The plan for today

Nutrition Support: Enteral tube feeding

0900-1045hrs Enteral lecture (Gwen) 1050-1210hrs Enteral workshops/tutorials (4 x 20 min) (Gwen, Jen S, Katrina, Michelle) 1215-1315hrs Lunch break

Gwen Hickey Clinical Dietitian Royal North Shore Hospital

1315-1440hrs Parenteral lecture (Chris) 1440-1600hrs Parenteral workshop/tutorials (4 x 20 min) (Chris, Gwen, Jen S, Kath A)

Enteral Feeding

Learning Outcomes 

   

Describe the disease states likely to necessitate the provision of enteral feeding Describe the delivery systems for enteral nutrition Describe the types of enteral nutrition formulae and plan a feeding regimen Understand the management of PEG, NGT, and NJT Describe and understand re-feeding syndrome and its management

Overview 



   

Revise physiology of the GI tract and digestion Route and site of delivery for enteral feeding Methods of enteral feeding Types of enteral formula Trouble Shooting Re-feeding Syndrome

What is ‘enteral feeding’? 



Enteral feeding literally means using the gastrointestinal tract for the delivery of nutrients, which includes eating food, consuming oral supplements and all types of tube feeding. Generally, however, the term enteral feeding is used to describe enteral tube feeding.

If remains inadequate

1

Who needs enteral tube feeding?

Contraindications to enteral tube feeding



Unconscious, semi-conscious eg ICU



Dysphagia/swallowing difficulty eg stroke, head injury



Non-functioning gut eg ileus gastrointestinal obstruction Gut ischaemia



High requirements eg burns, trauma



High output fistula



Inadequate intake eg anorexia, poor appetite

Revision of Digestion



What does it look like?

What does it look like?

2

What types are there?

What types are there?

Tube position- shorter term

Nasogastric/orogastric tubeshow do we insert them?



Nasogastric (NG) - most common - fine bore or wide bore

Nasogastric/orogastric tubeshow do we insert them? 





Measure the distance on the tube from the patient's ear to the tip of the nose, to the Xiphisternum Submerge the fine bore tube weight assemble in water for at least 5 seconds to activate the hydromer coating which lubricates the tube Tilt the head slightly backwards then gently pass the tube backwards and downwards into the nasopharynx along the floor of the nasal cavity

Nasogastric/orogastric tubeshow do we insert them? 

  

Tilt the head slightly forward and rotate the tube inward toward the other nostril and advance the tube Ask the patient to swallow if they can Advance tube to the pre-measured mark Non-radiological tube position confirmation (inject air and listen, gastric aspirate for pH testing)

3

Nasogastric/orogastric tubeshow do we insert them? 



The position of the naso/orogastric tube needs to be checked via a chest and upper abdominal x-ray Medical officer then confirms the position of the tube (removes the introducer/guide wire) prior to documenting permission to commence feeding

What types are there? Post-pyloric

Conditions where extreme caution is taken to insert enteral feeding tubes 







Severe facio-maxillary trauma/nasal injuries/base of skull fractures (under guidance or not at all) Post gastrectomy/oesophagectomy or post head and neck surgery (inserted in theatre) Plastics reconstruction to mouth, nose or oesophagus due to changes in anatomy (under guidance or in theatre) Oesophageal varices (under guidance)

Tube position- shorter term 

Nasojejunal/Nasoduodenal (NJ/ND) - longer tubes placed into the small bowel beyond ligament of treitz - less common, harder to place (often endoscopic or via peristalsis/migration - used in delayed gastric emptying, aspiration risk, upper GI surgery, pancreatitis

Shorter term tubes- How long can they stay in?   

Fine bore- up to 4 weeks Wide bore- change every 4 days If the same naso/orogastric tube is left insitu past these time frames it can cause nasal erosion, sinusitis, oesophagitis, gastric ulceration, oesophageal/tracheal fistula formation, oral infections and respiratory infections

Longer term feeding tubes 

Gastrostomy or jejunostomy feeding tubes

4

Longer term feeding tubesgastrostomy

Longer term feeding tubes- how do we insert them?  Percutaneous

Endoscopic Gastrostomy (PEG) placement by a gastroenterologist/surgeon   

Sedative and local anaesthetic Endoscopy via mouth and into stomach Stomach is filled with air to make it bigger and push the stomach wall closer to the abdominal wall.

PEG placement 







A needle and wire are guided through the skin and abdominal wall and into the stomach. The wire is then grasped inside the stomach with the endoscope and the wire pulled back through the mouth. A plastic tube is attached to the wire and pulled through the mouth and back along the wires path into the stomach. Tube is secured.

5

Longer term feeding tubes- how do we insert them?

Gastrostomy under fluoroscopic guidance 

2) Gastrostomy under fluoroscopic guidance   

Uses X-rays to guide placement. Stomach is filled with air. X-rays are completed to make sure nothing is in the way between the stomach and the abdominal wall.

