close the administration set’s roller clamp

To prepare administration set for use and minimise contamination


11 Use alcohol wipes, remove cap at end of administration set Cover end of set with an alcohol wipe

To prepare administration set for use and minimise contamination

NHS Tayside (2019) Infection Prevention and Control Policy

12 Clean the infusion port of the IV/PN bag with an alcohol wipe, allow to dry

To clean port prior to inserting administration set


13 Use alcohol wipe, break the bag seal; do not touch the port after the seal is broken

To access infusion bag and minimise contamination


14 Use alcohol wipes, remove the cover from the administration set, do not touch the spike

To prepare set for infusion and minimise contamination


15 Insert the spike of the administration set into the port of the IV bag, using a gentle pushing/ twisting motion.

To access infusion bag and connect administration set

16 Squeeze the drip chamber, open the flow control clamp, prime the administration set

Clearing air from administration set allowing fluids to drain

17 Apply Alcohol hand gel and allow too dry Put on sterile gloves

Decontaminate hands NHS Tayside (2019) Infection Prevention & Control Policy

18 Cleanse catheter bung with alcohol wipe, allow too dry

To decontaminate the bung prior to connection


19 Using alcohol wipes, attach administration set to catheter bung

To connect giving set to catheter minimising contamination


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20 Insert administration set into pump and set pump at prescribed rate/volume

To ensure rate of infusion is accurate and correct as prescribed


21 Unclamp catheter and commence infusion

To commence infusion






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4.2c STANDARD OPERATING PROCEDURE – Procedure for administration of medication via central venous catheter


Policy reference: 4.2c


Operation Procedure for administration of medication via central venous catheter

Part number/name



Tools/Equipment Antiseptic hand wash e.g. Hibiscrub Alcohol hand gel e.g. Hibisol Apron and sterile gloves 1 x Sterile drape 3 x 10ml syringes (DO NOT USE LESS THAN 10ml SYRINGE AS TOO MUCH PRESSURE IS PUT WITHIN THE LINE) 3 x Needles/filter straws 2 x 10 ml sodium chloride 0.9% 5ml of Heparin solution (50 units per 5 ml) 6 x alcohol wipes Medication Vial (as prescribed) Disposal bag







3 Obtain prescribed medicine vial checking patient details match







Nursing Times 2011




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8 Place alcohol wipes, sterile gloves, syringes and needles on to sterile field


9 Clean all non sterile vials, using a new alcohol wipe for each vial and remove end

To decontaminate vials prior to placing on sterile field


10 Apply alcohol gel to hands To decontaminate hands NHS Tayside (2019) Infection Prevention & Control Policy

11 Connect needles to syringes. Do not touch needles or tip of syringes


12 Draw up prescribed amount of solutions, expel air from the syringe, remove needles (mix antibiotics if required)

To prepare medicine and flushes before administration


13 Put on sterile gloves To prevent contamination NHS Tayside (2019) Infection Prevention & Control Policy

14 Cleanse catheter hub/bung with alcohol wipes, allow too dry

To decontaminate catheter bung prior to administration of medicines


15 Inject 10 ml sodium chloride 0.9% followed by medication and then another 10 ml sodium chloride 0.9% using push/pause technique

To flush catheter prior to and after administration of medicine

16 Inject 5ml Heparin solution (50 units per 5 ml) using push/pause technique Clamp line prior to removing syringe to maintain positive pressure

To prevent blockage of catheter






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4.2d STANDARD OPERATING PROCEDURE – Procedure for disconnecting Parenteral Nutrition (PN) from a central venous catheter


Policy reference: 4.2d


Operation Procedure for flushing central venous catheter after PN

Part number/name The procedure for flushing central venous catheter after PN



Tools/Equipment Antiseptic hand wash e.g. Hibiscrub Alcohol hand gel e.g. Hibisol Apron and sterile gloves 2 x Sterile drapes 2 x 10ml syringes (DO NOT USE LESS THAN 10ml SYRINGE AS TOO MUCH PRESSURE IS PUT WITHIN THE LINE) 2 x Needles/filter straws 10 ml sodium chloride 0.9% 5ml Heparin solution (50 units per 5 ml) 5 x alcohol wipes Disposal bag


