Transcript Enteral Nutrition

Enteral Access and
Drug Administration
Barbara Magnuson, PharmD BCNSP
Nutrition Support Service
Enteral Nutrition (EN)

Nutrition delivered to the GI tract
–
Normal eating
 Food
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Enteral access devices
 aka
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delivered to the stomach or small bowel
- feeding tubes (FT)
Standard formulas
Specialty formulas
Delivery pumps
Advantages of EN vs. PN
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Maintains intestinal villus height and enterocytes
Stimulates Mesenteric blood flow
Stimulate gut growth factors and normal GI secretions
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Easier to manage caloric/protein/vitamins and fluid requirements
Less metabolic complications (i.e. infections and glucose)
Provides conditionally essential nutrients not in PN
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Maintains the gut barrier & immune function
Prevents bacterial overgrowth and stasis
Glutamine (amino acid) essential for small bowel growth
Medium chain fatty acids
Additional trace elements
More physiologic & Less expensive - $20/day versus ~ $400/day
Case
Ms Johnson is an 82 yo nursing home resident
 She has insulin dependant diabetes and gastro
paresis with some vomiting after each meal
 The physician wants her to receive PN

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What is her indication for PN?
What nutritional alternatives is there for Ms. Johnson?
Would EN or PN be easier in a nursing home?
Is there harm in PN?
How would she receive her enteral nutrition
Case
Ms Johnson, 82 yo nursing home resident,
with diabetes, gastro paresis, and vomiting
 What is her indication for PN?

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NO
WHY?
She has a functional GI tract
What nutritional alternatives is there for Ms.
Johnson?
 EN
Case
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Ms Johnson, 82 yo nursing home resident, with
diabetes, gastro paresis, and vomiting
Would EN or PN be easier in a nursing home?
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Enteral is much easier, safer, and cost effective to
deliver
Is there harm in PN?
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Yes
hyperglycemia, infections, electrolyte abnormalities
Case
Ms Johnson, 82 yo nursing home resident, with
diabetes, gastro paresis, and vomiting
 How would she receive her enteral nutrition?
 A feeding tube (FT) placed into the
small bowel
 ? Why not the stomach?
Enteral Access Devices
Feeding Tube Nomenclature - locations
 Stomach
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Naso-gastric (NG)
Gastrostomy (G-tube)
Percutaneous Endoscopic Gastrostomy (PEG)
Small bowel (duodenum or jejunum)
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naso-duodenal (ND)
naso-jejunal (NJ)
jejunostomy (J-tube or PEG/J)
GI Anatomy
Case
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Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro
paresis, and vomiting, now has a PEG/J tube
Where is the enteral feeding delivered?
What formula would be best for her?
How does she receive her medications?
Which tube should the nurse place her medications?
How would maintain the feeding tube so it does not
get clogged?
Enteral Access Devices
•Naso-gastric tube (NG)
•Large bore tube 18 - 24 French
•Primarily used to remove
gastric secretions to prevent
aspiration, continuous suction
•Not usually used for feeding
•Can be used to administer
drugs into the stomach
•CAUTION – when
administering drugs via NG
when gastric contents are also
removed from it
Enteral Access Devices
Gastrostomy (G-tube)
Percutaneous Endoscopic Gastrostomy
(PEG)
•Food & Drugs are
delivered into stomach
•Removes gastric content
•Caution when removing
gastric residual, removes drug
therapy also
Enteral Access Devices
Naso-duodenal
Naso-jejunal
•Smaller tubes (8-14 Fr)
for nutrition support
•Optimal drug absorption
in the small bowel
•Medications best if
delivered in a liquid
•Avoids gastric emptying
problems
Enteral Access Devices
Jejunostomy
(J-tube)
•Very small (4-10 Fr.) tube
•Clogs easily with thick or
viscous EN or drugs
•Fiber formulas can clog the
J-tube
Enteral Access Devices
Jejunostomy
•CAUTION or Avoid
drug administration via
a small J-tube
•Very thin liquids
•Deliver meds with oral
syringe
Enteral Access Devices
Gastrostomy/Jejunostomy
(PEG/J) •G-tube
•J-tube clogs easily avoid
thick drugs or administration
•Small jejunostomy inside
PEG or G
•G-tube used for suction,
decompression, or drug
administration into stomach
•J-tube used for feeding
Establishing Enteral Access
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Prokinetic agents (motility)
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Metoclopramide
Pt on their right side
Abdominal X-ray
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confirm GI location
confirm it is NOT in the lung
Case
Ms Johnson, 82 yo, 66”, 56kg, with diabetes,
gastro paresis, and vomiting, now has a PEG/J
tube
 Where is the enteral feeding delivered?

