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2009 inservice aspen guideline presentation

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The document provides guidelines for enteral nutrition including criteria for use, access devices, initiation and advancement of feeding, administration methods, monitoring, and safety. It recommends starting enteral nutrition at 25% of goal rate and advancing slowly over 3-5 days to prevent refeeding syndrome in at-risk patients such as those with malnutrition. Guidelines are given for checking and interpreting gastric residual volumes to monitor for intolerance and reducing risks of aspiration.

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Enteral Nutrition Practice Recommendation
Introduction Criterion for enteral nutrition Unable to take nutrients orally With function gut and GI tract
Enteral Access Devices Nonsurgical Naso-gastric/ Naso-duodenal/Naso-jejunal Surgical Gastrostomy Percutaneous endoscopic gastrostomy (PEG) Jejunostomy Percutaneous endoscopic jejunostomy (PEJ)
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Enteral Access Devices Candidates Gastric With functional stomach Small Bowel Gastric obstruction Gastroparesis Pancreatitis Reflux of gastric contents Easily aspirate
Long-term Feeding Devices Should be considered when the need for enteral feeding is at least 4 weeks in adults, children, and infants after term age Considerations: Whether benefit outweighs the risk of placement Whether insertion of the feeding tubes near end-of-life warranted Whether insertion is indicated for patients who are close to achieving oral feeding Abdominal imaging should be performed prior to permanent feeding device placement Document tube types, tip location, and external markings in the medical record and in follow-up examinations.
Initiation of feeding after placement of Long-term Enteral Access Device
Timing of enteral support For all post-operative patients Feeding can be initiate without bowel movement or flatus Usually within 24 - 48 hours
Timing of enteral support For patients with PEG placement Feeding can be initiated, Within 2 hours of placement in adult Within 6 hours of placement in infant/children
Initiation and Advancement of Enteral Nutrition Regimen
Administration Rate Choose full-strength, isotonic formulas for initial feeding regimen. Preterm, critically ill, or malnourished children with continuous feeding, use 0.5 - 1 mL/kg/hr initial volume
Type of administration Intermittent Bolus Continuous Cyclic
Administration Rate INTERMITTENT 3-8 times/day With increases of 60-120mL every 8-12 hours as tolerate up to the goal volume Delivered via a feeding container/ bag over 30-45 minutes Stomach only, No jejunal and small bowel feeding
Administration Rate BOLUS (a form of intermittent feeding) 3-8times/day With increases of 60-120mL every 8-12 hours as tolerate up to the goal volume Delivered by gravity via a syringe over 15 minutes Stomach only NEVER in critically ill patients For children, start with 25% of goal volume. Increase by 25% per day as tolerated
CONTINUOUS Initial at 10-40mL/h Advanced to the goal rate in increments of 10-20 mL/h every 8-12 hours as tolerated OR Start at 1-2mL/kg/hr Advanced by 0.5-1mL/kg/hr every 6-24hrs until the goal volume is achieved Administration Rate
Enteral feeding pump Calibrate feeding pumps periodically Make sure it function properly Use pump that deliver within 10% of the prescribed amount of formula.
Flushes Recommendation Use sterile Water For Continuous feeding Flush every 4 hours, 30mL water For Intermittent feedings Flush before and after feeding, 30mL water For clogged tube, use Viokase, Sodium Bicarbonate Place the tip of feeding tube in the alkaline proximal small intestine to decrease clogging
Medications Administration
General Considerations NO MEDICATION SHOULD BE MIXED DIRECTLY WITH FEEDING FORMULA . Do not mix medications together. Each medications should be administered separately. Sublingual or buccal tablets should NOT be delivered via feeding tube. Certain medications should NOT be crushed or opened to administer via feeding tube, such as enteric coated extended release sustained release, or timed-release drugs
