Slides - University of Utah - School of Medicine

Enteral Feeeding Update: 2013
John Fang M.D.
Professor of Medicine
University of Utah Health Sciences Center

Objectives
•! Understand the different enteral feeding
options
•! Know the benefits and limitations of enteral
feeding
•! Be aware of the complications of enteral
feeding

Enteral Nutrition
Nutrition Support Therapy
•! Supplemental nutrition to enhance patients survival
•! People that cannot eat any or enough food due to
illness
–! Long-term feeding in a patient who is unable to eat or
swallow
•! A portion of the stomach or bowel may not be
working correctly
–! A patient may have gone through surgery to remove parts
of the GI system
–! Distal intestinal tract is functional

Enteral Nutrition
Tube Selection Criteria
•! Length of Time supplemental nutrition is needed
•! Surgical Patient or Non-Surgical Patient
•! Risk of Aspiration

Enteral Nutrition
Delivery Systems
•! Nasoenteric Tubes
–! Tube used is placed through the nose into the stomach or bowel
–! nasogastric or nasoenteral feeding tubes
–! 30 days of supplemental nutrition

Enteral Nutrition
Feeding Methods
–!Bolus Feeding
•! Syringe or Gravity
•! “Breakfast, Lunch, Dinner”
–!Continuous Feeding
•! “Pump”
•! Feeding over a longer period of time (~24 hr)
•! Slower rate of delivery

Enteral Feeding Tubes
•! NET – Nasoenteric Tubes
–! NG : Nasogastric
–! Dobhoff : Nasoduodenal/nasojejunal
•! PEG – Percutaneous Endoscopic
Gastrostomy/Percutaneous gastrostomy
•! Percutaneous GJ – Gastrostomy with
Jejunal Extension Tube
•! Percutaneous jejunostomy – Direct
Jejunostomy

NET Techniques
•! Bedside
–! Blind, Low cost
–! Post-pyloric position not mandatory
–! Experienced personnel to place post-pyloric
–! Requires radiographic confirmation
•! Fluoroscopic
–! Post-pyloric placement
–! Requires C-arm and/or transport
–! Radiation exposure
–! Immediate confirmation
•! Endoscopic

When
•! When unable to use oral route for short term
nutritional support (< 30 days)
•! When not on vasopressors
•! Within first 24 hours ABCD
–!Airway
–!Breathing
–!Circulation
–!Diet (Feed)
Tech GI Endo 2001;3:9-15

Naso-gastric tubes
•! More physiologic
•! Formula
–! isotonic, hypertonic
–! Can use blenderized
•! Infusion
–! continuous, bolus
•! Less reliable
–! ICU gastroparesis
30-70%
NGT vs.NET
Naso-enteric tubes
•! Less physiologic
•! Formula
–! isotonic
•! Infusion
–! continuous, ! 100 cc/hr
•! More reliable
–! feed 1-2 days post-op

NET Outcomes:
Complications
•! Nasopharyngeal lesions
•! Sinusitis
•! Diarrhea
•! Intestinal ischemia
•! Metabolic
DiSario, Fang et all. Gastrointest Endosc 2002;55(6)

NET Complications:
•! Misplacement
•! Aspiration
Tube related
–!Elevate HOB 30-45º
•! Post placement complications
–!Clogging
–!Displacement
–!Inadvertent tube removal
•! Taping
•! Suture/Staple
•! Nasal Bridle

•! Inadvertent NET removal ~
40%
•! Nasal Bridle 1980
•! “Nasal tube retention
system”
–! Magnet retrieval
•! QI project Pitt
–! 36%!10%
–! Use would " 275 tubes, " 330
Xrays, " 45 nurse days
Nasal Bridle
Gunn JPEN 2009;33:50-54