1 Introduce themselves to the patient by name and title










Nursing Times 2011







7 Place alcohol wipes, sterile gloves, syringes and needles on to sterile field



8 Clean all non sterile vials, using a new alcohol wipe for each vial and remove ends

To decontaminate vials prior to placing on sterile field


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9 To apply alcohol gel to hands. To decontaminate hands





11 Draw up desired amount of solutions, expel air from syringe, remove needles

To prepare flushes before administration


12 Put on sterile gloves To prevent contamination


13 Cleanse catheter hub/bung with alcohol wipes, allow too dry Using alcohol wipes, disconnect PN/IV fluids

To decontaminate catheter bung prior to administration of flushes


14 Inject 10 ml sodium chloride 0.9% using push/pause technique

To flush catheter

15 Inject 5ml Heparin solution (50 units per 5 ml) using push/pause technique; clamp catheter before removing syringe to maintain positive pressure

To prevent blockage of catheter






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4.2e STANDARD OPERATING PROCEDURE – Procedure for taking blood from a central venous catheter


Policy reference: 4.2e


Operation Procedure for taking blood from a central venous catheter

Part number/name The procedure for taking blood from a central venous catheter



Tools/Equipment Antiseptic hand wash e.g. Hibiscrub Alcohol hand gel e.g. Hibisol Apron Sterile gloves 2 x Sterile drapes 4 x 10ml syringes (DO NOT USE LESS THAN 10ml SYRINGE AS TOO MUCH PRESSURE IS PUT WITHIN THE LINE) 2 x Needles/filter straws 20 ml sodium chloride 0.9% 5ml Heparin solution (50 units per 5 ml) Blood bottles Vacutainer Blood transfer device 6 x alcohol wipes Disposal bag











To decontaminate surface prior to use


5 Wash hands using antiseptic hand wash, dry with paper towels



6 Open sterile drapes, touching corners only, place on trolley and under catheter



7 Open and place alcohol wipes, sterile gloves, syringes, needles onto sterile field

To prepare equipment and minimise contamination


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8 Clean all non sterile vials using a new alcohol wipe for each vial and remove end

To decontaminate and prepare vials prior to placing on sterile field


9 Apply alcohol gel to hands, allow to dry and put on sterile gloves

To decontaminate hands



To prepare syringes and minimise contamination


11 Draw up desired amount of solutions, expel air from syringe, remove needles

To prepare for flushing after blood sampling


12 Cleanse the catheter junction site with an alcohol wipe, leave to dry

To decontaminate catheter hub/bung To provide protection

13 Ensure catheter is clamped, using alcohol wipes remove bionector and discard

To prevent blood loss or air entry into line

14 Attach 10ml syringe Unclamp catheter

To access line and prepare for blood withdrawal

15 Draw back 10ml blood, clamp catheter and remove syringe (this blood should be discarded)

To remove blood which is unsuitable for analysis as likely to contain contaminant, which will affect results

16 Attach second 10ml syringe, unclamp catheter and draw back 10ml of blood (use larger syringe if more blood required for analysis). This sample should be used for blood bottles

To remove blood suitable for blood sampling

17 Clamp catheter and remove syringe To prevent blood loss and air entry

18 Attach new connection device (Bionector). Unclamp catheter

Catheter should always have closed connection device attached

19 Inject 20 ml sodium chloride 0.9% using push/pause technique

20 Inject 5ml Heparin solution (50 units per 5 ml) using push/pause technique

To flush blood from lumen of catheter creating turbulence and to prevent occlusion

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21 Clamp catheter before removing syringe to maintain positive pressure

To prevent blockage of catheter when not in use

22 Transfer required amounts of blood into each blood bottle using vacutainer blood transfer device Complete required information on blood bottles and request form or attach appropriate blood labels - if used Place in specimen bag. Transfer to blood laboratory

