Practical aspects on Feeding Protocols Enteral or Parenteral AM Poleÿ 2012
Enteral Feeding
Facts A reduction in mortality Prophylaxis for stress ulcers Full-strength
Time to start enteral nutrition If you feed them (better!) 24-48 hours of admission They will leave (sooner!) Stable hemodynamic condition Bowel sounds are not required for Formula Full strength, undiluted Avoidance contamination Routinely change every 24 hours Continuous vs. intermittent enteral nutrition Additional prophylaxis for peptic ulcers Gastric vs. small-bowel l placement of feeding tube Confirmation of tube placement Radiography is primary method for confirmation Use ink marking on feeding tube for secondary confirmation
Body positioning 30-45 degree Rate of administration of formula Begin at 25 ml/hr Increase rate by 25 ml/h every 4 hours if tolerated Gastric residual volume More than 200-250 250 ml Consider prokinetic agent and/or small-bowel feeding if gastric Avoid stopping enteral nutrition Prokinetic agents Give Metoclopramide Prevention of tube occlusions Routinely flush tube with 30ml of water every 4 hours Treatment of tube occlusions Soda Bic
Interruptions in feeding Minimize interruptions Stop enteral nutrition immediately before minor procedures and restart within 1 hour after procedure Avoid stopping enteral nutrition for more than 4 hours before major procedures
Feeding tube management
Routes Of feeding
FEEDING TUBE SELECTION & MANAGEMENT Types of feeding tubes Nasogastric Nasoduodenal Percutaneous Endoscopic Gastrostomy (PEG) Open gastrostomy Transgastric jejunostomy Surgical jejunostomy
Feeding Tube Obstruction 1. Causes of Clogged Feeding Tubes a. Improper flushing of tubes. b. Caloric dense formulations. c. Small bore feeding tubes. d. Rate of flow that could allow gastric ph to clump the formula as well as cause a build up on the sides of the feeding tube. e. While evaluating gastric residuals the low ph can cause formula coagulation. f. Medications that t are not properly crushed. Bulk forming medications
Solutions Unclogging: 1. Use 30 to 60 cc syringe, avoid small syringes due to high pressure. 2. Flush with warm water. 3. Flush with Carbonated beverage (approximately 5 ml). 4. Liquid meat tenderizer (approximately 5 ml). 5. Sodium Bicarbonate with 10 mls warm water to tube, clamp x 5 minutes then flush. 6. If these attempts to unclog the tube fail then the tube must be replaced
Safe Practice Annette M. Bourgault, g, Laura Ipe, Joanne Weaver, Sally Swartz, Patrick J. O Dea,
Malposition Radiography. Clinical assessment methods might be ineffective Auscultatory methods Marking the feeding tube with indelible ink
Aspiration Major risk factors for aspiration Haemodynamic instability
Gastric Motility and Risk of Aspiration Impaired by certain medicine May started when bowel sounds are not present. Gastric residual volumes greater than 200 to 250 ml are high Greater than 100 ml may be high for a gastrostomy Because secretion of saliva and gastric fluids alone may total t 188 ml/h A single gastric residual volume should be rechecked within 1 hour 50-to 60-ml syringe should be used
Gastric Aspirate Should it be returned to the patient or discarded. Tube occlusions more frequent Prokinetic agents Booth recommended the use of metoclopramide as a prokinetic agent in patients with consistently high gastric residual volumes. Erythromycin can increase gastric motility, potential complications
Gastric Versus Small-Bowel Tube Placement Feeding tubes beyond the gastric pylorus reduces aspiration Placement of feeding tubes in the small bowel not feasible when doing blind insertion Impaired gastric motility - small bowel feeding is the suggested route of choice.
Body Positioning Elevation of the head of bed Elevation to 30º Gastric residual volumes similar in prone and supine positions
Intolerance Number of causes, including diarrhea, constipation, nausea and vomiting, and the feeding formula itself. Common belief that enteral nutrition causes diarrhea Consideration of formula Nausea and vomiting - medicine Recommendations rule out impaction Bacterial contamination of GI tract Aseptic techniques. Closed feeding systems High fiber feeds might assist with reducing diarrhea
Prevention of Feeding Tube Occlusions Occlusions inside feeding tubes Performance of gastric residual checks. Gastric placement of small-bore tubes had a higher incidence of tube occlusions Routine water flushes Sterile water Water boluses to meet requirements or to normalize serum levels l of sodium.