Longer term feeding tubes- how do we insert them?

 

What do we put down the tube?

3) Open gastrostomy  

 

General anaesthetic The surgeon makes in incision into abdominal wall and through the wall of the stomach. Gastrostomy inserted and tube sewn to the abdominal wall. Incision sutured.



Formula



Water



Medications

Enteral formula What are they made from?

Enteral formula companies in Australia Abbott





Nestle (previously Novartis)





Nutricia



Pharmatel Fresenius Kabi



Sutures are placed in the stomach to bring it close to the wall of the abdomen. Local anaesthetic. Small cut is made through the abdominal wall and into the stomach. Tube inserted.

 

Milk/soy protein Vegetable fats Maltodextrin, corn syrup Added vitamins and minerals Nutrient Reference Values- aim for RDI/AI

6

Enteral formula What are the types?

Enteral formula What are the types?

Standard formula - 1kcal/mL (4.2kJ/mL)



-

Lactose free Gluten free Fibre free Polymeric Iso-osmolar (~280-300mOsm/kg H20)



Calorie dense/high energy 1.5 kcal/mL, 2kcal/mL (↑ osmolality)



With fibre ~15g/litre

Plasma osmolality is a measure of the concentration of substances such as sodium, chloride, potassium, urea, glucose, and other ions in human blood. It is calculated as the osmoles of solute per kilogram of solvent.

Enteral Feeding How is it delivered?

Enteral formula What are the types? 

Modified electrolytes (eg low sodium, reduced potassium)



Other: -

High protein Low Carbohydrate, modified fat Elemental/semi-elemental MCT oil Based High Branch Chain Amino Acid

Enteral Feeding How is it delivered? 1) Pump

(short term tube or longer term tube)

- continuous or intermittent - small regular volumes infused - rate mL/hour - overnight, jejunal feeding (usually) - reduces risk of reflux, vomiting, aspiration (due to smaller volumes) - recommended for critically ill or medically unstable patients



‘Open’ or ‘Closed’ System - Closed = Ready to hang - Open = Bottles/cans decanted

Enteral Feeding How is it delivered? 2) Bolus (via gastrostomy only, rarely jejunostomy, not short term tube)

- 60ml syringe - Infusion of formula via syringe with/without plunger - Maximum ~300mls formula per bolus (flush of ~50mls water pre/post) - Rate of administration should not exceed 30ml/min

7

Enteral Feeding How is it delivered? 3) Gravity drip - Infuses a given volume of formula on a continuous basis by the regulation of drip rate through the tubing - eg 75mL/hr is equivalent to 20 drops/min - Not precise, need to check regularly

Enteral Formulahow is it given? 



Enteral Feeding position

In hospital: - Pump - Bolus if teaching for home At home: - Bolus is cheaper - Pump (if cannot tolerate bolus volumes) - Gravity (infrequent)

Nil by tube/Nil by mouth - as per medical instruction - via endoscopy: for 4 hours post insertion



+/- Water trial



Commencement of Formula

Initial formula rate usually ~20-40ml/hr





- via surgery: up to 24 hours post insertion

Increase rate gradually as tolerated usually 10mL every 4 hours (more slowly for jejunal)

Check aspirates initially

Upper body raised above stomach level or head elevated to 45 degrees



i) the site of the tube ii) the patient 



Commencing feeding with a Gastrostomy/Jejunostomy

NG/NJ tube Dependant on

Never administer the formula lying flat (unless medically essential)

Minimises risk of nausea, vomiting, or aspiration

How to commence feeding with an 



40ml/hour for 4-6 hours (up to 24 hours) usually as a continuous regime

only possible with wide bore tube

8

Post pyloric enteral feeding considerations 

Volume delivered

Enteral Feeding Fluid 

depend on the patient’s condition

(care re Dumping Syndrome) 

Osmolality



Method of delivery

Requirements



Consider i) free water content of the formula ii) IV fluids, water with medications  

ICU: tend to control own fluid input Ward: need to specify additional fluid

Enteral Feeding Fluid 

Higher requirements       

Fever Burns Hypermetabolism Diarrhoea Vomiting Tracheostomy/suctioning High output fistulas

How to review a patient on enteral tube feeding 

Read medical record



Check blood results/biochemistry

 

Look at fluid balance chart and bowel chart Look at blood glucose level chart



Speak with nursing caring for patient



Speak with patient/family (as appropriate)  determine whether initial assessment /nutrition care plan remains appropriate

Enteral Feeding Fluid 

Lower requirements   

Renal impairment Congestive heart failure Hyponatraemia due to SIADH

Problem: Diarrhoea Loose or very frequent bowel movements May be due to:

- Medications eg antibx - Poor hygiene - Bacterial overgrowth - Impacted bowel - Infection eg C. difficile - Osmolality of formula - Fat malabsorption

What to check for:

- Medication lists - Abdo X-ray re overflow/obstruction - C difficile toxin - Osmolality of formula and location of feeding tube

Possible action:

- Fibre enriched formula may assist with bulking stool or bowel regularity - Handling/hygiene techniques - Assess risk of malabsorption - Feed formula at room temperature - Anti-diarrhoeal medication appropriate?

