A.S.P.E.N. Enteral Nutrition Practice Recommendations

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A.S.P.E.N. Enteral Nutrition Practice
Recommendations

• Kelly Tappenden, PhD, RD
• Professor of Gastrointestinal Physiology
  Nutrition
• University of Illinois Urbana-Champaign

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(No Transcript)
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Outline

1. Introduction
2. Ordering and Labelling of EN
3. Enteral Formula (Medical Foods) and Infant
   Formula Regulation
4. Water and Enteral Formula Safety and Stability
5. Enteral Access
6. EN Administration
7. Medication Administration
8. Monitoring EN Administration
9. Summary

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Glossary of Terms

• Beyond-Use Date
• Clinical Guidelines
• Closed Enteral System
• Computerized Prescriber Order Entry (CPOE)
• Distilled Water
• Drug-Nutrient Interactions
• Enteral Access Devices
• Enteral Misconnection
• Enteral Nutrition (EN)

• Expiration Date
• Fore Milk
• Hang Time
• Hind Milk
• Medical Food
• Modular Enteral Feeding
• Open Enteral System
• Purified Water
• Sentinel Event
• Tap Water
• Transitional Feeding

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Objective/Goal/Methodology

• Objective establish evidence-based practice
  guidelines following review of literature related
  to ordering, preparation, delivery, and
  monitoring of EN
• Goal identify safety issues related to EN
• Grading system modified Agency for Healthcare
  Research and Quality (AHRQ) method
• GOOD research-based evidence to support guideline
  (PRCTs).
• FAIR research-based evidence to support guideline
  (well-designed studies w/out randomization).
• The guideline is based on EXPERT OPINION and
  EDITORIAL CONSENSUS.

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Formulary Selection Process

• 1. Facilities should establish a formulary
  specific and available EN formulas. (C)
• 2. A specific EN formulary should be based on
  patient population and estimated nutrient needs
  rather than specific diagnosis. (C)
• 3. A clinician with expertise in nutrition
  support should be involved in corporate buying
  of EN products that best meets the patients
  nutrient requirements. (C)

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Use standardized order forms specific for adult
and pediatric EN regimens (C)
EN orders should include (C)1) patient info
2) formula 3) enteral access site/device4)
administration method/rate
All orders, evenre-orders, must be complete! (C)
Incorporate EN advancement, transitional,
monitoring and ancillary orders.(C)
Use generic terms, avoid abbreviations(C)
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Labels for EN formula administration containers,
bags, or syringes should be standardized. (C)
ALL EN labels, in all environments, shall express
clearly and accurately what the patient is
receiving at any time. (C)
Before administration, EN label should be
compared with the EN order for accuracy, hang
time, and beyond-use date. (C)
Clinician-to-clinician communication needed to
promote the accurate EN prescription during
patient transfers. (C)
Clearly label human breast milk with the
patients name/medical record number to prevent
delivery errors. Preprinted labels and/or bar
coding systems helpful. (C)
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Regulatory Issues

• Medical food a food which is formulated to be
  consumed or administered enterally under the
  supervision of a physician and which is intended
  for the specific dietary management of a disease
  or condition for which distinctive nutritional
  requirements, based on recognized scientific
  principles, are established by medical
  evaluation.
• Require good manufacturing practice
• Exempt from regulations on labeling and health
  claims that apply to conventional foods

BUYER BEWARE!!
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Eliminate EN Contamination

• Clean environment (A)
• Aseptic technique (A)
• Trained personnel (C)
• Sterile, liquidgtpowder(A)
• Controlled storage (B)
• Follow manufacturer recommendations (B)
• Disposable gloves (A)
• Screw cap gt flip top (A)
• Use recessed spikes (B)
• Pump with drip chamber (A)
• Peds products DEHP free (B)

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Formula Hang Times Vary
1. Institution need ongoing quality control
process for EN formula prep, distribution,
storage, handling, and administration. (B) 2.
Institutions need written policies and procedures
for safe EN formula and HBM prep/handling, as
well as maintain an ongoing surveillance program
for contamination. (B)
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Selection of Enteral Access Device

• 1. Select an enteral access device based on
  patient specific factors. (C)
• 2. Nasojejunal route for enteral feedings in ICU
  patients are not required unless gastric feeding
  intolerance is present. (A)
• 3. Patients with persistent dysphagia should have
  a long-term enteral access device placed. (B)

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Insertion of Enteral Access Device

• 1. Obtain radiographic confirmation of tube
  placement prior to use. (B)
• 2. Capnography may help prevent improper
  placement when inserting a gastric feeding tube.
  (B)
• 3. When inserting a small bowel feeding tube,
  observe for a change in pH and appearance of
  aspirates as the tube progresses from the stomach
  to small bowel. (B)
• 4. Do not rely on the ausculatory method to
  differentiate between gastric and small bowel
  placement. (A)
• 5. Mark exit site of feeding tube at the time of
  the initial radiograph observe for a change
  during feedings. (B)
• 6. In pediatrics and neonates, all methods but
  X-ray verification of enteral tube placement have
  been shown to be inaccurate however should be
  used judicious. (B)

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Longterm Enteral Feeding Devices

• 1. Considered when EN gt4 wks. (C)
• 2. Not for premature infants without strong
  justification. (C)
• 3. Multidisciplinary team should advise re
  placement to ensure (B)
• a. benefit gt risk of placement
• b. placement near end of life is warranted or
• c. insertion is indicated if close to achieving
  oral feeding.
• 4. Perform abdominal imaging prior to placement.
  (C)
• 5. Gastrostomy tube placement does not mandate
  fundoplication. (B)
• 6. Direct placement indicated in patients
  requiring a long-term jejunostomy. (B)
• 7. Document tube type, tip location, and external
  markings. (C)
• 8. Avoid placement of catheters or tubes not
  intended for use as enteral feeding devices. (B)

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When to start feeding following placement?

