Complication Cause/Contributing Factor Treatment/Prevention
Aspiration Deflated tracheostomy cuff Inflate tracheostomy cuff before feeding; keep inflated
1 hour after feeding; consider small-bore feeding tube
placed past the ligament of Treitz
Displaced feeding tube Reinsert tube, check placement; consider hand
head of bed 30–45 degrees; use lower-fat formula; use
prokinetic medication; use small bowel feeding tube
Lack of gag reflex; coma Place feeding tube into jejunum; keep head of bed
elevated to 45 degrees; provide continuous feeding
Large-bore, polyvinyl chloride
Reposition tube daily, change tape; use smaller-bore
tube; position tube to avoid pressure on tissues; moisten
mouth and nose several times daily
Tube obstruction Poorly crushed medications Crush medications thoroughly, dissolve in water; use
liquid medications whenever possible; check
compatibility of medication with tube and formula
Flush tube with 50- to 150-mL water after medications
or thick formula and every 4–6 hours with 30 mL
Use blender to mix powdered formula (check
manufacturer’s mixing guidelines); use ready-to-use
Avoid checking gastric residuals when safe to do so;
use larger-diameter tubes when checking residuals;
avoid administering acidic medications through
small-diameter tubes; consider a nonacidic therapeutic
alternative; flush with a minimum of 30-mL water
before and immediately after medication administration
Gastrointestinal Complications
Too rapid administration Slow administration rate; change bolus to intermittent
Osmolarity too high; intolerance
Use isotonic formula; increase the number of bolus or
intermittent feedings so the volume per feeding is
reduced, or change to continuous infusion; change to a
more calorically dense formula if volume is the major
problem (osmolarity will likely increase with higher
Place feeding tube distal to the pylorus; consider a
promotility agent, such as metoclopramide; evaluate
medications and change those possibly contributing to
gastric dysmotility, if possible
infused rapidly into the small
Do not bolus into the small bowel; temporarily decrease
continuous infusion rate and gradually increase rate
after symptoms subside; use an isotonic formula
Temporarily decrease continuous infusion rate or
volume of intermittent or bolus feeding, and gradually
increase rate after symptoms subside
Diarrhea Atrophy of microvilli;
Use a oligomeric formula until absorption improves; use
a relatively isotonic and advance slowly; use a formula
low in long-chain fatty acids when fat is malabsorbed
and/or consider pancreatic enzymes
Hypertonic formula Change to a lower-osmolarity formula
Dumping syndrome See dumping syndrome entry in this table
Temporarily reduce rate or volume, then advance
slowly; consider enteral pump for better control of
Lactose intolerance Change to lactose-free formula if previously using
lactose-containing formula; evaluate lactose content of
medications and supplemental foods, if patient is not
Contaminated formula Hang fresh formula every 4 to 6 hours when using an
open administration system; do not add fresh formula to
volume remaining in the feeding container; change the
formula container and tubing daily; follow clean/aseptic
technique when working with the formula or feeding
tube; minimize manipulation of the feeding tube;
consider changing to a closed enteralsystem; avoid
powdered formulas requiring reconstitution
Gastrointestinal Complications
Check stool for C. difficile and treat if present;
consider probiotic agent; administer antidiarrheal if not
contraindicated; consider alternate therapy such as
histamine-2 blocking agent or proton pump inhibitor;
use calcium-based antacid; reduce dose or divide dose
into 3–4/day, when feasible to do so; dilute medication
with water before administrations; consider alternate
dosage form (transdermal, IV); change to crushed
tablet and use appropriate precautions to avoid tube
Constipation Inadequate fluid or free-water
Increase volume and/or frequency of tube flushes to
increase fluid intake; change to a formula with lower
Inadequate fiber intake Change to a formula with fiber or with a higher-fiber
content; administer fruit juice or bulk-forming laxative
(e.g., psyllium) using caution to prevent tube occlusion
Fecal impaction Administer stoolsoftener daily using caution to prevent
tube occlusion if administered via the tube
Poor gastric/GI motility Encourage ambulation; consider promotility agent
narcotics and anticholinergics
Use lowest effective dose of medication and transition
to an alternate medication with fewer constipating
