A.S.P.E.N. Enteral

Nutrition Practice

Recommendations

Kelly Tappenden, PhD, RDProfessor of Gastrointestinal Physiology & Nutrition

University of Illinois Urbana-Champaign

OutlineI. Introduction

II. Ordering and Labelling of EN

III. Enteral Formula (Medical Foods) and Infant Formula Regulation

IV. Water and Enteral Formula Safety and Stability

V. Enteral Access

VI. EN Administration

VII. Medication Administration

VIII. Monitoring EN Administration

IX. Summary

Glossary of Terms• Beyond-Use Date

• Clinical Guidelines

• Closed Enteral System

• Computerized

Prescriber Order

Entry (CPOE)

• Distilled Water

• Drug-Nutrient

Interactions

• Enteral Access Devices

• Enteral Misconnection

• Enteral Nutrition (EN)

• Expiration Date

• Fore Milk

• Hang Time

• Hind Milk

• Medical Food

• Modular Enteral

Feeding

• Open Enteral System

• Purified Water

• Sentinel Event

• Tap Water

• Transitional Feeding

Objective/Goal/Methodology• Objective = establish evidence-based practice

guidelines following review of literature related

to ordering, preparation, delivery, and

monitoring of EN

• Goal = identify safety issues related to EN

• Grading system = modified Agency for

Healthcare Research and Quality (AHRQ) method

A. GOOD research-based evidence to support

guideline (PRCTs).

B. FAIR research-based evidence to support

guideline (well-designed studies w/out

randomization).

C. The guideline is based on EXPERT OPINION and

EDITORIAL CONSENSUS.

Formulary Selection Process

1. Facilities should establish a formulary specific

and available EN formulas. (C)

2. A specific EN formulary should be based on

patient population and estimated nutrient

needs rather than specific diagnosis. (C)

3. A clinician with expertise in nutrition support

should be involved in corporate buying of EN

products that best meets the patient’s nutrient

requirements. (C)

Use standardized order forms specific for

adult and pediatric EN regimens (C)

EN orders should

include (C):

1) patient info;

2) formula;

3) enteral access

site/device;

4) administration

method/rate

Incorporate EN

advancement,

transitional,

monitoring and

ancillary orders.(C)

Use generic terms,

avoid abbreviations

(C)

All orders,

even

re-orders,

must be

complete!

(C)

Labels for EN formula administration containers,

bags, or syringes should be standardized. (C)

ALL EN labels, in all

environments, shall

express clearly and

accurately what the

patient is receiving at any

time. (C)

Before administration, EN

label should be compared

with the EN order for

accuracy, hang time, and

beyond-use date. (C)

Clinician-to-clinician

communication needed to

promote the accurate EN

prescription during patient

transfers. (C)

Clearly label human breast milk with

the patient’s name/medical record

number to prevent delivery errors.

Preprinted labels and/or bar coding

systems helpful. (C)

Regulatory Issues

Medical food = a food which is formulated to be

consumed or administered enterally under the

supervision of a physician and which is

intended for the specific dietary management

of a disease or condition for which distinctive

nutritional requirements, based on recognized

scientific principles, are established by medical

evaluation.

• Require good manufacturing practice

• Exempt from regulations on labeling and health

claims that apply to conventional foods

BUYER BEWARE!!

Eliminate EN Contamination

Clean environment (A)

Aseptic technique (A)

Trained personnel (C)

Sterile, liquid>powder(A)

Controlled storage (B)

Follow manufacturer

recommendations (B)

Disposable gloves (A)

Screw cap > flip top (A)

Use recessed spikes (B)

Pump with drip chamber (A)

Peds products DEHP free (B)

1. Institution need ongoing quality control

process for EN formula prep, distribution,

storage, handling, and administration. (B)

2. Institutions need written policies and

procedures for safe EN formula and HBM

prep/handling, as well as maintain an ongoing

surveillance program for contamination. (B)

Formula Hang Times Vary

Selection of Enteral Access Device

1. Select an enteral access

device based on patient

specific factors. (C)

2. Nasojejunal route for

enteral feedings in ICU

patients are not required

unless gastric feeding

intolerance is present.

(A)

3. Patients with persistent

dysphagia should have a

long-term enteral access

device placed. (B)

Insertion of Enteral Access Device1. Obtain radiographic confirmation of tube placement

prior to use. (B)

2. Capnography may help prevent improper placement

when inserting a gastric feeding tube. (B)

3. When inserting a small bowel feeding tube, observe for

a change in pH and appearance of aspirates as the tube

progresses from the stomach to small bowel. (B)

4. Do not rely on the ausculatory method to differentiate

between gastric and small bowel placement. (A)

5. Mark exit site of feeding tube at the time of the initial

radiograph; observe for a change during feedings. (B)

6. In pediatrics and neonates, all methods but X-ray

verification of enteral tube placement have been shown

to be inaccurate; however should be used judicious. (B)

Longterm Enteral Feeding Devices

1. Considered when EN >4 wks. (C)

2. Not for premature infants without strong justification. (C)

3. Multidisciplinary team should advise re placement to ensure

(B):a. benefit > risk of placement;

b. placement near end of life is warranted; or

c. insertion is indicated if close to achieving oral feeding.

