E.N : Tubal Feeding Systems ; Closed vs. Open

Transcription

1 E.N : Tubal Feeding Systems ; Closed vs. Open Dr:Enas Mogawer, MD Head Of Clinical Nutrition Department,AFSH Professor Of Internal Medicine Kasr El Aini Medical Consultant Of Clinical Nutrition And Obesity

2 Introduction NUTRITION SUPPORT REFERS TO ENTERAL OR PARENTERAL PROVISION OF Calories Protein Electrolytes Minerals Vitamins Trace elements Fluids

3 How do we Select Patients for Nutrition Support? Critically ill patients are selected for nutrition support on the basis of whether they have contraindication to EN, as well as whether the patient is adequately nourished or malnourished. Patient EN Contraindication? Malnourished? No Yes Yes No Start early EN

4 Malnourished? Yes No < 1 week 1 week Do not start early P.N Do not start P.N Start P.N

5 EN as a Primary Nutritional Modality Three criteria must be fulfilled to consider EN as a primary nutritional modality:- Safe and free of serious side effects. Capable of being modified Capable of fulfilling all macro and micronutrients

6 So, what do we Mean by Enteral Nutrition ( EN )? Nutrition provided through the GIT via a tube, catheter or stoma that delivers nutrients distal to the oral cavity

7 Is EN a Totally Innocent Process when Used to Provide Nutrition Support? While the process of EN may appear less complex compared to PN, serious harm can occur Adverse events might occur through out the process of ordering, administering and monitoring Adverse events reported include:- GIT intolerance esp. due to contamination Misconnections Device misplacement and displacements Metabolic errors Aspiration Mechanical tube errors

8 So, What do we Need to do? Promote Patient Safety in the Enterally Fed Patient through:- Applying a multidisciplinary process Implement policies and procedures Continuous surveillance Delineate potential points for Contamination Recognizing areas of potential human errors

9 Potential Points for Contamination During EN Feeding Process Figure 1 Order Formula, Delivery Site, Administration Method, Rate Sterile Formula In Closed System Sterile Liquid Formula Non-Sterile Powder Formula Non-Sterile Additives HBM Preparation Pour, reconstitute, Mix place in an administration container Patient Care Unit Store or take to patient Contamination points Beside Connect delivery container To administration set And to patient

10 EN Formula Safety Contamination Can occur at any point as seen in fig.1 Poses a significant risk esp. if patient is immunocompromized Sterility of commercially available liquid EN products, sterile bags, and administration sets can be disrupted by any manipulation EN formulas prepared in a kitchen or in a patient care unit are at higher risks of contamination

11 Continuation EN formulas left over should be refrigerated Powdered formulas are not commercially sterile and require meticulous handling and reconstitution process Liquid formulas are considered a sterile end product in comparison to powder formulas Formulas prepared under aseptic conditions and undergo sterilization prior to administration ( closed system ) are safer With the availability of closed EN systems, contamination in the preparation of individualized EN admixtures is less frequent

12 Significant Definitions Open System Closed System Hanging Time Open enteral system : An enteral system in which the clinician / patient / caregiver is required to decant formula into the enteral container or bag. Closed Enteral system : A closed enteral container or bag, prefilled with sterile, liquid formula by the manufacturer, and considered ready to administer. A pump is used and the closed enteral feeding system can be used for either intermittent/bolus or continuous feeds The length of time an enteral formula is considered safe for delivery to the patient beginning with the time the formula has either been reconstituted, warmed, decanted, or has had the original package seal broken.

13 Difficulties Encountered When Dealing with Open Tubal Feeding Formula, preparation must take place in a clean environment, by trained personnel working in aseptic techniques and wearing appropriate attire Preparation area must be separate from any storage area Utensils or instruments used should either be disposable or undergo heat sterilization before using Hand Hygiene and aseptic practices should be in place strictly!! Exact hanging time as per ( manufacturer ) must be strict.

14 Continuation Contaminated enteral feeding systems can contribute to the etiology of diarrhea (common with open system) C. Difficile infection in post-pyloric EN is commonly found in environments applying the open system Personnel hygiene, enteral access device, enterostomy tube hub contamination are all contributing factors. If there is need to aspirate GR, moving from a dirty process to formula preparation. carries a risk for contamination process

15 Hanging Time: Another Factor to be Considered When Choosing Tubal Feeding 0 hours Sterile Formula In an Open System (Neonate) Sterile Formula In an Open System (at home) Sterile Formula In an Open System (at home) Sterile Formula In a Closed System Non-Sterile Powder Formula Non-Sterile Additives HBM

16 In a Nut Shell, Closed Enteral Feeding System Advantages and Characteristics Include:- Closed enteral feeding formulas and bags can be safely hung for 24 hours. The closed enteral feeding system can be disconnected and reconnected within the 24 hours period for intermittent feed. Formulas are available in either 1000 ml or 1500 ml. The formula rate ordered can be used to calculate the number of bags needed for 24 hours.

17 The bags are all stored at room temperature. No refrigeration is required. Keep bags out of direct sunlight Tubing that comes with the closed feeding system does not need to be flushed, but a need to flush any other tubing entering the patient is important. (i.e.nasogastric/gastrostomy/jejunostomy Tubes). Existing policies and procedures regarding feeding tube management/flushing are not impacted by the implementation of the closed enteral feeding system and should be referred to regarding the flushing of the actual feeding tube A new set is used for every new bag, up to a maximum hang time of 24 hours. The old tubing is discarded with the bag after 24 hours. Reduced nursing time, tubing cost and formula wastage

18 Can we set up a Closed Enteral Feeding System for Gravity Feeds? To provide a bolus type of infusion for closed systems, a pump will need to be used. Follow unit s protocols on enteral feeds (e.g. assessing tolerance).

19 A Take Home Message

20 Nutritionally appropriate sterile liquid formulas should replace powdered formulas due to sterility issues Contamination during Tubal Feeding is usually a strong culprit for GIT intolerance The Closed Feeding System saves time, cost, manpower No part of the delivery system, including the EN formula itself, should come into contact with hands, skin, clothing or any other non disinfected surface. Aseptic technique in the patient care area can reduce the infectious risk to the patient.

21 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 pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26 (Suppl):1SA-138SA. Errata 2002;26:144. Anderson A, Baker G, Carmody M, et al. Partnering to improve the supply chain. Mater Manag Health Care. 2006;15(2): Bischoff WE, Tucker BK, Wallis ML, et al. Preventing the airborne spread of Staphylococcus aureus by persons with the common cold: effect of surgical scrubs, gowns, and masks. Infect Control Hosp Epidemiol. 2007;28:

22 TANK YOU