14-15 Aug ASMIC L.Mageswary Dietitian Hospital Selayang

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1 14-15 Aug ASMIC 2015 Nurses Role L.Mageswary Dietitian Hospital Selayang

2 Doctor Dietitian Pharmacist Nurse Physiotherapist Occupational therapist Patient Patient Centered Care Patients needs & preferences Good communication between healthcare professionals & patients To promote & provide education To develop common protocols and guidelines

3 Discussion Today Safe EN Orders EN Label Storage & Administration Safe EN Preparation Selection and Maintenance of Enteral Access EN Complication & Management

4 Nutrition Screening & Assessment Weight Height Knee height Intake/ Output Appetite Ability to swallow and eat Patient Risk for Malnutrition Any critically ill patient who is anticipated to remain unable to take oral nutrition for 5 days with significant comorbid disease. Any patient who has or had oral intake that is inadequate to meet current nutritional needs. (i.e < 50% of estimated required calories for > 5 days)

5 Formula Orders Orders of EN should be written completely and specifically for each patient: Pt demographics (Name, Age, MRN and Bed No.) Formula trade name Enteral route (gastric or postpyloric) and access (nasogastric NG or nasoduodenal) Administration method (pump-assisted or bolus) Rate of administration

6 Label: EN formula administration All feeding bottles, bags and syringes in feeding pumps should have label Pt name Formula type Enteral access Administration method Name/ initial of those preparing & hanging products Date & time of formula preparation and hung Expiration date & time Not for I.V Use Always confirm that the correct formula is being given to the patient by comparing the label to the order.

7 Storage and administration Check date of expiry Store unopened formula in a designated dark, dry, cool place, according to institutional protocol and manufacturer recommendations Reconstituted formula that s not used should be immediately refrigerated and discarded within 24 hours Liquid EN formulas should be used in preference to powdered reconstituted formulas has higher risk of contamination Blenderised Diet NOT RECOMMENDED Enteral administration set with a drip chamber is preferable to one with no drip chamber to prevent retrograde bacterial contamination of the formula during administration.

8 Preparation of EN EN formulas be prepared in a clean environment by specially trained personnel using sterile technique. wearing a disposable mask, gown, gloves, and head cover may reduce the spread of airborne bacteria. Hand hygiene before preparing and administering EN When accessing the enteral tube hub, clean each tubing connection with an alcohol swab. Between glove changes and when moving from a dirty procedure, such as gastric residual aspiration, to a clean procedure, such as handling the EN formula Don t let any part of the delivery system come into contact with non-disinfected hands, skin, clothing, or other surfaces.

9 Water Type of water in EN Purified Water sterile, solute-free, non pyrogenic water used for preparing or reconstituting commercial products, rinsing equipment and utensils required to produce steril water for irrigation and sterile water for injection. Distilled Water water that has been vaporized and recondensed but is not necessarily free of dis-solved or suspended matter; therefore should not be used for the preparation or administration of medications. Tap Water municipal or locally-available potable water that meets the Drinking Water regulations and is consistent with World Health Organization (WHO) guidelines for water safety.

10 Selection & Maintenance of Enteral access Devices inserted via the nose or mouth are intended for short-term use, usually no longer than 6 weeks. 1 2 Type of enteral access is depending on An X-ray is the gold standard for confirming the correct position Patient s disease state GI anatomy GI function Estimated length of therapy Capacity of patient or caregiver 3 4 The auscultatory method isn t reliable. 5 Bedside checks for placement can be done by testing the ph of the aspirate. Fluid from the stomach is typically clear and colorless or grassy green and has a ph of 5 or less However, gastric aspirate may not be reliable if a patient is taking a medication to suppress gastric acid, such as famotidine or pantoprazole If the tube could possibly have migrated into the lungs, fluid looks pale yellow and has a ph of 7 or higher

11 Selection & Maintenance of Enteral access Percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic jejunostomy, and Percutaneous endoscopic gastrojejunostomy Long term feeding devices (> 4 weeks) DO NOT USE Urinary drainage catheters or GI drainage they don t have external anchoring devices and can migrate, causing obstruction or aspiration Feedings Initiation: within 2 hours of the placement of a PEG tube in adult. without waiting for flatus or a bowel movement.