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The food will be delivered via the J-tube into the
small bowel.
The food will not be put into the stomach.
Is there anything wrong with the stomach?
Feeding Techniques (ex. 2L)
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Bolus
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Intermittent –
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240ml (1 can) 8 times during the day
Continuous
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480ml (2 cans) 4 times during the day
@ 80ml/hr
Usually @ 40 - 90ml/hr
Feeding Pumps: Delivers accurate
continous volume
Feeding Techniques
Initiation - slow at first to determine tolerance
@ 10ml/hr
 Advancement
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by 10-25ml/hr every 6 - 8 hours if feeding
continuously
Diluting
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DO NOT dilute isotonic formulas
No benefit in diluting most formulas
Enteral Products
Enteral Products
Patient specific formulas
Specific amount of calories
 Specific amount & type of protein
 Specific type of fat supplement
 Small or large total volume
 Specific type of vitamins
 Additional fiber

Enteral Products – Protein
 Protein
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amount varies in different products
22g/L, 34g/L, 60g/L, 95g/L
 Intact
proteins (standard casein)
 Small peptides (easiest to absorb)
 Free amino acids
 Trauma & Burn patients need high protien
feedings
Enteral Products - Carbohydrates
 Simple
(single sugars)
 More complex (maltodextrin/corn starch)
 Lactose free - lactase deficiency in elderly
& stressed
 Soy or oat fiber, regulates bowel function
(only included in certain formulas) Ex.
Fibersource®, Jevity®
Enteral Products - Fats
 Essential

fatty acids - lineoleic & linolenic
Medium & Long Chain Fatty acids (LCFA)
 Fat
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Absorption
LCFA require lipase & bile salts
Medium chain fatty acids (MCFA) do not
require lipase or bile, better absorption if lipase
deficiency is present
Enteral Products - Fats
 Content
varies
 Optimal ratio: < 30% fats : 70% (CHO +
protein)
 Some products - very high or low fat %
 Vivonex® - 6% fat
 Pulmocare® 55% fat --> diarrhea
Enteral Products - Electrolytes
Amounts vary for special disease states
 Most all EN products are low in sodium

 Potassium
may vary with protein content, especially
if high protein content
 Renal Product - no electrolytes (RenalCal®)
 Renal Pruduct - low electrolytes (Nepro®)
 Heptic Product - very low sodium (NutraHep®)
Multivitamins & Minerals
Some vitamins are included in most all enteral
products
 RDI is listed as volume or calorie related (ie.
2L or 1400kcal to meet 100%)
 Volume RDI amount varies for specific
disease states
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More or less water/fat soluble vitamins
Vitamin K amount varies drastically Warfarin resistance has developed
Enteral Products – Caloric density
 Caloric
density varies
0.6Kcal/ml - very dilute
– 1 kcal/ml - (Osmolite®)
– 1.5 kcal/ml (Boost® Plus, Ensure® Plus)
– 2.0 kcal/ml (Nutren 2.0®) – very concentrated
Disease states - congestive heart failure or
traumatic brain injruy patients might need less
enteral volume
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Enteral Products
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Viscosity
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Osmolarity varies
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Increases with caloric density
High protein formulas are often very thick
Can clog a small feeding tube (J Tube)
Isotonic (300mOsm/L) IsoCal®
Up to 1200mosm/L (Vivonex®)
Fiber
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Regulates large bowel function
Ex. UltraCal®, Fibersource®, Jevity®
Enteral Products
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Flavored supplements
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Nonflavored
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Ensure®
Boost Plus®
Tube feeding products only
Osmolite®
Free water content: Range 50-85%
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Usually decreases with calorie dense products
Often need supplemental free water added to EN regimen for
home and nursing home patients
Case
Ms Johnson, 82 yo, 66”, 56kg, with
diabetes, gastro paresis, and vomiting,
now has a PEG/J tube
 What formula would be best for her?
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Osmolite®
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Calories: 1.0 kcal/mL
Non-flavored!
Protein 44.3g/L (16.7% Calories)
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soy protein
Fats: MCT:LCT Ratio: 20:80
Osmolality: 300
Free Water: 84.2%
100% RDIs: 1321mL (@ 1400kcal)
Excellent for Nursing home or LTAC patients
IsoSource® HN
Calories: 1.2 kcal/mL
 Protein 53.6g/L (18% Calories)
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soy protein
Fats: MCT:LCT Ratio: 20:80 n6:n3 Ratio: 2.7:1
 Osmolality: 490
 Free Water: 82%
 100% RDIs: 1165mL (@ 1400kcal)
 Excellent for Nursing home or LTAC patients
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Fibersource ® HN
Calories: 1.2 kcal/mL
 Protein: 54g/L (18% Calories)
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Protein: soy protein isolate
Fats: MCT:LCT Ratio: 20:80
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n6:n3 Ratio: 2.7:1
Osmolality: 490
Free water: Water 81%
100% RDI: 1250mL (1500kcal)
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Fiber : 10 g/L (soy fiber)
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®
Isosource 1.5
Cal
Calories: 1.5 cal/mL
 Protein: 67.6g/L (18% Calories)
 Fats: MCT:LCT Ratio: 30:70
n6:n3 Ratio: 4.1:1
 Osmolality: 585-650 (unflavored)
 Free water: Water 78%
 100% RDI: 980mL (1470kcal)
 Fiber : 8 g/L (soy fiber)

