308 CHAPTER 20 | Nutrition Support


for GRV in patients who are critically ill suggest that feedings should not be stopped for volumes less than 500 mL in the absence of signs and symptoms of feed- ing intolerance.21


Gastric and salivary secretions add


approximately 200 mL to the stomach hourly; there- fore, utilizing a volume at this level does not indi- cate a reason to stop the feeding. Emesis, abdominal distention or pain, constipation, nausea, and diarrhea are signs of intolerance and require a reevaluation of the feeding regimen. These GRV recommendations, based on critically ill individuals, state that after 48 to 72 hours of feeding with acceptable GRV, measure- ment of GRV is no longer needed. Additionally, GRV measurement is not necessary for individuals who are awake and can provide verbal communication on tol- erance. Laboratory studies, including electrolytes (eg, sodium, potassium, and chloride), blood urea nitro- gen, creatinine, phosphorous, calcium, liver function tests, magnesium, albumin, and transferrin, should be checked on initiation of EN and as needed for clients who are medically unstable.21


Laboratory studies may


only need to be monitored every 6 months for older adults who are stable with long-term tube feeding.


Complications


Although tube feeding is generally considered safe, it is not without complications.22


Problems related to


tube-feeding delivery may be classified as mechani- cal, infectious, gastrointestinal, or metabolic.


Mechanical Complications


Feeding tube displacement and migration is a serious mechanical complication of EN and may result in aspiration, diarrhea, or peritonitis (with gastrostomy or jejunostomy tubes). Verification of tube placement by x-ray is necessary before feedings are started or when the health care team suspects tube malposition. Nasogastric and nasoenteric tubes are associated


with pressure necrosis, which may also lead to sinus- itis, mucosal ulceration, abscess formation, and per- foration. The tube should be rotated in the nares and converted to a gastrostomy as soon as long-term need is identified. The health care team can obviate a clog of the feeding tube with proper flushing and medication administration.21,22


Formula coagulation, obstruction Infectious Complications


Contamination of any tube-feeding system may orig- inate from nonsterile ingredients, unsanitary equip- ment, and failure to maintain a clean technique when preparing the feeding. Common infectious complica- tions of sepsis and nosocomial pneumonia may occur. The risk of contamination may be minimized with proper hand washing, clean preparation methods, use of ready-to-hang or closed-system formulas, and adherence to formula hang time (refer to Table 20.2).


Gastrointestinal Complications


Gastrointestinal complications may result from the administration of tube feeding. The incidence of diar- rhea varies widely among enteral formula users and remains one of the most common complications.20-22 ASPEN defines diarrhea as stool output greater than 500 mL every 24 hours or more than three stools per day for two or more consecutive days.26


Before


changing the feeding regime and assuming that the tube feeding is the source of the diarrhea, the RDN should consider and rule out other causes such as antibiotic therapy, osmotically active medications, infection (eg, Clostridium difficile), hypoalbuminemia, zinc deficiency, and microbial contamination of the


by pill fragments, tube kinking, added fiber, and pre- cipitation of incompatible medications may lead to feeding tube obstruction. (See the Medication Admin- istration section of this chapter for guidelines regard- ing the delivery of medications via feeding tubes.) It is preferable to dislodge the obstruction rather than to replace the tube. Specialized products are available to assist in unclogging a feeding tube. It is important to note that only specific products should be used, and the guide wire should never be used to unclog a feeding tube.


Leakage of feeding tube contents can be secondary to several different problems. Although rare, leakage around the exit site of a feeding tube may be due to infection or trauma from the tube itself. To prevent or treat infection around the exit site, antibiotic ther- apy, debridement, or feeding tube removal may be indicated. Peritubular leakage around gastrostomy or jejunostomy tube sites cannot be fixed by placing a larger diameter tube.


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