To prevent backflow of blood in catheter


To enable requested tests to be performed



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4.2f STANDARD OPERATING PROCEDURE – Procedure for removal of a central venous catheter


Policy reference: 4.2f


Operation Procedure for removal of a central venous catheter

Part number/name The procedure for removal of a central venous catheter



Tools/Equipment Dressing pack Antiseptic solution i.e. Chlorhexidine Stitch cutter/sterile scissors Sterile Mepore dressing Sterile gloves Sterile specimen jar (if infection suspected) Disposal bag










4 Position patient flat on bed. Elevate the foot of the bed before removal of line if the catheter is positioned in the subclavian or internal jugular vein

To ensure the patient is in the correct position for the procedure

5 Put on apron and wash hands using standard hand wash, dry with paper towels; put on non sterile gloves and remove the line dressing

To prepare site

6 Clean trolley surface with an alcohol wipe, open dressing pack packet and drop on to trolley surface Wash hands using antiseptic hand wash, dry with paper towels, put on sterile gloves



7 Open sterile dressing pack, touching corners only, place on trolley surface; place drape at catheter area



8 Place sterile gloves, dressing and antiseptic on to sterile field; apply alcohol hand gel then put on sterile gloves



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9 Clean skin around line entry site using antiseptic solution and allow too dry

To decontaminate site prior to line removal


10 Remove sutures from line

To remove line

11 Place sterile gauze over the entry site applying light pressure Remove the line in one steady motion, avoiding contact with the tip If infection is suspected the catheter tip should be aseptically placed in a sterile sample container

12 Observe the patient for any changes in their breathing pattern


13 Apply firm pressure to entry site for a minimum of 1 minute

14 Check entry site, if no bleeding noted apply a sterile Mepore dressing

15 Check patients BP is within their normal parameters


16 If bleeding persists after 20 minutes of firm pressure, contact medical staff


17 Remove dressing after 24 hours if no contraindications


Dispose of waste safely



Patient safety. To ensure accurate records are maintained


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4.2.7 REFERRAL FOR HOME PARENTERAL NUTRITION (HPN) Home Parenteral Nutrition (HPN) is given via intravenous delivery of fluids and nutrients directly into a central vein. The patient or carer can be taught to manage the sterile routine to enable the transfer of care from hospital to the home. HPN is used to treat patients with chronic intestinal failure, which is defined as inadequate intestinal function for absorption of fluid, electrolyte and nutrient requirements leading to deteriorating nutritional and/or fluid status. Except in cases of short bowel syndrome with small intestinal length of < 50cm, patients should have undergone an adequate trial of enteral tube feeding. Patients who have documented nutritional failure but no diagnosis should be assessed by a clinician with expertise in intestinal failure. The commonest cause of patients requiring HPN is the development of short bowel syndrome from diseases such as Crohn's disease, mesenteric vascular disease and surgical complications. Some patients may require HPN for many years but some may only require it for a short period of time awaiting corrective surgery, until there is intestinal adaptation or in the terminal stages of malignancy. Table 8 lists the most common indications and underlying diagnoses in HPN patients. Table 8: Common HPN indications and underlying diagnoses in patients with chronic intestinal failure Indications Underlying diagnosis Short bowel syndrome Volvulus Mesenteric vascular disease Mesenteric tumours Crohn’s disease Gastric surgery Neoplastic disease/peptic disease Radiation enteritis Neoplastic disease Chronic intestinal obstruction Diffuse intra abdominal malignancy Intestinal pseudo obstruction Enteric neuropathies or myopathies Secondary amyloidosis

