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

• Background
• Procedure method (step by step)

Background

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 anaesthetic 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

a.  Enteral nutrition (EN) should be continued until patient leaves for theatres
b.  Prior to leaving the unit the naso-gastric tube (NGT) should be aspirated and gastric contents discarded. The NGT should be capped / spigoted.
c.  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

a.  NGT should be aspirated and gastric contents discarded. The NGT should be capped / spiggoted.
b.  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

a.  Enteral nutrition should be stopped 4 hours before planned operation
b.  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.
c.  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

a.  Time for the procedure must be confirmed with theatres and enteral nutrition stopped 4 hours before the procedure.
b.  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.
c.  Maintenance fluids should be started if enteral nutrition cessation is over 2 hours.

5. Before scans / off the unit procedures

a. 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.
b.  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.
c.  Consider the need for maintenance fluid depending on the length of time for the scan / off unit procedure.

 6. Before extubation

a.  Planned extubation should be discussed with the on call registrar or ICU Consultant.
b.  The NGT should be aspirated immediately prior to extubation and contents discarded.
c.  If unplanned extubation - stop enteral nutrition immediately and aspirate NGT (if time allows) and discard
d.  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.
e.  Maintenance fluids should be started if enteral nutrition cessation is over 2 hours.

7. 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)

a. 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

a.  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.

a.  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 –

a.  If the patient is stable and GCS is not compromised, 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.
b.  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

a.  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.

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