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Tube Feeding: How to Bolus Feed/Syringe Feed
In acute situations, in emergency medicine and intensive care medicine , drugs are most often given intravenously. It helped in creating risk management policies and plans in my hospital. Ask her doctor if this might help. Best quality harvested, slaughtered and butchered and clean constituents are used by food processing industry to manufacture very nutritious and easy to cook food products. We can't make any recommendations as far as how to clean products. Her clinical positions include in-patient diabetes education, private practice, and community diabetes education.

B. Nutritional assessment

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Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed conditional recommendation, very low level of evidence.

Nutrition assessment scoring systems used to determine nutrition risk NRS A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence. Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes. Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration strong recommendation, moderate-to-high level of evidence.

When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed conditional recommendation, very low level of evidence. A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding conditional recommendation, very low level of evidence.

For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement conditional recommendation, very low level of evidence. Initiating Enteral Nutrition Question: In the patient at high nutritional risk unable to maintain volitional intake, EN should be initiated within 24—48 h of admission to the hospital conditional recommendation, low level of evidence.

Although early EN should be initiated within 24—48 h of admission, the timing by which to advance to goal is unclear. When tolerated, feeding should be advanced to goal within 48—72 h conditional recommendation, very low level of evidence.

With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days conditional recommendation, very low level of evidence. A standard polymeric formula or a high-protein standard formula should be used routinely in the hospitalized patient requiring EN conditional recommendation, very low level of evidence.

An immune-modulating formula containing arginine and omega-3 fish oil should be used for patients who have had major surgery and are in a surgical ICU setting conditional recommendation, very low level of evidence. An immune-modulating formula containing arginine and omega-3 fish oil should not be used routinely in patients in a medical ICU conditional recommendation, very low level of evidence.

Monitoring tolerance and adequacy of EN Question: Hospitalized patients on EN should be monitored daily by physical exam conditional recommendation, very low level of evidence. Patients on EN should be monitored for adequacy of provision of EN as a percent of target goal calories, cumulative caloric deficit, and inappropriate cessation of EN conditional recommendation, very low level of evidence.

In the patient at high risk for refeeding syndrome, feeding should be ramped up slowly to goal over 3 to 4 days, while carefully monitoring electrolytes and volume status conditional recommendation, very low level of evidence.

Enteral feeding protocols should be used in hospitalized patients in need of nutrition therapy strong recommendation, moderate-to-high level of evidence. A validated protocol should be used, such as a volume-based feeding protocol or a multi-strategy bundled top-down protocol conditional recommendation, very low level of evidence. Gastric residual volume GRV should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence.

Patients on EN should be assessed for risk of aspiration conditional recommendation, very low level of evidence. For patients determined to be at high risk, the following steps should be taken to proactively reduce that risk: For the patient receiving EN who develops diarrhea, an evaluation should be initiated to identify an etiology and direct management conditional recommendation, very low level of evidence.

The patient receiving EN who develops diarrhea should be managed by one of the three strategies: Complications of enteral access Question: The percutaneous enteral access site should be monitored by cleaning daily with mild soap and water and maintaining correct positioning of the external bolster conditional recommendation, very low level of evidence.

Prevention of tube clogging is important to successful EN and may be achieved by frequent water flushes delivered every shift and each time medications are given conditional recommendation, very low level of evidence.

When a clogged tube is encountered and the use of water flushes is unsuccessful at clearing, a de-clogging solution comprising a nonenteric-coated pancreatic enzyme tablet dissolved in a sodium bicarbonate solution should be used conditional recommendation, very low level of evidence. If still unsuccessful, a mechanical de-clogging device should be considered prior to exchanging the tube for a new one conditional recommendation, very low level of evidence.

In this latter circumstance, radiologic confirmation should be carried out prior to feeding if there is any question of inappropriate location of the tube conditional recommendation, very low level of evidence.

Placement of a larger tube should not be used to manage leakage caused by an enlarging stoma around the percutaneous access device conditional recommendation, very low level of evidence.