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Referral for HPN Before the referring clinical team discusses the possibility of HPN with the patient, it is important to have preliminary discussion with members of the Nutrition Support Team (NST). The NST will assess the patient and advise on the suitability of the patient for treatment, including the ability of the patient to cooperate and personal preferences should be taken into account when assessing for HPN. Patients who have gastrointestinal obstruction because of malignancy may be suitable for HPN but the following points should be considered carefully: 1. Willingness of the patient to comply. 2. Expected survival of more than three months. 3. An awareness of diagnosis and likely prognosis. 4. Appropriate family/home support. Patients who are under the care of the Oncology Unit may require HPN for palliative care. Once the patient is considered clinically stable, it is important that arrangements are made to transfer the patient to Gastroenterology ward for nutritional assessment and training in the technique of HPN. The nutrition nurse specialist and senior nursing staff of the ward carry out the training with the patient and/or carer (see SOP 4.2a for referral for HPN). Education and training All people in the community having parenteral nutrition should be supported by a co-ordinated multidisciplinary team, which includes input from specialist nutrition nurses, dietitians, GPs, pharmacists and district and/or homecare company nurses. Close liaison between the multidisciplinary team and patients and carers regarding diagnoses, prescription, arrangements and potential problems is essential.

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4.2g STANDARD OPERATING PROCEDURE – Referral procedure for Home Parenteral Nutrition (HPN)


Policy reference: 4.2g

Originator:

Operation Referral procedure for Home Parenteral Nutrition (HPN)

Part number/name


Tools/Equipment Referral letter


1 Clinical team to clarify that patient is a suitable candidate for HPN (but do not discuss with patient at this stage)

To ensure that patients meet the common HPN indications

NMC. (2015) The Code HPN MCN Good Practice Guide (2012)

2 Clinical team refer patient for HPN to the Nutrition Support Team (NST)

To ensure the correct clinical team make the decision for HPN

NMC. (2015) The Code HPN MCN Good Practice Guide (2012)

3 The NST will assess the patient and advise on the suitability of the patient for treatment, including the ability of the patient to cooperate and personal preferences; HPN will be discussed with patient at this stage

To ensure suitability of HPN for the patient

NMC. (2015) The Code HPN MCN Good Practice Guide (2012) HPC Code of Conduct (year) NHS QIS Food, Fluid and Nutritional Care Standards (2003)

4 Once the patient is considered clinically stable, patient is transferred to the Gastrointestinal ward for nutritional assessment and training in the technique of HPN

To allow the specialist ward for HPN to prepare and train patient on HPN

NICE (2017) Nutritional Support in Adults

5 The nutrition nurse specialist and senior nursing staff of the ward carry out the training with the patient and/or carer

To ensure the patient/carers are competent in HPN techniques


6 The nutrition nurse specialist and pharmacist will arrange home delivery of feed and equipment for discharge

To ensure the correct HPN feed and equipment are arranged


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7. REFERENCES A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients. (2002) JPEN. 26 (1, Suppl), SA-138SA BAPEN 2003. The ‘MUST’ Explanatory booklet. Redditch, BAPEN www.bapen.org.uk Best C. (2005) Caring for the patient with a nasogastric tube. Nursing Standard 20, 59-65 BMJ Withholding and withdrawing life-prolonging medical treatment: guidance for decision making. BMA London, 2nd edition, 2001 British Geriatric Society, (2009) Revised Bukholm G, Tannaes T, Kjelsberg AB, Smith-Erichsen N. (2002). An outbreak of multidrug-resistant Pseudomonas aeruginosa associated with increased risk of patient death in an intensive care unit. Infection Control & Hospital Epidemiology 23, 441-446 Colagiovanni L (1999) Taking the tube Nursing Times 95, (21), 63-4 Duthorn L, Steinberg H, Hauser H, Neeser G, Pracki P (1998). Accidental intravascular placement of a feeding tube. Anesthesiology 89 (1); 251-253 Finucane TE, Bynum JPW. (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 1996; 348, 1421-24 FOOD Trial Collaboration (2005) Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multi-centred randomised controlled trial. Lancet 365, 764 – 772 Gariballa, S (2000). Nutritional factors in stroke. B J Nutr 84, 5-17 Gillick M. (2000) Rethinking the role of tube feeding in patients with advanced dementia. N Eng J Med 342, 206-210 Gregory C (2006). Drug and enteral feed interactions. Journal of Human Nutrition and Dietetics 19, 237-239 Griffith R. (2003). Tablet crushing and the law. The Pharmaceutical Journal 271, 90-91 Hughes J. Robinson L., Volicer L. (2005) Specialist palliative care in dementia. BMJ 330 57 –8 Guidelines Network Management of patients with dementia. http://www.sign.ac.uk/pdf/sign86.pdf

