enteral tube feeding
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enteral tube feeding
Short-term feeding (less than 4 weeks’ duration) can usually be managed with a nasogastric tube. Longer-term feeding requires a surgically implanted feeding tube. The choice of tube is determined by a number of factors, including the expected duration of feeding, the condition necessitating the feeding, concomitant conditions, and clinician preference. The percutaneous endoscopic gastrostomy tube (PEG) is the most common method for tube insertion. The tube is placed using direct endoscopic visualization through an abdominal incision, and anchored in place with an outer flange and an inner bump or balloon. It enters through the abdominal wall into the stomach. The gastrojejunostomy tube is a smaller-bore tube advanced through the stomach into the jejunum tube. It delivers contents into the jejunum and is used for patients with recurrent aspiration, upper gastrointestinal obstruction or fistula, gastroparesis, and gastroesophogeal reflux. It cannot be used in patients with small bowel disease because it can cause enterocutaneous fistulae. The smaller bore increases the probability of clogging, which requires more frequent tube flushing and replacement. The gastrostomy button prevents some of the chronic complications of gastrostomy tubes (clogging, leaking, and skin irritation). The button is skin level and out of sight when the patient is clothed. It usually replaces a gastrostomy tube 4 weeks after the initial PEG to ensure development of a mature tract. Tube placement is confirmed by X-ray. Health care professionals need to assess the patient (and teach the patient and other care providers how to assess) for leakage (recognizing that high abdominal pressure, as occurs with sneezing or coughing, often causes some normal leakage), skin irritation, infection, and formation of granulation tissue. Nutrition and hydration status and signs and symptoms of aspiration, pneumonia, or GI complications (such as bleeding or peritonitis) also need to be assessed. The professional care provider should use the time with the patient while flushing and assessing tube concerns to teach the patient and family caregivers how to care for the tube and to offer support as the patient and significant others adjust to body image changes and the loss of eating pleasures. Flushing enteral tubes to keep them free from build-up is essential, because unclogging a tube wastes time, effort, and resources. The best method of tube flushing is a matter of active research; local protocols apply. Tubes that cannot be unclogged must be replaced.
There are four types of nutrient formulas: intact nutrient, hydrolyzed nutrient, elemental (defined), and modular. Intact nutrient formulas are called standard because the nutrients are whole and therefore are appropriate for use whenever normal digestion takes place. They usually provide 1 kcal/ml and can be used orally. In hydrolyzed nutrient formulas the nutrients are predigested and are suitable for use whenever malabsorption is present or when the jejunum is the feeding site. These formulas are not appropriate for oral use because of their taste. They are more expensive than intact nutrient formulas. In elemental (defined) formulas the nutrients are in the simplest, most basic, form and are rapidly absorbed from the gut. These formulas are not appropriate for oral use. This type of formula is the most expensive. Formulas designed for specific diseases are available. In modular formulas, commercially produced nutritional products may be used as supplements to standard formulas. For example, the addition of a protein module would convert a standard formula to a high-protein formula.
There are four kinds of delivery: bolus, intermittent infusion, cyclic infusion, and continuous drip. In bolus administration the formula is delivered in four to six daily feedings by a large syringe attached to the feeding tube in the stomach. This type of delivery is the least well tolerated. In intermittent infusion the formula is delivered four to six times daily over 30 to 60 minutes using a pump or gravity flow. In cyclic infusion an infusion pump delivers the nutrient solution for specified hours of the day and is turned off during other hours. In continuous drip an infusion pump delivers nutrition all day long.