Enteral Access and Drug Administration Barbara Magnuson, PharmD BCNSP Nutrition Support Service

Enteral Nutrition (EN) Nutrition delivered to the GI tract Normal eating Food delivered to the stomach or small bowel Enteral access devices aka - feeding tubes (FT) Standard formulas Specialty formulas Delivery pumps

Advantages of EN vs. PN Maintains intestinal villus height and enterocytes Stimulates Mesenteric blood flow Stimulate gut growth factors and normal GI secretions Maintains the gut barrier & immune function Prevents bacterial overgrowth and stasis Easier to manage caloric/protein/vitamins and fluid requirements Less metabolic complications (i.e. infections and glucose) Provides conditionally essential nutrients not in PN Glutamine (amino acid) essential for small bowel growth Medium chain fatty acids Additional trace elements More physiologic & Less expensive - $20/day versus ~ $400/day

Case Ms Johnson is an 82 yo nursing home resident She has insulin dependant diabetes and gastro paresis with some vomiting after each meal The physician wants her to receive PN What is her indication for PN? What nutritional alternatives is there for Ms. Johnson? Would EN or PN be easier in a nursing home? Is there harm in PN? How would she receive her enteral nutrition

Case Ms Johnson, 82 yo nursing home resident, with diabetes, gastro paresis, and vomiting What is her indication for PN? NO WHY? She has a functional GI tract What nutritional alternatives is there for Ms. Johnson? EN

Case Ms Johnson, 82 yo nursing home resident, with diabetes, gastro paresis, and vomiting Would EN or PN be easier in a nursing home? Enteral is much easier, safer, and cost effective to deliver Is there harm in PN? Yes hyperglycemia, infections, electrolyte abnormalities

Case Ms Johnson, 82 yo nursing home resident, with diabetes, gastro paresis, and vomiting How would she receive her enteral nutrition? A feeding tube (FT) placed into the small bowel ? Why not the stomach?

Enteral Access Devices Feeding Tube Nomenclature - locations Stomach Naso-gastric (NG) Gastrostomy (G-tube) Percutaneous Endoscopic Gastrostomy (PEG) Small bowel (duodenum or jejunum) naso-duodenal (ND) naso-jejunal (NJ) jejunostomy (J-tube or PEG/J)

GI Anatomy

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J tube Where is the enteral feeding delivered? What formula would be best for her? How does she receive her medications? Which tube should the nurse place her medications? How would maintain the feeding tube so it does not get clogged?

Enteral Access Devices Naso-gastric tube (NG) Large bore tube 18 - 24 French Primarily used to remove gastric secretions to prevent aspiration, continuous suction Not usually used for feeding Can be used to administer drugs into the stomach CAUTION – when administering drugs via NG when gastric contents are also removed from it

Enteral Access Devices 3/1/10 & 3/3/10 Enteral Access Devices Gastrostomy (G-tube) Percutaneous Endoscopic Gastrostomy (PEG) Food & Drugs are delivered into stomach Removes gastric content Caution when removing gastric residual, removes drug therapy also Magnuson 2010

Enteral Access Devices 3/1/10 & 3/3/10 Enteral Access Devices Naso-duodenal Naso-jejunal Smaller tubes (8-14 Fr) for nutrition support Optimal drug absorption in the small bowel Medications best if delivered in a liquid Avoids gastric emptying problems Magnuson 2010

Enteral Access Devices Jejunostomy (J-tube) Very small (4-10 Fr.) tube Clogs easily with thick or viscous EN or drugs Fiber formulas can clog the J-tube

Enteral Access Devices 3/1/10 & 3/3/10 Enteral Access Devices Jejunostomy CAUTION or Avoid drug administration via a small J-tube Very thin liquids Deliver meds with oral syringe Magnuson 2010

Enteral Access Devices 3/1/10 & 3/3/10 Enteral Access Devices Gastrostomy/Jejunostomy (PEG/J) G-tube J-tube clogs easily avoid thick drugs or administration Small jejunostomy inside PEG or G G-tube used for suction, decompression, or drug administration into stomach J-tube used for feeding Magnuson 2010

Establishing Enteral Access Prokinetic agents (motility) Metoclopramide Pt on their right side Abdominal X-ray confirm GI location confirm it is NOT in the lung

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J tube Where is the enteral feeding delivered? The food will be delivered via the J-tube into the small bowel. The food will not be put into the stomach. Is there anything wrong with the stomach?

