Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.
Prospective fodnula evaluation of an initially placed button gastrostomy. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer. Enteral-tube-feeding diarrhoea: manipulating the colonic microbiota with probiotics and Problems with entral feeding fornula. J Am Coll Nutr. S Afr J Clin Nutr. Section 2 - Complications of enteral nutrition This page was last modified on August 11
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Nurses can prevent many of the problems associated with enteral feeding through careful monitoring.
- See Indications for enteral feeding.
- Enteral tube nutrition is indicated for patients who have a functioning GI tract but cannot ingest enough nutrients orally because they are unable or unwilling to take oral feedings.
Enteral tube feeding is the preferred method of nutritional support when the GI tract is functional and the patient is unable or unwilling to consume an adequate oral diet. The enteral route is efficient and cost-effective, however it is not always as easy as it looks. Gastrointestinal, mechanical, and metabolic complications can occur. It is important to thoroughly assess patients prior to initiation of tube feeding and to closely monitor them while they are receiving tube feedings in order to identify potential problems.
Vomiting increases the risk of aspiration. If delayed gastric emptying is suspected, consider reducing narcotic medications, switching to a low-fat formula, administering the feeding solution at room temperature, reducing the rate of administration, and administering a promotility agent.
If the patient appears distended, check gastric residuals before the next bolus feeding, or every four hours for continuous feeding. If gastric residuals are low yet nausea persists, consider antiemetic medications. If clinically significant diarrhea develops during enteral tube feeding, consider the following options: Add fiber, e. Constipation Constipation can result from inactivity, decreased bowel motility, decreased fluid intake, impaction, or lack of dietary fiber.
Poor bowel motility and dehydration may lead to impaction and abdominal distension. A standard abdominal x-ray is often effective for diagnosis and will clearly differentiate constipation from bowel obstructions. Constipation usually is improved through adequate hydration and use of fiber-containing formulas, stool softeners, or bowel stimulants.
Clinical manifestations include unexplained weight loss, steatorrhea, diarrhea, anemia, tetany, bone pain, bleeding, neuropath, glossitis, or edema. Causes of malabsorption are many and include gluten sensitive enteropathy, Crohn's disease, diverticular disease, radiation enteritis, enteric fistuals, HIV, pancreatic insufficiency, and short bowel syndrome.
Knowledge of the patient's history and selection of an appropriate enteral product should help reduce or prevent malabsorption. However, depending upon the extent of disease, parenteral nutrition may be necessary. Mechanical complications Aspiration Pulmonary aspiration is an extremely serious complication of enteral feeding and can be life-threatening in malnourished patients.
I can't help but relate a personal tragedy. This was the final insult to my father during his slow decline from lung cancer. Days before he died, Dad was given a bolus feeding which was not even ordered for him , it caused an aspiration pneumonia.
My sister-in-law an RN found the murder weapon a feeding syringe on his beside table. Shortly thereafter he slipped into a coma and died. I will never forget this horrible act against my father by those whom we had entrusted with his care. Symptoms of aspiriation include dyspnea, tachypnea, wheezing, rales, tachycardia, agitation, and cyanosis. Aspiration of small amounts of formula may not cause immediate symtoms, but a fever later may suggest development of aspiration pneumonia.
Use of small-bowel feeding tubes, promotility agents, periodic assessment of gastric residuals, and keeping the head of the bed elevated may reduce the risk of aspiration. Tube malposition Complications may arise during the placement of a feeding tube or simply from the presence of one. Feeding tube placement can cause bleeding, tracheal or parenchymal perforation, and GI tract perforation.
Placement of tubes by trained personnel and using appropriate post-placement montoring should minimize these complications. Presence of the feeding tube itself may cause upper and lower airway complications, aggravation of esophageal varices, cellulitis, necrotizing fasciitis, fistulas, and wound infection.
Use of a small-bore feeding tube and very attentive nursing care can minimize many of these problems. If this fails, a pancrelipase and sodium bicarbonate solution may be instilled in order to "digest" the clog. Metabolic complications Metabolic complications of enteral nutrition are similar to those that occur during PN, although the incidence and severity may be less. Careful monitoring can minimize or prevent metabolic complications.
Refeeding syndrome Refeeding of severely malnourished patients may result in "refeeding syndrome" in which there are acute decreases in circulating levels of potassium, magnesium, and phosphate.
The sequelae of refeeding syndrome adversely affect nearly every organ system and include cardiac dysrhythmias, heart failure, acute respiratory failure, coma, paralysis, nephropathy, and liver dysfunction. The primary cause of the metabolic response to refeeding is the shift from stored body fat to carbohydrate as the primary fuel source.
