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Section 2 - Management of enteral nutrition

Introduction

Enteral feeding provides physiologic, metabolic, safety, and cost benefits over parenteral nutrition. There are various ways enteral nutritional is administered and scheduled. The method of administration must be individualized to each patient's specific needs. The functioning and capacity of the GI tract, underlying disease states and patient tolerance must be assessed in order to determine the appropriate administration method.


Routes of administration

Understanding the purpose, advantages, and disadvantages of each access route will allow the clinician to choose a method which is best for the patient.

Routes of EN support

EN administration routes

Indications Advantages Disadvantages
Nasogastric
  • Intact gag reflex
  • No esophageal reflux
  • Normal gastric emptying
  • Stomach uninvolved with primary disease
  • Easy tube insertion
  • Larger reservoir capacity in stomach
  • Highest risk of pulmonary aspiration
  • Patient self-conscious due to appearance of nasogastric tube
Nasoduodenal
  • Gastroparesis or impaired gastric emptying
  • Esophageal reflux
  • Reduced aspiration risk compared to NG
  • Potential GI intolerance (bloating, cramping, diarrhea) to goal TF infusion rate
  • May require endoscopic placement of nasoenteric tube
  • Patient self-conscious due to appearance of nasoenteric tube
  • Tube displacement and potential aspiration
Nasojejunal
  • Gastroparesis or impaired gastric emptying
  • Esophageal reflux
  • Gastric dysfunction due to trama or surgery
  • TF may be initiated immediately after injury
  • Reduced aspiration risk compared to NG
  • Potential GI intolerance to goal TF infusion rate
  • May require endoscopic placement of tube
  • Patient self-conscious due to appearance of nasoenteric tube
  • Tube displacement and potential aspiration
Gastrostomy
  • Long-term feeding; normal gastric emptying
  • Swallowing dysfunction and subsequent impairment of ability to consume an oral diet
  • Nasoenteric route unavailable
  • Intact gag reflex; no esophageal reflux
  • Stomach uninvolved with primary disease
  • Placed adjunctly with GI surgery
  • No surgery needed for percutaneous endoscopic gastronomy (PEG)
  • PEG less costly than surgical gastronomy
  • Large bore tube provides decreased risk of tube occlusion
  • Larger reservior capacity in stomach
  • Potential risk of aspiration
  • Stoma care needed; potential infection at stoma site
  • Potential skin excoriation from leakages of digestive secretions at stoma site
  • Potential fistula after tube removed
  • Surgery needed for surgical gastrostomies
Jejunostomy
  • Long-term feeding
  • High risk of aspiration
  • Esophageal reflux
  • Inability to access upper GI tract
  • Gastroparesis or impaired gastric emptying
  • Gastric dysfunction due to trama or surgery
  • Reduced risk of aspiration
  • Placed adjunctly with GI surgery
  • No surgery needed for percutaneous endoscopic jejunostomy (PEJ)
  • PEJ less costly than surgical jejunostomy
  • TF may be initiated immediately after injury
  • Potential GI intolerance to goal TF infusion rate
  • Stoma care needed; potential infection at stoma site
  • Potential skin excoriation from leakages of digestive secretions at stoma site
  • Potential fistula after tube removed
  • Tube occlusion with small bore tube or needle catheter
  • Surgery needed for surgical jejunostomies


Methods of administration

Enteral tube feedings are administered either on a continuous or intermittent basis. Continuous feedings are used to prevent GI intolerance and minimize risk of aspiration. Intermittent feedings may be used in medically stable patients who have adequate absorptive capacity to tolerate bolus feedings. An enteral infusion device (feeding pump) may enhance the safety and accuracy of enteral feedings.

EN administration methods

Indications Advantages Disadvantages
Continuous
  • Initiation of TF
  • Crtically ill patient
  • Small bowel feeding
  • Intolerance of intermittent or bolus TF
  • Pump Assisted
  • Minimizes risk of high gastric residuals and aspiration
  • Minimizes risk of metabolic abnormalities
  • Restricts ambulation
  • Infused over 24 hr/d
  • Increased cost due to equipment and supplies
Intermittent
  • Noncritically ill patient
  • Home TF
  • Rehabilitation patient
  • Flexibility of feeding regimen
  • Inexpensive (less equipment and supplies)
  • Feeding over short time period allows free time between feedings
  • Higher risk of aspiration, nausea, vomiting, abdominal pain, distention, and diarrhea
  • Potential GI intolerance to goal TF infusion rate
  • May require formula with more calories and protein
Bolus intermittent
  • Noncritically ill patient
  • Home TF
  • Rehabilitation patient
  • Ease of administration
  • Inexpensive (no pump)
  • Feeding over short period (usually 15 minutes)
  • Highest risk of aspiration, nausea, vomiting, abdominal pain, distention, and diarrhea
  • Potential GI intolerance to goal TF infusion rate
Cyclic intermittent
  • Noncritically ill patient
  • Home TF
  • Rehabilitation patient
  • Physical and psychological freedom from equipment for 8-16 hr/d
  • Beneficial for transitioning TF to oral diet (TF at night with oral diet during the day)
  • Requires high infusion rate over short period (8-16 hr per period)
  • May require formula with higher calorie and protein density
  • Potential GI intolerance to goal TF infusion rate


Monitoring

Once EN has been initiated for a patient, a variety of complications may develop. For this reason, diligent monitoring is necessary.

Suggested monitoring schedule
Parameter During intiation Stable acute patient Long term patient
Blood chemistry 2 - 3 times/week Every 1 - 2 weeks Every 6 months
Lytes, BUN, creatinine Daily 2 - 3 times/week Every 6 months
Triglycerides Weekly Every 1 - 2 weeks Every 6 months
Glucose 2 - 3 times/week Every 1 - 2 weeks Every 6 months
Serum proteins Weekly Monthly Every 6 months
Weight Daily 2 - 3 times/week Weekly
I & O Daily 2 - 3 times/week Weekly
Nitrogen balance PRN PRN PRN


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Section 2 - Management of enteral nutrition

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