Enteral101

1.  
Continuing Education

2. FROM: http://patients.gi.org/

3.  Objectives:
o Understand indications for HEN
o Identify enteral routes and use
o Identify factors needing consideration when evaluating patient
for home enteral nutrition

4.  61 y/o patient Dx dysphagia due to CVA
 32 y/o patient with Pancreatitis
 45 y/o patient undergoing chemo/radiation tx for Ca
Esophagus
 45 y/o patient with Diabetic Gastroparesis-
 41 yr old Dx Tongue Ca-
 4 week old Dx s/p cardiac surgery

5.  Home enteral nutrition is a life-sustaining or supportive
nutrition therapy for those patients who are unable to
consume adequate oral nutrition on their own
 Duration of therapy: short term or lifetime

6.  Identify the goal of therapy
 GI tract must be useable in whole or part (think about
digestion; absorption; obstruction)
 Enteral feeding can be a total or adjunctive feeding
 Patient choice especially in terminal conditions
 Readiness and cognitive ability/emotional state
 Physical limitations
 Evaluate the home environment /sanitation/water
source/refrigeration/electricity Cultural/religious issues
 Lifestyle needs of patient and caregiver needs schedules
 Cost/ insurance
 Neighborhood safety

7.  HEN should be considered for those patients who cannot
meet their nutritional needs by oral diet and can manage
the therapy at home.
o Examples:
• Patients unsafe for oral nutrition; NPO; Dysphagia
• Anorexia; nausea, vomiting
• Chronic debilitating disease;
• Hypermetabolic with needs beyond oral intake;
• Total or adjunctive feeding
*** Clinical indicators that warrant the use of HEN are
significantly greater than those which are covered by
insurance

8.  Nasogastric
 Nasoduodenal
 Percutaneous Endoscopic
Gastrostomy (PEG)
 Open gastrostomy
 Transgastric jejunostomy
 Jejunostomy
 MICKEY/MINI One buttons

9.  Anticipated need for enteral feeding < 6 weeks
o 1. Nasogastric
• Easy to place at bedside
• Use small flexible tubes to avoid nasal skin erosion.
• Check position. Utilize aspiration precautions
• Keep HOB elevated with standard aspiration precautions /check
residuals
o 2. Nasojejunal
• Used for patients who do not tolerate gastric feeds or patients with
known abnormality of gastric emptying. /based on diagnosis
• Placed in Interventional radiology;
o 3. ORO-gastric/Jejunal :
• Used with nasal obstruction or severe facial fractures
o 4. TEP: Tracheoesophageal puncture
• Frequently used in Head and Neck Ca
• Usually placed at time of surgery for head and neck cancer

10.  1. Percutaneous Gastrostomy Tubes (PEG)
o Can be placed with endoscopic or radiographic guidance.
o Often placed during surgery in combination with another
procedure
o Post-placement may start enteral feeds between 4 and 24 hours.
o Tube is secured to skin by outer flange to prevent tube migration.
Can check for residuals
 2. Surgical Gastrostomy
o These are usually performed during surgery for another
condition
o The stomach is tacked to the abdominal wall with sutures
o Can check residuals for tolerance

11.  3. Transgastric Jejunostomy G/J
o These tubes can be placed surgically, or with endoscopic or
radiographic guidance.
o May contain a second port for gastric aspiration.
o Cannot monitor residuals to determine tolerance.
o Post placement care is same as PEG.
 4. Surgical Jejunostomy
o Tubes are placed in the proximal jejunum.
o Placed either via a laparoscopic or open approach
o The jejunum is tacked to the abdominal wall with sutures and an
external suture is usually placed around the tube to prevent it
from being dislodged.

12.  Care of the tube site:
o Generally Wash with warm soapy water
 FLUSHING FEEDING TUBES: lukewarm tap water
o Tubes should be marked at the skin entrance to allow monitoring
for migration of the tube.
o Before and after each intermittent feeding
o Before and after giving any medicine through the tube
o Every four to six hours if feeding is continuous
o Whenever feeding is interrupted
o When tubes not being used for enteral feeds, flush with 30cc
(water every 4 hrs to ensure patency.