4. Perform abdominal imaging prior to placement. (C)

5. Gastrostomy tube placement does not mandate

fundoplication. (B)

6. Direct placement indicated in patients requiring a long-term

jejunostomy. (B)

7. Document tube type, tip location, and external markings. (C)

8. Avoid placement of catheters or tubes not intended for use

as enteral feeding devices. (B)

When to start feeding following

placement?

1. Enteral feedings should be started postoperatively

in surgical patients without waiting for flatus or a

bowel movement. The current literature indicates

that these feedings can be initiated within 24-48

hours. (A)

2. A PEG tube may be utilized for feedings within

several hours of placement: current literature

supports within 2 hours in adults and 6 hours in

infants and children. (B)

Initiation and Advancement of EN

1. Base enteral delivery method and initiation and

advancement of EN regimens on patient condition,

age, enteral route (gastric vs small bowel),

nutrition requirements, and GI status. (C)

2. Choose full strength, isotonic formulas for initial

feeding regimen. (C)

3. Initiation and advancement of enteral formula in

pediatric patients is best done over several days in

a hospital setting using a flexible nutrition plan. (C)

Preterm Infant Considerations

1. For premature infants weighing < 1500 g and

at risk for NEC, it is recommended that

mothers be encouraged to supply breast milk

for their infants. (A)

2. ELBW and VLBW infants may benefit from

minimal enteral feeding starting very slowly

at 0.5-1 mL/kg/day and advancing to 20

mL/kg/day. (B)

3. Advance nutritive feedings for VLBW and

ELBW infants by a rate of 10-20 mL/kg/day.

(C)

Enteral Feeding Pumps

1. Feeding pumps should be calibrated

periodically to assure accuracy. (B)

2. Accuracy ±10% for adults (B); within 5% for

peds and neonates. (C)

3. HBM infused at low rates should be

administered via syringe pump with tip

elevated. (C)

4. Feeding pumps for home use should have

features that promote safety and minimize

sleep disturbances. (B)

Patient Positioning

1. Elevate the backrest to >30º, and preferably to

45º, for all patients receiving EN unless a

medical contraindication exists. (A)

2. Use the reverse Trendelenberg position to

elevate the HOB, unless contraindicated, when

the patient cannot tolerate a backrest

elevated position. (C)

3. If necessary to lower the HOB for a procedure

or a medical contraindication, return the

patient to an HOB elevated position as soon as

feasible. (C)

Flushes of feeding tubes

1. Flush with 30 mL water q 4h during continuous

feeding(A); before/after bolus feedings (A) and

residual volume measurements (B) in adults.

2. Use lowest volume necessary to clear tube in peds

and neonates. (C)

3. Sterile water is recommended before/after

medication administration. (C)

4. Adhere to protocols that call for proper flushing of

tubes before/after medication administration. (B)

5. Use pump when slow rates are required, such as with

neonates, and respond promptly to pump alarms. (C)

6. Use sterile water for tube flushes in

immunocompromised or critically ill patients. (C)

Enteral Misconnections1. Review current systems/practices for misconnect potential. (C)

2. Only allow trained clinicians to reconnect, in proper lighting. (C)

3. Do not modify or adapt IV or feeding devices. (C)

4. Routinely trace lines back to origins and in standardized

directions . (C)

5. Recheck connections, trace all tubes in new setting/hand-off. (C)

6. Use standardized labels or color-code feeding tubes and

connectors. (C)

7. Identify and confirm the EN label. (C)

8. Ensure purchasing policies dictate safe products:

• Avoid enteral equip that mates with female luer

connectors. (C)

• Dedicated enteral pumps. (C)

• Enteral feeding sets. (C)

• Preoper pre-filled EN containers. (C)

• Oral syringes, instead of luerlock, for enteral meds. (C)

Medication Administrion

1. Don’t add meds directly to enteral formula (B)

2. Don’t mix meds for EN admin (B)

3. Administer each med separately in appropriate

form (B)

4. Stop feeding flush med flush (A)

5. Hold EN < 30 min following med (A)

6. Use oral/enteral syringes labeled with ‘for oral

use only’ to measure/administer enteral meds.

(B)

7. Consult pharmacist for patients who receive

medications co-administered with EN. (C)

Monitor for Refeeding Syndrome

1. Monitor fluid and electrolyte, and other

metabolic parameters as needed based on

the patient’s clinical situation. (B)

2. Check metabolic and nutrition parameters,

and correct depleted levels prior to the

initiation of enteral feedings. (B)

Monitor Gastric Residual Volumes

1. With EN, always evaluate aspiration risk. (A)

2. Assure tube is properly placed before use (A)

3. Elevate HOB 30-45(A)

4. During first 48h, check GRV q 4h (B); may reduce to 6-

8h thereafter in non-critically ill (C)

5. If GRV is >250 mL after 2nd check, consider prokinetic

agent in adults (A)

6. If GRV is >500 mL, hold EN thoroughly reassess

patient tolerance (B)

7. If GRV is consistently >500 mL, consider tube below

loT (B)

8. In peds, check GRVs every 4h, hold if residual > hourly

rate. If bolus, check before next feed and hold if GRV

>50% of previous volume. (C)

Conclusions

• EN is also complex and safety is

critically important

• PRCTs are needed

• Implications for safe EN practices

extend far beyond those providing the

nutrition support

• Strong communication is essential