A percutaneous enteral access device that shows signs of fungal colonization with material deterioration and compromised structural integrity should be replaced in a non-urgent but timely manner conditional recommendation, very low level of evidence.

If early EN is not feasible and the patient is at low nutritional risk upon admission, no specialized nutrition therapy should be provided and PN should be withheld for the first week of hospitalization conditional recommendation, very low level of evidence.

If a patient is at high nutritional risk on admission to the hospital and EN is not feasible, PN should be initiated as soon as possible strong recommendation, moderate level of evidence. Initiating supplemental PN prior to this 7—day period in those patients already receiving EN does not improve outcomes and may be detrimental to the patient strong recommendation, moderate level of evidence. Following this first week if long-term PN is required , energy provision should be increased to meet energy goals conditional recommendation, low level of evidence.

Peripheral PN PPN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence. Careful transition feeding should be used in the patient on PN, for whom EN is now being initiated.

As tolerance to EN improves and volume of delivery increases, PN should be tapered to avoid overfeeding conditional recommendation, very low level of evidence. Nutritional Therapy at End-of-Life Question: The decision to place a gastrostomy tube in an end-of-life situation should be determined by patient autonomy and the wishes of that patient and their family, even though the nutrition therapy may do little to change traditional clinical outcomes conditional recommendation, very low level of evidence.

Percutaneous gastrostomy placement should be considered even if the only benefit is to provide improvement in the quality of life for the family, increased ease of providing nutrition, hydration, and medications, or to facilitate transfer out of the hospital setting to a facility closer to home conditional recommendation, very low level of evidence.

The clinician is not obligated to provide hydration and nutrition therapy in end-of-life situations. The decision to initiate nutrition therapy is no different than the decision to stop therapy once it has started thus, clinicians are not obligated to provide therapy that is unwarranted conditional recommendation, very low level of evidence. If requested, nutrition therapy in end-stage malignancy should be provided by the enteral route conditional recommendation, very low level of evidence.

Use of PN in this setting may cause net harm and should be highly or aggressively discouraged conditional recommendation, very low level of evidence. The clinician who has ethical concerns of his own in a difficult end-of-life situation should excuse himself from the case, as long as he can transfer care to an equally qualified and willing health-care provider conditional recommendation, very low level of evidence.

Summary of Recommendations Indications for nutritional therapy Question: EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy, and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence. Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence.

An additional assessment should be performed prior to initiation of nutrition therapy of factors, which may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence. Indirect calorimetry conditional recommendation, very low level of evidence. Simple weight-based equations conditional recommendation, very low level of evidence.

Published predictive equations conditional recommendation, very low level of evidence. How should enteral access be achieved, and at what level of the GI tract should enteral nutrition be infused? Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with use of electromagnetic transmitter-guided feeding tubes. A percutaneous enteral access device should be placed, either via the gastric or jejunal route, if enteral feeding is anticipated to be required for greater than 4 weeks duration conditional recommendation, very low level of evidence.

Initiating enteral nutrition Question: Placement on PN over the first week of nutrition therapy conditional recommendation, low level of evidence. Monitoring tolerance and adequacy of enteral nutrition Question: How should adequacy and tolerance of enteral nutrition be assessed in the hospitalized patient?

Gastric residual volume should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence. Use a prokinetic agent conditional recommendation, low level of evidence.

Divert the level of feeding lower in the GI tract strong recommendation, moderate-to-high level of evidence. Switch to continuous infusion conditional recommendation, very low level of evidence. Use chlorhexidine mouthwash twice daily conditional recommendation, very low level of evidence. Use of fermentable soluble fiber as an adjunctive supplement to a standard EN formula conditional recommendation, very low level of evidence.

Switching to a commercial mixed fiber soluble and insoluble formula conditional recommendation, low level of evidence. When and how should parenteral nutrition be utilized in the hospitalized patient? Peripheral PN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence.

