II. Physiology: Enteral Nutrition Benefits

  1. Enteral Nutrition is preferred (even in intubated patients)
  2. Gastrointestinal integrity is maintained with enteral feedings
    1. Decreased risk of Gram Negative bacteremia from translocation
  3. Decreases Malnutrition
  4. Decreases Stress Ulcer risk
  5. Decreases ileus risk

III. Contraindications: Enteral Nutrition

  1. Bowel perforation
  2. Complete Small Bowel Obstruction
  3. Upper Gastrointestinal Hemorrhage
  4. Mesenteric Ischemia
  5. Circulatory shock requiring high dose Vasopressors
  6. Pancreatitis is NOT a contraindication to enteral feeding
  7. Absent bowel sounds in ICU patients is NOT a contraindication to enteral feeding
    1. Baid (2009) Br J Nurs 18(18):1125-29 [PubMed]

IV. Types: Delivery

  1. Short-term Feeding Tubes
    1. Orogastric Tube
      1. Typically used in intubated patients
    2. Nasogastric Tube
      1. Most commonly used as is physiologic and allows for large volume bolus feedings
    3. Smaller caliber nasal Feeding Tube (post-intubation)
      1. Smaller caliber does not allow for gastric suctioning
      2. Can be left in place longer than larger bore tubes
    4. Nasoduodenal Tube (post-pyloric Feeding Tube)
      1. Indicated if higher Aspiration Pneumonia risk, gastric dysmotility or obstruction
        1. Alkhawaja (2015) Cochrane Database Syst Rev 4;(8):CD008875 +PMID:26241698 [PubMed]
      2. Requires continuous delivery device
  2. Enterostomy Tube
    1. Indicated for anticipated enteral feeding beyond 4 weeks
    2. Sub-types
      1. G-Tube: Gastrostomy or Gastric Tube
        1. Medication delivery
        2. Feedings may be drip or bolus
      2. GJ-Tube: Combined tube with both Gastric and Jejunal ports
        1. Medication delivery or bolus feeds via gastric port
        2. Drip feeds via jejunal port
      3. J-Tube: Jejunostomy or Jejunal Tube
        1. Requires drip feeds
        2. Bolus feeds result in Osmotic Diarrhea

V. Preparations

  1. See Enteral Nutrition
  2. Obtain nutrition Consultation
  3. Standard solution: 1 kcal/ml (e.g. Osmolite, Isocal, Replete)
  4. Renal Failure: 2 kcal/ml of renal preparation (e.g. Novasource Renal)

VI. Technique

  1. Confirm Feeding Tube placement on XRay before first use
    1. Feeding Tubes may be misplaced into airway and lungs with catastrophic results if used
  2. Start Tube Feeding early (within first 24-48 hours of ICU admission)
    1. Consider starting with small volumes (10-20 ml/h) and advance to target over 6-8 hours
    2. Start regardless of presence of bowel sounds (see above) unless other contraindications
    3. Typical target rate: 1 ml/hour/kg (based on Ideal Body Weight if obese)
    4. Renal Failure rate: 0.5 ml/hour/kg of the concentrated 2 kcal/ml formula
    5. Subtract Propofol (1 kcal/ml) rate from the target rate
  3. Avoid holding feeding aside from procedures or intolerance (e.g. Abdominal Distention, Vomiting)
    1. Gastric Residual Volumes do NOT need to be obtained and should not result in held feedings
    2. However, large Residual Volumes >500 ml may be of concern (see aspiration risk reduction below)
    3. Poulard (2010) JPEN J Parenter Enteral Nutr 34(2):125-30 +PMID:19861528 [PubMed]
    4. Reignier (2013) JAMA 309(3):249-56 +PMID:23321763 [PubMed]

VII. Complications: Obstructed or Clogged Feeding Tube

  1. Attempt to flush tube with warm water (effective in 30% of cases)
    1. Alternate aspirating and injecting may help to dislodge obstruction
  2. Instill Pancreatic Enzymes (effective in 75% of cases)
    1. Dissolve 1 tablet Viokase and 1 tablet Sodium carbonate 324 mg in 5 ml water
    2. Inject solution into Feeding Tube and clamp for 5 minutes
    3. Last, instill warm water flush
  3. Fogarty catheter technique
    1. Obtain Informed Consent
      1. Technique increases Feeding Tube pressure and may result in perforation, leak or tube aneurysm
    2. Obtain proper Fogarty catheter size (#4 for 10 to 12F Feeding Tubes, #5 for 14F Feeding Tubes)
    3. Estimate the length of the indwelling Feeding Tube and mark the Fogarty catheter at this length
    4. Insert the Fogarty catheter to the end of the estimated Feeding Tube length (marked distance)
    5. As resistance is met, inflate and deflate the Fogarty balloon and attempt to advance further
      1. Repeat as needed until estimated end of Feeding Tube is reached
      2. Inflate and deflate the Fogarty balloon one last time at the end of the Feeding Tube
    6. Withdraw the Fogarty catheter, stopping periodically to inflate and deflate the balloon
    7. Confirm clearance and tube integrity with KUB XRay after instilling 20-30 ml contrast via tube
    8. References
      1. Warrington (2022) Crit Dec Emerg Med 36(8):20
  4. Attempt to carefully pass flexible wire or drum cartridge catheter down tube
  5. Replace persistently clogged tubes