Feeding Techniques (ex. 2L) Bolus 480ml (2 cans) 4 times during the day Intermittent – 240ml (1 can) 8 times during the day Continuous @ 80ml/hr Usually @ 40 - 90ml/hr Feeding Pumps: Delivers accurate continous volume

Feeding Techniques Initiation - slow at first to determine tolerance @ 10ml/hr Advancement by 10-25ml/hr every 6 - 8 hours if feeding continuously Diluting DO NOT dilute isotonic formulas No benefit in diluting most formulas

Enteral Products

Patient specific formulas Enteral Products Patient specific formulas Specific amount of calories Specific amount & type of protein Specific type of fat supplement Small or large total volume Specific type of vitamins Additional fiber

Enteral Products – Protein Protein amount varies in different products 22g/L, 34g/L, 60g/L, 95g/L Intact proteins (standard casein) Small peptides (easiest to absorb) Free amino acids Trauma & Burn patients need high protien feedings

Enteral Products - Carbohydrates Simple (single sugars) More complex (maltodextrin/corn starch) Lactose free - lactase deficiency in elderly & stressed Soy or oat fiber, regulates bowel function (only included in certain formulas) Ex. Fibersource®, Jevity®

Enteral Products - Fats Essential fatty acids - lineoleic & linolenic Medium & Long Chain Fatty acids (LCFA) Fat Absorption LCFA require lipase & bile salts Medium chain fatty acids (MCFA) do not require lipase or bile, better absorption if lipase deficiency is present

Enteral Products - Fats Content varies Optimal ratio: < 30% fats : 70% (CHO + protein) Some products - very high or low fat % Vivonex® - 6% fat Pulmocare® 55% fat --> diarrhea

Enteral Products - Electrolytes Amounts vary for special disease states Most all EN products are low in sodium Potassium may vary with protein content, especially if high protein content Renal Product - no electrolytes (RenalCal®) Renal Pruduct - low electrolytes (Nepro®) Heptic Product - very low sodium (NutraHep®)

Multivitamins & Minerals Some vitamins are included in most all enteral products RDI is listed as volume or calorie related (ie. 2L or 1400kcal to meet 100%) Volume RDI amount varies for specific disease states More or less water/fat soluble vitamins Vitamin K amount varies drastically - Warfarin resistance has developed

Enteral Products – Caloric density Caloric density varies 0.6Kcal/ml - very dilute 1 kcal/ml - (Osmolite®) 1.5 kcal/ml (Boost® Plus, Ensure® Plus) 2.0 kcal/ml (Nutren 2.0®) – very concentrated Disease states - congestive heart failure or traumatic brain injruy patients might need less enteral volume

Enteral Products Viscosity Osmolarity varies Fiber Increases with caloric density High protein formulas are often very thick Can clog a small feeding tube (J Tube) Osmolarity varies Isotonic (300mOsm/L) IsoCal® Up to 1200mosm/L (Vivonex®) Fiber Regulates large bowel function Ex. UltraCal®, Fibersource®, Jevity®

Enteral Products Flavored supplements Nonflavored Ensure® Boost Plus® Nonflavored Tube feeding products only Osmolite® Free water content: Range 50-85% Usually decreases with calorie dense products Often need supplemental free water added to EN regimen for home and nursing home patients

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J tube What formula would be best for her?

Osmolite® Calories: 1.0 kcal/mL Non-flavored! Protein 44.3g/L (16.7% Calories) soy protein Fats: MCT:LCT Ratio: 20:80  Osmolality: 300 Free Water: 84.2% 100% RDIs: 1321mL (@ 1400kcal) Excellent for Nursing home or LTAC patients

IsoSource® HN Calories: 1.2 kcal/mL Protein 53.6g/L (18% Calories) soy protein Fats: MCT:LCT Ratio: 20:80  n6:n3 Ratio: 2.7:1 Osmolality: 490 Free Water: 82% 100% RDIs: 1165mL (@ 1400kcal) Excellent for Nursing home or LTAC patients

Fibersource ® HN Calories: 1.2 kcal/mL Protein: 54g/L (18% Calories) Protein: soy protein isolate Fats: MCT:LCT Ratio: 20:80  n6:n3 Ratio: 2.7:1 Osmolality: 490 Free water: Water 81% 100% RDI: 1250mL (1500kcal) Fiber : 10 g/L (soy fiber)

Isosource®1.5 Cal Calories: 1.5 cal/mL Protein: 67.6g/L (18% Calories) Fats: MCT:LCT Ratio: 30:70  n6:n3 Ratio: 4.1:1 Osmolality: 585-650 (unflavored) Free water: Water 78% 100% RDI: 980mL (1470kcal) Fiber : 8 g/L (soy fiber)