Monitor fingerstick glucose every 6 hours, use sliding
scale insulin plus appropriate routine insulin (e.g., insulin
High-carbohydrate formula Change formula
Drug therapy (steroids) Monitor intake and output accurately
carbohydrate calories or excess
Reduce total calories to avoid overfeeding; consider
formula with higher-fat calories
Hyponatremia Dilutional (fluid excess,
Use full-strength formula or change to 1.5–2 kcal/mL
formula; add salt to tube feeding (1 tsp = 2 g Na = 90
mEq); use diuretics if appropriate; replace GI losses
Hypernatremia Inadequate free-water intake Use 1 kcal/mL formula; monitor intake and output
accurately; temperature and weight daily; increase
insipidus, osmotic diuresis from
Correct hyperglycemia and the cause of fever or
Hypokalemia Medications (diuretics,
Monitor serum potassium; give PO or IV potassium
Intracellular or extracellular
shifts (insulin therapy, acidosis)
small bowel fistula, diarrhea)
Routinely provide potassium in replacement fluid
Hyperkalemia Potassium-sparing medications
spironolactone, ACE inhibitors);
Monitor serum potassium; change to medications
without potassium-sparing effect or without potassium
Renal failure Monitor renal function; change to formula with lower
Hypercoagulability Warfarin antagonism due to
Hold formula 1–2 hours before and after warfarin
dose; monitor coagulation status; check vitamin K
content and change to lower vitamin K, if appropriate
(most EN formulas are not high in vitamin K)
antidiuretic hormone secretion.
Weight and fluid status are important parameters to monitor throughout EN therapy,
especially in patients with unusual losses, an inability to recognize thirst, or inability
to voluntarily adjust their oral fluid intake. For hospitalized patients, weight is
primarily a reflection of fluid status and increasing weight for 3 or 4 consecutive
days may be an indication fluid intake needs to be reduced, whereas decreasing
weight may indicate a need for increased fluid unless the patient had been fluid
overloaded. Generally, total fluid can be adjusted by the number of times the feeding
tube is flushed daily and the volume of each flush. In long-term patients, fluid is an
important parameter for adequacy of caloric intake. Consistent increases or
decreases from the required enteral formula volume can have significant effects on
weight. For example, a weight loss of 12.5 pounds over the course of a year can be
expected if the daily intake of a 1-kcal/mL formula is 120 mL less than required.
Changing caloric density of the formula may be a potential option to help manage
fluid when altering the number or volume of flushes is not adequate for fluid control.
For patients with a stable fluid status, the week-to-week weight change can be used
as an indicator of appropriate caloric intake. An upward trend in weight (e.g., ≥3
consecutive weeks with an increase) may indicate a need for fewer calories unless
weight gain is a goal. A downward trend may indicate a need to increase caloric
intake, unless weight loss is desired. A plan that includes gradual weight loss is
appropriate for M.P. based on his obesity.
Respiratory status should be evaluated every 8 hours in hospitalized patients, to
help recognize pulmonary edema and pulmonary aspiration. Auscultation with a
stethoscope should be conducted at least 2 times per week, but simple observation of
the patient’s breathing pattern is adequate at other times unless altered respirations
are noted. Coughing or respiratory distress may be indications of aspiration or other
developing respiratory problems. Vital signs also may provide clues to aspiration or
other problems, such as dehydration, fluid overload, or infection.
In addition to monitoring for complications, monitoring for response to EN and
changes in nutritional status is recommended. This should occur routinely in patients
receiving either short-term or long-term EN. Chapter 35, Basic Nutrition and Patient
Assessment, discusses parameters used for nutrition assessment and ongoing
monitoring of nutritional status.
Gastrointestinal Complications
Assessment of GI symptoms is important for determining EN tolerance because GI
complications are frequently associated with tube feeding. Abdominal distension and
bloating should be evaluated at least every 8 hours while M.P. is hospitalized.
Abdominal distension may be an indication of accumulating formula. The possibility
of falsely low GRV due to malposition or collapse of the tube during withdrawal of
gastric fluid should be considered if abdominal distension occurs when GRV is low.
