Enteral Feeding Guidelines for Adult Critical Care

Publication: 16/01/2009  --
Last review: 14/08/2019  
Next review: 14/08/2022  
Clinical Guideline
CURRENT 
ID: 1452 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for the Provision, Assessment and Management of Adult Critical Care Patients Requiring Enteral Feeding

  1. Summary
  2. Scope
  3. Aim
  4. Objectives
  5. Establishing nutritional support
  6. Commencing enteral feeding
  7. Before starting feed
  8. Starting enteral feed
  9. If the patient is not tolerating feed
  10. Prokinetics
  11. Diarrhoea
  12. For those who can safely eat and drink
  13. Hypernatraemia

1. Summary

Originally developed as an evidence based guideline and implemented on Adult Intensive care at St James’s Hospital in 1996. Reviewed in 2002 via a working group and implemented throughout Adult Critical Care CMT Leeds Teaching Hospitals NHS Trust (LTHT). The guidelines have been updated on a regular basis to incorporate new evidence and best practice and to standardise care across LTHT.

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2. Scope

  • Applicable to patients in level 2 and 3 areas of care who demonstrate a need for enteral feed as identified by the multi-disciplinary team.
  • Applicable to all registered nurses working in level 2 and 3 areas who are required as part of their role to undertake feeding patients via the enteral route.
  • These guidelines do not cover those requiring parenteral nutrition, where this is indicated see: Administration of Adult Parenteral Nutrition guideline.

These guidelines should be used in conjunction with:

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3. Aim

To provide an evidence based critical care enteral feeding guideline

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4. Objectives

  1. To help support decision making in the management of patients commencing enteral nutrition, when a dietitian is unavailable
  2. To support the management of those patients who are at risk of refeeding syndrome when commencing enteral nutrition (in conjunction with the guidelines for managing adult patients at risk of refeeding syndrome).
  3. To provide an expert opinion base to support clinical practice, knowledge and skills in the management of patients undergoing nutrition support via an enteral feeding tube

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5. Establishing nutritional support

Malnutrition in critically ill patients is associated with increased morbidity and mortality. Nutrition support in critically ill patients is a “proactive therapeutic strategy” (ASPEN 2016) aiming to improve wound healing, reduce metabolic response to injury, improve gut structure and function, reduce length of hospital stay, improve clinical outcomes and provide cost savings.

Detrimental effects can occur with both over and under feeding therefore it is crucial a prompt referral is made to the dietitian.
When oral intake cannot be established enteral feeding is the preferred route of nutrition for haemodynamically stable critically ill patients. Where possible, all patients should be nutritionally assessed and their requirements estimated prior to commencing tube feeding, this should be undertaken by a dietitian. At times when a dietitian is unavailable enteral feeding can commence using agreed starter regimens as soon as is indicated.

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6. Commencing enteral feeding

Which enteral feed should I give to the patient?

Please note all the recommended feeds are gluten and lactose free. They are also halal and kosher certified.

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7. Before Starting feed

What do I need to consider before starting the enteral feed?

1

Ensure the patient has consented to receiving an enteral feed via the appropriate route of feeding. If unable to consent, ensure it is documented as being in the patient’s best interests

2

Check the patient has an appropriate care plan for the route of feeding you are using e.g. NG, Gastrostomy, NJ, Jejunostomy and follow the plan

3

Only radio-opaque nasogastric/orogastric tubes should be used for feeding Intensive Care patients; Ryle’s tubes are not licenced for feeding and should not be used for this purpose.

4

Check it is safe to feed the patient using appropriate method/procedure for the required route of feeding

5

Check that a referral to a dietitian has been made to ensure a review can be completed in a suitable time frame

6

If patient is at risk of refeeding syndrome ensure prescription of either

  • Pabrinex® (both vials) One pair IV once daily for 10days (if oral/enteral route cannot be used)

or

  • Thiamine (oral/enteral) 100mg TDS for 10 days
    Vitamin B co-strong 2 tablets TDS for 10 days and
    Forceval soluble OD (or a suitable alternative) for 10 days*

Please give the first dose before the enteral feed startsand continue for 10 days.
Refer also to the refeeding guidelines:
* For alcohol dependent patients, follow LTHT guideline as vitamin doses will differ

7

Ensure the patient can receive adequate fluid for hydration. Please note the starter regimen will not provide adequate fluid within the first 2-3 days

8

Check most recent U & E, Calcium, Magnesium and Phosphate.
Monitor levels and correct abnormalities and replace any deficiencies.

9

Document the name, date, time and rate of the selected feed in nursing notes OR ensure the doctors have prescribed on e-meds

 

Out of Hours Build-up Regimen for Enteral Feeding*

Day 1:  480ml of feed @ 20ml/hour for 24 hours
Day 2:  720ml of feed @ 30ml/hour for 24 hours
Day 3: 960ml of feed @ 40ml/hour for 24 hours **

* If feeding via nasojejunal or jejunostomy there is no need to check Gastric Residual Volume (GRV)
** Do not increase beyond this rate prior to dietetic review.
Note: For patients with potassium above the normal reference range who are unlikely to commence CVVHD, it may be appropriate to commence a concentrated feed such as Nepro HP. Liaise with Dietitian as needed.

