II. Physiology: Enteral Nutrition Benefits
- Enteral Nutrition is preferred (even in intubated patients)
- Gastrointestinal integrity is maintained with enteral feedings
- Decreased risk of Gram Negative bacteremia from translocation
- Decreases Malnutrition
- Decreases Stress Ulcer risk
- Decreases ileus risk
III. Contraindications: Enteral Nutrition
- Bowel perforation
- Complete Small Bowel Obstruction
- Upper Gastrointestinal Hemorrhage
- Mesenteric Ischemia
- Circulatory shock requiring high dose Vasopressors
- Pancreatitis is NOT a contraindication to enteral feeding
- Absent bowel sounds in ICU patients is NOT a contraindication to enteral feeding
IV. Types: Delivery
- Short-term Feeding Tubes
- Orogastric Tube
- Typically used in intubated patients
- Nasogastric Tube
- Most commonly used as is physiologic and allows for large volume bolus feedings
- Smaller caliber nasal Feeding Tube (post-intubation)
- Smaller caliber does not allow for gastric suctioning
- Can be left in place longer than larger bore tubes
- Nasoduodenal Tube (post-pyloric Feeding Tube)
- Indicated if higher Aspiration Pneumonia risk, gastric dysmotility or obstruction
- Requires continuous delivery device
- Orogastric Tube
-
Enterostomy Tube
- Indicated for anticipated enteral feeding beyond 4 weeks
- Sub-types
- G-Tube: Gastrostomy or Gastric Tube
- Medication delivery
- Feedings may be drip or bolus
- GJ-Tube: Combined tube with both Gastric and Jejunal ports
- Medication delivery or bolus feeds via gastric port
- Drip feeds via jejunal port
- J-Tube: Jejunostomy or Jejunal Tube
- Requires drip feeds
- Bolus feeds result in Osmotic Diarrhea
- G-Tube: Gastrostomy or Gastric Tube
V. Preparations
- See Enteral Nutrition
- Obtain nutrition Consultation
- Standard solution: 1 kcal/ml (e.g. Osmolite, Isocal, Replete)
- Renal Failure: 2 kcal/ml of renal preparation (e.g. Novasource Renal)
VI. Technique
- Confirm Feeding Tube placement on XRay before first use
- Feeding Tubes may be misplaced into airway and lungs with catastrophic results if used
- Start Tube Feeding early (within first 24-48 hours of ICU admission)
- Consider starting with small volumes (10-20 ml/h) and advance to target over 6-8 hours
- Start regardless of presence of bowel sounds (see above) unless other contraindications
- Typical target rate: 1 ml/hour/kg (based on Ideal Body Weight if obese)
- Renal Failure rate: 0.5 ml/hour/kg of the concentrated 2 kcal/ml formula
- Subtract Propofol (1 kcal/ml) rate from the target rate
- Avoid holding feeding aside from procedures or intolerance (e.g. Abdominal Distention, Vomiting)
- Gastric Residual Volumes do NOT need to be obtained and should not result in held feedings
- However, large Residual Volumes >500 ml may be of concern (see aspiration risk reduction below)
- Poulard (2010) JPEN J Parenter Enteral Nutr 34(2):125-30 +PMID:19861528 [PubMed]
- Reignier (2013) JAMA 309(3):249-56 +PMID:23321763 [PubMed]
VII. Complications: Obstructed or Clogged Feeding Tube
- Attempt to flush tube with warm water (effective in 30% of cases)
- Alternate aspirating and injecting may help to dislodge obstruction
- Instill Pancreatic Enzymes (effective in 75% of cases)
- Dissolve 1 tablet Viokase and 1 tablet Sodium carbonate 324 mg in 5 ml water
- Inject solution into Feeding Tube and clamp for 5 minutes
- Last, instill warm water flush
- Fogarty catheter technique
- Obtain Informed Consent
- Technique increases Feeding Tube pressure and may result in perforation, leak or tube aneurysm
- Obtain proper Fogarty catheter size (#4 for 10 to 12F Feeding Tubes, #5 for 14F Feeding Tubes)