Gas formation secondary to lactose intolerance or rapid increases in fiber intake, and
poor gastric emptying secondary to a high-fat formula, medications, recent surgery,
critical illness, or an underlying disease such as diabetes are among the conditions
associated with distension. When considerable distension is present, the formula
should be held temporarily, and the patient evaluated further to rule out a
Nausea, vomiting, abdominal cramping, diarrhea, and constipation are other GI
symptoms monitored as indicators of EN tolerance. M.P. has some of these symptoms
associated with his gastroparesis, and disease-associated symptoms should not be
confused with feeding intolerance. Vomiting creates the most immediate concern
because tube displacement and pulmonary aspiration can occur. Nausea and vomiting
commonly occur with a high GRV, severe gastric distension, poor gastric emptying
during gastric feeding, GI tract obstruction, or poor GI motility. Diarrhea occurs in
2% to 70% of patients, depending on the definition used, and is one of the most
difficult problems for patients and caregivers to address.
including diabetes mellitus, GI infections, pancreatic insufficiency, and
malabsorption syndromes, are more likely to cause diarrhea in patients receiving EN
30,33,36 M.P. has type 2 diabetes; however, at this time, diarrhea
has not been reported as a problem.
Formula-related GI infections could occur from contamination of an opened can or
package. Sources of contamination include the water used for reconstitution or
dilution, transfer to the delivery bag, formula kept in the delivery bag for a prolonged
period, and poorly cleaned feeding bags or administration sets. Water used to flush
the tube can also be a source of contamination; therefore, current practice
recommendations are to use sterile water as the flush solution for
35 Closed enteral feeding systems using ready-to-hang
bags of formula decrease contamination by reducing manipulation of the bag and
formula, and are commonly used in the hospital setting. Concurrent drug therapy (e.g.,
antibiotics) is another major contributor to diarrhea in tube-fed patients, potentially
accounting for 61% of diarrhea cases.
Bolus feeding into the jejunum can lead to diarrhea and abdominal cramping, as
well as nausea and vomiting. Because M.P. is being fed into the jejunum, he should
remain on a continuous infusion protocol. Initiation of EN with a hypertonic formula,
a rapid rate of infusion or a large volume, and use of formula at refrigerator
temperature are other factors often cited as causing GI symptoms. Although
controlled studies have not supported these factors as significant contributors to GI
intolerance, subjective evidence suggests they are important. Constipation is most
likely to occur with long-term tube feeding in nonambulatory patients. Inadequate
fluid intake and lack of fiber may be factors associated with constipation. Diabetic
EN formulas contain fiber. However, if the decision is to use a very high protein
formula for M.P., a fiber-containing formula would be reasonable to use based on his
MEDICATIONS AND ENTERAL NUTRITION BY
Patients receiving EN often receive medications through the same tube. Feeding tube
occlusion, adverse effects caused by changes in pharmaceutical dosage forms, and
alteration of medication pharmacokinetics and pharmacodynamics are among the
Interactions related to pharmacologic or physiologic effects
of medications or enteral nutrients also may occur. For this reason, oral medication
administration should be considered unless a strict NPO status is required. M.P. has
severe gastroparesis, a diagnosis not requiring a strict NPO status; however, the
team is concerned that medications administered by mouth may have erratic
absorption and poor efficacy due to delayed gastric emptying. Medications are
ordered to be administered through M.P.’s feeding tube.
CASE 37-4, QUESTION 3: M.P. has been receiving EN for 5 days and has been at goal rate for 2 days.
Laboratory evaluation today shows the following:
Potassium, 2.8 mEq/L (decreased from 3.7 mEq/L yesterday, 4.1 mEq/L the previous day, and 4.8 mEq/L
Magnesium, 1.3 mEq/L (decreased from 2.5 mEq/L 2 days ago)
Phosphorus, 2.5 mg/dL (decreased from 4.7 mg/dL 2 days ago)
Micro-K (8 mEq KCl/capsule) has been ordered as six capsules via feeding tube along with calcium
M.P.’s medications be administered when he is receiving EN?