Parenteral
High Risk of Infection
High Infection Risk Septic complications. Line infections are the most common reason for the cessation of PN. Maintain asepsis The nurse manages the nutritional care on a 24-hour basis. Other sources of contamination also need to be considered Insertion procedure of the central feeding catheter The presence of other sources of infection
Infection control principles Hand decontamination Sterile gloves Insertion site care Cleaning solution The recommended insertion site dressing The administration set Changed after 24 hours Never be disconnected and then reconnected
Never be stopped, left for a while and then recommenced. Needle-free connectors must be used on PN lines. Three way taps must never be used on PN lines. Dedicated lumen. Tip must be sent for culture Signs of infection Administered via a peripheral canula
Following details: Patient name and hospital number. TPN code correct. Expire date for TPN. Radiation sticker. No holes/ tears in outer plastic bag. No fluid leakage into outer bag.- DO NOT USE TPN Document the change of TPN in the nursing notes. TPN should not hang for more than 24 hours before changed. 4 Hourly blood glucose to be done. Insulin to be administered according to doctor s protocol. Vital signs Storage and return of TPN very important t fid fridge
Administration of PN general principles Chest X-ray is required for line position Administered via a volumetric pump Infusions must not be switched off Peripheral PN can be delivered centrally, but central PN must not be delivered peripherally
ROUTES OF NUTRITION SUPPORT GUIDELINE www.criticalcarenutrition.com Able to meet needs via oral route? No Contraindication to EN? (see blue box) Yes Hypermetabolic&/or malnourished: EN contraindicated >7-10 days? Yes No Yes No Oral diet. EN PN; reassess q 24-48 hrs re EN. No PN; reassess q 24-48 hrs re EN. Gastric EN. No Contraindication to gastric EN? (see purple box) Yes Postpyloric EN. Absolute contraindications: Mechanical bowel obstruction Bowel ischemia Relative contraindications: Hemodynamic instability Small bowel ileus Small bowel fistulae Bowel anastomosis Nasoduodenal Feeding Tubes Manual Placement Techniques: Kalliafas S, et al. Erythromycin facilitates postpyloric placement of nasoduodenal feeding tubes in intensive care unit patients: randomized, double-blinded, placebo-controlled trial. JPEN 20:385-388,1996. Nicholas CD, et al. Simple bedside placement of nasal-enteral feeding tubes: a case series. Nutr Clin Pract 16:165-168, 2001. Salasidis R, et al. Air insufflation technique of enteral tube insertion: a randomized, controlled trial. Crit Care Med 26:1036-1039,1998. Ugo PJ, et al. Bedside postpyloric placement of weighted feeding tubes. Nutr Clin Pract 7:284-287,1992. Zaloga G. Bedside method for placing small bowel feeding tubes in critically ill patients. Chest 100:1643-1646,1991. Yes Planned abdominal surgery? No Contraindication to gastric EN: 1) Gastric residual volumes > threshold maximum (250 ml) despite prokinetics agents. 2) Chronic/acute gastroesophageal reflux. 3) High risk pulmonary aspiration (i.e. required to be cared for in prone or supine position). Developed by J. Greenwood, RD, (Vancouver General Hospital) in collaboration with the CCCCPGC (1/1/07). Intraoperative postpyloric py feeding tube. Short term: nasoduodenal tube. Long term: feeding jejunostomy. Short term: manual (see pink box), endoscopic, or fluoroscopic nasoduodenal feeding tube. Long term: endoscopic or fluoroscopic gastrojejunostomy.
References Guidelines for Nutrition i Therapy in the ICU : How do they differ? Rupinder Dhaliwal, RD Nutrition in Intensive Care; Richard Leonard Critical Care Nutrition; Practice Management Guidelines Bridging the Gap: Effective Dissemination Strategies Improving Nutrition Practice; Daren K Heyland Optimizing Enteral Nutrition in the ICU; Daren K Heyland Evidence updated by the ANZICS CTG Feeding Investigators Group; Dr. Gordon S. Doig, NUTRITION and IMMUNONUTRITION in the ICU; Marcia McDougall Enteral Feeding Protocols in the ICU; Michele McCall RD