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

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