Solid dosage forms are a challenge to administer by feeding tube. Crushing a
medication and mixing the powder in water results in an altered pharmaceutical
dosage form, and this may affect its efficacy or patient tolerance. Liquid dosage
forms are generally recommended for administration through a feeding tube, but they
are not without problems, and a liquid dosage form may not always be the best
choice. Liquids should be diluted at a minimum of 1:1 with water before
administration to avoid coating the tube interior. High-viscosity liquids, such as
suspensions, should be diluted 3:1 with water. Pharmaceutical syrups with a pH of 4
or less must be used with caution because immediate clumping and tackiness of
formulas mixed with the syrups have been reported.
available in liquid form, a therapeutically equivalent medication in a liquid form can
be considered. Extemporaneous preparation of a liquid also may be considered, but
can increase cost significantly. Medications in a soft gelatin capsule are best avoided
for administration through a feeding tube. If there is no alternative, the capsule can be
dissolved in warm water. Undissolved gelatin should not be administered, because
this may occlude the tube. The safety and efficacy of simple compressed tablets are
not affected by crushing and dissolving in water immediately before use. Simple
compressed tablets can be crushed to a fine powder, then dissolved or suspended in
water for administration. Powder in hard gelatin capsules can be poured into water
and mixed thoroughly before administration through a feeding tube. Failure to
adequately suspend or thoroughly dissolve any of these dosage forms in water before
administration through the tube can result in occlusion. Some medications appear to
be particularly troublesome for administration through a feeding tube. Calcium salts,
iron salts, lansoprazole, omeprazole, multivitamins, pentoxifylline, potassium
chloride, phenytoin, protein supplements, sucralfate, and zinc salts were identified by
nurses as the products most frequently contributing to feeding tube occlusion.
M.P. has both calcium and potassium ordered today.
Calcium carbonate is a simple compressed tablet that can be crushed, suspended in
30 mL of water, and administered through the feeding tube. Risk of tube occlusion
from an inadequately crushed tablet may be decreased by use of calcium carbonate
suspension (500-mg calcium/5 mL), if available. Administration of either crushed
and suspended tablets or commercial suspension requires flushing the tube with 15
mL of water before and after medication administration.
least 1:1 with water, preferably 3:1, and flushing with 75 to 100 mL may be
advisable because suspensions may otherwise coat the tube. The appropriateness of
calcium supplementation should be questioned, however, because M.P.’s serum
calcium concentration is within normal limits after correction for his low serum
albumin concentration, and the ionized calcium concentration would likely be within
normal limits. Administering any medication via the feeding tube may occlude the
tube; therefore, administering an unneeded medication through the feeding tube is an
unwarranted risk. For calcium, and for electrolytes in general, only oral and IV
dosage forms are available, so the easiest and most cost effective route is an oral
dosage form via feeding tube if M.P. cannot take oral medications.
Potassium supplementation is ordered today for M.P.’s low serum potassium.
Potassium should have been considered yesterday because the serum level has been
decreasing since tube feeding began. The selected potassium supplement is
inappropriate for administration by tube because Micro-K is a slow-release product.
medication at one time. An exaggerated therapeutic response may be seen initially,
followed by a loss of response part way through the dosing interval. Deaths have
occurred when sustained-release or long-acting products are crushed before
administrations; therefore, these dosage forms should not be crushed.
immediate-release dosage form should be used, with appropriate adjustment of dose
and dosing interval, or an alternate administration route (e.g., intravenous,
suppository, transdermal patch) may be available. Potassium chloride powder for
solution (three packets with 15 mEq KCl/packet) or liquid (10% KCl 35 mL, 15%
KCl 25 mL, or 20% KCl 15–20 mL) should be ordered rather than the slow-release
product. Dividing the potassium dose into two or three smaller doses and diluting
each dose with 60 mL of water may be better tolerated. Giving 45 to 50 mEq of
potassium as a single dose may cause nausea, vomiting, abdominal discomfort, or
diarrhea. These symptoms might be mistaken as intolerance to EN, resulting in the
tube feeding being stopped temporarily. The larger fluid volume for administration
also may help reduce the GI irritation associated with potassium doses.
Potassium supplementation could also be partially accomplished by changing part
of the potassium ordered to potassium phosphate, which is available as a 250-mg
capsule that provides 8.1 mmol of phosphate and 14.2 mEq of potassium. M.P.
appears to have a mild refeeding syndrome, with phosphorus and magnesium slightly
less than the normal range and having decreased significantly during the past 2 days.
