Editing Artificial nutrition (section)

== Enteral feeding ==

* Delivery of nutrients into the GIT

=== Routes: ===

* '''Oral, including supplements'''
** Patients who can drink but have impaired appetite or intake for other reasons
* '''Tube-feeding (NGT/NJT/PEG/PEJ)'''
** '''Route selection'''
*** Standard NGT is ok, but use a fine-bore feeding tube if planning to do it for more than a week - causes fewer gastric and oesophageal erosions
*** If planning for more than 4-6 weeks, use a PEG to minimise risk of complications from long-term NGT
*** In most patients, it is appropriate to start with gastric feeding and then progress to jejunal feeding if required
*** Jejunal feeding may be preferable in pancreatitis or if there is another reason to want to bypass the stomach
** Techniques
*** Fine-bored NGT insertion
**** See 'NGT insertion'
*** PEG insertion
**** See description under 'gastroscopy procedures'
** Regime
*** Should have regime by dietician
**** Boluses of 200-500mL pushed by syringe several times per day - the most physiologic and easiest method - only for gastric feeding
**** Intermittent infusions over 20-30 mins - generally tolerated well in gastric/small bowel feeding tubes
**** Continuous - common in ICU - can be run overnight to increase appetite for eating during the day
*** Aim to reach goal rate at 2 or 3 days
*** Start at 20-30mL/hr
*** Discontinue feeding for 4-5 hours overnight to allow gastric pH to return to normal
*** Aspirates on a regular basis, and if they exceed 200mL over a two hour period, then feeding temporarily discontinued

=== Types of feeds: ===

* Polymeric - contain intact protein, so require digestion
* Elemental/monomeric - contain nitrogen in the form either free amino acids or peptides
** Much less palatable, rarely used
* Other newer options may contain glutamine or fibre or arginine or fish oil, but generally seen as controversial and unproven

=== Advantages of enteral feeding as opposed to TPN: ===

=== Risks: ===

* Resulting from intubation of GIT
** Malposition
** Blockage
*** Tube blockage is common, especially with fine-bore NGT
**** Prevention - flush twice daily
**** Treatment - flush with chymotrypsin or papain. Don't use guidewire as this may perforate the tube and/or patient.
** Displacement
*** Insert Foley if it comes out
*** If suspicious of displaced enterostomy, need contrast imaging
** Breakage/leakage
** Pressure necrosis of nasal mucosa
** Aspiration pneumonia
*** Keep head up while feeding
*** Use of PPI/H2 antagonist increases pH, which reduces risk of harm
*** Prokinetics if delayed emptying suspected
*** Consider more distal tube
* Resulting from nutrient delivery
** Diarrhoea
*** Occurs in >30%, especially critically ill
*** Usually multifactorial, including antibiotic treatment
*** Villous atrophy due to prior periods without enteral feeding
*** Infections
*** Reducing feed rates or using loperamide/codeine to slow transit time can help
** Bloating
** Vomiting
*** Elevate head of bed
*** Continuous feeding
*** Assess sedation + analgaesia requirements
*** Oropharyngeal decontamination
*** Distal feeding
*** Prokinetics
* Metabolic complications are uncommon
* Enteric infections are rare if feeds are stored properly

=== Intolerance ===

* Try more distal access
* Prokinetics
* Look for institutional protocols