Module 4.1 Enteral Feeding

Basic Principles of Critical Care

1. ENTERAL FEEDING Gradian Health Systems Basic Principles of Critical Care NUTRITIONAL SUPPORT

2. Disclaimer Basic Principles of Critical Care Training I Enteral Feeding Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications regarding medical care and clinical service delivery. The tables, checklists, and other clinical documents referenced in this training have not been validated in all settings. These documents are intended to serve as examples only. We recognize that all clinical training content and activities must be customized to meet the needs of each facility and its clinical staff, factoring in available resources, practitioner skill level, and other environmental considerations. For any questions regarding the contents or applications of this training, please contact Gradian Health Systems : 40 W 25 th St, 6 th Floor New York, NY 10010 USA [phone] [email protected]

3. Module 4 Gradian Health Systems Basics Principles of Critical Care Nutritional Support

4. Module 4: Nutritional Su pport MODULE OVERVIEW Lesson 1 I Enteral Feeding Lesson 2 I Parenteral Feeding Basic Principles of Critical Care Training I Enteral Feeding

5. Components of the Gradian CCV System Lesson 1: Enteral Feeding Lesson Objectives Describe aspects of enteral feeding Outline the types of enteral feeding tubes Identify patient conditions requiring enteral feeding Basic Principles of Critical Care Training I Enteral Feeding

6. Components of the Gradian CCV System Lesson 1: Enteral Feeding Key Concepts Nutritional status Types of enteral feeding tubes Indications for enteral reeds Types of enteral feeds Complications of enteral feeding Basic Principles of Critical Care Training I Enteral Feeding

7. Components of the Gradian CCV System Enteral Feeding What is Enteral Feeding? Enteral nutrition support refers to the provision of nutritionally complete feeds containing calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids into the stomach or intestine through a tube. The aim of enteral nutrition is to provide adequate nutrition to prevent or reverse the development of malnutrition in patients who are not able to ingest or derive sufficient nutrients from ordinary foods despite having a functional GIT. Enteral nutrition is typically delivered into the stomach (gastric feeding). However, it can also be administered into more distal parts of the alimentary tract (post-pyloric-jejunum), particularly in those at high risk of aspiration or gastric enteral nutrition intolerance. It can be supplemented with parenteral feeding. Basic Principles of Critical Care Training I Enteral Feeding

8. Components of the Gradian CCV System Enteral Feeding Enteral Feeding Indications Critically ill patients Patients with limited or no oral intake due to: Postoperative patients – head and neck surgery Head injury Neuromuscular disorders (e.g. stroke) Cancer patients Upper GI obstruction GU dysfunction Poor mental health Increased nutritional requirements (e.g. burns, prolonged anorexia, HIV wasting disease) Ventilated patients Basic Principles of Critical Care Training I Enteral Feeding

9. Components of the Gradian CCV System Enteral Feeding Enteral Feeding Contraindications Non-functional GIT Paralytic ileus Surgical discontinuity Peritonitis Acute pancreatitis Persistent vomiting and diarrhea Necrosis or mesenteric ischemia GIT obstruction Basic Principles of Critical Care Training I Enteral Feeding

10. Components of the Gradian CCV System Enteral Feeding Enteral Feeding Advantages Maintains mucosal mass Prevents infection by maintaining normal anaerobic flora and preventing overgrowth of pathogenic organisms Maintains functional and structural integrity of the gut Inexpensive Simple placement of feeding tube into correct site Stimulation of GIT hormones and consequently regulated metabolism and utilization of nutrients Ensures adequate supply of nutrition to the mucosal wall and protection against atrophy of the intestinal wall Psychological protection against ulcer (buffering effect from gastric acids) Basic Principles of Critical Care Training I Enteral Feeding

11. Components of the Gradian CCV System Enteral Feeding Types of Enteral Feeds Many different products available Common differences between formulas include osmolarity, caloric density, amount of protein per calorie, and differences in electrolyte, vitamin, and mineral content Most are formulated to provide 100% of daily vitamin and mineral dose when a delivering a minimum of 1,000 or more kilocalories per day Other differences: Intact versus predigested Presence or absence of fiber Presence of absence of disease-specific nutrients Basic Principles of Critical Care Training I Enteral Feeding