Serum insulin levels rise, causing intracellular movement of electrolytes for use in metabolism. The best advice when initiating nutritional support is to "start low and go slow". Section 2 - Complications of enteral nutrition This page was last modified on August 11 RxKinetics, Plattsburg, MO This is a Norton safe site.
The Problem : The patient is having diarrhea, so tube feeding is held. Antibiotics, particularly the fluoroquinolones ciprofloxacin, levofloxacin, etc. There are a few strategies to cope with this. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. However, milk-based formulas tend to taste better than lactose-free formulas. American Nurse Today. Postpyloric feedings must be administered on a continuous basis.
Problems with entral feeding fornula. SOCIAL MEDIA
Section 2 - Complications of enteral nutrition
Introduction In long-term care LTC residents with impaired caloric or fluid intake and a functional gastrointestinal tract, enteral nutrition through the use of a feeding tube is an important option. State-to-state rates varied widely, with Nebraska having the lowest rate of 3. Enteral nutrition may be provided to patients utilizing nasoenteral, gastrostomy , and jejunal feeding tubes. However, feeding tubes are associated with various complications that require close monitoring.
Nasoduodenal and nasojejunal tubes may be used in patients who cannot tolerate gastric feedings or who need to lie flat, ie, ileus, critically ill patients. Feeding Tube Complications Aspiration. Feeding beyond the duodenum likely lowers the incidence of aspiration, although no conclusive evidence supports this premise. The goal in the LTC setting is to use preventive measures to decrease the incidence of aspiration and its development into pneumonia by targeting modifiable risk factors.
To minimize the risk of aspiration, patients should be fed sitting up or at a to degree semirecumbent body position.
Iso-osmotic feeds may be preferred since high-osmolality feeds can delay gastric emptying. However, the effect of feeding type on risk of aspiration is inconsistent. There is no standard definition as to what constitutes a safe RV. For continuous feedings, residual can be checked while the infusion is in progress; for intermittent feedings it is checked one hour after cessation of feeding.
Although acid suppression may help with symptoms of reflux, it does not prevent aspiration pneumonia. Promotility drugs may reduce the risk of aspiration in patients at risk. Another modifiable risk factor is dental hygiene. One study looking at oral care in nursing home residents demonstrated that aggressive oral care lowered the risk of pneumonia. When a patient develops diarrhea, the clinician should begin by checking for changes in infusion rate or change in formula.
Many liquid medications contain sorbitol and can induce diarrhea by increasing the osmotic load to the intestines. Other common offenders are medications containing magnesium, nonsteroidal anti-inflammatory drugs, H2 blockers, proton pump inhibitors, and antibiotics. Reduced gastric acid caused by H2 blockers and proton pump inhibitors may lead to small intestinal bacterial overgrowth. Opened formulas should be refrigerated. In addition to gastrointestinal problems, sepsis can occur.
Management of diarrhea is directed at the underlying cause; however, several therapeutic strategies are available in the absence of an obvious etiology. Decreasing the feeding flow rate may alleviate diarrhea by allowing time for intestinal mucosal adaptation to occur when the gastrointestinal tract has not been used for extended periods of time. The flow rate is then increased gradually over the next several days. If lactose intolerance is suspected, switch to a lactose-free formula.
Consider obtaining a fecal fat test for malabsorption if diarrhea persists. However, the concept that diarrhea relates to malabsorption is not well supported due to the efficiency of the gatrointestinal tract. A change to an elemental or predigested feeding formula is rarely needed unless significant impairment in gastrointestinal function and absorption is well documented. Additionally, isotonic formulas are well tolerated when started at full strength.
However, hypertonic formulas such as calorically dense 2 calories per mL and elemental formulas are best initiated at half strength and changed to full strength 24 hours later. Importantly, patients should be also examined for fecal impaction. Nausea, vomiting, or abdominal bloating. Nausea may be due to smell, abdominal bloating, and cramps. Abdominal bloating and cramps are often be due to excess feed administration rates, delayed gastric emptying, or decreased bowel motility that often present in frail elderly.
Importantly, clinical evidence of abdominal distention is a contraindication to enteral feeding. Management includes assessment for abdominal distention and fecal impaction.
If a patient is receiving intermittent feeds, then the feedings can be changed to a slower rate of continuous feeds. If the residual volumes are elevated, a prokinetic agent such as metoclopramide or erythromycin may be tried.
Metabolic Complications Metabolic and electrolyte imbalances are common complications associated with enteral feedings. Fluid management must be carefully monitored in patients receiving enteral feeding to avoid electrolyte imbalances and fluid balance alteration. This may occur when a patient is receiving IV fluids or high volumes of free-water boluses. Slowing the infusion rate or substitution of a 1. High calorie intake may unmask glucose intolerance or diabetes.