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8. Starting Enteral Feed

  • GRVs should be monitored in conjunction with clinical parameters to assess tolerance of enteral feeding. Seek advice from medical team/dietitian and consider stopping feeding if there are overt signs of intolerance:
    • Regurgitation
    • Aspiration
    • Patient reported nausea
    • Bowels not open
    • Vomiting
    • Abdominal distension
  • It is the responsibility of the individual clinician to ensure that GRV is monitored appropriately in conjunction with additional clinical parameters to assess tolerance of enteral feeding. Excessive reliance on GRV as a marker to direct care should be avoided.
  • Review the need for stress ulcer prophylaxis as per LTHT policy
  • All patients who are enterally fed should be referred to the dietitian
  • Patients requiring parenteral nutrition will require a referral to the nutrition team
  • Review prokinetics if the patient develops loose stools (refer to Bristol stool chart)

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9. If the patient is not tolerating feed:

  • Has anything changed clinically?
  • Re-check for contraindications
  • Is the patient receiving sedatives, paralysing agents, opioids or inotropes/vasopressors (these will decrease motility)?
  • Are bowels open/stomas functioning? Do they require aperients?
  • Could the patient have an ileus or a bowel obstruction?
  • Is the patient supine? Could they be repositioned at 30-450?
  • Re-check feeding tube position
  • Consider prokinetics
  • Consider possible medication side effects

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10. Prokinetics

*PLEASE NOTE: The policy below is applicable to both new starter enteral feed regimes and those patients previously established on enteral feed*

  • The most commonly used prokinetic medicines are Erythromycin and Metoclopramide.
  • When used as a single agent Erythromycin is the more effective medicine.
  • Both drugs are prone to tachyphylaxis (gradual loss of effect). This is less likely if the two drugs are used in combination.
  • Previous concerns about bacterial resistance and drug interactions with Erythromycin mean that metoclopramide was historically chosen first line (Grant & Thomas, 2009: Nguyen et al 2007; ESPEN, 2006).
  • The recommendations proposed by ESPEN (2018) has challenged the above bacterial resistance concerns and identified evidence for the use of erythromycin as a first line choice for prokinetic. A meta-analysis based on six studies concluded that a significant advantage to erythromycin and its use should be encouraged for 24-48 hours.
  • In the majority of studies, medicines were administered intravenously and as a result there is insufficient data to support enteral administration in preference to intravenous (ASPEN, 2016; ESPEN, 2006; Grant & Thomas, 2009).
  • The suggested Erythromycin dose is 3-7mg/kg/day (ESPEN, 2018) and for safety reasons metoclopramide doses should not exceed 30mg/day. (Grant &Thomas, 2009)
    The recommended treatment is therefore:
    IV Erythromycin 250mg BD (3-7 mg/kg/day) for 48hrs
  • If there is no response at 48 hours and GRVs still >350/500mls, post-pyloric feeding should be considered and prokinetic stopped. Liaise with medical staff and dietitian re further management. Prokinetic medicines should be stopped as soon as enteral absorption is established.
  •  
    • If a patient is taking a medication that interacts with erythromycin (e.g. liver transplant patients, certain anti-epileptic medications etc.) then IV Metoclopramide (10mg TDS) is first line choice
    • If there are any other contraindications for erythromycin use (e.g. concerns of antimicrobial resistance etc) then metoclopramide would also be first line choice
    • Please be aware metoclopramide also has its contraindications (e.g Parkinsons patients)
  1. Contra-indications:
    • Erythromycin – increased risk if given with drugs known to prolong QTc interval, drug interactions (see below)
    • Metoclopramide ­– caution in severe renal or hepatic insufficiency. Avoid in gastrointestinal obstruction, perforation or haemorrhage and parkinson’s disease.
  2. Drug Interactions
    • Erythromycin
      Erythromycin reduces metabolism of many medicines resulting in increased concentrations and toxicity. e.g. atorvastatin, carbamazepine, ciclosporin, digoxin, phenytoin, simvastatin, tacrolimus, theophylline, sodium valproate, and warfarin. It should be avoided in patients receiving any of these medicines. Contact pharmacy if this is problematic.

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11. Diarrhoea

If introduced slowly and monitored carefully enteral feeding, is an unlikely cause of diarrhoea. If diarrhoea occurs, tube feeding should not be stopped and other potential causes investigated. Intravenous fluids may be required to prevent dehydration.