Recommendation Dilute medications with sterile water prior to administration Identify the tube tip’s location prior to medication delivery Flush tube with at least 15mL of water before and after administering medications Flush tube with 15mL water between multiple doses of medications.
Recommendation (cont’) Notify the pharmacy that the medication is for feeding tube delivery. Ask for liquid form if possible. Confirm with the pharmacy which medications can be crushed or opened. Crush the tablet into a fine powder and mix with room temperature sterile water.
Monitoring Enteral Nutrition Administration
Monitoring Refeeding Syndrome (RS)
Monitoring Refeeding Syndrome (RS) Procedures Identify patients at high risk for RS Check metabolic and nutrition parameters Prevent RS Initiate nutrition support at ~25% of the estimate goal and advanced over 3-5 days of goal rate
Patients at high risk for RS Anorexia Protein-energy malnutrition Patients from skilled nursing facilities Unfed for 7-10 days Chronic disease patients Hx of excessive alcoholic intake Morbid obesity with massive wt loss
Check Metabolic and nutrition parameters Signs of RS % IBW < 100 Low serum potassium , magnesium , and phosphorus (hallmark sign of RS) Pro-long starvation (usually > 24 - 72 hours) Other signs include Sodium and water retention Thiamin deficiency
Prevent RS For severe malnutrition , critically ill , severe trauma , and burns patients, Correct electrolytes abnormalities before initiation of nutrition support, even serum level is normal
Recommendation (Not from ASPEN Guideline) For NORMAL renal function patients Provide electrolytes supplementation before and during nutrition support 10-15 mmol of phosphate/1000kcal Minimize sodium to < 460mg/day Minimize total fluid to <1000mL/day 3-6mg thiamine/day 1mg folic acid/day, for 5-7 days
Initiation of Nutrition Support START LOW & GO SLOW Initiate at ~25% of the estimate goal and, Advanced over 3-5 days of goal rate
Monitoring Gastric Residual Volume (GRV)
Method to Detect Aspiration Blue Dye Method & Glucose Oxidase Strips are no longer used
Guideline for checking GRV For critically ill patients (both adult and pediatric), Check GRV every 4 hours For non-critically ill patients, Check GRV every 4 hours during the first 48 hours Decrease to 6-8 hours to monitor GRV level
Interpreting the Relationship Between Aspiration and GRVs GRV of 200-500mL should stimulate a step-wise approach to assess the potential of GI intolerance. In the absence of GI intolerance, EF should not be stopped if GRV <400-500mL. In critically ill patients, a GRV ≥ 250mL should be accepted to improve the delivery of EN
Use of Prokinetic Agent If the GRV is ≥ 250mL after a second gastric residual check, a promotility agent should be considered in adult patients.
When to hold EF? For all TF adult patients GRV > 500mL For continuous feeding, GRV ≥ hourly rate For bolus feeding, GRV > half of the previous feeding volume
Labeling EN order should include: Patient demographics (pt name, DOB, wt, location, MRN) Formula name Delivery site/device (NG, PEG, PEJ) Administration method and rate Bolus/intermittent/continuous/cyclic Volume Rate of administration
Enteral Formula Safety Sterile, liquid EN formulas should be used in preference to powdered, reconstituted formulas whenever possible Store unopened commercially-available liquid EN formulas under controlled conditions (dark, dry and cool) Formulas reconstituted in advance should be immediately refrigerated, and discarded within 24 hrs of preparation if not used Discard formulas that exposed to room temperature for longer than 4 hrs
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2009 inservice aspen guideline presentation

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

Editor's Notes

  • #6: Gastroparesis (N/V due to retention of food in the)
  • #9: Traditionally – wait until there was evidence that bowel function had returned as evidenced by flatus or a bowel movement
  • #12: Usually recommendation = 30mL/hr
  • #18: Gastric tubes are more easy to clog due to coagulations of protein with the acidic gastric fluid.
  • #20: 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)
  • #21: 2) because drug absorption can be affected by the tip’s location.
  • #32: Larger GRV, slower Gastric emptying