Acute illness, overfeeding, in addition to inappropriately low insulin or medication supplementation can account for hyperglycemia. The refeeding syndrome is a potentially fatal complication seen when severely malnourished patients are refed via enteral or parenteral support.
Those at risk for this syndrome include individuals who are chronically malnourished, chronic alcoholics, anorectics, and those chronically ill and receiving IV fluids without nutrients for days. This is often accompanied by alteration in levels of sodium, potassium, magnesium, phosphorous, and thiamine.
The syndrome can cause cardiac, respiratory, neuromuscular, gastrointestinal, and renal complications Table I. The insertion of a nasoenteral tube may cause discomfort, rhinitis, esophageal reflux and strictures, esophagitis, perforation of a pharyngeal or esophageal pouch, intracranial insertion, and accidental bronchial insertion and perforation. This risk is minimized by the use of flexible polyurethane or silicone tubes; however, modern tubes with internal wires increase this risk.
Reinsertion of guidewires with feeding tubes in situ should not be attempted due to the risk of wire passing either through an outflow port or perforating the tube, and then perforating the viscus. The position of the nasoenteral feeding tube should be confirmed radiologically before initiating feeding since checking the position of a tube by aspiration of gastric contents or injection with air through it and listening for bubbles with a stethoscope is unreliable.
Nasoenteral tubes should be secured with tape, and the distance the tubes are inserted should be recorded—or even the tube itself marked with tape—so migration can be identified. The length should be checked every 4 hours during tube feeding. It should also be checked every time it is used by confirming that the external length of the tube remains unchanged. Post-insertion nasoenteral tubes are associated with discomfort, sore mouths, thirst, dry mucous membranes, and hoarseness.
Local pressure of nasoenteral tubes may cause nasal erosions, abscess formation, sinusitis, and otitis media. Esophageal complications can include esophagitis, ulceration, strictures, tracheal fistulas especially in presence of endotracheal tube , and exacerbation of variceal bleed. These complications can be minimized by the use of fine bore tubes. Tube feeding may also be associated with higher rates of restraints and pressure sores.
Accidental removal of the gastrostomy tube within the first four weeks of placement can be problematic since a formed tract is not established, and the stomach wall may not yet have adhered to the abdominal wall. A Foley catheter can be inserted through the tract and feeding restarted until the gastrostomy is replaced either endoscopically or non-endoscopically with a replaceable gastrostomy tube.
After non-endoscopic re-insertion, tube position should be verified by a combination of auscultation and aspiration of gastric contents. Unintentional dislodgement can be minimized by checking that the balloon volume is adequate every seven days. A common complication of gastrostomy tubes is leakage. A larger replacement tube may help. Lowering the acidity of the gastric contents by the use of H2 blockers or proton pump inhibitors will decrease skin excoriation and may decrease gastric secretions.
Additionally, aluminum hydroxide and magnesium hydroxide antacid can be applied around the stoma twice daily. This can be prevented by adjusting the bumper if weight loss occurs.
Feeding tubes can commonly become blocked, especially if they are not flushed with at least mL of water every feeding or medication administration. Bolus feeding, hypertonic, high-fiber formulas, crushed tablets, potassium, iron supplements, and sucralfate are particularly likely to cause blockage. The tube should be flushed every hours during continuous feeds and after every medication dose and bolus feeding.
The use of solutions with pancreatic enzymes or meat tenderizer should be done with caution, as this may harm the gastric mucosa or the tube.
Carbonated drinks, pineapple juice, and sodium bicarbonate solution may cause tube degradation. Gastrostomy tubes may also be blocked by gastric mucosal overgrowth, which requires endoscopic repair. Buried bumper syndrome is an unusual late complication of gastrostomy tubes due to migration of the internal bumper through or into the abdominal wall. Failure to recognize these interactions may lead to treatment failure, toxicity, and life-threatening adverse events.
Such interactions often involve drugs with a narrow therapeutic index, drugs that interact with food or electrolytes, or when multiple drugs in liquid form are given concomitantly with enteral feeds. Summary Feeding tubes are commonly used in the LTC setting.
Their use may be associated with complications such as aspiration, diarrhea, nausea, abdominal bloating, and metabolic or mechanical problems. A systematic and careful analysis of the underlying cause of these complications is critical to a successful enteral nutrition program.
The authors report no relevant financial relationships. References 1. Gastroenterology ; 4 Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: Its indications and limitations. Postgrad Med J ;78 Guidelines for enteral feeding in adult hospital patients. Gut ;52 Suppl 7 :vii1-vii J Am Geriatr Soc ;41 6 Parrish CR. Enteral feeding: The art and the science. Nutr Clin Pract ;18 1 Dharmarajan TS, Unnikrishnan D.
Tube feeding in the elderly. The technique, complications, and outcome. Postgrad Med ; 2 ,