• 1. Enteral feedings should be started
  postoperatively in surgical patients without
  waiting for flatus or a bowel movement. The
  current literature indicates that these feedings
  can be initiated within 24-48 hours. (A)
• 2. A PEG tube may be utilized for feedings within
  several hours of placement current literature
  supports within 2 hours in adults and 6 hours in
  infants and children. (B)

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Initiation and Advancement of EN

• 1. Base enteral delivery method and initiation
  and advancement of EN regimens on patient
  condition, age, enteral route (gastric vs small
  bowel), nutrition requirements, and GI status.
  (C)
• 2. Choose full strength, isotonic formulas for
  initial feeding regimen. (C)
• 3. Initiation and advancement of enteral formula
  in pediatric patients is best done over several
  days in a hospital setting using a flexible
  nutrition plan. (C)

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Preterm Infant Considerations

• 1. For premature infants weighing lt 1500 g and at
  risk for NEC, it is recommended that mothers be
  encouraged to supply breast milk for their
  infants. (A)
• 2. ELBW and VLBW infants may benefit from minimal
  enteral feeding starting very slowly at 0.5-1
  mL/kg/day and advancing to 20 mL/kg/day. (B)
• 3. Advance nutritive feedings for VLBW and ELBW
  infants by a rate of 10-20 mL/kg/day. (C)

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Enteral Feeding Pumps

1. Feeding pumps should be calibrated periodically
   to assure accuracy. (B)
2. Accuracy 10 for adults (B) within 5 for peds
   and neonates. (C)
3. HBM infused at low rates should be administered
   via syringe pump with tip elevated. (C)
4. Feeding pumps for home use should have features
   that promote safety and minimize sleep
   disturbances. (B)

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Patient Positioning

1. Elevate the backrest to gt30º, and preferably to
   45º, for all patients receiving EN unless a
   medical contraindication exists. (A)
2. Use the reverse Trendelenberg position to elevate
   the HOB, unless contraindicated, when the patient
   cannot tolerate a backrest elevated position. (C)
3. If necessary to lower the HOB for a procedure or
   a medical contraindication, return the patient to
   an HOB elevated position as soon as feasible. (C)

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Flushes of feeding tubes

• 1. Flush with 30 mL water q 4h during continuous
  feeding(A) before/after bolus feedings (A) and
  residual volume measurements (B) in adults.
• 2. Use lowest volume necessary to clear tube in
  peds and neonates. (C)
• 3. Sterile water is recommended before/after
  medication administration. (C)
• 4. Adhere to protocols that call for proper
  flushing of tubes before/after medication
  administration. (B)
• 5. Use pump when slow rates are required, such as
  with neonates, and respond promptly to pump
  alarms. (C)
• 6. Use sterile water for tube flushes in
  immunocompromised or critically ill patients. (C)

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Enteral Misconnections

• 1. Review current systems/practices for
  misconnect potential. (C)
• 2. Only allow trained clinicians to reconnect,
  in proper lighting. (C)
• 3. Do not modify or adapt IV or feeding devices.
  (C)
• 4. Routinely trace lines back to origins and in
  standardized directions . (C)
• 5. Recheck connections, trace all tubes in new
  setting/hand-off. (C)
• 6. Use standardized labels or color-code feeding
  tubes and connectors. (C)
• 7. Identify and confirm the EN label. (C)
• Ensure purchasing policies dictate safe products
• Avoid enteral equip that mates with female luer
  connectors. (C)
• Dedicated enteral pumps. (C)
• Enteral feeding sets. (C)
• Preoper pre-filled EN containers. (C)
• Oral syringes, instead of luerlock, for enteral
  meds. (C)

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Medication Administrion

1. Dont add meds directly to enteral formula (B)
2. Dont mix meds for EN admin (B)
3. Administer each med separately in appropriate
   form (B)
4. Stop feeding ? flush ? med ? flush (A)
5. Hold EN lt 30 min following med (A)
6. Use oral/enteral syringes labeled with for oral
   use only to measure/administer enteral meds. (B)
7. Consult pharmacist for patients who receive
   medications co-administered with EN. (C)

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Monitor for Refeeding Syndrome

• 1. Monitor fluid and electrolyte, and other
  metabolic parameters as needed based on the
  patients clinical situation. (B)
• 2. Check metabolic and nutrition parameters, and
  correct depleted levels prior to the initiation
  of enteral feedings. (B)

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Monitor Gastric Residual Volumes

1. With EN, always evaluate aspiration risk. (A)
2. Assure tube is properly placed before use (A)
3. Elevate HOB 30-45?(A)
4. During first 48h, check GRV q 4h (B) may reduce
   to 6-8h thereafter in non-critically ill (C)
5. If GRV is gt250 mL after 2nd check, consider
   prokinetic agent in adults (A)
6. If GRV is gt500 mL, hold EN ? thoroughly reassess
   patient tolerance (B)
7. If GRV is consistently gt500 mL, consider tube
   below loT (B)
8. In peds, check GRVs every 4h, hold if residual gt
   hourly rate. If bolus, check before next feed
   and hold if GRV gt50 of previous volume. (C)

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Conclusions

• EN is also complex and safety is critically
  important
• PRCTs are needed
• Implications for safe EN practices extend far
  beyond those providing the nutrition support
• Strong communication is essential