Guidelines for enteral feeding in adult hospital patients
Free- M Stroud,
- H Duncan,
- J Nightingale
- Institute of Human Nutrition, Southampton General Hospital, Southampton, UK
- Correspondence to:
Dr M Stroud
Institute of Human Nutrition, Mail point 113, F Level, Southampton General Hospital, Tremona Rd, Southampton, UK; m.a.stroudsoton.ac.uk
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- malnutrition
- nutrition support
- enteral feeding
- guidelines
- ETF, enteral tube feeding
- EN, enteral nutrition
- PN, parenteral nutrition
- BMI, body mass index
- BSG, British Society of Gastroenterology
- BAPEN, British Association of Parenteral and Enteral Nutrition
- NG, nasogastric
- NJ, nasojejunal
- PEG, percutaneous endoscopic gastrostomy
- PEGJ, percutaneous endoscopic transgastric jejunostomy
- LCT, long chain triglyceride
- MCT, medium chain triglyceride
- SCFA, short chain fatty acid
1.0 FOREWORD
Patients with undernutrition to a degree that may impair immunity, wound healing, muscle strength, and psychological drive are common in UK hospital populations.1 These individuals cope poorly with modern medical and surgical interventions and, on average, stay in hospital for approximately five days longer than the normally nourished, incurring approximately 50% greater costs.2,3 Hospitals should therefore aim to provide at least adequate nutrition to all patients. In the majority, this can be achieved by the catering services if they offer good food and care is taken to avoid missed meals and to provide physical help with eating, as necessary. However, even if these ideals are met, many hospital patients do not or cannot eat adequately. Some of these will benefit from oral supplements but others will need active nutritional support. This can usually be provided by enteral tube feeding [ETF].
This document contains guidelines covering the indications, benefits, administration, and problems of ETF in adult hospital practice. The guidelines were commissioned by the British Society of Gastroenterology [BSG] as part of an initiative in several areas of clinical practice. They are not rigid protocols and should be used alongside clinical judgement, taking local service provision into account.
2.0 FORMULATION OF GUIDELINES
These guidelines were compiled from the relevant literature by the authors in discussion with dietitians and specialist nutrition nurses. They were subsequently reviewed by the BSG small bowel/nutrition committee and dietetic, nursing, pharmacy, and medical representatives of the British Association of Parenteral and Enteral Nutrition [BAPEN]. The strength of evidence used is as recommended by the North of England evidence based guidelines development project.4
Ia—Evidence obtained from meta-analysis of randomised controlled trials.
Ib—Evidence obtained from at least one randomised trial.
IIa—Evidence obtained from at least one well designed controlled study without randomisation.
IIb—Evidence obtained from at least one other type of well designed quasi experimental study.
III—Evidence obtained from well designed non-experimental descriptive studies such as comparative studies, correlation studies, and case studies.
IV—Evidence obtained from expert committee reports or opinions or clinical experiences of respected authorities.
Unfortunately, many aspects of ETF have not undergone rigorous evaluation, partly because ethical considerations make placebo controlled trials of any nutritional intervention difficult [see section 4.2]. Nevertheless, recommendations based on the level of evidence are presented and graded as:
grade A—requiring at least one randomised controlled trial of good quality addressing their topic of recommendation;
grade B—requiring the availability of clinical studies without randomisation on the topic of recommendation;
grade C—requiring evidence from category IV in the absence of directly applicable clinical studies.
3.0 SUMMARY OF RECOMMENDATIONS
Indications for enteral feeding
Health care professionals should aim to provide adequate nutrition to every patient unless prolongation of life is not in the patient’s best interest [grade C].
It should be hospital policy that the results of an admission nutritional screening are recorded in the notes of all patients with serious illness or those needing major surgery [grade C].
Artificial nutrition support is needed when oral intake is absent or likely to be absent for a period >5–7 days. Earlier instigation may be needed in malnourished patients [grade A]. Support may also be needed in patients with inadequate oral intake over longer periods.
Decisions on route, content, and management of nutritional support are best made by multidisciplinary nutrition teams [grade A].
ETF can be used in unconscious patients, those with swallowing disorders, and those with partial intestinal failure. It may be appropriate in some cases of anorexia nervosa [grade B].
Early post pyloric ETF is generally safe and effective in postoperative patients, even if there is apparent ileus [grade A].
Early ETF after major gastrointestinal surgery reduces infections and shortens length of stay [grade A]
In all post surgical patients not tolerating oral intake, ETF should be considered within 1–2 days of surgery in the severely malnourished, 3–5 days of surgery in the moderately malnourished, and within seven days of surgery in the normally or over nourished [grade C].