Percutaneous Gastrostomy:
Indications and Contraindicatons
Indications Contraindications
•! Altered consciousness
•! Oropharyngeal/esophageal
CA
•! Gastric decompression
•! Neurological swallowing
dysfunction
•! Facial trauma
•! Catabolic states
–! Burns, HIV, CF
•! Absolute
–! Coagulation disorders
•! Relative
–! Poor survival
–! Dementia
–! Massive ascites
–! Severe obesity
–! Peritoneal dialysis/
metastases
–! Disease of gastric/abdominal
wall

Initial Placement & Adjunct
Procedures
•! GI Endoscopic Procedures
•! IR Radiographic Procedures
•! OR Surgical Procedures
–!Adjunct Procedure – Nissen Fundoplication

PEG Video

PEG Replacement

Complications of PEG
!! Aspiration
!! Infection
!! Leakage
!! Buried bumper syndrome
!! Gastrocolic fistula
!! Pneumoperitoneum
!! Neoplastic seeding to abdominal wall
!! Clogging
!! Inadvertent removal

Buried Bumper Syndrome
Too much tension!!!

Gastrocolic fistula
•! Causes:
–! puncture of colon at the time of
gastrostomy
–! pinching of colon between the
gastric and abdominal walls
•! Usually becomes apparent after
several weeks
–! severe diarrhea following
feedings
•! In nearly all cases, the condition
may be treated by removing the
gastrostomy tube

Neoplastic seeding to skin

•! Motility
J-Tube instead of PEG for:
–!gastroparesis (diabetes – result & cause)
•! Obstruction
–!malignant, pancreatitis, surgical, etc
•! Aspiration
–!salivary/bronchial stimulation or reflux
•! Reflux
–!severe GERD, esophageal ulcers

Jejunal Feeding: Options
•! Nasojejunal
•! Gastrostomy with
jejunal extension
•!Single piece jejunal
extension
•! Direct
Percutaneous
Jejunostomy

Direct PEJ

EN Formula Selection
• Initial decision – Candidate for Immune-modulating
formula?
–! Elective major GI surgery (esophageal, gastric, pancreatic)
–! Trauma (ISS >18, ATI >20) - Including severe head injury
–! Burns (TBSA > 30%)
–! Head/neck cancer
–! Critically ill on mechanical ventilation (caution-sepsis)
•! Standard enteral formula (1 cal/cc) – if not
candidate
–! Possible malassimilation –
–! Consider: Small peptide/MCT oil
•! Specialty formulas rarely indicated
1

What the #*!? Tube is this?
a b
c d

PEG
Tube Types
b d f h
Replacement
PEG
PEGJ
Low Profile
PEG

What the #*!? Ports are these?
Medication/Jejunal Port
Feeding/Jejunal Port
Gastric/Decompression Port

Percutaneous Gastrostomy:
Outcomes
•! Procedure M+M
–! Mortality

PEG in Dementia Myths
•!PEG Dementia Facts:
•!Eating is last ADL to be lost
•!Dementia survival 12-18 mos
•!Final phase of illness

PEG ethics
•! Enteral feeding aims to improve nutritional status
–! Improves mortality, LOS, complications
–! Proven in post-CVA, H+N cancer
–! Not proven in metastatic malignancy, dementia
•! Nutrition support is no more essential or basic than
any other form of medical therapy
–! No obligation to offer, recommend or perform intervention
of no benefit
–! Do not have to continue once started

PEG ethics con.
•! What about hunger/thirst?
–! majority of patients (up to 63%) never experience hunger or thirst
–! If occur usually transient, relieved easily with minimal intake.
•! Hand feeding important to social interaction
–! touch, taste, nurturing, and the
–! PEG’s may require physical restraints may lead to distress, agitation,
and the need for sedation
–! Hand feeding often difficult, time consuming
•! QOL family, relatives, and caregivers improves with
gastrostomy placement
–! Unable to measure QOL in demented pt’s
–! Some nursing homes require PEG

To PEG or not to PEG

Feeding Tube Goal
before Fang after Fang