12 EN Formula Hang Time Hang time is defined as the time an EN formula is considered safe for delivery to the patient, beginning from the time when the formula was reconstituted, warmed, or decanted, or from the time when the original package seal was broken. Administration sets for open systems should be changed at least every 24 hours ASPEN Enteral Nutrition Practice Recommendations 2009

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14 Tube Occlusion Poor flushing technique Interaction between multiple medications and protein-rich formula Inappropriate administration of medication Mixing of tube feeding formula with gastric fluid during gastric residual checks small-diameter tubes Loosening and rotating a gastrostomy tube may prevent blockage through mucosal overgrowth and may reduce peristomal infections (grade C).

15 Tube Occlusion Do not Use acidic flush fluids Cranberry juice, carbonated cola Water is the best flush fluid use sterile water in immuno-compromised or critically ill & Post-pyloric feeding Do Use liquid form drugs when available Dilute thick liquid medications to reduce osmolality Consider timing of medication empty or full stomach Phenytoin Warfarin Antibiotics (Tetracyclines, Quinolone) Flush feeding tube with ml water frequently Before and after checking residuals Before and after feeding between medication doses Every 4 hourly if continuous feeding Choose feeding tube with appropriate size

16 Enteral Tube Misconnections Multiple medical committees have convened since 1972 to address the safety requirements for enteral feeding set connectors and adaptors. Color-coding and/or labeling should always be used (doesn t entirely eliminate the risk) Be knowledgeable about the use of the devices, trace all lines back to their origin, and ensure that they re secure. Use only oral syringes, not luer-lock syringes, labeled for oral use only, to draw up and administer medications into the feeding tube Golden Standard: Develop and use enteral equipment that is designed to be completely incompatible with all existing I.V. connections

17 GRV AND ASPIRATION RISK When should I get worried?

18 Gastric Residual Volumes: Controversial? ADA Guidelines 2008 > 250 cc Canadian C.P.G. > 250 cc ESPEN Guidelines 2006 not addressed ASPEN / SCCM > 500 cc New Canadian CPG Guidelines late 2009 over 400 cc

19 Jaime C.P et al. JPEN 2001 Purpose: To compare gastrointestinal tolerance to two EN protocols in critically ill patients in medical/surgical/trauma ICU. Method: 1. Prospective RCT, 96 consecutive pts expected to stay in ICU 3 days on EN. 2. Group I: GRV 150 ml w optional prokinetic. Group II: GRV < 250 ml w mandatory prokinetic 3. GI tolerance (high GRV, emesis and diarrhea) time to reach the goal rate of feeding and the percentage of nutritional requirements received and was recorded. Results: 1. Group I: 19 of 36 patients (53%) had one or more episodes of high GRV (p <.005) 2. Group 1: reached their goal rates on average in 22 hours and received 70 % of nutritional requirements Results: 1. Group II: 10 of 44 patients (23%) had one or more episodes of high GRV (p <.005) 2. Group II: reached their goal rates on average in 15 hours and received 76% of nutritional requirements No significant difference between emesis, diarrhea total episodes of intolerance.

20 Jaime C.P et al. JPEN 2001 Conclusion: The incidence of EN intolerance was reduced by using a GRV of 250 ml along with the mandatory use of prokinetics. The study showed a trend of improved enteral nutrition provision and reduced the time to reach the goal rate in group II. These improvements support the adoption of the proposed feeding protocol for critically ill patients.

21 GRV Levels Severity Definition Treatment Mild < 200 ml Return GRV Continue EN protocol Moderate 200 to 500 ml 1 st episode, continue EN protocol 2 nd episode, start prokinetic agent 3 rd episode, reduce EN rate by half 4 th episode, Stop Gastric feeding Place NJ tube Start EN protocol Severe > 500 ml Stop gastric feeding Place NJ tube Start EN protocol Marr AR et. Al. Gastric Feeding as an Extension of an Established Enteral Nutrition protocol.