Supplements should be started today so that smaller daily quantities can be used
before electrolytes are critically low. This may decrease the risk of diarrhea and GI
upset caused by the administration of oral phosphate or magnesium. Contents of each
potassium phosphate capsule are designed to be dissolved in 75 mL of water for
administration, so dissolution is not a concern. One potassium phosphate capsule
twice a day plus KCl liquid to provide 20 mEq potassium is the same potassium dose
as is ordered currently. The liquid KCl dose should be separated from the potassium
phosphate to minimize GI effects.
Magnesium supplementation could be accomplished with a magnesium oxide tablet
(400 or 500 mg) administered 2 to 4 times daily. These are simple compressed
tablets that can be crushed and suspended for administration via feeding tube. An
alternative would be magnesium hydroxide suspension 5 mL 2 to 4 times daily.
Magnesium doses are distributed through the day to reduce the risk of diarrhea. The
feeding tube must be flushed adequately before and after each dose of electrolyte
replacement. The flush volume should be a minimum of 15 mL, although 75 to 100
mL after the magnesium dose may be better to ensure the electrolyte preparation is
out of the tube. The volume of other tube flushes can be adjusted to limit the total
fluid intake to the estimated requirements. It can be difficult to provide large
quantities of potassium, phosphate, and magnesium via feeding tube secondary to the
GI intolerance they cause. Therefore, IV electrolyte replacement may be necessary if
intracellular depletion is extensive and M.P. does not tolerate oral electrolyte
Famotidine is a simple compressed tablet that can be crushed. However, both the
verapamil and metoprolol dosage forms ordered for M.P. contain multiple doses
intended to be slowly released. The once-daily dosing schedule helps identify these
two medications as slow-release products and, for metoprolol, the succinate salt is
also a clue as this is different than other dosage forms of metoprolol. Both verapamil
and metoprolol should be changed to immediate-release dosage forms if M.P. cannot
take them by mouth. The dose and frequency of dosing will need to be adjusted to
reflect the immediate release dosage form.
Enteric-coated tablets are designed to release medication in the small bowel
because the medication is either acid labile or irritates the stomach. Protection for
the medication or stomach is lost when enteric-coated tablets are crushed and
delivered via feeding tube into the stomach, resulting in decreased efficacy of the
medication or increased gastric irritation. When an irritating medication must be
given by tube into the stomach, diluting the medication in at least 60 mL of water is
65 M.P. has enteric-coated aspirin ordered for administration into a
jejunal feeding tube. The enteric coating is designed to dissolve in the small bowel
and could be dissolved with bicarbonate solution before administration into the small
bowel. However, it would be better to use a noncoated tablet for his aspirin dose. If
enteric-coated beads, such as those found in several proton pump inhibitor dosage
forms, are to be administered through a feeding tube, use of an acidic liquid (e.g.,
fruit juice) helps prevent the enteric coating from becoming sticky and adhering to the
inside of the feeding tube. This should only be considered for a large-bore feeding
tube, such as a gastrostomy, or the beads will occlude the tube. Film-coated tablets
also cause problems when crushed because the coating does not crush well and
becomes sticky in water. M.P.’s simvastatin has a film coating and may be a problem
to crush and administer through the feeding tube.
Administering buccal or sublingual dosage forms via feeding tube may result in
altered absorption or destruction of the medication by stomach acid. Therefore,
therapeutically equivalent medications (e.g., isosorbide dinitrate rather than
sublingual nitroglycerin) or an alternate route of administration (e.g., nitroglycerin
ointment or transdermal system rather than sublingual nitroglycerin) should be used.
A listing of medications that should not be crushed is available at
http://www.ismp.org/Tools/DoNotCrush.pdf.
70 Carcinogens, teratogens, or
cytotoxic agents that should not be crushed are included in the list.
Pharmacokinetic parameters can be altered when medications are administered by
feeding tube. M.P. has a jejunal tube and delivering medication into the jejunum
could affect bioavailability, although few studies address this issue. Medications
taken orally are delivered to the stomach, where dissolution occurs for most dosage
forms and hydrolysis of some medications may occur. Delivery into the small bowel
may alter these processes, thereby affecting bioavailability. For instance, recovery of
digoxin from intrajejunal dosing is higher than with oral administration, primarily
because of reduced intragastric hydrolysis.