9

Problem: Constipation

Problem: Stomach Upset

difficult or very infrequent bowel movements

nausea, vomiting, bloating, reflux

May be due to:

-Lack of fluid - Lack of fibre - Lack of activity/exercise - Medications eg strong pain relief

May be due to:

- Total volume of formula - Rate per hour of formula -Temperature of formula - Level of activity post formula - Position of feeding

What to check for:

-

Amount of fluid Amount of fibre Amount of activity (if appropriate) Abdo X-ray to check for overflow

What to check for:

- Feeding regimen

Possible action:

Possible action:

-

Adequate fluid Adequate fibre Regular aperients/laxatives eg coloxyl Enema

- Anti-emetic or prokinetic medications eg maxalon, mylanta/ antacids. - Reduce rate of feeding/ increase energy density of formula - Deliver formula at room temperature - Remain elevated to 45 degrees for 30 mins after formula

Problem: Aspiration Aspiration Pneumonia is defined “as an inflammatory reaction to aspirated material mediated by an infectious agent” Aspiration of formula can occur without obvious evidence of vomiting, particularly in those patients with poor mental status, and absent gag reflex.

May be due to:

-

What to check for:

- Feeding regimen - Positioning

Possible action:

-

Positioning Large gastric residuals Infusion rate Reflux Tube position incorrect

Other problems Problem

What to look for?

Possible Action

Dehydration

- Adequate fluid

Increase fluid via enteral or IV, always discuss with medical team

Elevated Serum Electrolytes

Low Serum Electrolytes

Check position of person whilst feeding Check position of feeding tube Reduce volume via increased kcal formula Reposition tube distal to stomach

Re-feeding Syndrome Refers to the various metabolic complications that can arise as a result of feeding (oral, enteral, or parenteral) a malnourished patient (Brooks & Melnik, 1995)

Hyperglycaemia

-Adequate fluid - ? due to medications

- Salt wasting - SIADH - Diarrhoea

High blood glucose levels

Increase fluid if appropriate, always discuss with medical team

Low K+: needs replacement Low Na+: depends on cause, may need fluid restriction or sodium replacement May need insulin

Re-feeding Syndrome In chronically starved state:  Insulin secretion ↓ in parallel with ↓ CHO intake  Body relies on fat for energy to spare protein hence FFAs + ketones replace glucose as major energy source…  In severe starvation body stores of PO4, K+, Mg2+ are depleted (serum levels maintained)

10

Re-feeding Syndrome

Re-feeding Syndrome

Once feeding commences shift back to CHO metabolism  ↑ insulin levels  movement of PO4, K+, Mg2+ into cells  ↓ serum levels…  Tissue anabolism ↑ cell demand for PO4, glucose, K+ and water  Thiamine (required for transport of glucose) may be depleted



Re-feeding Syndrome 

Major complications: Heart failure, Wernicke’s encephalopathy, confusion, lethargy, weakness, anaemia, seizures, acute ventilatory failure, constipation, ileus, fatty liver, hyperglycaemia, sudden death

Re-feeding may lead to: - profoundly low serum concentrations of phosphorus, potassium, magnesium - thiamin deficiency - fluid balance abnormalities (fluid overload)

Patients at Risk  

   

Severely underweight Severe recent weight loss (loss of >10% within 3 months) Chronic malnutrition or underfeeding Anorexia nervosa IV hydration only for a number of days Alcohol dependence (Solomon and Kirby 1989)

Acute factors that compound risk of refeeding

Chronic factors that compound risk of refeeding



Severe vomiting



Thiazide diuretics



Septicaemia



Vit D deficiency



Hypokalaemia





Hypomagnesaemia



Hypophosphataemia

Chronic excessive antacid use (magnesium)

11

Refeeding Syndrome

Refeeding Syndrome Management - Obtain baseline levels of potassium, magnesium and phosphorus



Alert medical team of your assessment



Commence nutrition SLOWLY (~500kcal/day)

- Correct any pre-existing electrolyte abnormalities before commencing nutrition support



Daily biochemistry and BGL monitoring



Supplement abnormalities as required and do not increase feeding until normalised



Restrict fluid to ~800mL/day initially and gradually increase (IV fluid supplement)



Increase ~250kcal per day until goal reached

- Thiamin supplement + multivitamin supplement

Recommended Reading 

Enteral feeding guide for adults in health care facilities Nutrition Support Interest Group January 2007 download free from DAA website (DINER)

12