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Kannan S Morrow B Furness G (1999) Tension pneumothorax and pneumomediastinum after nasogastric tube insertion Anaesthesia 54 (10) 1012-1013 Lennard-Jones J. (1999) Giving or withholding fluid and nutrients: ethical and legal aspects. J R Coll Physicians Lond 33, 39-45 Lourenco R. (2001). Enteral feeding: drug/nutrient interaction. Clinical Nutrition 60, 187-193 McClave SA. Chang WK. Dhaliwal R. Heyland DK. (2006) Nutrition support in acute pancreatitis: a systematic review of the literature. 30(2):143-56 Madigan SM., Courtney DE, Macauley D. (2002). The solution was the problem. Clin Nutr 21(6), 531-532 Metheny N (1988) Measures taken to test placement of nasogastric and nasointestinal feeding tubes: A review. Metheny N (2002) Inadvertent intracranial nasogastric tube placement American Journal of Nursing 102 (8), 25-27 Metheny NA, Stewart J, Nuetzel G, Oliver D and Clouse RE. (2005). Effect of feeding-tube properties on residual volume measurements in tube-fed patients. Journal of Parenteral and Enteral Nutrition 29, 192-197 MHRA Medicines and Healthcare products Regulatory Agency (2004). MDA/2004/ 006 – Medical devices in general and non-medical products www.mhra.gov.uk MHRA Medicines and Healthcare products Regulatory Agency (2006). DB2006 (04) – Single-use Medical Devices: Implications and Consequences of Reuse. www.mhra.gov.uk Mitchell S., Buchanan J., Littlehale S., Hamel M. (2004) Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. JAMDA 5(2) S23 – 29 Mitchell S., Berkowitz R., Lawson F., Lipsitz L. (2000) A cross-national survey of tube-feeding decisions in cognitively impaired older persons. J Am Geriatr Soc 48, 391-397 National Patient Safety Agency (2006). Patient Safety Alert: Preventing Wrong Route Errors with Oral/Enteral Medicines, Feeds and Flushes www.saferhealthcare.org.uk Neumann M J, Meyer C T, Dutton JL, Smith R (1995) Hold that x-ray: aspirate pH and auscultation prove enteral tube placement, Journal of Clinical Gastroenterology 20 (4) 293-295. Newton M, Burnham WR and Kamm MA. (2000). Morbidity, mortality, and risk factors for oesophagitis in hospital inpatients. Journal of Clinical Gastroenterology 30, 264-269

