Enteral Nutrition Protocol &

Continuous feeding practices

-Nabanita Saha
Chief Clinical Dietician
Feeding access routes
 ROUTE OF FEEDING
• Nasogastric
– Requires gastric motility/emptying

• Transpyloric
– Effective in gastric atony/ colonic ileus
– Silicone/polyurethane tubing
– Positioning, Prokinetic agents/ fluoroscopic/ pH/ endoscopic
guidance

• Percutaneous/surgical placement
– PEG if > 4 weeks nutritional support anticipated
– Jejunostomy if GE reflux, gastroparesis, pancreatitis
 Types of Feeding Tubes

• Naso-gastric tubes
• Oro-gastric tubes
• Naso-duodenal tubes
• Naso-jejunal tubes

Tubes inserted down the upper GIT,

following normal anatomy
 Types of Feeding Tubes

• Gastrostomy tubes
– Percutaneous Endoscopic Gastrostomy (PEG)
– Open Gastrostomy

• Jejunostomy tubes

Tubes that require an invasive

procedure for insertion
 Advantages, disadvantages, and indications of each
feeding method
Feeding Advantage Disadvantage Indications
method

Continuous • Improve tolerance • Feeding • Initiation of feeding in

• May reduce risk of pump/Gravity critically ill patients
aspiration bag required • Promote tolerance
• Increased time for • May restrict • Compromised gastric
nutrient absorption ambulation function
• Feeding into small bowel
Intolerance to other
feeding methods

Cyclic • Facilitates transition • Feeding pump • Transitioning from EN to

of support to oral diet required oral nutrition (enhance
• Allows daytime • May require appetite during the day)
ambulation high infusion • Supplement inadequate
• Encourages patient to rates oral intake
eat normal meals and • May promote • Free patient from enteral
snacks intolerance feedings during the day

Intermittent and Bolus Methods of Feeding in Critical Care S.Ichimarua

 Advantages, disadvantages, and indications of each feeding method
Feeding Advantage Disadvantage Indications
method
Intermittent • Feeding pump may not be • Increased risk for • Intolerance to
required aspiration bolus
• May enhance QoL • Gastric distention administration
• Allows greater mobility • Delayed gastric • Initiation of EN
between feedings emptying without feeding
• More physiological pump
• May be better tolerated
than bolus feeding
Bolus • More physiological • Increased risk of • Recommended
• Feeding pump not aspiration for gastric feeding
required • Hypertonic, high- • Normal gastric
• Inexpensive & easy fat or high-fiber function
administration formulas may
• Limits feeding time delay gastric
• Patient is free to move emptying or result
about, participate in in osmotic
rehabilitation therapies & diarrhoea
live a relatively normal life
• More likely patient will
receive all of Formula

Intermittent and Bolus Methods of Feeding in Critical Care S.Ichimarua

 Preventing Diarrhea

• Rule out non-tube feeding problems

• Review formula composition, quality, and administration
method
• Avoid unnecessarily discontinuing formula use

Most diarrhea can be managed without

discontinuing tube feeding
 Potential causes of diarrhea related to enteral
feeding

• Low-fiber enteral solutions

• Post pyloric administration of hypertonic

formulas

• Formulas with high fat content

• Bacterial contamination of formula or

administration set
 Bacterial Contamination of Tube Feedings

• Foodborne illness is a longstanding problem

• Foods are highly nutritious for growth of
opportunistic bacteria
• Like other foods, tube-fed products can become
contaminated

Foodborne illnesses have been prevalent since

mankind began to produce and store food.
 Sources of Feeding Contamination

• Handling technique
• Unsanitary equipment
• Unsterile ingredients
• Improper storage and hangtime
• Reuse of feeding sets
• Formula manipulation
Clin Nutr 1990; 9: 157-162
Brit Jnl Nurs 1995; 4: 368-376
JPEN 1991; 15: 567-571
 Sequelae of Feeding Contamination
• Diarrhea, vomiting
• Nosocomial infections
• Enterobacter and Pseudomonas septicemia
• Longer hospital length of stay
• Increased number of ICU days
JPEN 1983; 7: 364-368
Jnl Hosp Infection 1990; 15: 203-217
Nutr Clin Pract 1991; 6: 55-64
Human Nutr 1986; 40A: 163-167
Pathway to Contamination: Hospital-prepared
Feedings

MIXING
FOOD
 Bacterial Contamination of Tube Feedings
• Unacceptable levels of bacteria in tube feedings are
associated with:
– Addition of non-sterile ingredients
– Touch contamination
– Prolonged hangtime
– Re-use of delivery system
– Lack of refrigerated storage