28,65 Bioavailability of medications also
can be affected by the presence of enteral formula in the GI tract. Medications
affected by the presence of food are expected to be affected in a similar manner by
66,68 For example, administration of tetracycline with formula
present is expected to reduce tetracycline bioavailability because of interactions with
divalent cations. A similar interaction is expected between ciprofloxacin and enteral
formula, although some evidence suggests a mechanism other than binding with
divalent cations is responsible for reduced ciprofloxacin concentrations with enteral
Phenytoin is particularly troublesome to manage in patients receiving EN, with
reduced phenytoin concentrations reported in numerous case reports and small
studies. Methods suggested for management include using a meat-based formula,
administering phenytoin capsules rather than the suspension, and stopping formula
delivery for 1 to 2 hours before and after the phenytoin dose.
administration before and after phenytoin dosing is often recommended, although
others claim that adequate dilution will reduce loss of the medication. None of these
methods, however, clearly prevents low phenytoin concentrations; thus, monitoring of
serum concentrations is important whenever EN is started or altered. Large-scale,
controlled trials are needed to determine the most appropriate method for managing
Warfarin can also be troublesome to manage in patients with a feeding tube, and
M.P. is to start warfarin for a newly diagnosed DVT. Reversal of warfarin
anticoagulation by vitamin K included in enteral formulas is an important
28 The vitamin K content of most enteral formulas today is
about the same as found in a mixed diet and is unlikely to interfere with
anticoagulation, but should be evaluated if adequate anticoagulation is difficult to
achieve. In addition, binding of warfarin to a component of enteral formulas, likely
protein, has been proposed to explain warfarin resistance with formulas containing
low vitamin K content; others suggest binding to the feeding tube itself may occur.
Stopping formula administration for an hour before and after warfarin administration
appears to prevent this type of interaction. Unfortunately, rigorous, randomized
studies to provide evidenced based guidance for the management of this potential
Liquid dosage forms are often hypertonic. Diarrhea is a potential problem related
to physiologic effects of hypertonic medications. Diluting hypertonic medications
(e.g., potassium chloride) with 30 to 60 mL of water before administration is
suggested. Dividing the medication dose and separating doses by about 2 hours also
decrease GI effects of hypertonic medications. In addition, selection of brands and
dosage forms with minimal sorbitol can reduce the risk of diarrhea. Sorbitol is a
nonabsorbed sugar alcohol found in many liquid dosage forms. Cumulative sorbitol
doses greater than 5 g can cause bloating and flatulence, whereas larger doses may
CASE 37-4, QUESTION 4: M.P.’s feeding tube has occluded (clogged). What are the causes of feeding
The incidence of feeding tube occlusion is 1.6% to 66%.
lack of periodic tube flushing, formula characteristics, and tube characteristics are
factors affecting tube occlusion. Important tube characteristics include the inner
diameter (bore size), tube material, and the arrangement and number of delivery
holes (ports) at the distal end. The most important formula characteristic appears to
be the protein source. In vitro studies suggest formulas with intact protein,
particularly caseinates or soy, coagulate and clump when exposed to an acidic pH,
whereas formulas with hydrolyzed protein do not.
Medication-related factors influencing feeding tube occlusion include the
administration method, dosage form, pH, and viscosity. Medications must be crushed
to a fine powder, mixed with water to form a smooth slurry, and adequately diluted
before administration. Medications admixed with formula have the greatest potential
for occluding tubes owing to alteration of the texture, viscosity, or physical form of
the medication or formula. Therefore, medications should not be admixed directly
with formula. The enteral formula infusion should be stopped, and the tube flushed
with a minimum of 15-mL water before and after medication administration and with
15 mL between each medication.
34,35,36,39,65 Contact between medications and formula
within the tube lumen should be limited to decrease the risk of occlusion. Each
medication should be administered separately to reduce the risk of interactions.
When a feeding tube occludes, it must be replaced unless patency can be restored.