Nutren® 2.0 Calories: 2.0 kcal/mL (dense) 80g/L protein (16% Calories) Fats: MCT:LCT Ratio: 75:25 n6:n3 Ratio: 4.6:1 Osmolality: 745 Free Water: 70% 100% RDIs: 750mL (@ 1500kcal) High ICU usage because calorically dense

Fat Modulars Benecalorie: 330 kcal, 7 gm protein, 33 gm Fat Posaconazole - Noxafil® MCT - Medium Chain Triglycerides 115Kcal/Tbsp, expensive Microlipid - primarily LCT (Long Chain) 4.5Kcal/ml

Nutritional Modules Protein Fiber – intact protein supplement Ex. Egg whites (13g/120ml) Prostat BeneProtein ® (6gm) Fiber – Unifiber ® Benefiber ® (4gm)

Medicare – Enteral Nutrition EN is available for a beneficiary requiring tube feeding “to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status” because of either: a. “ Permanent non-function or disease of the structures that normally permit food to reach the small bowel,” or b. “disease of the small bowel which impairs digestion and absorption of an oral diet.” (www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=180.2&ncd_version=1&basket=ncd%3A180%2E2%3A1%3AEnteral+and+Parenteral+Nutritional+Therapy) EN may be given by nasogastric, jejunostomy, or gastrostomy tubes and can be provided safely and effectively in the home by nonprofessional persons who have undergone special training.

Medicare Part B Reimbursement EN 25-30Kcal/kg/day Reimbursement: UNITS = 100calories EN - reimbursed based on the number of “units” of formula and a supplier must submit the appropriate Medicare billing documents with “units” per day consumed by a beneficiary and not the number of cans or cases used. Recertification required every 3, 9, & 24 months

Enteral Products Product Kcal/ml Prot (g)/L Peptamen Bariatric® 1.0 93.2 Isosource HN® 1.2 53.6 Isosource 1.5® 1.5 67.6 Impact Peptide® 1.5 94 Nutren 2.0® 2.0 80

Case Ms Johnson, 82 yo, 66”, 56kg, nursing home resident, with diabetes, gastro paresis, and vomiting Feeding tube placed into the small bowel Nasojejunal feeding tube Jejunostomy feeding tube PEG/J Ms Johnson requires: @ 1400 – 1680 total Kcals/day @ 62 - 73g/d protein (1.1 – 1.3g/kg/day) @ 1500ml/day fluids Which enteral product & rate best meets her needs?

Case Ms Johnson requires: @ 1400 – 1680 total Kcals/day @ 62 - 73g/d protein (1.1 – 1.3g/kg/day) @ 1500ml/day fluids Rate Total Protein Product (ml/hr) (Kcal/d) (Gm/d) Isosource HN® 55 (1320ml) 1584 71 Isosource 1.5® 45 (1080ml) 1620 73 Impact Peptide® 45 (1080ml) 1620 102 Nutren 2.0® 35 (840ml) 1680 67

Case What if Ms Johnson has: Dehydration or diarrhea - dilute formula, fiber Congestive heart failure? – concentrated formula Skin breakdown – increase protein Rate Total Protein Product (ml/hr) (Kcal/d) (Gm/d) Fibersource ® 55 (1320ml) 1584 71 Isosource 1.5® 45 (1080ml) 1620 73 Impact Peptide® 45 (1080ml) 1620 102 Nutren 2.0® 35 (840ml) 1680 67 Beneprotein 2packets 50 12

Complications of Enteral Nutrition Tracheobronchial aspiration risk ICU patients - absent gag reflex DM - poor gastric empty History of aspirations Maxillary-mandibular Fixation (IMF) Prevention elevate bed 30 degrees use pump for accurate infusions rate observe for vomiting or excessive gastric residuals

Complications of Enteral Nutrition (Diarrhea) DRUGS, DRUGS, DRUGS!!! Drug related (SORBITOL) Prolong antibiotic therapy or other drug therapy Hyperosmotic enteral formula or electrolyte solution Laxative therapy Hypoalbuminemia - bowel edema Lactose intolerance or fat malabsorption Rapid GI transit Low-residue intolerance (lack of bulk) Rapid formula administration using syringe force Bacterial contamination - Change feeding bag every 24 hr

Complications of Enteral Nutrition Nausea/Vomiting Drug therapy – chemotherapy, anesthesia, narcotics Rapid gastric administration Constipation Inadequate fluid or free water intake Inactivity Abdominal distention Decrease gastric emptying from anesthesia, surgery, narcotics, diabetes, or renal failure

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J tube Isosource 1.2 HN® running @ 55ml/hr 1584kcal/day 71g/day protein Which tube should the nurse place her medications?