Nutritional therapy at end-of-life Question: All authors contributed to the manuscript. History of parenteral nutrition. J Am Coll Nutr ; The skeleton in the hospital closet. Brief history of enteral and parenteral nutrition in the hospital in the USA.

In Elia M, Bistrian B, eds. Vol 12 pp —Nestec Ltd. Enteral compared with parenteral nutrition: Am J Clin Nutr ; Total parenteral nutrition in the critically ill patient: Perioperative total parenteral nutrition in surgical patients.

N Engl J Med ; Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: Calorie Intake of enteral nutrition and clinical outcomes in acutely critically ill patients: J Parenter Enteral Nutr ; Initial trophic vs full enteral feeding in patients with acute lung injury: Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: Trial of the route of early nutritional support in critically ill adults.

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. The presence and effect of bias in trials of early enteral nutrition in critical care. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: Intensive Care Med ; Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: J Gastrointest Surg ; Nutrition support in acute pancreatitis: Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.

Computerized energy balance and complications in critically ill patients: The relationship between nutritional intake and clinical outcomes in critically ill patients: Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med ; The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract ; Feeding the critically ill patient.

Rating the quality of evidence. J Clin Epidem ; Grading quality of evidence and strength of recommendations. Percentage of weight loss, a basic indicator of surgical risk in patients.

Recognizing malnutrition in adults: Identifying critically ill patients who benefit the most from nutrition therapy: Incidence of nutritional risk and causes of inadequate nutritional care in hospitals.

Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature.

A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Overview of enteral and parenteral feeding access techniques: Surg Clin North Am ; Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care ; Nutrition screening tools for hospitalized patients. Nutritional-risk scoring systems in the intensive care unit.

Identifying critically ill patients who will benefit most from nutritional therapy: J Acad Nutr Diet ; Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients.

The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: J Am Coll Surg ; Fleck A, Path FR. Usefulness of data on albumin and prealbumin concentrations in determining effectiveness of nutritional support.

A critical evaluation of body composition modalities used to assess adipose and skeletal muscle tissue in cancer.

Appl Physiol Nutr Metab ; Interactions between nutrition and immune function: Proc Nutr Soc ; Monitoring health by values of acute phase proteins. Evaluation of serum C-reactive protein, procacitonin, tumor necrosis factor alpha, and interleukin levels as diagnostic and prognostic parameters in patients with community-acquired sepsis, sepsis syndrome and septic shock.

Clinical outcomes related to muscle mass in humans with cancer and catabolic illnesses. Int J Biochem Cell Biol ; Acute skeletal muscle wasting in critical illness. The use of indirect calorimetry in the intensive care unit. Best practices for determining resting energy expenditure in the critically ill adults. Nutr Clin Practice ; Feeding critically ill patients: Predictive equations for energy needs for the critically ill.

Prediction of resting metabolic rate in critically ill adult patients: J Am Diet Assoc ; Resting energy expenditure in malnourished older patients at hospital admission and three months after discharge: Longitudinal prediction of metabolic rate in critically ill patients.

Resting energy expenditure of morbidly obese patients using indirect calorimetry: Analysis of estimation methods for resting metabolic rate in critically ill adults. Improved equations for predicting energy expenditure in patients: A new predictive equation for resting energy expenditure in healthy individuals. Accurate determination of energy needs in hospitalized patients.

Caloric requirements in total parenteral nutrition. J Am Coll Nutr ;6: Measured versus calculated resting energy expenditure in critically ill adult patients. Do mathematics match the gold standard? Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs. Provision of protein and energy in relation to measured requirements in intensive care patients. Protein recommendations in the ICU: A reappraisal of nitrogen requirements for patients with critical illness and trauma.

J Trauma Acute Care Surg ; Nutritional strategies to counteract muscle atrophy caused by disuse and to improve recovery. Nutrit Res Rev ; Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: Motility disorders of the upper gastrointestinal tract in the intensive care unit: J Clin Gastroent ; Motility disorders in the ICU: Gastrointestinal symptoms in intensive care patients.

Acta Anaesthesiol Scand ; Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care ; Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Enteral nutrition practice recommendations.