Nonsterile ingredients can cause tube-

Contaminated components Basic Food Microbiology, ed 2. feeding contamination.
New York: Van Nostrand Reinhold, 1989:101-164.
 Why the Concern About Contaminated Tube
Feedings?
• Contribute to poor outcomes:
– Foodborne infections and poisoning
– GI symptoms
– GI colonization
– Infection and sepsis
– Pneumonia
– Longer intensive care unit stay
– Prolonged length of hospital stay
– Increased costs
– Increased mortality
Contaminated tube feedings can lead to
infection and longer hospital length of stay.
WHAT DO GUIDELINES SAY…
Guidelines for the Provision and 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)

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.) 2016
 Guidelines for the Provision and 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)
Rationale:
• Measures to improve tolerance to EN in patients with moderate to
severe acute pancreatitis include
– minimizing the period of ileus by starting EN as soon as possible
within the first 48 hours of admission to the ICU
– changing from a standard polymeric formula to one that
contains small peptides and MCTs or to one that is a nearly fat-
free elemental formulation
– switching from bolus to continuous infusion

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.) 2016
Indian Recommendations regarding continuous
feeding…
In ICUs/ Bed-ridden patients, TMH paper recommends continuous feeding
Recommendations…
WHAT MAKES THE DIFFERENCE….
Continuous nasogastric feeding did not elevate gastric liquid
volume, small bowel water content, or superior mesenteric
artery blood flow or velocity to any great extent, whereas the
converse was true for an equivalent volume given via bolus.
 Why Diarrhea post bolus feeding…
Small Bowel Water Content
• During the first 2 hours, the responses to both feeds were similar with a
decline in mean small bowel water content of around 90mL but with
differing responses following this time point.
• After 90 minutes in the bolus fed group, mean small bowel water content
was seen to increase leading to a net efflux of small bowel water of 30mL
by the end of the study. This was reflected in a between treatment
difference (P<0.0068).
• This is coupled with inconsistent hike in Peptide YY levels.
 Why better Glycemic controls…
• The rate of gastric emptying is known to affect subsequent plasma glucose
concentrations, although hyperglycaemia is tightly controlled by regulatory
hormones, insulin, glucagon-like peptide-1, and gastric inhibitory
polypeptide.
• In this study, insulin responses corresponded closely with gastric liquid
volumes. By the time gastric emptying was complete in the bolus group at
180 minutes, the insulin concentrations had returned toward fasted values.
• In contrast, elevated plasma insulin concentration was observed beyond 180
minutes with the continuous strategy, probably as a result of sustained
duodenal glucose delivery.
OTHER BENEFITS OF CONTINUOUS
FEEDING….
 J Educ Health Promot. 2015; 4: 95.
Comparison of the effects of enteral feeding through the bolus and continuous methods on
blood sugar and prealbumin levels in ICU inpatients
Mohsen Shahriari, Ehsaneh Rezaei,1 Leila Azad Bakht,2 and Saeid Abbasi3

• Methodology: Fifty subjects were selected by convenient

sampling from April to Aug 2013 in the ICU wards of Alzahra
Hospital, Isfahan, Iran
• The subjects in the study group received infusion pump
feeding while the control group received bolus feeding for 72
h. Blood sugar was checked for every 4 h for 72 h and the
prealbumin level was assessed on the first and the fourth day
in two groups.
 J Educ Health Promot. 2015; 4: 95.
Comparison of the effects of enteral feeding through the bolus and continuous methods on
blood sugar and prealbumin levels in ICU inpatients
Mohsen Shahriari, Ehsaneh Rezaei,1 Leila Azad Bakht,2 and Saeid Abbasi3

• Results:
• In the study group, the mean blood sugar significantly decreased on
the fourth day, compared with the first (P = 0.03) and third (P =
0.01) day. In the control group, the mean blood sugar increased
from the first day. It was significantly higher in the control group on
the second day (P = 0.02), compared with the study group.
• In the study group, there was a significant difference in the mean
pre-albumin before and after intervention (P = 0.048), but no
significant difference was observed in the control group. Also, there
was a significant difference between two groups after intervention
(P = 0.04).
 J Educ Health Promot. 2015; 4: 95.
Comparison of the effects of enteral feeding through the bolus and continuous methods on
blood sugar and prealbumin levels in ICU inpatients
Mohsen Shahriari, Ehsaneh Rezaei,1 Leila Azad Bakht,2 and Saeid Abbasi3

Conclusion:
• The obtained results showed that supportive
nutrition through a continuous method had an
effect on critical patients’ blood sugar control and
made a better nutritional status for these patients
through an increase of pre-albumin level.
• Positive effects of this feeding method can result in
appropriate outcomes for patients’ recovery and
reduce the complications.
Benefits of continuous Feeding in the Critically ill patients

Provide nutritional Help protect vital

substrates to meet organs and reduce
protein and energy break down of
skeletal muscle
requirements

To provide nutrients
needed for repair To maintain gut
and healing of barrier function
wounds and injuries

To modulate stress
response and
improve outcome
 “A long habit of not thinking a thing
wrong, gives it a superficial appearance of
being right.”