Other causes include: (this is not an exhaustive list)

  • Gastrointestinal (GI) infection such as clostridium difficille
  • Small bowel atrophy can occur when the GI tract has been unused for as little as two or three days, leading to malabsorption
  • High osmolality feeds
  • Pancreatitis
  • Bacterial contamination of feeds

Medications that can contribute to diarrhoea include:

  • Oral Potassium, magnesium and other electrolyte supplements
  • Laxatives
  • Drugs containing sorbitol e.g Digoxin, Metoclopramide, Theophylline, Furosemide
  • Ursodeoxycholic acid
  • Proton pump inhibitors e.g. lansoprazole, omeprazole
  • Antibiotics - particularly clindamycin

Discontinue any contributing medication if possible
If other causes of diarrhoea are ruled out liaise with the dietitian as to whether it is appropriate to change the enteral feed or feeding rate
For the treatment and management of diarrhoea refer to the LTHT local ICU guidelines (Bowel management in critical care).

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12. For those who can safely eat and drink

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13. Hypernatraemia

Hypernatraemia is defined as a serum sodium concentration above 146mmol/L. Treatment depends on the underlying cause and whether there is overall fluid depletion or sodium excess. Efforts should be made to identify and rectify the underlying cause and this should be interpreted with knowledge of fluid balance and medication.

  • Liaise with medical team
  • Stop causative agents
  • Consider calculating the estimated total body water deficit
  • Urinary sodium may be helpful in complex cases with gastrointestinal fluid loss
Enteral water replacement should be considered first line. A suggested starting rate is 50ml/hr.

Provenance

Record: 1452
Objective:
  1. To help support decision making in the management of patients commencing enteral nutrition, when a dietitian is unavailable
  2. To support the management of those patients who are at risk of refeeding syndrome when commencing enteral nutrition (in conjunction with the guidelines for managing adult patients at risk of refeeding syndrome).
  3. To provide an expert opinion base to support clinical practice, knowledge and skills in the management of patients undergoing nutrition support via an enteral feeding tube
Clinical condition:
Target patient group: All patients in level 2 and 3 areas of critical care.
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References

Bankhead et al (2009) Enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition. Vol 33 No 2 p162-167

Cohen J, Aharon A, Singer P. (2000) The paracetamol absorption test: a useful addition to the enteral nutrition algorithm? Clin Nutr, 19 (4): 233-236.

Dhaliwal R, Cahill N, Lemieux M et al (2014). The Canadian Critical Care Nutrition Guidelines in 2013
An Update on Current Recommendations and Implementation Strategies. Nutr Clin Pract., 29(1): 29-43

Grant K and Thomas R. (2009) Prokinetic drugs in the intensive care: reviewing the evidence. Journal of Intensive Care Society. 10 (1): 34-37.

Hartl WH, Parhofer KG, Kuppinger D, Rittler P and the German Society for Nutritional Medicine (DGEM) Steering Committee (2013). S3-Guideline of the German Society for Nutritional Medicine (DGEM) in cooperation with the GESKES and the AKE monitoring of artificial nutrition: specific aspects. Aktuel Ernahrungsmed, 38: e90-e100

Kreymann KG, Berger MM, Deutz N.E.P et al. (2006) ESPEN Guidelines on Enteral Nutrition: Intensive Care. Journal of Clinical Nutrition. 25, 210-223

Landzinski J, Kiser TH, Fish DN, et al. (2008). Gastric motility function in critically ill patients tolerant vs intolerant to gastric nutrition. JPEN, 32(1): 45-50.

McClave SA, DeMeo MT, DeLegge MH et al (2002). North American summit on aspiration in the critically ill patient: consensus statement. JPEN, 26(6) :S80-S85.

McClave SA, Lukan JK, Stefater JA et al. (2005) Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med, 33(2): 324-330.

McClave, S, Taylor B, Martindale, R et al (2016) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN, 40(2): 159-211

Montejo JC, Miñambres E, Bordejé L et al (2010). Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med, 36(8): 1386-93.

National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes. NPSA. NHS

NICE (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. What to give in hospital and the community. Nice guideline No 32, February

Nguyen N, Chapman M, Fraser R et al. (2007) Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Critical Care Medicine. 35 (2): 483-489.

Nguyen N, Chapman M, Fraser R et al. (2007) Prokinetic therapy for feed intolerance in critical illness: one drug or two? Critical Care Medicine. 35 (11): 2561-2567.

Poulard F, Dimet J, Martin-Lefevre L, et al (2010). Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr. 34(2): 125-130.

Reignier J, Mercier E, Le Gouge A et al (2013) Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA, 309(3): 249-56.

Rice TW (2013). Gastric residual volume: end of an era. JAMA, 309(3): 283-4.

Singer P, Blaser AR, Berger MM et al. (2018) ESPEN Guidelines on Clinical Nutrition In The Intensive Care Unit. Journal of Clinical Nutrition, PROOF 1-32

Tarling MM, Toner CC, Withington PS et al (1997) A model of gastric emptying using paracetamol absorption in intensive care patients. Intensive Care Med, 23(3): 256-260.

Weimann A, Braga M, Harsanyi L. et al. (2006) ESPEN Guidelines on Enteral Nutrition: Surgery including Organ Transplantation. Journal of clinical Nutrition, Vol 25, 224-244

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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