complications of enteral nutrition part 1

8/22/2019 Complications of Enteral Nutrition Part 1

1/18

Complications of Enteral Tube

Feeding

Stephen A. McClave, MD

Professor of Medicine

University of Louisville School of Medicine


2/18

Objectives

1. To assess delivery of EN and maintenance of the feeding tube.

2. To be able to perform an exam on a patient receiving EN and toassess tolerance of feeds and status of the tube.

3. To learn what complications to expect in the patient on EN and to

know appropriate strategies to manage problems when theyarise.


3/18

Managing

Ileus

Evaluate segmental contractilityStomach NG output


4/18

Use of Narcan to Enhance Tolerance

Critically ill pts (n=84) on MV and Fentanyl anaesthesia

Randomized to 8mg narcan vs placebo q6hrs per NG tube

Rate of pneumonia reduced 56% to 34% (p=0.04)

*

Meissner (CCM 2003;31:776)

* p=0.03

= 54 mL

= 129 mL

Amt EN

GRV


5/18

Ischemic Bowel

Epidemiology

Ischemic bowel rare complication of EN (vs benefit)

Incidence usually far less than 1%

0.2% pts admitted for burns (4/1504)1

0.3 3.8% pts receiving SB feeds2

Most often reported with surgical jejunostonomies2-4

Recent report with nasojejunal tubes1

1Scaife (J Trauma 1999;47:859) 2Schunn (Am er Coll Surg 1995;180:410)3Choban (Am er J Surg 1988;155:112) 4Law lor (Can J Surg 1998;41:459)


6/18

Ischemic Bowel

SB at risk due to countercurrent mechanism

Blood shunted arteriole to subepithelium

Villous tips affected first Absorption


7/18

Process of Intestinal

Ischemia/Infarction

Mucosal then transmural ischemia

Capillary sludging, mucosal perfusion

Gas formation, bowel distention

Intestinal motility, SBO, fermentation

Osmotic effect leads to fluid shifts Unabsorbed formula in lumen of gut

Disordered nutrient absorption in SB

Ischemic injury to tips of villi

Scaife (J Trauma 1999;47:859) Schunn (J Amer Coll Surg 1995;180:410)


8/18

Recommendations

for EN in Hypotension

Hold feeds in hypotension :

Initiating pressor Rx

Increasing dose of pressors

Adding second or third agent

OK to feed in hypotension on pressors :

Stable (24-48 hrs) or decreasing doses

Mean arterial pressure > 75 mmHg

Avoid fiber, stomach may be better than SB

Hold feeds (on pressors) for any sign of intolerance :

NG output increases New abdominal pain

Abdominal distention Cessation of flatus, stool

X X X


9/18

Complication of Nasal Bridle

Limit duration of bridle use to 6-8 weeks


10/18

Risk factors (incidence 9-20%):

Tube length Infrequent flushes Instilling meds

Tube caliber Continuous infusion Using GRVs

Declogging agents (0=none to 3=dissolution) * (p < 0.01)

Agent: Viokase (bicarb) Coke Papain Viokase (plain)

Score: 2.9 * 1.4 0.8 0.8

Marcuard (JPEN 1989;13:81-83)

Tube Occlusion


11/18

Tube Declogging

Marcuard (JPEN 1989;13:81-83)


12/18

Diarrhea

R/O low volume incontinence Evaluate etiology

Meds (sorbitol) 55%

Clostridia Difficile 17%

Formula 20%

no diarrhea

diarrhea

Benya (J Clin Gastro 1991;13:167)

Dont stop feeds

Switch formulas

Fiber-containing

Small peptide

100gm

Mean Stool

Volume4x


13/18

Free Air Under the Diaphram

Air under diaphram signifies perforated bowel

Pneumoperitoneum occurs in 40-56% of routine PEGs


14/18

Normal Appearance

2 days

Mature Track

7 days


15/18

Longterm Care:Examine Plug

Fused Plug CapSeparate Plug Cap

Replace entire PEG Replace Cap only


16/18

Longterm Care: Examine PEG Tubing

Polyurethane

Fungal Colonization (silicone)Silicone


17/18

Excess Drainage:Deterioration

of PEG Site

Complaint varies

Excess drainage

Enlarging hole

Breakdown of site

Physical exam of site, PEG tube is critical

Identify (and correct) etiologic factors

Determine need to treat infectionEvaluate salvageability of PEG site

Endoscopy probably required :

Bleeding Fixation Breakdown PEG site


18/18

Excess Drainage : Breakdown of SiteCorrosive Injury

PEG

Site

Stop orders for acid-reducing drugs

Vitamin C (Ascorbic Acid)

Any Peroxide washes post placement

complications of enteral nutrition part 1

Documents