drug administration via feeding tubes in icu
DESCRIPTION
drug administration via feeding tubes in intensive care: nasogastric tube, nasoduodenal/nasojejunal tubes, PEG & PEJ caveats, complications and problems related this administration route; risk management somministrazione di farmaci tramite sonda enterale in terapia intensiva: problematiche e complicanze associate e gestione del rischio clinicoTRANSCRIPT
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in feeding tubes
Velia Marta Antonini, Parma University Hospital I° Department of Anesthesia and Intensive Care
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Administration via feeding tube often falls
outside license
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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become liable for any adverse event
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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become liable for therapy failure
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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complications obstruction of feeding tubes cross-‐contamination
exposure to powders environmental contamination
(patients)
(HCP)
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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equipment
avoid handling or inhaling
cytotoxics agents hormones antibiotics
eg steroids!
personal protective
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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tubes
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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nasogastric feeding tube
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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duodenal-jejunal feeding tube
caveats: length & diameter Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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PEG/PEJ tubes
manage as nasal inserted Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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drugs formulations
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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soluble/effervescent tabs dispersible tablets buccal/sublingual tablets coated/uncoated tablets hard/soft gelatin capsules modified-‐release tablets
solid formulations
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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uncoated tablets
crush administered immediately do not mix powders Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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soluble tablets
dose adjustment is difficult allow complete dissolution
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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effervescent tablets
require large volumes produces CO2g when in water
caveats: gas & sediment Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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coated tablets
not crush nor break Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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coated tablets
if administered in small intestine tube may be crushed or coat removed Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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capsules (hard)
open & give content if not modified release Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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capsules (soft)
draw fluid with a syringe if not modified release complete dosing not guaranteed Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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buccal sublingual chewable cytotoxic agents hormones & enzymes
never to be crushed
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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alternative formulation alternative drug alternative route
never to be crushed …if essential
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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liquid formulations
preferable if available do not mix
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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liquid formulations suspensions solutions syrups elixirs linctus
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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liquid formulations
caveats co-‐solvents excipients viscosity granule size
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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paracetamol
high Na in soluble tablets oral liquids are hyperosmolar
(acetaminophen)
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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oral liquids are hyperosmolar
metoclopramide
dilute with at least an equal volume of water
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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do not use oral liquid tubes due to absorption into plastic tubing
diazepam
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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lactulose
dilute3 times before administration via ND/NJ/PEJ
dilute avoiding tube obstruction
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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drug -‐feed interactions
delayed -impaired reduced -augmented
absorption
bioavailability Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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drug -‐feed interactions
stop feeding before stop after flush tube
how long?
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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small syringe = high pressure
30-50 m l recommended
flush
may damage tube/mucosa use largest functional size
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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avoiding occlusions
reducing the formation &/or clearing debris built-‐up on inner wall
water flush effective
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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tap/sterile H2O
sterile H2O
water flush
for gastric tubes
beyond the stomach
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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pulsatile flush = turbulence within the inner lumen more effective cleaning
15-30 m l before 5-10 m l between each 15-30 m l after drug
water flush
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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sediment in syringe pediatric pts small bowel tubes
15-30 m l ? relates to lumen total volume
water flush
diameter & length! attention!
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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revise volumes take account in balance replace water with air
fluid restriction?
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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absorption affected by high-‐fibre containing feeds
digoxin
stop 2h before stop 2h after Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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isoniazid
rifampicin
stop 2h before stop 2h after
stop 2h before stop 1/2h after Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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bioavailability reduced to up 30% but no recommendations
furosemide
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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decreased absorption up to 75% if administered with feed absorption extremely poor via jejunal route
stop 2h before stop 2h after
phenytoin
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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enteral feed delays but not decrease absorption
stop 1h before stop 2h after
quinolone antibiotics
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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impair absorption by binding when containing
stop 1h before stop 1h after
antacids
Al Mg Ca
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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levothyroxine
no documented interaction no feeding break required Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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stop 2h before stop 2h after
carbamazepine
impaired absorption
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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drug -‐device interactions
know administered drug know tubes in place
you have to
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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oral syringes
do not use devices compatible with IV ports & catheters
catheter tipped
Handbook of Drug Administration via Enteral Feeding Tubes
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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catheter-tipped syringes
do not measure liquid drugs: risk of excessive dosing owing to tip volume Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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dead-‐space volume is approximately 1–1.5 mL
catheter-tipped syringes
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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patency of feeding tubes
main cause of occlusion incorrect drug administration Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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obstructed feeding tube
particle obstruction precipitate obstruction
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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food-‐drug drug-‐drug drug-‐device interactions
obstructed feeding tube
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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irrigation enzymes mechanical devices
unblock obstructed tube
Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy
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Velia Marta Antonini Parma University Hospital
I° Department of Anesthesia and Intensive Care
thanks for attention