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NHS HIS (2014). NHS Healthcare Improvement Scotland. Food, fluid and nutritional care in hospitals; clinical standards. Edinburgh: NHS Quality Improvement Scotland. (ISBN 1-84404-194-8) http://www.healthcareimprovementscotland.org/our_work/patient_safety/improving_nutritional_care/nutritional_care_standards.aspx NHS HIS (2015) NHS Healthcare Improvement Scotland. Complex Nutritional Care Standards http://www.healthcareimprovementscotland.org/our_work/patient_safety/improving_nutritional_care/complex_nutrition_standards.aspx NHS Tayside (2019) Infection Prevention & Control Policy NHS Tayside (2018) Informed Consent Policy NHS Tayside (2015) Safe & Secure Handling of Medicines Guidance NICE (2003) Section 4 – Enteral Feeding: Guidelines for preventing healthcare-associated infections during enteral feeding in primary and community care in Prevention of healthcare-associated infections in primary and community care NICE (2017). Nutrition support in adults: oral nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition www.nice.org.uk NNNG (2017) Good Practice Guideline – Safe Insertion of a Retaining Device for Nasogastric (NG) and Nasojejunal (NJ) Feeding Tubes (in Adults) www.nnng.org.uk NNNG (2016) Safe Insertion and ongoing care of nasogastric feeding tubes in adults NPSA (2005) National Patient Safety Agency: Reducing harm caused by the misplacement of nasogastric feeding tubes; Patient Safety Alert 05; Feb. 05 Available online at: www.nrls.npsa.nhs.uk/resources/?EntryId45=59794 NPSA (2011) Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants March 2011 Available online at: www.nrls.npsa.nhs.uk/resources/ NPSA RRR 0101 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 Nursing Research 37 (6) 324-329 Nursing & Midwifery Council. (2015) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates https://www.nmc.org.uk/standards/code/ Olah A, Pardavi G, Belagyi T, Nagy A, Issekutz A and Mohamed GE. (2002). Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition. 18, 259-262 Pofahl WE and Ringold F. (1999). Management of early dislodgement of percutaneous endoscopic gastrostomy tubes. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 9, 253-256

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Rabeneck L, McCullough LB, Wray NP. (1997). Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 349; 496-98 Reising DL. Neal RS. (2005) Enteral Tube Flushing: What you think are the best practices may not be. American Journal of Nursing 3, 58-63 Royal College of Physicians and British Society of Gastroenterology. Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life. London: Royal College of Physicians, 2010 Sacks AD (1993) Intracranial placement of a nasogastric tube after complex craniofacial trauma. Ear Nose and Throat Journal 72(12); 800-2 Sanders D., Anderson A., Bardhan K. (2004) Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia .Clinical Medicine 4 (3) 235 – 41 SIGN 119 (2010) Management of patients with stroke: identification and management of Dysphagia http://sign.ac.uk/po4/sign119.pdf Stroud M, Duncan H and Nightingale J. (2003). Guidelines for enteral feeding in adult hospital patients. Gut 52 (Supply VII): vii1-vii12 Van dem Bemt PMLA, Cusell MBI, Overbeeke PW, Trommelen M, Van Dooren D, Ophorst, WR and Egberts ACG. (2006). Quality improvement of oral medication administration in patients with enteral feeding tubes. Quality & Safety in Health Care 15, 44-47 White R. (2007). NPSA Guidance on Wrong Route Errors: Implications doze drug administration via enteral feeding tubes. Complete Nutrition 7, 21-23 Wright D (2003). Swallowing difficulties protocol: Achieving best practice in medication administration. Nursing Standards 17, 14-15, 43-45 Indian J Crit Care Med. 2015 May; 19(5): 270–274. doi: 10.4103/0972-5229.156473 PMCID: PMC4430745 Metabolic acidosis during parenteral nutrition: Pathophysiological mechanisms Evangelia Dounousi, Xanthi Zikou, Vasilis Koulouras, and Kostas Katopodis Tietz Fundamentals of Clinical Chemistry A rise in plasma creatinine that is not a sign of renal failure: which drugs can be responsible? E. Andreev, M. Koopman, L. Arisz. First published: September 1999 Abnormal liver function tests in the parenteral nutrition fed patient. S M Gabe, A Culkin Management of Hyperglycemia During Enteral and Parenteral Nutrition Therapy. Aidar R. Gosmanov. Curr Diab Rep. 2013 February ; 13(1): 155–162 doi:10.1007/s11892-012-0335-y

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Marshall’s Textbook of Clinical Chemistry Clinical Laboratory Medicine for mental health professionals http://www.gov.scot/Resource/0038/00386785.pdf http://www.nhstaysideadtc.scot.nhs.uk/TAPG%20html/pdf%20docs/Management%20of%20Vitamin%20D%20deficiency%20in%20Adults%20Dec%2012.pdf

http://www.gov.scot/Resource/0038/00386785.pdf



clinical food, fluid and nutritional care policy (adults)

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