VIII. Complications: Aspiration Pneumonia

  1. Consider aspiration mitigation strategies if signs of regurgitation, Vomiting, or very high Residual Volumes (>500 ml)
  2. Raise head of bed to 45 degrees
  3. Advance Feeding Tube into Small Bowel (post-pyloric)
  4. Consider short-term prokinetic use in Gastroparesis (marginal efficacy that wanes to ineffective over days)
    1. Avoid these agents in Bowel Obstruction
    2. Erythromycin 200 mg IV every 12 hours
      1. Risk of promoting Antibiotic Resistance
      2. Consider starting with Erythromycin and adding Metoclopramide in 24 hours if needed
    3. Metoclopramide (Reglan) 10 mg IV every 6 hours
      1. More effective when used in combination with Erythromycin
    4. Naloxone 8 mg via Nasogastric Tube every 8 hours
      1. May improve gastric emptying if due to Opioid induced Gastroparesis

IX. Complications: Diarrhea

  1. Occurs in 30% of patients on enteral feedings
  2. Liquid drug preparations contribute to most cases
  3. High osmolality Oral Liquid Medications causing Diarrhea (>3000 mosm/kg water)
    1. Acetaminophen
    2. Dexamethasone
    3. Ferrous Sulfate
    4. Hydroxyzine
    5. Metoclopramide (Reglan)
    6. Multivitamin
    7. Potassium chloride
    8. Promethazine
    9. Sodium phosphate
  4. Sorbitol Containing Oral Liquid Medications causing Diarrhea
    1. Acetaminophen
    2. Cimetidine
    3. Isoniazid
    4. Lithium
    5. Metoclopramide (Reglan)
    6. Theophylline
    7. Tetracycline
  5. References
    1. Williams (2008) Am J Health-Sys Pharm 65:2347-57 +PMID:19052281 [PubMed]

X. Complications: General

  1. Nasogastric or Nasoduodenal Tube Intolerance (nasal discomfort, gagging)
  2. Tube malfunction, obstruction or migration
  3. Nausea or Vomiting
  4. Abdominal cramping, Diarrhea
    1. Higher risk with hyperosmolar medications (e.g. Acetaminophen, Potassium), Sorbitol (>15 g/day)
    2. Dilute liquid medications with 10-30 ml water
  5. Gastrointestinal Bleeding
  6. Bowel Obstruction
  7. Provocation of Gastroesophageal Reflux
  8. Increased skin moisture and maceration
  9. Agitation with a greater need for restraints
  10. Hyperglycemia
    1. Be aware of the high sugar content in liquid medications

XI. Prevention: Complication avoidance with nasogastric and nasoduodenal Feeding Tubes

  1. Periodic confirmation of Feeding Tube (depth marker, Xray)
  2. Flush Feeding Tube with 30 ml water every 4 hours
  3. Medications
    1. Flush Feeding Tube with 10 ml water after each medication instillation
    2. Avoid mixing medications before instilling (risk of medication precipitation and obstruction)
    3. Liquid medications are preferred when available
      1. However, avoid thick suspensions (e.g. Ciprofloxacin suspension) due to risk of tube plugging
    4. Medication delivery options
      1. Intravenous medication forms given via Enteral Tube
      2. Crush tablets or open capsules and dissolve in water (NOT sustained release medications)
    5. Hold tube feeds for 30-60 minutes before and after medications that require an empty Stomach
    6. Monitor levels of medications with narrow therapeutic range
  4. References
    1. (2023) Presc Lett 30(3):17-8

XII. Resources

XIII. References

  1. Majoewsky (2012) EM:Rap 2(9): 7
  2. Marino (2014) The ICU Book, p. 859-73
  3. Finucane (1999) JAMA 282:1368 [PubMed]
  4. Li (2002) Am Fam Physician 65(8):1605-10 [PubMed]

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