The use of bedside electromagnetically guided nasointestinal tube for jejunal feeding of critically ill surgical patients. Technol Health Care ; Analysis of an electromagnetic tube placement device vs a self-advancing nasal jejunal device for postpyloric feeding tube placement. J Hosp Med ;9: Fang J The University of Utah www. North American summit on aspiration in the critically ill patient: J Parenter Enteral Nutr ;26 6 Suppl: The Canadian critical care nutrition guidelines in Nosocomial sinusitis in patients in the medical intensive care unit: Clin Infect Dis ; Complications of enteral access.

Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev ; The effect of nutritional supplementation on survival in seriously ill hospitalized adults: J Am Geriatr Soc ;48 5 Suppl: Techniques in enteral access. Nasal Bridles for securing nasoenteric tubes: Early enteral nutrition in acutely ill patients: Early supplemental parenteral nutrition in critically ill adults increased infections, ICU length of stay and cost.

Evid Based Med ; Port AM, Apovian C. Metabolic support of the obese intensive care unit patients: World Rev Nutr Diet ; Efficacy of hypocaloric parenteral nutrition for surgical patients: Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy.

World J Gastroenterol ; Consensus recommendations from the US summit on immune-enhancing enteral therapy. J Parenter Enteral Nutr ;25 Supplement: Early enteral supplementation with key pharmaconutrients improves sequential organ failure assessment score in critically ill patients with sepsis: Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: Should immunonutrition become routine in critically ill patients?

A systematic review of the evidence. J Parenter Enteral Nutr ;37 5 Suppl: Nutrition optimization prior to surgery. Early ICU energy deficit is a risk factor for Staphylococcus aureus ventilator-associated pneumonia.

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: J Gastroenterol Hepatol ;28 Suppl 4: Nutrition support protocols and their influence on the delivery of enteral nutrition: Worldviews Evid Based Nurs ; Postinjury enteral tolerance is reliably achieved by a standardized protocol. J Surg Res ; Effect of evidence-based feeding guidelines on mortality of critically ill adults: Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol.

Infusion protocol improves delivery of enteral tube feeding in the critical care unit. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: Volume-based feeding in the critically ill patient.

Mechanisms underlying feed intolerance in the critically ill: Methods for the assessment of gastric emptying in critically ill, enterally fed adults. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.

Gastric residual volumes in critical illness: Crit Care Clin ; Aspirating gastric residuals causes occlusion of small-bore feeding tubes. Microaspiration in intubated critically ill patients: Infect Disord Drug Targets ; Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: J Clin Monit Comput ; Diarrhea in enterally fed patients: Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients.

J Adv Nurs ; Bartel B, Gau E. Risk of Clostridium difficile diarrhoea in critically ill patients treated with erythromycin-based prokinetic therapy for feed intolerance. Current issues on safety of prokinetics in critically ill patients with feed intolerance. Ther Adv Drug Saf ;2: Pharmacological therapy of feed intolerance in the critically ill.

World J Gastrointest Pharmacol Ther ;5: Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: Effect of a fecal bulking agent on diarrhea during enteral feeding in the critically ill. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: Effect of a bulk-forming cathartic on diarrhea in tube-fed patients.

Mixed fibers diet in surgical ICU septic patients. Asia Pac J Clin Nutr ; Common examples include oral and intravenous administration. Routes can also be classified based on where the target of action is. Action may be topical local , enteral system-wide effect, but delivered through the gastrointestinal tract , or parenteral systemic action, but delivered by routes other than the GI tract. Route of administration and dosage form are aspects of drug delivery.

The route or course the active substance takes from application location to the location where it has its target effect is usually rather a matter of pharmacokinetics concerning the processes of uptake, distribution, and elimination of drugs.

Exceptions include the transdermal or transmucosal routes, which are still commonly referred to as routes of administration. The location of the target effect of active substances are usually rather a matter of pharmacodynamics concerning e. An exception is topical administration , which generally means that both the application location and the effect thereof is local.