- Estimate the length of the indwelling Feeding Tube and mark the Fogarty catheter at this length
- Insert the Fogarty catheter to the end of the estimated Feeding Tube length (marked distance)
- As resistance is met, inflate and deflate the Fogarty balloon and attempt to advance further
- Repeat as needed until estimated end of Feeding Tube is reached
- Inflate and deflate the Fogarty balloon one last time at the end of the Feeding Tube
- Withdraw the Fogarty catheter, stopping periodically to inflate and deflate the balloon
- Confirm clearance and tube integrity with KUB XRay after instilling 20-30 ml contrast via tube
- References
- Warrington (2022) Crit Dec Emerg Med 36(8):20
- Obtain Informed Consent
- Attempt to carefully pass flexible wire or drum cartridge catheter down tube
- Replace persistently clogged tubes
VIII. Complications: Aspiration Pneumonia
- Consider aspiration mitigation strategies if signs of regurgitation, Vomiting, or very high Residual Volumes (>500 ml)
- Raise head of bed to 45 degrees
- Advance Feeding Tube into Small Bowel (post-pyloric)
- Consider short-term prokinetic use in Gastroparesis (marginal efficacy that wanes to ineffective over days)
- Avoid these agents in Bowel Obstruction
- Erythromycin 200 mg IV every 12 hours
- Risk of promoting Antibiotic Resistance
- Consider starting with Erythromycin and adding Metoclopramide in 24 hours if needed
- Metoclopramide (Reglan) 10 mg IV every 6 hours
- More effective when used in combination with Erythromycin
- Naloxone 8 mg via Nasogastric Tube every 8 hours
- May improve gastric emptying if due to Opioid induced Gastroparesis
IX. Complications: Diarrhea
X. Complications: General
- Nasogastric or Nasoduodenal Tube Intolerance (nasal discomfort, gagging)
- Tube malfunction, obstruction or migration
- Nausea or Vomiting
- Abdominal cramping, Diarrhea
- Higher risk with hyperosmolar medications (e.g. Acetaminophen, Potassium), Sorbitol (>15 g/day)
- Dilute liquid medications with 10-30 ml water
- Gastrointestinal Bleeding
- Bowel Obstruction
- Provocation of Gastroesophageal Reflux
- Increased skin moisture and maceration
- Agitation with a greater need for restraints
-
Hyperglycemia
- Be aware of the high sugar content in liquid medications
XI. Prevention: Complication avoidance with nasogastric and nasoduodenal Feeding Tubes
- Periodic confirmation of Feeding Tube (depth marker, Xray)
- Flush Feeding Tube with 30 ml water every 4 hours
- Medications
- Flush Feeding Tube with 10 ml water after each medication instillation
- Avoid mixing medications before instilling (risk of medication precipitation and obstruction)
- Liquid medications are preferred when available
- However, avoid thick suspensions (e.g. Ciprofloxacin suspension) due to risk of tube plugging
- Medication delivery options
- Intravenous medication forms given via Enteral Tube
- Crush tablets or open capsules and dissolve in water (NOT sustained release medications)
- Hold tube feeds for 30-60 minutes before and after medications that require an empty Stomach
- Monitor levels of medications with narrow therapeutic range
- References
- (2023) Presc Lett 30(3):17-8
XII. Resources
- EMedicine G-Tube Replacement
- Internet Book of Critical Care (EM-Crit, Farkas)
XIII. References
- Majoewsky (2012) EM:Rap 2(9): 7
- Marino (2014) The ICU Book, p. 859-73
- Finucane (1999) JAMA 282:1368 [PubMed]
- Li (2002) Am Fam Physician 65(8):1605-10 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | Administration of nutritional support by means of a tube passed into the stomach. |