Frequent tube replacement disrupts nutrient delivery and increases patient discomfort
as well as the cost of care. The initial treatment for tube occlusion is to flush the tube
with warm water using a large syringe, at least 20 mL but preferably 50 mL, to avoid
generation of excessive pressure that could rupture the tube. When a specific cause
for occlusion can be identified (e.g., a specific medication) and physiochemical
characteristics of the responsible product are known (e.g., solubility, pH), it may be
possible to select a more appropriate flush preparation than water. In most cases,
however, use of an acidic or basic flush preparation could worsen the occlusion.
Acidic liquids (e.g., cranberry juice, diet soda, regular soda) may perpetuate or
extend the occlusion, especially when coagulated proteins are the cause.
water fails to restore patency, activated pancreatic enzymes may be effective.
Previously, one crushed pancrelipase tablet and one sodium bicarbonate tablet (324
mg) were dissolved in 5 mL of warm water just before instillation into the occluded
36,65 A product containing multiple enzymes, buffers, and antibacterial agents in a
powder form (Clog Zapper) is commercially available. Adherence to flush protocols
and proper medication administration techniques are essential to maintain patency
once tube patency is restored.
Transfer to Home on Enteral Nutrition
QUESTION 1: D.S., an 80-year-old man, was admitted 2 days ago from an SNF for evaluation of large
feedings through his PEG. The volume is 1,680 mL (seven cans) daily. D.S.’s history indicates he was
able to transfer from bed to chair and to the bedside commode with minimal assistance. He is deemed
daughter has made arrangements for him to move in with her family. She is concerned about insurance
Before addressing the coverage of EN therapy in the home, it should be determined
whether D.S. is an appropriate candidate for home versus return to the SNF. Based
on the PT assessment, it is likely D.S. is appropriate for discharge home, providing
he will have some supervision and assistance available. Typically, a case manager
or social worker is involved in arranging appropriate discharge facilities; however,
the healthcare professional managing nutrition support in the hospital setting should
facilitate the nutrition support portion of discharge, as necessary. The pharmacist
should review the medication regimen to assure it is appropriate for administration
Strict guidelines exist for home EN coverage. Medicare Part B (not Part D) will
cover 80% of the cost if criteria are met.
72–74 EN must be medically necessary to
“maintain weight and strength commensurate with overall health status” and there
must be a functional disability of the GI tract (e.g., dysphagia, swallowing disorder)
that is expected to be “permanent.” The formula must be delivered by feeding tube
(i.e., not oral supplements) and must provide most of the patient’s nutritional
requirements (i.e., not supplemental nutrition). Approval is on an individual basis,
requires a physician’s written order, and sufficient documentation must be available
to support the need for EN. Calories less than 20 kcal/kg/day or greater than 35
kcal/kg/day require additional documentation. The duration of therapy must be 90
days or more to meet the test of permanence. D.S.’s therapy falls within these
guidelines. In addition, the formula D.S. receives is in a category that does not
require him to meet additional eligibility criteria related to the formula itself.
Additional documentation would be needed to justify a pump if D.S. was receiving
Enteral formulas are divided into five categories for reimbursement purposes by
Medicare Part B (Table 37-6). Formula manufacturers typically list the Medicare
category on the product label. Most polymeric formulas containing intact (whole)
protein and 1 to 1.2 kcal/mL are in category I. These products do not require
documentation of medical necessity for the specific formula itself, but still require
documentation of the need for EN. Clear documentation of medical need for formulas
in specific categories (e.g., categories III and IV) is required for their higher
reimbursement rates. Appropriate forms available from the Centers for Medicare and
Medicaid must be completed for Medicare reimbursement of any EN therapy.
Evaluation of Tube Feeding Intolerance
were done during the last laparotomy
should be stopped and the PN formulation restarted?
Diarrhea develops in 12% to 32% of hospitalized patients, and in up to 80% of
high-risk patients; a point preference of 12.4% has been reported.
receiving EN, 15% to 40% develop diarrhea, which is multifactorial. Factors
associated with diarrhea, but not related to EN, include medications, partial small
bowel obstruction or fecal impaction, bile salt malabsorption, intestinal atrophy,
hypoalbuminemia, malnutrition, infections such as C. difficile, and underlying
conditions affecting the GI tract.
4,30,36,37,39,65,66,76–78 The LOS, particularly over 3
weeks, and EN over 11 days have also been associated with developing diarrhea.