12. Components of the Gradian CCV System Enteral Feeding Enteral Feeds for Critically Ill Patients Standard enteral nutrition provides sufficient nourishment for most critically ill patients if given with caloric adequacy Concentrated and predigested enteral nutrition may be preferable for selected patients Basic Principles of Critical Care Training I Enteral Feeding

13. Components of the Gradian CCV System Enteral Feeding Enteral Feeds Daily amount of enteral nutrition is tailored to the nutritional and fluid needs of each patient Most patients require supplementation of water All feeding tubes should have periodic water flushes to minimize cloggin Only water should be used for flushing Acidic fluids should be specifically avoided as they increase clogging Critically ill patients frequently require volume restriction (e.g. patients with respiratory failure or volume overload); concentrated enteral nutrition may be useful for such patients Basic Principles of Critical Care Training I Enteral Feeding

14. Components of the Gradian CCV System Enteral Feeding Enteral Feed Types Standard feeds  1 kcal/ml with or without fiber High energy feeds  1.2-2 kcal/ml with or without fiber Milk free feeds Low sodium feeds Disease specific formulas: Renal – lower protein, potassium, magnesium, and phosphorous Liver disease – increased amino acids (valine, leucine, isoleucine) Diabetes / hyperglycemia – lower carbohydrates, higher fat Pulmonary disease – reduced carbohydrates (COPD), added fish oils (ARDS) Jejunostomy / high output ileostomy Basic Principles of Critical Care Training I Enteral Feeding

15. Components of the Gradian CCV System Enteral Feeding Enteral Feeding Tubes and Routes Nasogastric tube Nasojejunal tube (NJT) – tube is in the jejunum Gastrostomy – percutaneous endoscopic gastrostomy tubes (PEG); surgical Jejunostomy – percutaneous endoscopic jejunostomy tubes (JEJ or PEJ); surgical Basic Principles of Critical Care Training I Enteral Feeding Cancer Research UK / CC BY-SA (https:// creativecommons.org /licenses/by- sa /4.0)

16. Components of the Gradian CCV System Enteral Feeding Nasogastric Tubes Nasogastric and nasojejunal tubes are for short-term use (3-4 weeks) Stomas (PEG, PEJ) are for longer-term feeding (>4 weeks) Mark at the nose should always be recorded Nasogastric tubes that are used for feeding are fine-bore tubes Easy to insert and less invasive as gastrostomy tubes Should not be used in patients with obstructive pathology, base of skull fracture, sinus surgery After insertion, confirm position of NGT Basic Principles of Critical Care Training I Enteral Feeding

17. Components of the Gradian CCV System Enteral Feeding Methods to Assess Tube Placement pH Gastric aspirate should be less than 5.5 Chest X-ray Radiopaque line should follow midline in chest to below the diaphragm and 10 cm beyond the gastroesophageal junction Disadvantage is radiation exposure Basic Principles of Critical Care Training I Enteral Feeding

18. Components of the Gradian CCV System Enteral Feeding Chest X-ray for NGT Placement This is an adequate view that shows below the diaphragm NGT remains midline NGT does to bisect the carina NGT tube tip is visible below the diaphragm for about 10cm Basic Principles of Critical Care Training I Enteral Feeding Case courtesy of Andrew Murphy, <a href ="https:// radiopaedia.org /"> Radiopaedia.org </a>. From the case <a href ="https:// radiopaedia.org /cases/50337"> rID : 50337</a>

19. Components of the Gradian CCV System Enteral Feeding NGT Complications Accidental removal or purposeful removal by patient Malposition – lungs are the most common Aspiration – minimized by elevating head 30 Blockage – tubes should be flushed with water before and after feeds Ulceration of the nasal mucosa Sinusitis Esophagitis and/or ulceration, especially with prolonged use Basic Principles of Critical Care Training I Enteral Feeding

20. Components of the Gradian CCV System Enteral Feeding Nasoduodenal and Nasojejunal (NJ) Tubes Distal tip is in the duodenum or jejunum and may be single, double or triple lumen Placed under endoscopic guidance Placement confirmed with an abdominal X-ray Reduced incidence of gastro-esophageal reflux Basic Principles of Critical Care Training I Enteral Feeding

