You ll Need a Tube to Get There!

Transcription

1 You ll Need a Tube to Get There! Ryan T. Hurt, MD,PhD Associate Professor of Medicine Divisions of General Internal Medicine, Gastroenterology, and Endocrinology Director Home Parenteral Enteral Nutrition Mayo Clinic College of Medicine

2 Objectives Describe the routes for EN feeding Treat some potential complications associated with EN Discuss what can be put down tubes Blenderized tube feeds Standard formulas Medication delivery

3 Tube Replacement When should you have your tube replaced? 1. Not broke don t fix 2. Follow manufacture guidelines Wait for tract maturation 4-6 weeks Bumper PEG Manufacturer 12 months Balloon PEG Manufacturer 3 months

4 Tube Complications

5 PEG Long-term Complications Overall complications % Risk factors PCM, advanced malignancy, outpatients Minor complications % Major complications % Mortality Procedure related negligible <1% Long-term PEG related % Little change over past years Larson (Gastro 1987;93:48) Lin (Laryngoscope 2001;111:1847) Grant (Ann Surg 1993;217:168) Rimon (Endosc 2001;33:241)

6 Question: You had a PEG placed 8 weeks ago for HEN. A home nurse is worried that you have an infection. You feel it is a normal tract. Is anything wrong with this PEG site?

7 Normal Appearance 7 days 2 days Mature Track

8 Question: You have gained 20 lbs on HEN feeds. Skin is moist and red under dressing. What are you worried about?

9 Answer: Fungal Infection

10 Question: Pain, tenderness, warmth at 5 day old PEG site. What s wrong?

11 Etiologic Factors - PEG Site Infection Risk factors for PEG site infection Patient Diabetes, obesity, malnutrition, steroids Technique Introducer vs pull PEG (0% vs 21%) Small incision No antibiotic prophylaxis Nursing Care Excessive traction Further risk factors for peritonitis Removal/displacement of tube Leakage around PEG site Buried bumper syndrome Viscous perforation PUD Presentation: Abd pain, leukocytosis, fever, ileus, rebound Schapiro (GE Clin N Amer 1996;6:409) Larson (Gastro 1987;93:48) Grant (Ann Surg 1993;217:168) Mamel (Am J Gastro 1989:84:703)

12 PEG Site Infection Management for PEG site infection Prompt broad spectrum IV antibiotics Local wound care Incision and drainage rarely (necrotizing fasciitis) Further management for peritonitis Contrast studies Tube position, presence of leak Leakage requires surgical intervention Schapiro (GE Clin N Amer 1996;6:409) Larson (Gastro 1987;93:48) Grant (Ann Surg 1993;217:168) Mamel (Am J Gastro 1989:84:703)

13 What Can I Put Down My Tube?

14 Formula Selection Which one? Why? When? Insurance coverage > 200 formulas on the market Not under FDA regulatory control OK to make structure and function claim NO curative claims

15 Mayo Formulary

16 Water content of various formulas: Caloric density % water 1.0 kcal/ml kcal/ml kcal/ml kcal/ml 70 Caution with Hypersomotic Formulas In SBS Calorically dense indications: Volume sensitive (CHF, Renal Failure, SIADH) McClave et al 2009; JPEN

17 Blenderized Tube Feeding Has been used since tubes were first put in There are a few studies raising concerns about the safety of BTF in the hospital HEN pediatric studies show a benefit Studies lacking in HEN adults

18 ASPEN Recommendations Nutrition Support for Home and Alternate Site Care EN formulations shall be prepared to prevent contamination. Commercially available EN formulations shall be used whenever possible. (15.1) 5 The use of home blenderized or reconstituted powered EN formula requires additional safe food handling and storage practices. (18.4) 5 5. A.S.P.E.N. Standards for Nutrition Support: Home and Alternate Site Care. Nutr. Clin Pract August 2014; 29 (4):

19 Mayo HEN Program Program started in 1985 Train 700 HEN patients per year Have trained over 12,000 since program started Patients have told HEN team members for years they have used BTF at home

20 Mayo Oley BTF Survey 2015 Validated BTF Survey Sent Out to Oley Consumers Responses All participation voluntary IRB Approved

21 Mayo Oley BTF Survey 2015

22 Mayo Oley BTF Survey 2015

23 Mayo Oley BTF Survey 2015

24 Mayo Oley BTF Survey 2015

25 Blenderized Tube Feeding Use nutritionally complete recipes Commercially Available formulas may or may not be complete Use standard precautions you would with food preparation for non tube feeders

26 Medications Down the Tube No crushing extended release medications No crushing sublingual meds No crushing enteric coated meds Flush before and after meds Use liquid formulations when available Administer medications individually

27 What about Beer?