Tube feeding

Information about Tube Feeding by Dr Dhaval Mangukiya.
Details of tube feeding, gastric feeding, jejunal or duodenal feeding, continuous feeding, cyclic feeding, bolus feeding, present guidelines, GRV etc.

https://drdhavalmangukiya.com/

http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat

https://gastrosurgerysurat.blogspot.com/

1. Tube Feeding Dr Dhaval Mangukiya

2. Short Term Access: Anticipated need for enteral feeding < 6-8 weeks Nasogastric Nasojejunal Long Term Access (anticipated need for enteral feeding > 6-8 weeks) Percutaneous Gastrostomy Tubes (PEG) Open Gastrostomy Transgastric Jejunostomy Surgical Jejunostomy

3. Rate of Administration

4. Gastric Feeding Start at a rate of 40 to 50cc/hr If tolerated advanced by 25cc/hr every 4-8 hours (Range 10 to 50 cc/hr) Maximum 250 ml/hr Elemental formulas should start at full strength at 25cc/hr for the first 12 hours then advance by 25cc/hr every 6-12 hours until reaching goal rate

5. Jejunal or duodenal feeding Standard or elemental feedings at full strength at 25 cc/hr for the first 12 hours then advance by 25cc/hr every 6-12 hrs until reaching goal rate. Do not use bolus feeding method Max 100 to 120 ml/hr

6. Methods

7. Continuous feeding Feeding for 24 hours continuously either by gravity drip or feeding pump Preferred method of use if the patient has rapid intestinal transit and may be more suitable for critically ill patients than other regimens Postpyloric feeding is required, continuous feeding is often tolerated better than intermittent

8. Advantages: • Allows the lowest possible hourly feed rate to meet nutrient requirements • Better gastrointestinal tolerance due to the lower feed rate • Better control of blood glucose levels due to continuous carbohydrate input Disadvantages: • Physical attachment to the feeding apparatus (may affect quality of life) • Expense of equipment (pump and giving sets)

9. Cyclic / intermittent feeding Enteral nutrition is stopped for a 4-16 hour period either during the day or at night. The shorter the period of feeding the higher the rate may need to be in order to meet the patient’s requirements. Suitable for pump and gravity drip.

10. Advantages: • Allows greater patient mobility (may improve quality of life) • Allows breaks for physical activity, for administration of medications that are incompatible with feeds, and to encourage oral intake if applicable. • Useful in the transition from continuous to bolus feeding, or from tube feeding to oral intake. • Daytime feeds may reduce aspiration risk if it is difficult to maintain a 30° elevation overnight • Feeding during daytime only is more physiological and may therefore have benefits such as helping to re-establish the diurnal cycle; promoting normal gastrointestinal motility and promoting re-acidification of the stomach (which protects against bacteria).There is no evidence for a benefit of ‘gut rest’, however. Disadvantages: • Compared with continuous feeding, a higher infusion rate is required to provide the same volume of feed. This may be less well-tolerated, with a higher risk of problems such as reflux, aspiration, abdominal distension, diarrhoea and nausea

11. Bolus feeding Defined as rapid administration of a bolus feed /water by syringe (usually by gravity, without the plunger). Bolus feeding is usually into the stomach, which has the reservoir capacity to tolerate a large volume of feed. A prescribed volume of feed is given (such as 100-400ml) over 15-60 minutes at regular intervals. The patient must have a competent oesophageal sphincter and be able to protect his/her airway adequately to minimise aspiration risk, as this risk is higher with larger feed volumes and administration rates.

12. Advantages: • Physiologically similar to a typical eating pattern • Allows greater patient mobility • Convenient for gastrostomy feeding • Can be used to supplement oral intake • Can be flexible to suit the patient’s lifestyle and improve quality of life • May facilitate transition to oral intake

13. Disadvantages: • Large boluses may be poorly tolerated, especially in small bowel feeding • Requires more nursing time compared with pump-controlled feeding • Highest risk of aspiration, reflux, abdominal distension, diarrhoea and nausea

14. Present Guidelines SCCM & A.S.P.E.N Guidelines, McClave et al 2009 Immune modulating enteral formulations for surgical ICU patients – Grade A Patients with ARDS should be placed on an enteral formulation characterized by anti inflammatory lipid profile (Omega 3 fish oil) and anti oxidants – Grade A Combination of anti oxidant vitamins (E &C) and trace minerals (selenium) to be provided to all critically ill patients receiving NS – Grade B Additional of enternal glutamine should be considered in Burn, Trauma and mixed ICU patients – Grade B

15. Evaluate all enterally fed patients for risk of aspiration. (A) Assure that the feeding tube is in the proper position before initiating feedings. (A) After enteral feeding goal rate is achieved and/or the sump tube is replaced with a soft, smallbore feeding tube, gastric residual monitoring may be decreased to every 6-8 hours in noncritically ill patients. (C) However, every-4- hour measurements are prudent in critically ill patients. (B)

16. Monitoring Gastric Residual Volume (GRV) When possible, use a large-bore sump tube for the first 1-2 days of enteral feeding and evaluate gastric residuals using at least a 60 mL syringe. (A) Check gastric residuals every 4 hours during the first 48 hours for gastrically fed patients. If the GRV is > 250 mL after a second gastric residual check, a promotility agent should be considered in adult patients. (A) A GRV >500 mL should result in holding EN and reassessing patient tolerance by use of an established algorithm including physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility agent use, if not already prescribed. (B) Consideration of a feeding tube placed below the ligament of Treitz when GRVs are consistently measured at > 500 mL. (B)

17. Flush feeding tubes with 30 mL of water every 4 hours during continuous feeding or before and after intermittent feedings in an adult patient.(A)

18. Elevate the backrest to a minimum of 30º, and preferably to 45º, for all patients receiving EN unless a medical contraindication exists. (A)