enteral access and tube feeding administration

Enteral Access and Tube Feeding

AdministrationMichele Port, P.Dt.

Clinical DietitianMarch 2014

Outline➢ Selection of the appropriate enteral access device➢ Short-term enteral feeding tubes➢ Long-term enteral feeding tubes➢ Delivery systems: Open vs Closed➢ Administration➢ Case Study➢ Monitoring and Documentation

Learning ObjectivesAt the end of this presentation, the participant will be able:

Determine the appropriate type of enteral access / device when assessing patients.

Understand the importance of a tube feeding protocol in advancing a tube feeding to maintenance and managing complications.

Inform medical team on appropriate method for medication administration via feeding tubes.

Selection of the Appropriate Enteral Access Device

➢ Factors to consider:○ Functional and accessible gastrointestinal tract

■ Normal digestion and absorption■ No gastric outlet obstruction■ No intestinal stricture■ Gastric motility

➢ Expected length of time enteral feeds required○ Short-term (< 4 weeks)

■ Orogastric (intubated patients only)■ Nasoenteric (nasogastric, nasoduodenal, nasojejunal)

○ Long-term (> 4 weeks)■ Gastrostomy■ Jejunostomy

➢ Aspiration risk?○ Gastric vs small bowel access

➢ Surgical intervention planned?○ Tube could be placed during surgery (ex.: jejunostomy)

➢ Patient and family preferences / activity➢ Pre-existing medical conditions such coagulopathy or ascites➢ Plan for discharge

○ Often rehab and long-term care facilities will only accept: Percutaneous endoscopic gastrostomy (PEG) Jejunostomy

Selection of the Appropriate Enteral Access Device

Short-Term Enteral Feeding Tubes (< 4 weeks)

Short-term use in hospitalized patients : nasogastric,nasoduodenal,nasojejunal

Pediatric IBD patients may use these tubes at home➢ Insertion route

○ Oral: in ICU post-op only with patient sedated○ Nasal: Preferred route

➢ Access○ Nasogastric

■ Able to feed larger volumes■ Large bore PVC tubes (14-18 Fr.) may be used initially but

should be changed to softer more flexible tubes● PVC tubes may cause nose irritation, gastric and

esophageal erosions■ Not preferred access in hospitalized patients due to

aspiration risk■ Confirm correct feeding tube position radiographically

➢ Nasoduodenal or nasojejunal○ Nasoduodenal (distal to pylorus)○ Nasojejunal (distal to ligament of Treitz in jejunum)○ Used when problems with delayed gastric emptying, aspiration

risk, early post-op feeding (liver transplant patients malnourished pre-op)

○ More commonly used in non-ICU hospitalized patients

➢ Contraindications○ Obstruction head, neck, esophagus or gastric outlet obstruction


➢ Tubes : nasoduodenal or nasojejunal○ Polyurethane or Silicone

■ Most nasoenteric tubes are made of polyurethane

○ Length■ Varies: usually 36” (91 cm) to 60” (152 cm)

○ Size■ Measured by external diameter in French size (Fr.)■ Usually 8-12 French in adults■ 10-12 Fr. commonly used due to problems with tube clogging

with meds


➢ Tubes : nasoduodenal or nasojejunal○ Stylet or guidewire

■ Provided for guiding tube insertion■ Water-activated lubricant coats the inner surface of tube,

needs to syringe 5-10 mL into tube before removing guidewire

■ Guidewire must never be reinserted, could cause perforation

○ Other■ Tips: vary, end holes, side holes, no particular advantage■ Weighted vs Unweighted tip: No advantage■ Feeding connector: Y port


➢ Insertion : nasoduodenal or nasojejunal○ Bedside: MD, nurse, dietitian (in certain Canadian provinces

when certified)■ Prokinetic agent (maxeran or erythromycin) may facilitate

passage into small bowel○ Endoscopic

■ Often tube displaced when scope removed○ Fluoroscopically guided

■ Need to go to radiology if portable not available■ Used when bedside insertion unsucessful