®
Nutren
2.0
Calories: 2.0 kcal/mL (dense)
 80g/L protein (16% Calories)
 Fats: MCT:LCT Ratio: 75:25
n6:n3 Ratio: 4.6:1
 Osmolality: 745
 Free Water: 70%
 100% RDIs: 750mL (@ 1500kcal)
 High ICU usage because calorically dense
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Fat
Modulars
Benecalorie:
330 kcal, 7 gm protein, 33 gm Fat
Posaconazole - Noxafil®
•MCT - Medium Chain Triglycerides
115Kcal/Tbsp, expensive
•Microlipid - primarily LCT (Long Chain)
4.5Kcal/ml
Nutritional Modules
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Protein
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intact protein supplement
Ex. Egg whites (13g/120ml)
Prostat
BeneProtein ® (6gm)
Fiber –
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Unifiber ®
Benefiber ® (4gm)
Medicare – Enteral Nutrition
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EN is available for a beneficiary requiring tube feeding “to provide
sufficient nutrients to maintain weight and strength commensurate
with the patient’s overall health status” because of either:
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a. “ Permanent non-function or disease of the structures that normally permit
food to reach the small bowel,” or
b. “disease of the small bowel which impairs digestion and absorption of an
oral diet.”
(www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=180.2&ncd_version=1&basket=ncd%
3A180%2E2%3A1%3AEnteral+and+Parenteral+Nutritional+Therapy)
EN may be given by nasogastric, jejunostomy, or gastrostomy
tubes and can be provided safely and effectively in the home by
nonprofessional persons who have undergone special training.
Medicare Part B
Reimbursement EN
25-30Kcal/kg/day
 Reimbursement: UNITS = 100calories
 EN - reimbursed based on the number of “units”
of formula and a supplier must submit the
appropriate Medicare billing documents with
“units” per day consumed by a beneficiary and
not the number of cans or cases used.
 Recertification required every 3, 9, & 24 months

Enteral Products
Product
Kcal/ml
 Peptamen Bariatric® 1.0
 Isosource HN®
1.2
 Isosource 1.5®
1.5
 Impact Peptide®
1.5
 Nutren 2.0®
2.0

Prot (g)/L
93.2
53.6
67.6
94
80
Case
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Ms Johnson, 82 yo, 66”, 56kg, nursing home
resident, with diabetes, gastro paresis, and vomiting
Feeding tube placed into the small bowel
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Ms Johnson requires:
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Nasojejunal feeding tube
Jejunostomy feeding tube
PEG/J
@ 1400 – 1680 total Kcals/day
@ 62 - 73g/d protein (1.1 – 1.3g/kg/day)
@ 1500ml/day fluids
Which enteral product & rate best meets her needs?
Case

Ms Johnson requires:
@ 1400 – 1680 total Kcals/day
– @ 62 - 73g/d protein (1.1 – 1.3g/kg/day)
– @ 1500ml/day fluids
Rate
Total
Protein
Product
(ml/hr)
(Kcal/d)
(Gm/d)
Isosource HN® 55 (1320ml)
1584
71
Isosource 1.5®
45 (1080ml)
1620
73
Impact Peptide® 45 (1080ml)
1620
102
Nutren 2.0®
35 (840ml)
1680
67
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Case