21. Components of the Gradian CCV System Enteral Feeding Gastrotomy Recommended if feeding required for longer than 4-6 weeks Can be placed endoscopically (PEG), radiologically (RIG), or surgically Vary in size 9-24 FG PEG insertion is not a sterile procedure and prophylactic antibiotics is recommended Contraindications include: Inability to pass the endoscope due to obstructing pathology in oropharynx or esophagus Gastric outflow Ascites coagulopathy (relative contraindication) Insertion may be difficult in obesity Basic Principles of Critical Care Training I Enteral Feeding

22. Components of the Gradian CCV System Enteral Feeding Jejunostomy Passed beyond the duodenojejunal flexure Technically more difficult to insert than PEG Complications of Stomas Early – pain, bleeding, peritonitis, pneumoperitoneum, gastrocolic fistula (if the colon is punctured between the stomach and the anterior abdominal wall) Late – local infection, tube blockage, over granulation Basic Principles of Critical Care Training I Enteral Feeding

23. Components of the Gradian CCV System Enteral Feeding Delivery of Enteral Feeds Feeding can be done as bolus or continuously Continuous  given over 16-18 hours Bolus  given over 15-60 minutes at 3-hour intervals Basic Principles of Critical Care Training I Enteral Feeding

24. Components of the Gradian CCV System Enteral Feeding Complications of Enteral Nutrition Gastrointestinal I regurgitation, aspiration, diarrhea, constipation, dehydration, abdominal discomfort, drug interaction, and contamination Tube-related I m alposition, knotting, perforation of GIT, obstruction, leakage, infection and bleeding, erosion, ulceration, necrosis of skin and mucosal hemorrhage Metabolic I electrolyte imbalance, hypo/hyperglycemia Basic Principles of Critical Care Training I Enteral Feeding

25. Components of the Gradian CCV System Enteral Feeding Nursing Care for Enteral Feeding Nurse the patient with head of the bed elevated at 30-45 degrees Flush tube with 20-30 mls of warm water hourly during continuous feeds and administration of medications Monitor for gradual increase in residual volume  indicator for poor tube feeding tolerance and/or aspiration Evaluate adequacy of gastric emptying, determined by presence or absence of nausea, vomiting, high NGT output Stop feeding if residual volume is > 250 mls Reassess after 2 hours  resume feeding if volume is < 250 mls Assess colonic motility, determined by stool passage Basic Principles of Critical Care Training I Enteral Feeding

26. Components of the Gradian CCV System Enteral Feeding Nursing Care for Enteral Feeding Evaluate small bowel motility by presence or absence of abdominal distension and bowel sounds Determine assimilation of nutrients, clinically indicated by absence of diarrhea Monitor circulating concentration of glucose, triglycerides, BUN, creatinine ratio Maintain intake and output records Label the feeding  time and date started, rate Change administration tubes every 24 hours Avoid contamination of the feeds Check residual volume before each intermittent feed and every 4 hours for continuous feeds Basic Principles of Critical Care Training I Enteral Feeding

27. Components of the Gradian CCV System Enteral Feeding Nursing Care for Enteral Feeding Maintain adequate hydration – 1 ml of water per calorie of formula received Weigh patient regularly Monitor vital signs Monitor blood sugar Promote coping ability – encourage and support the patient to adapt to physical changes, convey hope based on reality Basic Principles of Critical Care Training I Enteral Feeding

28. Components of the Gradian CCV System Lesson 1: Activities Basic Principles of Critical Care Training I Enteral Feeding Question An 94yr old male is admitted for pneumonia. A chest X-ray is requested to assess progression of pneumonia and confirm nasogastric tube position. 1. What is the position of the NGT? 2. What needs to be done next? Answers on the next slide Case courtesy of Andrew Murphy, <a href ="https:// radiopaedia.org /"> Radiopaedia.org </a>. From the case <a href ="https:// radiopaedia.org /cases/50337"> rID : 50337</a>

29. Components of the Gradian CCV System Lesson 1: Activities Basic Principles of Critical Care Training I Enteral Feeding What is the position of the NGT? Answer : the n asogastric tube is positioned within the left lower lobe bronchus 2. What needs to be done next? Answer : repositioning is required Case courtesy of Andrew Murphy, <a href ="https:// radiopaedia.org /"> Radiopaedia.org </a>. From the case <a href ="https:// radiopaedia.org /cases/50337"> rID : 50337</a>