Enteral Nutrition

Continuing Education

FROM: http://patients.gi.org/

Enteral Routes

Objectives: o Understand indications for HENo Identify enteral routes and use o Identify factors needing consideration when evaluating

patient for home enteral nutrition

Home Enteral Nutrition

61 y/o patient Dx dysphagia due to CVA 32 y/o patient with Pancreatitis 45 y/o patient undergoing chemo/radiation tx for

Ca Esophagus 45 y/o patient with Diabetic Gastroparesis- 41 yr old Dx Tongue Ca- 4 week old Dx s/p cardiac surgery

Snapshot of the home enteral patient

population

What is Home Enteral Nutrition ?

Home enteral nutrition is a life-sustaining or supportive nutrition therapy for those patients who are unable to consume adequate oral nutrition on their own

Duration of therapy: short term or lifetime

Factors to consider when evaluating a patient for enteral

feeding Identify the goal of therapy GI tract must be useable in whole or part (think about

digestion; absorption; obstruction) Enteral feeding can be a total or adjunctive feeding Patient choice especially in terminal conditions Readiness and cognitive ability/emotional state Physical limitations Evaluate the home environment /sanitation/water

source/refrigeration/electricity Cultural/religious issues Lifestyle needs of patient and caregiver needs schedules Cost/ insurance Neighborhood safety

 

Indications for Home Enteral Feeding / Candidates

HEN should be considered for those patients who cannot meet their nutritional needs by oral diet and can manage the therapy at home.o Examples:

• Patients unsafe for oral nutrition; NPO; Dysphagia • Anorexia; nausea, vomiting • Chronic debilitating disease; • Hypermetabolic with needs beyond oral intake;• Total or adjunctive feeding

*** Clinical indicators that warrant the use of HEN are significantly greater than those which are covered by insurance

Nasogastric Nasoduodenal Percutaneous

Endoscopic Gastrostomy (PEG)

Open gastrostomy Transgastric

jejunostomy Jejunostomy MICKEY/MINI One

buttons

Types of feeding tubes

Short Term Access Tubes

Anticipated need for enteral feeding < 6 weeks o 1. Nasogastric

• Easy to place at bedside • Use small flexible tubes to avoid nasal skin erosion. • Check position. Utilize aspiration precautions • Keep HOB elevated with standard aspiration precautions /check

residualso 2. Nasojejunal

• Used for patients who do not tolerate gastric feeds or patients with known abnormality of gastric emptying. /based on diagnosis

• Placed in Interventional radiology; o 3. ORO-gastric/Jejunal :

• Used with nasal obstruction or severe facial fractures o 4. TEP: Tracheoesophageal puncture

• Frequently used in Head and Neck Ca • Usually placed at time of surgery for head and neck cancer

Long Term Access > 6 weeks

1. Percutaneous Gastrostomy Tubes (PEG) o Can be placed with endoscopic or radiographic guidance. o Often placed during surgery in combination with another

procedure o Post-placement may start enteral feeds between 4 and 24

hours. o Tube is secured to skin by outer flange to prevent tube

migration. Can check for residuals 2. Surgical Gastrostomy

o These are usually performed during surgery for another condition

o The stomach is tacked to the abdominal wall with sutures o Can check residuals for tolerance

Long Term Access > 6 weeks

3. Transgastric Jejunostomy G/J o These tubes can be placed surgically, or with endoscopic

or radiographic guidance. o May contain a second port for gastric aspiration. o Cannot monitor residuals to determine tolerance. o Post placement care is same as PEG.

4. Surgical Jejunostomy o Tubes are placed in the proximal jejunum.o Placed either via a laparoscopic or open approach o The jejunum is tacked to the abdominal wall with sutures

and an external suture is usually placed around the tube to prevent it from being dislodged.

Enteral Tube Flushing

Care of the tube site: o Generally Wash with warm soapy water

FLUSHING FEEDING TUBES: lukewarm tap water o Tubes should be marked at the skin entrance to allow

monitoring for migration of the tube. o Before and after each intermittent feedingo Before and after giving any medicine through the tubeo Every four to six hours if feeding is continuouso Whenever feeding is interrupted o When tubes not being used for enteral feeds, flush with

30cc (water every 4 hrs to ensure patency.