○ Surgically-placed■ Often done in ENT cancer surgeries and GI surgeries where

patient expected to be NPO > 1 week, malnourished pre-op, expected gastroparesis


➢ Tube position – check:○ All nasogastric and nasoenteric tubes needs radiographic verification before use○ With a permanent marker, mark nasal exit site○ Secure tube with tape to nose


➢ Complications: nasoenteric○ Insertion

■ Epistaxis■ Respiratory compromise during tube insertion■ Misplacement of tube in bronchopulmonary tree, often

results in pneumothorax ○ Other

■ Tube dislodgement● Inadvertent● Patient pulls it out

■ Tube occlusion: Often due to medications■ Tube malfunction: Kinking■ Aspiration

Short-Term Enteral Feeding Tubes (> 4 weeks)

Long-Term Enteral Feeding Tubes (> 4 weeks)

Google imagehttp://pedsurg.ucsf.edu/conditions--procedures/gastrostomy-

tubes.aspx

➢ Placement techniques○ Surgically: open gastrostomy, jejunostomy○ Endoscopically (sedation, local anesthetic)

■ Percutaneous endoscopic gastrostomy (PEG)■ Percutaneous transgastric jejunostomy (PEG/J)

○ Radiologically ■ Radiologically inserted gastrostomy■ Radiologically inserted transgastric jejunostomy■ Radiologically inserted jejunostomy – rarely done at my

center.


➢ Size○ Gastrostomies: usually 18-28 Fr., average 22 French○ Jejunostomies: 8-14 Fr.

➢ Internal and external bolster or bumper (silicone or polyurethane) and/or balloon (silicone) of PEG

○ Balloons have lifespan of 3-4 months➢ Ports

○ Usually a port for feeding and a port for medication○ PEG/J: Percutaneous endoscopic gastrostomy with jejunal

extension■ 3 ports:

● Bal. = Balloon● Jejunal = Feed● Gastric


➢ Peristomal Care○ Clean area with mild soap and water○ Dressings are not needed unless there is drainage at site

➢ Complications○ Aspiration during procedure○ Hemorrhage○ Peritonitis○ Pneumoperitoneum○ Peristomal infection○ Accidental tube removal

■ If stoma tract mature put foley in to keep open until tube replaced

○ Buried bumper syndrome: Gastric mucosa grows over internal bumper

○ Clogging


➢ Replacement as per manufacturer’s recommendation and hospital policy

➢ Removal of PEG○ Only after tract has matured, after 4 weeks○ If on steroids, after 6 weeks

➢ Some contraindications to PEG○ Ascites○ Extensive gastric ulceration○ Gastric varices○ Coagulopathy○ Morbid obesity


➢ Practice recommendations for long-term enteral device placement include:

○ Document tube type, tip location and external markings in medical record and on follow-up

○ Avoid placement of catheters or tubes not intended for use as feeding devices such as foleys

○ Evaluation by multidisciplinary team prior to insertion of long-term feeding device


Delivery Systems: Open vs. Closed

OPEN feeding system

CLOSED feeding system

Google imageswww.dhphomedelivery.com

www.berktree.comwww.abbott.ca

http://www.dhphomedelivery.com/

http://www.berktree.com/

Nursing practice for monitoring of enteral feedingCare of Open Feeding System1. Use disposable gloves during the administration of TF.2. Label each container with patient’s name, date, time of first use, and

formula’s name.3. Wipe top of formula container with damp paper towel before opening.4. Do not add anything to the container other than the formula.5. Fill container with maximum of 4 hours of the feeding formula.6. Rinse container and tube well q 4 hours with water for continuous

feedings or after each intermittent feedings.7. Change administration sets for open tube feeds every 24 hours.

8. Discard any opened or mixed formula after 24 hours.9. Store unopened commercial liquid tube feeding (TF) formulas under

controlled (dark, dry, cool) conditions.

Care of Closed Feeding System1. Use disposable gloves during the administration of TF.2. Label container along with patient’s name, date, and time when

container was spiked.3. Shake feeding bag well for 10 seconds when starting, then every 4

hours.4. Do not add anything to the container.5. Closed-system TF formulas can hang for 48 hours as per

manufacturer’s guidelines.6. Change administration set each time formula container is changed.7. Discard any unused formulas and spike set after 48 hours.8. Refer to product information sheet for further detail.9. Store unopened commercial liquid tube feeding (TF) formulas under

controlled (dark, dry, cool) conditions.