13.  Inpatient Discharge coordinators
o inpatient education / reviews with patient choices
 Contacts DME
o Validate insurance/options for payment
o Review prescription, ordering, proper storage and hang time with
pt.

14.  DME - Durable Medical Equipment
 RD Role: review prescription with pt demographics/dx:
o is it appropriate?
o cost effective ?
o is it suitable to goal?
o Is it realistic in the home environment?
 IF Enteral feeding is not covered by insurance options?
…… Communicate with inpatient RDs

15.  Coverage of NUTRITIONAL THERAPY is a Part B
benefit under the prosthetic device benefit provision
o Permanent* nonfunctional disease of the structures that normally
permit food to reach the small bowel
OR
o Disease of the small bowel which impairs digestion and
absorption of an oral diet,
 Either of which requires tube feedings to provide
sufficient nutrients to maintain weight and strength
commensurate with the patients overall health status.
 Permanence – 90 DAYS.

16.  Calorie Levels: 25-35 cal kg
 Formula Selection: must be a standard polymeric formula
 Route of administration: Pump, Gravity, or Syringe
 Pump:only covered under specific circumstances for example:
 bolus via syringe or gravity feeding is contraindicated
 documented aspiration; glycemic control, dumping
syndrome,slow infusion; jejunostomy tube used for feeding.
 Gravity feeding –
 Bolus feeding-

17.  Examples:
o UPMC
o GATEWAY
o Health America
o Highmark

18.  1. Clogged tubes
o Prevention and care of tube is the BEST way manage it
o cost of radiographic replacement @ $1,000.00
o Causes of clogged tubes:
• a. Improper flushing of tubes.
• b. Caloric dense formulations.
• c. Small bore feeding tubes.
• d. Medications that are not properly crushed.
o Bulk forming medications (Psyllium); never add to formula.
o Encourage patient to work with the Pharmacists to transition meds
to liquid form
o Give medications singularly
 2. Dehydration/constipation
o check formula concentration/free water; narcotic use;

19.  3. Nausea/Vomiting
o check where tube is located; consider lower rate?; elevate hob; consider formula
w/o fiber
 4. Diarrhea
o check meds for sorbitol;
o use soluble fiber;
o check use of stool softeners;
o check rate;
o concentration of formula;
o may need predigested formula;?
o Fat content check stool culture before using immodium;
 5. Equipment malfunction
 6. Weight loss (lack of follow up with RD/MD; disease process/ financial
impact)

20.  National Resources:
Oley Foundation – The Oley Foundation is a national, independent, non-profit organization that provides information
and social support to consumers and practitioners of home parenteral and enteral nutrition.. – www.oley.org
 ASPEN – American Society for Parenteral and Enteral Nutrition – ASPEN is a national organization composed of
nutrition professionals including physicians, nurses, pharmacists, dietitians and members of industry who are
dedicated to improve patient care by advancing the science and practice of clinical nutrition. –
www.nutritioncare.org
 American Cancer Society. www.cancer.org.
References :
 Mueller PhD,Charles (ed):The A.S.P.E.N. Nutrition Support Core Curriculum.ASPEN,Silver Springs,MD.2012.
www.nutirtioncare.org
 Fisher C, Blalock B. Clogged Feeding Tubes: A Clinician’s Thorn Practical. Gastroenterology. MARCH 2014
 Newton A, Barnadas, G. Understanding Medicare Coverage for Home Enteral Nutrition. Practical
Gastroenterology. May 2013
 Enteral Nutrition, criteria, documentation requirements, coding, coverage and payment rules may be found on the
NHIC web site: http://www.medicarenhic.com
 Ref. DME MAC LCD for Enteral Nutrition(L5041)
 Ref. Local Coverage Article for Enteral Nutrition – Policy Enteral Nutrition: L11568 & A25361
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/enteral_nutrition.htm
 Mclave S, Martindale R. etal. ASPEN Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult
and Pediatric Patients JPEN May-June2009;33:255259 http://pen.sagepub.com/content/33/3/255.full