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23 Recommendation: To reintroduce gastric content to improve GRV management without increasing the risk for potential complications

24 Reduce Risk of Aspiration Recommendation EN patients should be assessed for aspiration risk Elevate head of the bed 30-45º in all patients Switch to continuous infusion if intolerant Initiate agents to promote motility where feasible Prokinetic drugs (metoclopramide and erythromycin) Narcotic antagonists (naloxone and alvimopan) Divert level of feeding by post-pyloric placement Use of chlorhexidine mouthwash twice daily to reduce risk of ventilator-associated pneumonia. Evidence Level E C D C C C

25 Head Up Position Prop-up patient at during and after feeding To minimise aspiration, patients should be fed propped up by 30 or more and should be kept propped up for 30 minutes after feeding. Continuous feed should not be given overnight in patients who are at risk (grade C). Both gastric enteral feeding and feeding in supine position vs. semi recumbent position, are independent risk factors for nosocomial pneumonia in ventilated patients Drakulovic MB, Lancet 354:

26 Small Bowel Feeding Small bowel fed patients have improved energy delivery in some studies Improved tolerance of enteral nutrition and concomitant faster achievement of desired calories Kortbeek JB J. Trauma 46: Postpyloric tube suggested for high-risk patients in ICU High gastric residual volume Sedation Supine position Canadian Clinical Practice Guidelines, JPEN 2003 Long term rehabilitation patients should transit to gastric feeding AM Cook et al. Nutrition Consideration in Traumatic Brain Injury, NCP Dec 2008

27 Diarrhea Quantify stool volume Is it really diarrhea? Review medication list Not Always the Formula Switch from IV to enteral route Antibiotic prescription Sodium and potassium phosphate Lactulose Check for C. difficile or other infectious causes Check hypoalbuminemia Try fiber (soluble fiber) Check feeding method Anti-diarrheal agents once infectious causes are rule out Continue to feed

28 Is Diarrhea present YES * Is stool clinically significant? NO Liquid stool > 300 ml/day * 4 loose stools/day Risk of contamination of wound or catheters Continue same feeding YES Are medications the possible Cause? NO Is patient receiving antibiotic/ Laxatives? NO Consider fibre supplement If hypoalbuminaemia, consider semi or elemental formula Is diarrhea resolved? NO Decrease rate until tolerance achieved YES YES YES Change medication Continue feeding Check stool for C.difficile toxin Continue feeding Continue same feeding Advance to goal rate

29 Metabolic Complications Complication Possible Cause Possible Treatment Hyponatremia Hypernatremia Hypokalemia Hyperkalemia Excessive free water, abnormal sodium loss Inadequate hydration, increased fluid losses, Diabetes Insipidus Anabolism/ refeeding, diuretics/medications Renal Failure, metabolic acidosis, catabolism, GI bleed, Acute dehydration Change to Fluid restricted formula, discontinue water boluses/ivf, replace sodium losses Add or increase water boluses or IVF Supplement potassium Correct imbalance, Change to renal formula as appropriate Hypophosphatemia Anabolism/ refeeding Supplement phosphorus Hyperphosphatemia Renal failure Change to renal formula, phosphate binders if necessary Hypomagnesemia Hyperglycemia Anabolism/ refeeding, diuretics/medications Diabetes, steroid therapy, Sepsis, Trauma, Pancreatitis Supplement magnesium Insulin drip per protocol. Goal is to maintain blood glucose at or less than 110 mg/dl (6.1 mmol/l)

30 Evidence-Based Feeding Protocol Highlights of the protocol Volume of feeds Feeding progression Acceptable gastric aspirates Use of prokinetic Use of small bowel feeding When to consider TPN Management of Complications

31 Intermittent Feeding Bolus Feeding

32 At all ward Hospital Selayang Storage Preparation Delivery Cleanliness of utensil

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35 Stay current to keep patient safe 1. Practice hand hygiene and sterile technique 2. Proper patient positioning 3. Appropriate medication administration technique 4. Good & Safe Nutrition Support Practices 5. Detailed documentation

36 Continuous Nurses Education in GICU Feeding Pump Training

37 Kursus Nutrition Support for Nurses

38 Safe Delivery of Nutrition Support Involves Multidisciplinary Approach THE MOST IMPORTANT MEMBER ARE ***NURSES***