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2009 inservice aspen guideline presentation
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2009 inservice aspen guideline presentation






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  • Gastroparesis (N/V due to retention of food in the)
  • Traditionally – wait until there was evidence that bowel function had returned as evidenced by flatus or a bowel movement
  • Usually recommendation = 30mL/hr
  • Gastric tubes are more easy to clog due to coagulations of protein with the acidic gastric fluid.
  • 2) Avoid altered therapeutic drug response and incompatibility (e.g. high conc. Morphine vs low conc. Morphine), imcompatible  clogging tube 3) Sublingual/buccal tablets - direct absorption of the active ingredient through the oral mucosa. (drugs for dysphasia patient)
  • 2) because drug absorption can be affected by the tip’s location.
  • Larger GRV, slower Gastric emptying

2009 inservice aspen guideline presentation 2009 inservice aspen guideline presentation Presentation Transcript

  • Enteral Nutrition Practice Recommendation
  • Introduction
    • Criterion for enteral nutrition
      • Unable to take nutrients orally
      • With function gut and GI tract
  • Enteral Access Devices
    • Nonsurgical
    • Naso-gastric/ Naso-duodenal/Naso-jejunal
    • Surgical
    • Gastrostomy
      • Percutaneous endoscopic gastrostomy (PEG)
    • Jejunostomy
      • Percutaneous endoscopic jejunostomy (PEJ)
  • Enteral Access Devices
    • Candidates
        • Gastric
            • With functional stomach
        • Small Bowel
            • Gastric obstruction
            • Gastroparesis
            • Pancreatitis
            • Reflux of gastric contents
            • Easily aspirate
  • Long-term Feeding Devices
    • Should be considered when the need for enteral feeding is at least 4 weeks in adults, children, and infants after term age
    • Considerations:
      • Whether benefit outweighs the risk of placement
      • Whether insertion of the feeding tubes near end-of-life warranted
      • Whether insertion is indicated for patients who are close to achieving oral feeding
    • Abdominal imaging should be performed prior to permanent feeding device placement
    • Document tube types, tip location, and external markings in the medical record and in follow-up examinations.
  • Initiation of feeding after placement of Long-term Enteral Access Device
  • Timing of enteral support
    • For all post-operative patients
    • Feeding can be initiate without bowel movement or flatus
    • Usually within 24 - 48 hours
  • Timing of enteral support
    • For patients with PEG placement
    • Feeding can be initiated,
      • Within 2 hours of placement in adult
      • Within 6 hours of placement in infant/children
  • Initiation and Advancement of Enteral Nutrition Regimen
  • Administration Rate
    • Choose full-strength, isotonic formulas for initial feeding regimen.
    • Preterm, critically ill, or malnourished children with continuous feeding,
          • use 0.5 - 1 mL/kg/hr initial volume
  • Type of administration
    • Intermittent
    • Bolus
    • Continuous
    • Cyclic
  • Administration Rate
        • 3-8 times/day
        • With increases of 60-120mL every 8-12 hours as tolerate up to the goal volume
        • Delivered via a feeding container/ bag over 30-45 minutes
        • Stomach only, No jejunal and small bowel feeding
  • Administration Rate
    • BOLUS (a form of intermittent feeding)
        • 3-8times/day
        • With increases of 60-120mL every 8-12 hours as tolerate up to the goal volume
        • Delivered by gravity via a syringe over 15 minutes
        • Stomach only
        • NEVER in critically ill patients
        • For children, start with 25% of goal volume. Increase by 25% per day as tolerated
        • Initial at 10-40mL/h
        • Advanced to the goal rate in increments of 10-20 mL/h every 8-12 hours as tolerated
    • OR
        • Start at 1-2mL/kg/hr
        • Advanced by 0.5-1mL/kg/hr every 6-24hrs until the goal volume is achieved
    Administration Rate
  • Enteral feeding pump
    • Calibrate feeding pumps periodically
    • Make sure it function properly
    • Use pump that deliver within 10% of the prescribed amount of formula.
  • Flushes
    • Recommendation
    • Use sterile Water
    • For Continuous feeding
        • Flush every 4 hours, 30mL water
    • For Intermittent feedings
        • Flush before and after feeding, 30mL water
    • For clogged tube, use Viokase, Sodium Bicarbonate
    • Place the tip of feeding tube in the alkaline proximal small intestine to decrease clogging
