Complications of Enteral Tube Feeding

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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 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.

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Managing Ileus
1200 ml (25)
5000 ml
3800 ml (75)

• Evaluate segmental contractility Stomach NG
  output
• 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

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Use of Narcan to Enhance Tolerance
Amt EN
54 mL
129 mL

GRV
p0.03

• Critically ill pts (n84) on MV and Fentanyl
  anaesthesia
• Randomized to 8mg narcan vs placebo q6hrs per NG
  tube
• Rate of pneumonia reduced 56 to 34 (p0.04)

Meissner (CCM 200331776)
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Ischemic BowelEpidemiology

• 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 199947859) 2Schunn (Amer
  Coll Surg 1995180410)
• 3Choban (Amer J Surg 1988155112) 4Lawlor (Can
  J Surg 199841459)

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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 199947859) Schunn (J Amer Coll
Surg 1995180410)
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Recommendations for EN in Hypotension
X
X
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

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Complication of Nasal Bridle
Limit duration of bridle use to 6-8 weeks
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Tube Occlusion

• Risk factors (incidence 9-20)
  Tube length Infrequent
  flushes Instilling meds Tube caliber Continuous
  infusion Using GRVs
• Declogging agents (0none to 3dissolution)
  (p
• Agent Viokase (bicarb) Coke
  Papain Viokase (plain)
• Score 2.9 1.4
  0.8 0.8
• Marcuard (JPEN 19891381-83)

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Tube Declogging
Marcuard (JPEN 19891381-83)
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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
Mean Stool Volume
4x
diarrhea
no diarrhea
Benya (J Clin Gastro 199113167)
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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
7 days
2 days
Mature Track
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Longterm Care Examine Plug
Fused Plug Cap
Separate Plug Cap
Replace Cap only
Replace entire PEG
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Longterm Care Examine PEG Tubing
Polyurethane
Fungal Colonization (silicone)
Silicone
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Excess DrainageDeteriorationof 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

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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