If there are specific contraindications to ETF, parenteral feeding should be considered. If patients are taking >50% of estimated nutritional requirements, it may be appropriate to delay instigation of ETF [grade C].
ETF can be used for the support of patients with uncomplicated pancreatitis [grade A].
Ethical issues
ETF should never be started without consideration of all related ethical issues and must be in a patient’s best interests [grade C].
ETF is considered to be a medical treatment in law. Starting, stopping, or withholding such treatment is therefore a medical decision which is always made taking the wishes of the patient into account.
In cases where a patient cannot express a wish regarding ETF, the doctor must make decisions on ETF in the patient’s best interest. Consulting widely with all carers and family is essential.
Access techniques
Fine bore [5–8 French gauge] nasogastric [NG] tubes should be used for ETF unless there is a need for repeated gastric aspiration or administration of high viscosity feeds/drugs via the tube. Most fibre enriched feeds can be given via these fine bore tubes [grade A].
NG tubes can be placed on the ward by experienced medical or nursing staff, without x rays to check position. Their position must be checked using pH testing prior to every use [grade A].
The position of a nasojejunal [NJ] tube should be confirmed by x ray 8–12 hours after placement. Auscultation and pH aspiration techniques can be inconclusive [grade A].
NG tube insertion should be avoided for three days after acute variceal bleeding and only fine bore tubes should be used [grade C].
There is no evidence to support the use of weighted NG tubes, in terms of either placement or maintenance of position [grade A].
Long term NG and NJ tubes should usually be changed every 4–6 weeks swapping them to the other nostril [grade C].
Gastrostomy or jejunostomy feeding should be considered whenever patients are likely to require ETF for more than 4–6 weeks [grade C] and there is some evidence that these routes should be considered at 14 days [grade B].
Suitability for gastrostomy placement should be assessed by an experienced gastroenterologist or member of a nutrition support team. Expert advice on the prognosis of swallowing difficulties may be needed [grade C].
In patients with no risk of distal adhesions or strictures, gastrostomy tubes with rigid internal fixation devices can be removed by cutting them off close to the skin, pushing them into the stomach, and allowing them to pass spontaneously [grade A].
Feed administration
Giving enteral feed into the stomach rather than the small intestine permits the use of hypertonic feeds, higher feeding rates, and bolus feeding [grade A].
Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week [grade A]. Diluting feeds risks infection and osmolality difficulties.
Both inadequate or excessive feeding may be harmful. Dietitians or other experts should be consulted on feed prescription [grade C].
If no advice is available, 30 ml/kg/day of standard 1 kcal/ml feed is often appropriate but may be excessive in undernourished or metabolically unstable patients [grade C].
When patients are discharged to the community on continuing ETF, care must be taken to ensure all community carers are fully informed and that continuing prescription of feed and relevant equipment is in place [grade C].
Complications of enteral feeding
Close monitoring of fluid, glucose, sodium, potassium, magnesium, calcium, and phosphate status is essential in the first few days after instigation of ETF [grade C].
Life threatening problems due to refeeding syndrome are particularly common in the very malnourished and there are also risks from over feeding shortly after major surgery or during major sepsis and/or multiorgan failure [grade C].
To minimise aspiration, patients should be fed propped up by 30° or more and should be kept propped up for 30 minutes after feeding. Continuous feed should not be given overnight in patients who are at risk [grade C].
Any drugs administered via an ETF tube should be liquid and should be given separately from the feed with flushing of the tube before and after [grade C].
Loosening and rotating a gastrostomy tube may prevent blockage through mucosal overgrowth and may reduce peristomal infections [grade C].
In patients with doubtful gastrointestinal motility, the stomach should be aspirated every four hours. If aspirates exceed 200 ml, feeding policy should be reviewed [grade C].
Continuous pump feeding can reduce gastrointestinal discomfort and may maximise levels of nutrition support when absorptive capacity is diminished. However, intermittent infusion should be initiated as soon as possible [grade A].
Simultaneous use of other drugs, particularly antibiotics, is usually the cause of apparent ETF related diarrhoea [grade A].
Fibre containing feeds sometimes help with ETF related diarrhoea, as will breaks in the feeding of 4–8 hours [grade B].
Careful measures are needed to avoid bacterial contamination of feeds which can give rise to sepsis, pneumonia, and urinary tract infections, as well as gastrointestinal problems [grade A].
Avoiding gastric acid suppression and allowing breaks in feeding to let gastric pH fall will help prevent bacterial overgrowth during ETF [grade A].
4.0 BACKGROUND
4.1 Malnutrition in the UK
Recent studies in a nationally representative sample showed that undernutrition is common in UK adults in both community and hospital populations.1,5,6 Approximately 5% of apparently “healthy” UK adults were shown to have a body mass index [BMI]