  • Medications Administration
  • General Considerations
    • Do not mix medications together. Each medications should be administered separately.
    • Sublingual or buccal tablets should NOT be delivered via feeding tube.
    • Certain medications should NOT be crushed or opened to administer via feeding tube, such as
          • enteric coated
          • extended release
          • sustained release, or
          • timed-release drugs
  • Recommendation
    • Dilute medications with sterile water prior to administration
    • Identify the tube tip’s location prior to medication delivery
    • Flush tube with at least 15mL of water before and after administering medications
    • Flush tube with 15mL water between multiple doses of medications.
  • Recommendation (cont’)
    • Notify the pharmacy that the medication is for feeding tube delivery. Ask for liquid form if possible.
    • Confirm with the pharmacy which medications can be crushed or opened.
    • Crush the tablet into a fine powder and mix with room temperature sterile water.
  • Monitoring Enteral Nutrition Administration
  • Monitoring Refeeding Syndrome (RS)
  • Monitoring Refeeding Syndrome (RS)
    • Procedures
    • Identify patients at high risk for RS
    • Check metabolic and nutrition parameters
    • Prevent RS
    • Initiate nutrition support at ~25% of the estimate goal and advanced over 3-5 days of goal rate
  • Patients at high risk for RS
    • Anorexia
    • Protein-energy malnutrition
    • Patients from skilled nursing facilities
    • Unfed for 7-10 days
    • Chronic disease patients
    • Hx of excessive alcoholic intake
    • Morbid obesity with massive wt loss
  • Check Metabolic and nutrition parameters
    • Signs of RS
      • % IBW < 100
      • Low serum
            • potassium ,
            • magnesium , and
            • phosphorus (hallmark sign of RS)
      • Pro-long starvation (usually > 24 - 72 hours)
      • Other signs include
            • Sodium and water retention
            • Thiamin deficiency
  • Prevent RS
    • For severe malnutrition , critically ill , severe trauma , and burns patients,
        • Correct electrolytes abnormalities before initiation of nutrition support, even serum level is normal
  • Recommendation (Not from ASPEN Guideline)
    • For NORMAL renal function patients
      • Provide electrolytes supplementation before and during nutrition support
      • 10-15 mmol of phosphate/1000kcal
      • Minimize sodium to < 460mg/day
      • Minimize total fluid to <1000mL/day
      • 3-6mg thiamine/day
      • 1mg folic acid/day, for 5-7 days
  • Initiation of Nutrition Support
    • Initiate at ~25% of the estimate goal and,
    • Advanced over 3-5 days of goal rate
  • Monitoring Gastric Residual Volume (GRV)
  • Method to Detect Aspiration
    • Blue Dye Method & Glucose Oxidase Strips are no longer used
  • Guideline for checking GRV
    • For critically ill patients (both adult and pediatric),
        • Check GRV every 4 hours
    • For non-critically ill patients,
        • Check GRV every 4 hours during the first 48 hours
        • Decrease to 6-8 hours to monitor GRV level
  • Interpreting the Relationship Between Aspiration and GRVs
    • GRV of 200-500mL should stimulate a step-wise approach to assess the potential of GI intolerance.
    • In the absence of GI intolerance, EF should not be stopped if GRV <400-500mL.
    • In critically ill patients, a GRV ≥ 250mL should be accepted to improve the delivery of EN
  • Use of Prokinetic Agent
    • If the GRV is ≥ 250mL after a second gastric residual check, a promotility agent should be considered in adult patients.
  • When to hold EF?
    • For all TF adult patients
    • GRV > 500mL
    • For continuous feeding,
    • GRV ≥ hourly rate
    • For bolus feeding,
    • GRV > half of the previous feeding volume
  • Labeling
    • EN order should include:
    • Patient demographics (pt name, DOB, wt, location, MRN)
    • Formula name
    • Delivery site/device (NG, PEG, PEJ)
    • Administration method and rate
        • Bolus/intermittent/continuous/cyclic
        • Volume
        • Rate of administration
  • Enteral Formula Safety
    • Sterile, liquid EN formulas should be used in preference to powdered, reconstituted formulas whenever possible
    • Store unopened commercially-available liquid EN formulas under controlled conditions (dark, dry and cool)
    • Formulas reconstituted in advance should be immediately refrigerated, and discarded within 24 hrs of preparation if not used
    • Discard formulas that exposed to room temperature for longer than 4 hrs
  • Questions?