Complications of Enteral Tube Feeding

Stephen A. McClave, MD Professor of Medicine University of Louisville School of Medicine

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 to assess 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 they arise.

1200 ml (25%)

Managing Ileus

5000 ml

3800 ml (75%)

Evaluate segmental contractility Stomach NG output <1200 cc/d SB Abd distention, BS, A/F levels Colon Flatus, stool Select tube, feed level, decompression? Minimize ileus Correct electrolytes Reassess sedation, analgesia Narcan thru NE tube Minimize periods of ileus Feed an ileus

Use of Narcan to Enhance Tolerance

Amt EN

= 54 mL = 129 mL

GRV

* * p=0.03

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)

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

2Schunn (Amer Coll Surg 1995;180:410) (J Trauma 1999;47:859) 3Choban (Amer J Surg 1988;155:112) 4Lawlor (Can J Surg 1998;41:459)

Ischemic Bowel

SB at risk due to countercurrent mechanism Blood shunted arteriole to subepithelium Villous tips affected first Absorption

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
Schunn (J Amer Coll Surg 1995;180:410)

Scaife (J Trauma 1999;47:859)

Recommendations for EN in Hypotension

X

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

Complication of Nasal Bridle

Limit duration of bridle use to 6-8 weeks

Tube Occlusion
Risk factors (incidence 9-20%) :
Tube length Tube caliber Infrequent flushes Continuous infusion Instilling meds Using GRVs * (p < 0.01)

Declogging agents (0=none to 3=dissolution)

Agent: Viokase (bicarb) Score: 2.9 *

Coke 1.4

Papain 0.8

Viokase (plain) 0.8

Marcuard (JPEN 1989;13:81-83)

Tube Declogging

Marcuard (JPEN 1989;13:81-83)

Diarrhea

R/O low volume incontinence Evaluate etiology Meds (sorbitol) 55% Clostridia Difficile 17% Formula 20%

Dont stop feeds Switch formulas Fiber-containing Small peptide

100gm 4x diarrhea
Mean Stool Volume

no diarrhea

Benya (J Clin Gastro 1991;13:167)

Free Air Under the Diaphram

Air under diaphram signifies perforated bowel Pneumoperitoneum occurs in 40-56% of routine PEGs

Normal Appearance
7 days

2 days

Mature Track

Longterm Care:
Examine Plug

Fused Plug Cap

Separate Plug Cap

Replace entire PEG

Replace Cap only

Longterm Care: Examine PEG Tubing

Polyurethane

Silicone

Fungal Colonization (silicone)

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 infection Evaluate salvageability of PEG site

Endoscopy probably required : Bleeding Fixation Breakdown PEG site

Excess Drainage : Breakdown of Site

Corrosive Injury

PEG Site

Stop orders for acid-reducing drugs Vitamin C (Ascorbic Acid) Any Peroxide washes post placement