Nursing practice for monitoring of enteral feeding

Choice of system:oProduct availabilityoPreference of patient and family

Nursing practice for monitoring of enteral feeding

Administration3 METHODS

Continuous drip

Feeds run continuously with a pump either X 24 hr or for a specified # of hours, such as 06h00-22h00 or 06h00-24h00Necessary when have small bowel accessGenerally best tolerated especially in patients with GI disordersRate of advancement of feeds depends on whether patient fed recently or not and medical condition

Intermittent

In adults, usually 3-6 feedings per dayAdministered over 20-60 minutes Initiate feeds at 150mL-200mL per feeding and increase as toleratedPump or gravity method may be used

Bolus

Formulas delivered via syringe over 5-20 minutesNot used in hospitals and generally not recommended unless pump failsCan result in bloating, abdominal discomfortUsed in clinically stable patients

Protocol for Enterally

FedPatients

Adult Gastric Residual Monitoring Algorithm

Clinical Nutrition Services – Adult Sites

Evaluate all gastrically fed patients for risk of aspiration (NG or PEG).

Confirm feeding tube is in proper position before initiating feeds.

Measure gastric residual volumes (GRV) q 4h for first 48h. (Use at least a 60 cc syringe)

Elevate head of bed (HOB) 30 -45 at all times during feeding unless contraindicated.

Discard aspirate. Hold feeds. Inform MD and Clinical Dietitian. Proceed as per MD assessment.

In absence of any signs of intolerance: Re-instill 250 mL gastric

residual contents (GRC) Resume feeds at currently

tolerated rate

Re-instill gastric residual contents (GRC). Continue or increase feed as per protocol.

Enteral feeding goal rate achieved: In non-critically ill, continue to monitor GRV's q 8h and discontinue after 48 hours if no signs of intolerance. In critically ill, continue to monitor GRV's q 4h

In presence of any signs of intolerance: Re-instill 250 mL of GRC Inform MD and Clinical Dietitian Consider replacing with small bowel

feedings and/or initiating use of prokinetic agent

If GRV: 250 mL

If GRV between 250 - 500 mL

If GRV: 500 mL

Initiation and

Monitoring of Enteral Feeding

PUMPS

Pumps needs to be calibrated periodically to assess accuracy. Small, portable with battery for 4-8 hours Pumps in back-pack for home use Feed and flush pumps

oWill automatically flush tube as programmedoQuantify feeding provided

Administration

Positioning: o Important to GER and possible aspiration

Practice recommendations:o HOB to a minimum of 30⁰ (preferably 45⁰), for all patients on

EN, unless medically contraindicatedo Use reverse trendelenberg position if HOB can't be elevated,

unless medically contraindicatedo If head of bed must be lowered for a procedure, return patient to

elevated HOB position Bankhead et al. JPEN 2009, Boullata, J et al. eds. A.S.P.E.N. Enteral Nutrition handbook. ASPEN 2010

Water flushesoFor hydration and cleaning of tube oUse sterile water in immunocompromised and critically ill

Medication administration

Administration

Oral HygieneoPoor oral / dental hygiene can increase bacteria in oral

secretions risk for aspiration pneumoniaoNeed tooth brushing / mouth wash twice per day

Administration

Administration of Medications1. Use oral route if safe / possible.2. Check with pharmacy if uncertain which medications can be delivered

by tube and/or the appropriate delivery method. 3. Never add medication directly to an enteral feeding formula.4. Never mix medications together (to avoid chemical incompatibilities,

tube obstruction…) 5. Dilute medications appropriately prior to administration:

oUse liquid forms when available. oGrind simple compressed tablets to a fine powder and mix with

30 mL water. oDilute viscous liquids with 15-30 mL water and concentrated

liquids with 30-60 mL water. oDo not crush slow release tablets or enteric coated tablets. oOpen hard gelatin capsules and mix contents with water.

