Optimising cessation of enteral feeding for Critically Ill Adult patients with a protected airway undergoing off ward procedure

Publication: 19/07/2016  --
Last review: 29/04/2019  
Next review: 29/04/2022  
Standard Operating Procedure
CURRENT 
ID: 4694 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Standard Operating Procedure 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.

Optimising cessation of enteral feeding for Critically Ill Adult patients with a protected airway undergoing off ward procedure

This SOP is to optimise the nutritional intake of Adult critically ill patients at LTH

Aims

  • To standardise and optimise the cessation of enteral feeding for critically ill adult patients with a protected airway undergoing off the ward procedures

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Background and indications

Previously critically ill patients with a protected airway have had enteral feeding stopped prior to a procedure.
Evidence suggests that a number of patients experience a delay in planned interventions which result in feeding being discontinued for long periods; this increases the risk of malnutrition in this vulnerable group.
The question was raised nationally as to practice elsewhere and from this the Imperial College guidelines were gained from which this guideline has been taken. The question was also asked across the anesthetic department at Leeds Teaching Hospital about when enteral feed should be stopped on patients with protected airways.
This SOP is to be applied for patients who have a protected airway and are having off the ward procedures. There may be occasions for exceptions to this SOP, MDT discussions should take place and be documented.

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Procedure method (step by step)

Stopping Enteral Nutrition (E.N.)

  1. Before non-airway surgery and procedures (e.g. orthopaedic surgery, plastic surgery, neurosurgery) - NO FASTING
    1. Enteral nutrition should be continued until patient leaves for theatres
    2. Prior to leaving the unit the naso-gastric tube (NGT) should be aspirated and gastric contents discarded. The NGT should be capped / spigoted.
    3. Accompanying insulin infusions should be stopped at the same time, and blood glucose monitored hourly. If insulin is felt necessary to control blood sugar, then glucose must be provided intravenously while enteral nutrition is ceased. If feed is planned to be off for more than 2 hours then maintenance fluid should be started.
  2. Before percutaneous tracheostomy
    1. Stop NG feed 2 hours before proposed time for procedure. NGT should be aspirated and gastric contents discarded. The NGT should be capped / spigoted.
    2. Accompanying insulin infusions should be stopped at the same time, and blood glucose monitored hourly. If insulin is felt necessary to control blood sugar, then glucose must be provided intravenously while enteral nutrition is ceased. If feed is planned to be off for more than 2 hours then maintenance fluid should be started.
  3. Before laparotomy and all abdominal surgery
    1. Enteral nutrition should be stopped 4 hours before planned operation
    2. Accompanying insulin infusions should be stopped at the same time. If insulin is felt necessary to control blood sugar, then glucose must be provided intravenously while enteral nutrition is ceased.
    3. Blood glucose should be monitored hourly and maintenance fluids should be prescribed and started if enteral nutrition cessation is over 2 hours.
  4. Before surgical tracheostomy / airway procedure or airway change
    1. Time for the procedure must be confirmed with theatres and enteral nutrition stopped 4 hours before the procedure.
    2. Accompanying insulin infusions should be stopped at the same time, and blood glucose monitored hourly. If insulin is felt necessary to control blood sugar, then glucose must be provided intravenously while enteral nutrition is ceased.
    3. Maintenance fluids should be started if enteral nutrition cessation is over 2 hours.
    4. Before scans / off the unit procedures - no cessation of enteral nutrition is required before transfer to scan (follow medical advice for endoscopy procedures) The NG tube should be aspirated and gastric contents discarded and the NG tube capped before transfer.
    5. Accompanying insulin infusions should be stopped at the same time and the blood glucose should be monitored hourly. If insulin is felt necessary to control blood sugar then glucose must be provided intravenously while enteral nutrition is ceased.
    6. Consider the need for maintenance fluid depending on the length of time for the scan / off unit procedure.
  5. Before extubation
    1. Planned extubation should be discussed with the on call registrar or ICU Consultant and the enteral nutrition stopped 4 hours before hand.
    2. The NGT should be aspirated immediately prior to extubation and contents discarded.
    3. If unplanned extubation - stop enteral nutrition immediately and aspirate NGT (if time allows) and discard
    4. Accompanying insulin infusions should be stopped at the same time as enteral nutrition is discontinued and the blood glucose should be monitored hourly. If insulin is felt necessary to control blood sugar then glucose must be provided intravenously while enteral nutrition is ceased.
    5. Maintenance fluids should be started if enteral nutrition cessation is over 2 hours.
  6. Sedation holds
    Risk assess patient and discuss as part of decision for sedation hold and continue enteral nutrition as prescribed unless otherwise indicated.

Restarting Enteral Nutrition

  1. After tracheostomy (percutaneous & surgical)
    1. The NGT tube position must be checked on X-Ray and the pH checked after the procedure to confirm correct tube position, before restarting EN at the rate before surgery.
  2. After theatre (non-abdominal surgery) with a protected airway
    1. the EN should be restarted immediately on return from theatre, at the rate before surgery , as long as the position of the NGT has not changed during the procedure (confirm with anaesthetist & re check position of the tube as per LTHT guidelines for the insertion of a NG tube and ongoing care for adults.). If there is any uncertainty, the NGT tube position must be checked on X-ray to confirm correct tube position before feeding is re-started.
  3. After laparotomy and all abdominal surgery – Check with the ICU consultant (+/- surgical team) before restarting EN.
    1. If a Ryles tube is in situ, wherever possible it should be changed to a fine bore feeding tube, The NGT tube position must be checked on X-ray or by pH before feeding can start. It may be appropriate to start feed at a reduced rate following the surgery.
  4. After theatre with an unprotected airway or after extubation
    1. If after 4 hours the patient is stable then EN should be restarted at the rate before cessation as long as the position of the NGT has not changed during the procedure (confirm with anaesthetist & re check position of the tube as per LTHT guidelines for the insertion of a NG tube and ongoing care for adults.). If there is any uncertainty, the NGT tube position must be checked on X-ray to confirm correct tube position before feeding is re-started.
    2. If reintubation is likely this should be discussed with the ITU registrar/ Consultant and EN not restarted until a decision has been made. Consider restarting EN after 2 hours
  5. After scans
    1. EN should be restarted immediately on return from scans at the rate before cessation, as long as the position of the NGT has not changed during the procedure. Recheck position of the tube as per LTHT guidelines for the insertion of a NG tube and ongoing care for adults.

Provenance

Record: 4694
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Adapted from Imperial College Healthcare NHS Trust 


Evidence base

Evidence Base: References
Imperial College Healthcare NHS Trust guidelines on stopping & restarting enteral nutrition prior to operative and non-operative procedures 2015

References:
Alberda, C et al (2009) The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicentre observational study. Intensive Care Med., 35,(10) 1728-173
Dvir D et al. Computerized energy balance and complications in critically ill patients: An observational study. Clin Nutr. 2006; 25:37-44
Faisy C et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. British Journal of Nutrition (2009), 101, 1079–1087
O’Meara et al. Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation. Am J Crit Care (2008) 17: 53-61
Villet S et al. Negative impact of hypocaloric feeding and energy balance on clinical outcomes in ICU patients. Clin Nutr. 2005; 24:502-509

Evidence levels: C & D
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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