Discharge Planning

Inpatient Discharge coordinators o inpatient education / reviews with patient choices

Contacts DME o Validate insurance/options for payment o Review prescription, ordering, proper storage and hang

time with pt.

Discharge Planning

DME - Durable Medical Equipment RD Role: review prescription with pt

demographics/dx: o is it appropriate? o cost effective ? o is it suitable to goal? o Is it realistic in the home environment?

IF Enteral feeding is not covered by insurance options? …… Communicate with inpatient RDs

Medicare Enteral Coverage

Coverage of NUTRITIONAL THERAPY is a Part B benefit under the prosthetic device benefit provision o Permanent* nonfunctional disease of the structures that

normally permit food to reach the small bowel

ORo Disease of the small bowel which impairs digestion and

absorption of an oral diet, Either of which requires tube feedings to provide

sufficient nutrients to maintain weight and strength commensurate with the patients overall health status.

Permanence – 90 DAYS. 

Medicare Criteria continued

Calorie Levels: 25-35 cal kg Formula Selection: must be a standard polymeric formula

Route of administration: Pump, Gravity, or Syringe

Pump:only covered under specific circumstances for example:

bolus via syringe or gravity feeding is contraindicated documented aspiration; glycemic control, dumping

syndrome,slow infusion; jejunostomy tube used for feeding.  Gravity feeding – Bolus feeding-

Area Insurance

Examples: o UPMC

o GATEWAY

o Health America

o Highmark

1. Clogged tubes o Prevention and care of tube is the BEST way manage it o cost of radiographic replacement @ $1,000.00 o Causes of clogged tubes:

• a. Improper flushing of tubes. • b. Caloric dense formulations. • c. Small bore feeding tubes. • d. Medications that are not properly crushed.

o Bulk forming medications (Psyllium); never add to formula. o Encourage patient to work with the Pharmacists to transition

meds to liquid form o Give medications singularly

2. Dehydration/constipationo check formula concentration/free water; narcotic use;

Most common complications HEN:

Most common complications HEN, Cont.

3. Nausea/Vomiting o check where tube is located; consider lower rate?; elevate hob; consider formula

w/o fiber

4. Diarrhea o check meds for sorbitol; o use soluble fiber; o check use of stool softeners; o check rate; o concentration of formula; o may need predigested formula;? o Fat content check stool culture before using immodium;

5. Equipment malfunction

6. Weight loss (lack of follow up with RD/MD; disease process/ financial impact)

National Resources: Oley Foundation – The Oley Foundation is a national, independent, non-profit organization that provides information and social support to consumers and practitioners of home parenteral and enteral nutrition.. – www.oley.org   ASPEN –

American Society for Parenteral and Enteral Nutrition – ASPEN is a national organization composed of nutrition professionals including physicians, nurses, pharmacists, dietitians and members of industry who are dedicated to improve patient care by advancing the science and practice of clinical nutrition. – www.nutritioncare.org

American Cancer Society. www.cancer.org.  References : Mueller PhD,Charles (ed):The A.S.P.E.N. Nutrition Support Core Curriculum.ASPEN,Silver

Springs,MD.2012. www.nutirtioncare.org Fisher C, Blalock B. Clogged Feeding Tubes: A Clinician’s Thorn Practical. Gastroenterology. MARCH

2014 Newton A, Barnadas, G. Understanding Medicare Coverage for Home Enteral Nutrition. Practical

Gastroenterology. May 2013 Enteral Nutrition, criteria, documentation requirements, coding, coverage and payment rules may

be found on the NHIC web site: http://www.medicarenhic.com Ref. DME MAC LCD for Enteral Nutrition(L5041) Ref. Local Coverage Article for Enteral Nutrition – Policy Enteral Nutrition: L11568 & A25361

https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/enteral_nutrition.htm Mclave S, Martindale R. etal. ASPEN Clinical Guidelines for the Use of Parenteral and Enteral

Nutrition in Adult and Pediatric Patients JPEN May-June2009;33:255259 http://pen.sagepub.com/content/33/3/255.full

National Resources and References