Administration of Medications6. Prior to administering medication, stop feeding and flush the tube

with 30 mL water.

7. Administer each medication separately and flush the tube with at least 30 mL of water after each medication.

8. Use sterile water for immunocompromised patients.

9. Start with liquid medications, followed by those that have been diluted. Keep viscous medications until the end.

10.Rinse the tube one final time with 30 mL water.

11.Record the volume of water given on the input/output sheets.

12.In the case of continuous feeding, resume formula administration immediately unless contraindicated as in the case of drug-nutrient interaction.

Drug nutrient interactions Many possible drug - nutrient interactions.Drug Solution

PhenytoinHold EN formula 1-2hr before and after administration of diluted suspensionMonitor levels

CarbamazepineIf jejunal feedings, hold EN formula 2hrs before and after drug administration of diluted suspension (1:1)

Warfarin (Interaction between wafarin and Vitamin K)

Hold the EN formaula 1hr before and after warfarin dose

Fluoroquinolines (Ciprofloxacin, Levofloxacin)Forms complexes with divalent cations i.e.: Ca

Holds feeds 1hr before and 2hr after drug Boulatta et al.

2010

Administration

Enteral feeding protocol After nutrition assessment, caloric and protein requirements are

calculated. If Na, K, phosphorus or fluid is limited i.e.: in case of dialysis patients

this must also be taken in consideration.Case study43 yo male, unwell x 1 week, admitted with PCP pneumonia. Intubated and ventilated. Had renal transplant in 2005. Has AKI on CKD. Patient will be intermittently hemodialyzed.

Urine output 300mL/day. K=5.1, Phos=1.80, Cr=300 Height: 170cm IBW: 67 Minute ventilation = 12 Weight: 67kg BMI: 23 Tmax = 37.8C

Calorie Requirement: Mifflin formula: 10 (67) + 6.25 (170) - 5 (43) + 5 = 1523 Penn State (Mifflin): 1523 (.96) + 12 (31) + 37.8 (167) - 6212 = 1935

Protein Requirement: 67 X 1.2 = 80 Na: 80mmoL; K: less than 60mmoL; Phos: 800-1000mg; Fluid: Output plus 500-700mL = 1000mL

Due to the K, phosphorus and fluid limitation, there are very few formulas to meet our requirements. Nepro would be the formula of choice. Required Kcal/day = 1935 Kcal; Nepro provides 2 Kcal/mL; 1935 Kcal = 968mL of Nepro 2 Kcal/mL 960mL Nepro provides: 78g protein; 26 mmoL K; 670mg phosphorus; 696mL water Patient needs 1000mL fluid: 1000mL-696mL (in formula) = 304mL

1. Following tube placement verification by x-ray, mark exit point of tube.2. Confirm HOB elevation at 30o – 45o, unless medically contraindicated.3. Observe and document any signs of intolerance such as abdominal

distension, firmness, discomfort, nausea, vomiting, or diarrhea. Notify and consult the Clinical Dietitian and MD of any of these feeding intolerances and interruptions.

4. Ensure adequate mouth care.5. Document GRV for gastrically fed patients in progress notes.6. Verify placement of feeding tube q 8 hours, prn.7. Weigh patient on day 1 of tube feeding, then every 1-7 day(s). Enter data

in OACIS.8. Document volume delivered for each tube flush.9. Document the volume of formula delivered each shift including the volume

of any modular product also delivered (ex., protein powder) if needed.

Monitoring and Documentation of Enteral Feeding Administration

Possible causes include inadequate tube irrigation, administering improperly crushed medication, intraluminal accumulation of formula residue, solidification of formula, medication residue. To prevent feeding tube blockage:

1. Immediately flush the feeding tube with a minimum of 30 mL of water after each feeding, after administration of each medication, after any interruption in feeding.