| Definition (CSP) | nutritional support given via the alimentary canal or any route connected to the gastrointestinal system (ie, the enteral route); includes oral feeding, sip feeding, and tube feeding using nasogastric, gastrostomy, and jejunostomy tubes. |
| Definition (NIC) | Delivering nutrients and water through a gastrointestinal tube |
| Concepts | Therapeutic or Preventive Procedure (T061) |
| MSH | D004750 |
| SnomedCT | 151309007, 266821004, 61420007, 183028005, 229912004 |
| English | Feeding, Tube, Tube feeding of patient, Enteral Tube Feeding, Gastrogavage, enteral tube feeding, tube feeding, gavage, tube feed, tube feed patient, Gavage, Tube feeding, Enteral tube feeding, TF - Tube feeding, Tube feeding of patient (regime/therapy), Tube feeding of patient (procedure), Tube Feeding |
| Dutch | sondevoeding, Sondevoeding |
| German | Sondenernaehrung, Sondenfütterung, Ernährung, Sonden-, Sondenernährung |
| Italian | Alimentazione forzata, Tubo d'alimentazione |
| Portuguese | Alimentação forçada, Alimentação por Tubo |
| Spanish | Alimentación por sonda, Alimentación por Tubo, gavaje, alimentación del paciente por sonda (procedimiento), alimentación del paciente por sonda (régimen/tratamiento), alimentación del paciente por sonda, alimentación por sonda |
| Japanese | 経管栄養, ｹｲｶﾝｴｲﾖｳ |
| Czech | Výživa žaludeční sondou, krmení sondou |
| French | Alimentation par sonde, Gavage, Alimentation entérale par sonde |
| Hungarian | Orrszondán keresztüli táplálás |
| Norwegian | Sondeforing, Sondemating |
Ontology: enteral tube (C0489826)
| Concepts | Medical Device (T074) |
| LNC | LP71953-1, LP7210-0, MTHU001289 |
| English | Enteral tube, enteral tube, enteral tubes |
Ontology: feeding tube blocked (C2233536)
| Concepts | Sign or Symptom (T184) |
| English | feeding tube blocked (symptom), feeding tube blocked |
Ontology: Feeding tube (C2945625)
| Definition (NCI) | A tube used to provide nutrients to patients who can not swallow. It may be inserted through the nose or placed into the stomach through the abdominal wall. |
| Definition (SPN) | A gastrointestinal tube and accessories is a device that consists of flexible or semi-rigid tubing used for instilling fluids into, withdrawing fluids from, splinting, or suppressing bleeding of the alimentary tract. This device may incorporate an integral inflatable balloon for retention or hemostasis. This generic type of device includes the hemostatic bag, irrigation and aspiration catheter (gastric, colonic, etc.), rectal catheter, sterile infant gavage set, gastrointestinal string and tubes to locate internal bleeding, double lumen tube for intestinal decompression or intubation, feeding tube, gastroenterostomy tube, Levine tube, nasogastric tube, single lumen tube with mercury weight balloon for intestinal intubation or decompression, and gastro-urological irrigation tray (for gastrological use). |
| Concepts | Medical Device (T074) |
| SnomedCT | 9129003, 25062003, 360116009 |
| LNC | MTHU020888 |
| English | Feeding Tubes, TUBE, FEEDING, TUBES,FEEDING, Feeding catheter, device, Feeding tube, device, feeding tube (treatment), feeding tube, a feeding tube, feeding tubes, feedings tube, Feeding Tube, Tubes, Feeding, Feeding tube (physical object), Feeding tube, Feeding catheter, Feeding catheter, device (physical object), Feeding tube, device (physical object) |
| Spanish | sonda de alimentación (objeto físico), sonda de alimentación, catéter para alimentación (objeto físico), catéter para alimentación, tubo de alimentación (objeto físico), tubo de alimentación |