Topical administration is sometimes defined as both a local application location and local pharmacodynamic effect, [3] and sometimes merely as a local application location regardless of location of the effects. Administration through the gastrointestinal tract is sometimes termed enteral or enteric administration literally meaning 'through the intestines '. However, uptake of drugs administered orally may also occur already in the stomach , and as such gastrointestinal along the gastrointestinal tract may be a more fitting term for this route of administration.

Strictly enteral administration directly into the intestines can be used for systemic administration, as well as local sometimes termed topical , such as in a contrast enema , whereby contrast media is infused into the intestines for imaging.

However, for the purposes of classification based on location of effects, the term enteral is reserved for substances with systemic effects. Many drugs as tablets , capsules , or drops are taken orally. Administration methods directly into the stomach include those by gastric feeding tube or gastrostomy. Substances may also be placed into the small intestines , as with a duodenal feeding tube and enteral nutrition.

Enteric coated tablets are designed to dissolve in the intestine, not the stomach, because the drug present in the tablet causes irritation in the stomach.

The rectal route is an effective route of administration for many medications, especially those used at the end of life. Rectal mucosa is highly vascularized tissue that allows for rapid and effective absorption of medications. In hospice care , a specialized rectal catheter , designed to provide comfortable and discreet administration of ongoing medications provides a practical way to deliver and retain liquid formulations in the distal rectum, giving health practitioners a way to leverage the established benefits of rectal administration.

Parenteral administration can be performed by injection , that is, using a needle usually a hypodermic needle and a syringe , [16] or by the insertion of an indwelling catheter. The definition of the topical route of administration sometimes states that both the application location and the pharmacodynamic effect thereof is local.

In other cases, topical is defined as applied to a localized area of the body or to the surface of a body part regardless of the location of the effect. If defined strictly as having local effect, the topical route of administration can also include enteral administration of medications that are poorly absorbable by the gastrointestinal tract. One poorly absorbable antibiotic is vancomycin , which is recommended by mouth as a treatment for severe Clostridium difficile colitis. In acute situations, in emergency medicine and intensive care medicine , drugs are most often given intravenously.

This is the most reliable route, as in acutely ill patients the absorption of substances from the tissues and from the digestive tract can often be unpredictable due to altered blood flow or bowel motility. Enteral routes are generally the most convenient for the patient, as no punctures or sterile procedures are necessary. Enteral medications are therefore often preferred in the treatment of chronic disease. However, some drugs can not be used enterally because their absorption in the digestive tract is low or unpredictable.

Transdermal administration is a comfortable alternative; there are, however, only a few drug preparations that are suitable for transdermal administration. Identical drugs can produce different results depending on the route of administration. For example, some drugs are not significantly absorbed into the bloodstream from the gastrointestinal tract and their action after enteral administration is therefore different from that after parenteral administration. This can be illustrated by the action of naloxone Narcan , an antagonist of opiates such as morphine.

Naloxone counteracts opiate action in the central nervous system when given intravenously and is therefore used in the treatment of opiate overdose. The same drug, when swallowed, acts exclusively on the bowels; it is here used to treat constipation under opiate pain therapy and does not affect the pain-reducing effect of the opiate.

The oral route is generally the most convenient and costs the least. Biopharmaceuticals have to be given by injection or infusion. However, recent research found an organic ionic liquid suitable for oral insulin delivery a biopharmaceutical into the blood stream. Oral administration is often denoted "PO" from "per os", the Latin for "by mouth". By delivering drugs almost directly to the site of action, the risk of systemic side effects is reduced. Inhaled medications can be absorbed quickly and act both locally and systemically.

Some medications can have an unpleasant taste or irritate the mouth. Inhalation by smoking a substance is likely the most rapid way to deliver drugs to the brain, as the substance travels directly to the brain without being diluted in the systemic circulation. Parenteral administration generally acts more rapidly than topical or enteral administration, with onset of action often occurring in 15—30 seconds for IV, 10—20 minutes for IM and 15—30 minutes for SC.

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