2. Shake the enteral feeding container before hanging for 10 seconds.3. Shake formula every 4 hours (i.e. when flushing the tubing).4. Change the feeding bag and tubing used for enteral feeding every 24 hr for

the open system and every 48 hr for the closed system.5. Use liquid formulations of medications whenever possible.6. Unless contraindicated, crush solid medications thoroughly.7. Use a syringe (60 mL) filled with 30 ml water to flush the tube before and

after administering medications. Replace syringe every 24 hours.8. Rinse using 30 ml water after measuring gastric residual volume.9. Use a feeding pump.

Preventing Feeding Tube Blockage

Possible Causes:o Inadequate irrigation of tube.o Administration of improperly crushed medication, intraluminal

accumulation of formula residue, solidification of formula or medication residue because of drug/nutrient interaction.

o Improperly dissolved enteral formula due to poor mixing technique

Unblocking of Obstructed Feeding Tubes

Prevention:oImmediately flush the feeding tube with a minimum of 30 mL

of water after each feeding, after administration of each medication, after any interruption in feeding.

oShake the enteral feeding container before hanging for 10 seconds.

oShake formula regularly (i.e. every 8 hours or when flushing the tubing).

oChange the feeding bag and tubing used for enteral feeding every 24 hr for the open system and every 48 hr for the closed system.

oUse liquid formulations of medications whenever possible.oUnless contradicted, crush solid medications thoroughly.oUse a syringe (60 mL) filled with 30 ml water to flush the

tube before and after administering medications. Replace syringe very 24 hours.

oRinse using 30 mL of water after measuring gastric residual volume.

oUse a feeding pump equipped with a flush feature. Schedule flushes q 4h.


Treatment as per MD’s orders. In order to restore tube patency, first flush with warm water. If this is ineffective:

oDissolve one 500 mg crushed tablet of sodium bicarbonate in 5-10 mL sterile water (this will take about 3-5 minutes).

oOnce dissolved, mix contents of 1 opened capsule of pancreatic enzyme, Cotazym ECS20, into the sodium bicarbonate / water mix, allow to dissolve 5 minutes, the mixture should turn a light brown color.

oSuspend mixture by adding 15 mL of warm water.oIntroduce the pancreatic enzyme solution into the feeding

tube while gently massaging the tube.oClamp the tube and leave the pancreatic enzyme solution in

the tube for 30 minutes before flushing the tube. Repeat the above once if necessary. Contact MD in event of failure.


NEVER USE Cranberry juice or carbonated beverages such as cola as their acidity may aggravate the blockage.

NEVER try to restore patency of a feeding tube by reinserting the stylet because of the risk of intestinal perforation.


Monitoring Monitoring and documentation of enteral feed administration

(nurse, dietitian) Monitoring by team to prevent and correct complications Adequacy of nutritional intake Physical assessment ex.: check for edema GI tolerance:

oStool frequency / consistencyoOstomy outputoAbdominal distension / painoNausea and vomitingoResidual volumes: look for changeoGlycemic control

Fluid intake and output Weight (1 x per week): look at trend Lab data Markers of nutrition adequacy if applicable (include CRP) Review medications Medical procedures which require discontinuation of feeding

Monitoring

ConclusionThere are many enteral access devices to choose from. It is important to

communicate

to the patient and family (if possible) why you recommend a specific device

i.e: PEG vs PEG/J.

The best way to ensure enteral feeding safety is to implement enteral nutrition

practice guidelines such as those from ASPEN or ESPEN, educate all staff and then

audit to see if those guidelines are being followed.

ReferencesBankhead R, Fang J. Enteral Access Devices. In Gottschlich P, ed. in chief.

The A.S.P.E.N. Nutrition Support Core Curriculum, Silver Spring, MD. 2007; 233-245.

Bankhead R, Boullatta J, Brantley S, et al and the A.S.P.E.N. Board of Directors, Enteral nutrition practice recommendations. JPEN 2009; 33; 122-167.

Boullata J, Nieman Carney L, Guenter P, eds. A.S.P.E.N. Enteral Nutrition Henadbook. Silver Spring, MD. A.S.P.E.N. 2010.

Shroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients Gut 2003; 52 (Suppl VII); vii1-vii12.

MUHC Adult Sites. Interprofessional Professional protocol for the initiation and monitoring of enteral feedings. 2013

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