What if Ms Johnson has:
Dehydration or diarrhea - dilute formula, fiber
– Congestive heart failure? – concentrated formula
– Skin breakdown – increase protein
Rate
Total
Protein
Product
(ml/hr)
(Kcal/d)
(Gm/d)
Fibersource ®
55 (1320ml)
1584
71
Isosource 1.5®
45 (1080ml)
1620
73
Impact Peptide® 45 (1080ml)
1620
102
Nutren 2.0®
35 (840ml)
1680
67
Beneprotein
2packets
50
12
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Complications of Enteral Nutrition
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Tracheobronchial aspiration risk
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ICU patients - absent gag reflex
DM - poor gastric empty
History of aspirations
Maxillary-mandibular Fixation (IMF)
Prevention
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elevate bed 30 degrees
use pump for accurate infusions rate
observe for vomiting or excessive gastric residuals
Complications of Enteral
Nutrition (Diarrhea)
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DRUGS, DRUGS, DRUGS!!!
Drug related (SORBITOL)
Prolong antibiotic therapy or other drug therapy
Hyperosmotic enteral formula or electrolyte solution
Laxative therapy
Hypoalbuminemia - bowel edema
Lactose intolerance or fat malabsorption
Rapid GI transit
Low-residue intolerance (lack of bulk)
Rapid formula administration using syringe force
Bacterial contamination - Change feeding bag every 24 hr
Complications of Enteral Nutrition
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Nausea/Vomiting
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Constipation
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Drug therapy – chemotherapy, anesthesia, narcotics
Rapid gastric administration
Inadequate fluid or free water intake
Inactivity
Abdominal distention
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Decrease gastric emptying from anesthesia, surgery,
narcotics, diabetes, or renal failure
Case
Ms Johnson, 82 yo, 66”, 56kg, with
diabetes, gastro paresis, and vomiting,
now has a PEG/J tube
 Isosource 1.2 HN® running @ 55ml/hr
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1584kcal/day
71g/day protein
Which tube should the nurse place her
medications?
Drug Administration
via Enteral Access
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Know the type of enteral access
Know the location of the enteral access
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Gastric – NG, G-tube, PEG
Small bowel – ND, NJ, PEG/J, J-tube
Know the drug therapy and formulation
Know the special drug properties
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drug route, IV or PO
enteric coated
extended release
Drug Administration
Which tube to administer the drug?
 Stomach
 Preferably a gastric tube (NG)
–
Feeding tube if high NG output
 G-port
of PEG/J
 Avoid J-tubes
–
too small unless finely crushed and completely
liquefied
Drug Administration
Flush all feeding tubes with water before
and after each medication
 Change medications to liquid route and
dilute *sorbitol exception*
 Administer each drug separately
 Do not add drug directly to enteral
nutrition product

Drug Delivery: Know FT tip location
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Stomach
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Duodenum
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Antacids, iron, sucralfate, ketaconazole
Most medications are absorbed in the small bowel
Digoxin undergoes acid hydrolysis in the stomach, higher
levels when delivered in the small bowel
Jejunum
–
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Decrease ciprofloxacin absorption (prefer duodenum/ early
jejunum)
Extensive first-pass hepatic metabolism (e.g., opioids, tricyclic
antidepressants, β-blockers, nitrates) may have increased
absorption and greater systemic effects
Physical Incompatibilities
Enteral Nutrition

Viscous medications
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Hypertonic medications (3,000-11,000mmol/kg)
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Thick syrups or mineral oil
Sevelamer® – manufacture recommends against TF
administration  clogs feeding tubes!
Electrolytes and elixirs
Osmotic gap diarrhea (>100mOsm/Kg) – unabsorbed
osmotic substances in the stool
Physical Incompatibilities
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Bolus most all medications
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Acidic Medications
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Kaopectate
Electrolytes
Potassium chloride, guaifenesin
Do not mixed directly with Enteral Products
Curdles intact protein
Alcohol from elixers – precipitate inorganic
salts in the enteral formula
Physical Incompatibilities
Enteral Nutrition
Special drug properties – DO NOT CRUSH!
 EC, XL, SR, CD
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enteric coating
extended length
sustained release
controlled release
Toxic or Sub therapeutic effects
Change medication to standard formulation
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Example: ASA, Viokase powder, non SR formula
Physical Incompatibilities
Special drug properties – OK to give but DO NOT
CRUSH!
 Microencapsulated drug via a Large bore feeding
tube

