Implementing Enteral Implementing Enteral Nutrition Therapy:Nutrition Therapy:

Enteral AccessEnteral Access

Objectives

• To describe the benefits of enteral nutrition therapy• To review indications and contraindications of enteral

nutrition• To describe access routes for enteral nutrition infusion• To describe the advantages and disadvantages of

various enteral access routes

Enteral Nutrition Therapy: Benefits

• Maintains gastrointestinal structure and function• Reduces translocation of toxins and possibly bacteria• Less expensive than parenteral nutrition therapy• Fewer complications

“If the gut works, use it.”

Enteral Nutrition: Indications

• Patients unable or unwilling to consume adequate nutrition to meet metabolic requirements alone or with assistance

• Complement insufficient intake or increased demand

Enteral Nutrition: Indications

Requires total or partial GI tract function•Anorexia•Apoplexy•Coma•Sepsis•Trauma/surgery •Transition from parenteral nutrition

Enteral Nutrition: Contraindications

Absolute

• Complete bowel obstruction• Severe small bowel ileus with abdominal distention• Complete inability to absorb nutrients through the GI

tract

Enteral Nutrition: Contraindications

Relative• Severe postprandial pain• Short bowel syndrome • Intractable vomiting• Severe diarrhea

Gastric Access

Gastric Route Preferred • Adequate gastric motility• Minimum risk of aspiration

Gastric Route Contraindicated• Delayed gastric emptying (gastroparesis)• High risk for aspiration

Gastric Access

Gastric Route Advantages• Normal reservoir for food• Easy access• Tolerates high osmotic loads• Tolerates intermittent feedings• Gastric acid destroys contaminants• Can be placed by nurses

Gastric Feeding Techniques

Nasogastric Tube

Short term

Manual or radiologic

placement

Gastrostomy

Long term

Endoscopic,radiologic, or

surgical placement

Rugeles S, et al. Universitas Medica 1993;34(I):19-23

Nasogastric Tubes

8 Fr, stylet,

opaquebolus, 45"

12 Fr,opaque, 36"

12 Fr,clear, 36"

Nasogastric Tube: Disadvantages

• Short-term use only• Higher risk for aspiration• Difficult to confirm position• Small bore• Nasopharyngeal trauma/irritation• Accidental tube displacement

Percutaneous Endoscopic Gastrostomy: PEG Tubes

Rigid Flexible

Minard G. Nutr Clin Prac 1994;9:172-182

Percutaneous Endoscopic Gastrostomy: Advantages

• The same as for surgical gastrostomy• No surgery / less invasive• Minimal sedation• Direct visualization• < 30 minutes to place tube• Lower costs

Percutaneous Endoscopic Gastrostomy: Placement Criteria

• Adequate passage for endoscope• Ease in identifying safe site• Ease in determining a safe tract• Functioning GI tract• Absence of ascites / morbid obesity

Stellato TA, et al. Ann Surg 1984;200:46-50Lee M, et al. Clin Radiol 1991;44:332-334

Surgical Gastrostomy

• Performed in operating room• Indicated when PEG is contraindicated or during other

surgical procedures• Requires general anesthesia and full surgical team• In observation during recovery• More expensive than PEG

Gastrostomy: Low-Profile Tube

Post-pyloric Access

Indications for post-pyloric route

• Patient at risk for bronchial aspiration, gastric reflux• Gastric feeding contraindicated

– Gastric motility disorders; e.g., gastroparesis– Upper GI tract condition; e.g., carcinoma, stricture, fistula

Post-pyloric Access

Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387

Advantages

Allows earlier post-op feeding

Lower risk of aspiration

Disadvantages

Small bore tubes, prone to obstruction

Tubes can be dislodged into stomach

Difficult to maintain long term Potential for dumping syndrome Requires infusion pump

Post-pyloric Feeding Techniques

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875

Short Term

Nasoenteric – Nasoduodenal – Nasojejunal

Long Term

Jejunostomy – Percutaneous endoscopic

jejunostomy or through the PEG tube

– Surgical jejunostomy

Nasal Access: Tubes

Nasogastric Nasoduodenal / Jejunal

Easy

Short term

Y-Port

Small bore

Weighted tip

Metal guidewire

Post-pyloric Enteral Nutrition: Indications

• History / risk of reflux or aspiration• Gastric motility disorders• Upper GI tract fistulae• Acute pancreatitis

Post-pyloric Enteral Nutrition:Advantages

• Easily accessible• Less invasive• Lower risk of aspiration• Manual, fluoroscopic, or endoscopic placement

Post-pyloric Enteral Nutrition:Disadvantages

• Placement can be difficult to achieve and maintain • Requires x-ray confirmation• Short term use only• Nasopharyngeal trauma / irritation• Small bore tube

Jejunostomy Feeding: Indications

• Feeding

contraindicated for upper GI tract

• Gastric motility disorders

• History / risk of reflux or aspiration

Nutrition by Jejunostomy: Disadvantages

• Small bore tube• Placement can be difficult to achieve and maintain• Difficult to maintain for long term

Percutaneous Endoscopic Jejunostomy

• Tube placed with or without existing PEG• Requires endoscopy• Placed distal to Ligament of Treitz

Bumpers HL, et al. Surg Endosc 1994;8:121-123

Nasal Access: Multilumen Tubes

Choosing the Feeding Site

Can the GI tract be used?

No Yes

Tube feeding for more than 6 weeks?

No Yes

Nasoenteric Tube

Risk for pulmonary aspiration?

YesNo YesNo

Nasogastric Tube Jejunostomy

Parenteral Nutrition

Enterostomy Tube

Nasoduodenalor nasojejunal tube

Gastrostomy

Summary

• Enteral nutrition should always be the first option considered

• Gastric access is the first choice• Use post-pyloric route if gastric access not possible• Nasogastric route should be used for short term

feedings• Surgical or percutaneous enterostomies should be the

choice for long term cases and for laparotomy patients