Tube feeding-related causes of diarrhea include high-fat content, lactose content, and
bacterial contamination. Formula temperature, caloric density, osmolality, formula
strength, lack of fiber content, and method of delivery have been associated with
diarrhea, although these factors are not shown to affect diarrhea in some studies,
making a cause-and-effect relationship unclear.
J.N.’s hospitalization has been unusually long and complicated. Many factors
could contribute to diarrhea; however, the diarrhea coincides relatively closely with
initiation and advancement of tube feeding. He may have intestinal atrophy and
impaired absorptive function because of his prolonged period without GI tract
stimulation. He has had multiple surgeries, including GI surgeries, and may have
reduced absorptive capacity, bile salt malabsorption, dumping syndrome, or reduced
pancreatic enzyme availability related to his complications and surgeries. At least
theoretically, an oligomeric formula would be better absorbed if any of these
conditions exist. The SCCM–ASPEN guidelines recommend a standard formulation
for those not meeting guidelines for an immune-modulating product.
guidelines were downgraded in 2013 from recommending use of a polymeric formula
to consider use of a polymeric formula, although clinical outcomes do not appear to
differ between the types of formula.
18–20 However, studies have not evaluated patients
without use of the GI tract for weeks before EN initiation. Formula selection is often
determined by physician preference and the calorie, protein, and fat content of
formulas on the institution’s formulary. Because J.N. had been more than 2 months
without significant use of the GI tract, he was started on an oligomeric formula.
The EN formula selected for J.N. is only slightly more than isotonic. Risk of
diarrhea from fat malabsorption should be minimal with the low-fat content and MCT
mix. Increasing EN to goal rate within 24 hours may have contributed to diarrhea.
Initiation at 10 to 20 mL/hour and advancement by 10 mL every 8 to 12 hours to
reach goal in 48 to 72 hours would have been appropriate for J.N. because he had not
used his GI tract for over 2 months.
33–37 The jejunum adapts slowly to changes in
volume or concentration, and formula volume was increased less than 24 hours
before diarrhea started. Also, an enteral infusion pump should be used to maintain
consistent flow. Changing to a lower volume should decrease stool output within 24
hours if the volume change was responsible. If J.N. does not respond to decreasing
formula volume, the formula may be held for 24 hours to assess whether diarrhea
decreases or stops. Diarrhea related directly to EN usually is an osmotic diarrhea
that stops within 24 hours of stopping the formula.
39 A more objective approach than
stopping the formula is to measure stool osmolality. Enteral-formula-induced
diarrhea is associated with a large osmotic gap, whereas secretory diarrhea (e.g.,
infectious diarrhea) is associated with a low or negative osmotic gap.
Medicare Categories for Enteral Formulas
a Description Examples (Partial Listing)
Boost, Isosource HN, Jevity 1.0 Cal, Nutren1.0 Fiber, Osmolite 1.2
Boost Plus, Ensure Plus HN, Isosource 1.5 Cal, Jevity 1.5 Cal,
Optimental, Peptamen 1.5, Peptamen AF, Perative, Vital HN
Documentation that may provide justification for use: dumping
syndrome, uncontrolled diarrhea, evidence of malabsorption on
appropriate semisynthetic formulas (e.g., isotonic, low long-chain
fat content, lactose-free) that resolves with an oligomeric formula
or documentation of the disease process causing malabsorption
need (i.e., diseasespecific formulas)
Advera, Alitraq, Glucerna 1.0, Glucerna 1.5, NutriHep, Nepro with
Carb Steady, Nutren Renal, Oxepa, Peptamen, Pulmocare,
Renalcal, Suplena with Carb Steady
Documentation that may provide justification for use: evidence of
inability to meet nutritional goals with category I or II products
without compromising patient safety and documentation of the
specific diagnosis for which a formula is intended
Protein: Complete amino acid mix, ProMod Liquid Protein
Carbohydrate: Moducal, Polycal, Polycose
Documentation that may provide justification for use: inability to
meet specific nutrient requirements (i.e., protein, carbohydrate, or
fat) with a commercially available formula
Center for Medicare and Medicaid.
of claim or payment at the lower category I rate for Medicare Part B insurance coverage.
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