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Beads or pellets
Mixed with water or acid and not crushed but flushed
down feeding tube
Ex. Diltiazem, ferrous gluconate, nizatidine, pancreatic
enzymes, verapamil
CAUTION: clogged tubes  no food or meds!
Physical Incompatibilities

Phenytoin
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Carbamazepine
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Adsorbs to the FT
Dilute suspension and monitor for efficacy
Itraconazole
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Unknown if due to the EN protein, electrolytes, pH, or if adsorbs to the
enteral access device
Hold TF one hour before and after each dose
Erratic bioavailability but improved in fasted state
Hold TF one hr before and after each dose
Option: Doubles the dose (increases GI side effects of diarrhea)
Tetracyclines
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Complexes with di and trivalent cations – separate dose from EN or hold
EN for an hour before an after and flush FT
Physical Incompatibilities

Fluoroquinolones:
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Levothyroxine
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? Chelates with multivalent cations: Ca, Iron, Mg or binds to EN protein
Holding TF before and after each dose: often recommended but has not
shown to improve absorption
Ciprofloxacin: Option: increase dose for Levofloxacin – no data
Moxifloxacin – best bioavailability with EN
Best absorbed in fasted state
Hold TF 1-2hr prior to dose OR – adjust drug dose accordingly
Warfarin
–
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Vitamin K in most all enteral formulas
Highly protein bound drug can bind to protein in the EN formula
Hold TF 1hr before warfarin dose
Dose adjusted for EN with monitoring target INR
PPI
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Omeprazole/Pantoprazole
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Enteric coated
Active drug destroyed by gastric acids
Crushed and mixed with water will render less
effective
For liquid preparation - need to dissolve in bicarb
(expiration is limitation)
Zegerid ® omeprazole and bicarb powder
Fat Modulars
 Posaconazole
- Noxafil® 4 fold increase in serum
concentrations when co-administered with a meal,
especially high fat diet or supplement
 Atovaquon – bioavailability doubled with oral liquid
supplement containing 28g of fat (compared to 21g fat
meal)

Benecalorie:
– 330 kcal, 7 gm protein, 33 gm Fat
Medications via Enteral Access
 Know
–
the type of enteral access device
gastric or small bowel
 Medications
–
–
–
liquid form
Do not crush or destroy special properties
dispense & teach use of liquid syringe
 Flush
feeding tubes 15-30ml of water
before and after each medication
Case
Ms Johnson, 82 yo, 66”, 56kg, with diabetes,
gastro paresis, and vomiting, now has a PEG/J
 Which tube should the nurse place her
medications?

–
–
Medications should preferably be administered
in the G tube because of the larger tube and
dilution of the stomach for less irritation
If there is gastric intolerance of the medication,
it has to be finely crushed and mixed with @
60ml of water for J-tube administration
Case
Ms Johnson, 82 yo, 66”, 56kg, with diabetes,
gastro paresis, and vomiting, now has a PEG/J
 How would maintain the feeding tube so it
does not get clogged?
 Flush feeding tubes with15-30ml of water
before and after each medication
 If the J-tube clogs, attempt to flush with hot
water to dissolve the drug or food

Extra Case Example
 Sally
Sue lives in the Rest Easy Nursing
Home. She is bed ridden with stage III
decubitus ulcers. She receives continuous
tube feeding and drug therapy via a PEG
 Sally Sue is 45kg, 5’1”, 78yo
 PEE = 1380-1500kcal/day
 Protein requirements = 72-90g/d
Case - Answer
PEE = 1380-1500kcal/day
 Protein requirements = 59-72g/d
 Which of the following choices provides
optimal enteral nutrition therapy.

Product
Isosource HN®
Fibersource ®
Isosource 1.5®
Impact Peptide®
Nutren 2.0®
Rate
Total
ml/hr
(Kcal/d)
50 (1200ml)
1440
50 (1200ml)
1440
40 (960ml)
1440
40 (960ml)
1440
30 (720ml)
1440
Protein
(Gm/d)
64
65
65
90
58
Objectives
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Describe the advantages of EN over PN
Describe the various enteral access devises and their GI
locations
Describe the major differences in the available enteral
products
Calculate a 24 hour infusion of enteral nutrition to meet
a patients nutritional needs
Describe how medications are administered in various
feeding tube
Describe why certain medications can NOT be
administered in a feeding tube
ANY QUESTIONS