Complications of Enteral Nutrition Part 1
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Transcript of Complications of Enteral Nutrition Part 1
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Complications of Enteral Tube
Feeding
Stephen A. McClave, MD
Professor of Medicine
University of Louisville School of Medicine
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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.
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Managing
Ileus
Evaluate segmental contractilityStomach NG output
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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
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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)
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Ischemic Bowel
SB at risk due to countercurrent mechanism
Blood shunted arteriole to subepithelium
Villous tips affected first Absorption
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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)
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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
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Complication of Nasal Bridle
Limit duration of bridle use to 6-8 weeks
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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
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Tube Declogging
Marcuard (JPEN 1989;13:81-83)
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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
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Free Air Under the Diaphram
Air under diaphram signifies perforated bowel
Pneumoperitoneum occurs in 40-56% of routine PEGs
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Normal Appearance
2 days
Mature Track
7 days
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Longterm Care:Examine Plug
Fused Plug CapSeparate Plug Cap
Replace entire PEG Replace Cap only
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Longterm Care: Examine PEG Tubing
Polyurethane
Fungal Colonization (silicone)Silicone
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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
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Excess Drainage : Breakdown of SiteCorrosive Injury
PEG
Site
Stop orders for acid-reducing drugs
Vitamin C (Ascorbic Acid)
Any Peroxide washes post placement