Thomas Paine
Common Sense, 1776
ENTERAL FEEDING PROTOCOL – NURSING
AT MANIPAL HOSPITAL
• Feeding Initiation
 Enteral Nutrition should be started early, preferably within fist 24-48 hrs as
advised by the Doctor

• Feed preparation
 Feed preparation will be at the bed side by in-charge nurse as per the Enteral
feed chart provided by the Dietician

• Feeding method
 Continuous Feeding Only using Gravity bag (Fresenius Kabi) /Feeding pump
 Adjust the feeding rate as per Gravity drip rate Chart

• Head of Bed
 Head of bed should be elevated to 30°- 45° at all times (unless contra
indicated) to prevent aspiration
 Feeding level should be higher than the stomach by at least 1 ½ feet (18
inches) or more
• Formula
– Commercial formula only
– Start with a Peptide based commercial formula during Day 1
and Day 2 of feeding to ensure optimum toleration.
– Minimize handling the feed
– Wash hands as per standard protocol before touching the
feeding formula container or the delivery system
– NEVER add fresh feed to the old feed in the gravity bag
– Use the three way system (Feed –E) provided with the gravity
bag. Do not add water, medications or any other substances
directly to the feeding formula.
– Notify Physician / Clinical Dietitian of any intolerance

• Hang Time
– Not more than 6 hours per feed
• Feeding Gravity Bag
– To be changed once in 5 days or earlier, if found needed.
– To be washed with drinking water as per standard protocol
every day before 6 am (before first feed initiation). Do not use
any soap or chemicals for washing the gravity bag.
– Date and time of new gravity bag to be labeled without fail

• Video on Continuous feeding with Gravity Bag

https://youtu.be/bcW7u6s2dYk
• Medication Administration
– DO NOT disconnect the continuous system for administering medication. All
medications should be administered using the medication port of the three
way Feed –E system.
– Use liquid medication when possible
– Always flush feeding tube with 10 ml of drinking water before and after
administrating medications

• With Holding
– With hold the feed for any procedure when required after checking with
the ICU doctor/ ward duty doctor. Document when feed is being withheld
and specify reason for the same.
– If the feed is interrupted in between, the interrupted amount need to be
given with the remaining feed within the stipulated time i.e. 2hrs, (Catch Up
period) by increasing the rate of feed according to the patient’s tolerance,
unless contraindicated. If it is contraindicated, then the interrupted amount
of feed need to be discarded and recorded
– If feed has been stopped for more than two hours, discard the feed,
prepare & use fresh feed and record it in the intake chart
• VOLUME OF ENTERAL FEED ADMINISTRATION IN ADULTS

• Initially 25 ml per hour will be initiated for a patient starting on Enteral Feed Formula.

• Based on tolerance gradually the feeds will be increased to

– 50 ml per hour  75 ml per hour  100 ml per hour  125 ml per hour
– by Doctor / Clinical Dietician (in consent Doctor)

• In a 24 hour cycle the feeds will be administered at 5 different set of feeding with intermittent gaps-

• 6- 10am 4 hours Enteral Feeding

• 10- 11am 1 hour For aspirating if needed, washing the enteral gravity bag & preparing next
feed

• 11- 3pm 4 hours Enteral Feeding

• 3- 4pm 1 hour For aspirating if needed, washing the enteral gravity bag & preparing next
feed

• 4- 8pm 4 hour Enteral Feeding

• 8- 9pm 1 hour For aspirating if needed, washing the enteral
gravity bag & preparing next feed

• 9- 1am 4 hour Enteral Feeding

• 1-2 am 1 hour For aspirating if needed, washing the enteral gravity

bag & preparing next feed

• 2- 5am 3 hour Enteral Feeding

• 5-6am 1 hour For aspirating if needed , washing the enteral gravity

bag & preparing next feed

Any changes in the protocol will be intimated prior by Clinical Dietician in

consent with Doctor
 Tube Feeding Process- Flow Chart

Tube feeding initiation instruction

given by Consultant Dr (eg 25ml/hr
and increase as tolerated)

Update the same on

TrakCare and also inform
the Dietician on Duty
mobile

Follow the Enteral feeding Follow the Gravity drip rate

chart given by Dietician chart to adjust the feeding rate

Feed the patient 4th hourly Rinse the gravity bag

Prepare the feed at
with a gap of one hr as per with drinking water
bed side and pour in
the protocol before adding fresh
gravity bag
feed
Thanks