Drug Administration via Enteral Access Know the type of enteral access Know the location of the enteral access Gastric – NG, G-tube, PEG Small bowel – ND, NJ, PEG/J, J-tube Know the drug therapy and formulation Know the special drug properties drug route, IV or PO enteric coated extended release

Drug Administration Which tube to administer the drug? Stomach Preferably a gastric tube (NG) Feeding tube if high NG output G-port of PEG/J Avoid J-tubes too small unless finely crushed and completely liquefied

Drug Administration Flush all feeding tubes with water before and after each medication Change medications to liquid route and dilute *sorbitol exception* Administer each drug separately Do not add drug directly to enteral nutrition product

Drug Delivery: Know FT tip location Stomach Antacids, iron, sucralfate, ketaconazole Duodenum Most medications are absorbed in the small bowel Digoxin undergoes acid hydrolysis in the stomach, higher levels when delivered in the small bowel Jejunum Decrease ciprofloxacin absorption (prefer duodenum/ early jejunum) Extensive first-pass hepatic metabolism (e.g., opioids, tricyclic antidepressants, β-blockers, nitrates) may have increased absorption and greater systemic effects

Physical Incompatibilities Enteral Nutrition Viscous medications Thick syrups or mineral oil Sevelamer® – manufacture recommends against TF administration  clogs feeding tubes! Hypertonic medications (3,000-11,000mmol/kg) Electrolytes and elixirs Osmotic gap diarrhea (>100mOsm/Kg) – unabsorbed osmotic substances in the stool

Physical Incompatibilities Bolus most all medications Kaopectate Electrolytes Acidic Medications Potassium chloride, guaifenesin Do not mixed directly with Enteral Products Curdles intact protein Alcohol from elixers – precipitate inorganic salts in the enteral formula

Physical Incompatibilities Enteral Nutrition Special drug properties – DO NOT CRUSH! EC, XL, SR, CD enteric coating extended length sustained release controlled release Toxic or Sub therapeutic effects Change medication to standard formulation Example: ASA, Viokase powder, non SR formula

Physical Incompatibilities Special drug properties – OK to give but DO NOT CRUSH! Microencapsulated drug via a Large bore feeding tube Beads or pellets Mixed with water or acid and not crushed but flushed down feeding tube Ex. Diltiazem, ferrous gluconate, nizatidine, pancreatic enzymes, verapamil CAUTION: clogged tubes  no food or meds!

Physical Incompatibilities Phenytoin Unknown if due to the EN protein, electrolytes, pH, or if adsorbs to the enteral access device Hold TF one hour before and after each dose Carbamazepine Adsorbs to the FT Dilute suspension and monitor for efficacy Itraconazole Erratic bioavailability but improved in fasted state Hold TF one hr before and after each dose Option: Doubles the dose (increases GI side effects of diarrhea) Tetracyclines Complexes with di and trivalent cations – separate dose from EN or hold EN for an hour before an after and flush FT

Physical Incompatibilities Fluoroquinolones: ? Chelates with multivalent cations: Ca, Iron, Mg or binds to EN protein Holding TF before and after each dose: often recommended but has not shown to improve absorption Ciprofloxacin: Option: increase dose for Levofloxacin – no data Moxifloxacin – best bioavailability with EN Levothyroxine Best absorbed in fasted state Hold TF 1-2hr prior to dose OR – adjust drug dose accordingly Warfarin Vitamin K in most all enteral formulas Highly protein bound drug can bind to protein in the EN formula Hold TF 1hr before warfarin dose Dose adjusted for EN with monitoring target INR

PPI Omeprazole/Pantoprazole Enteric coated Active drug destroyed by gastric acids Crushed and mixed with water will render less effective For liquid preparation - need to dissolve in bicarb (expiration is limitation) Zegerid ® omeprazole and bicarb powder

Fat Modulars Posaconazole - Noxafil® 4 fold increase in serum concentrations when co-administered with a meal, especially high fat diet or supplement Atovaquon – bioavailability doubled with oral liquid supplement containing 28g of fat (compared to 21g fat meal) Benecalorie: 330 kcal, 7 gm protein, 33 gm Fat

Medications via Enteral Access Know the type of enteral access device gastric or small bowel Medications liquid form Do not crush or destroy special properties dispense & teach use of liquid syringe Flush feeding tubes 15-30ml of water before and after each medication

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J Which tube should the nurse place her medications? Medications should preferably be administered in the G tube because of the larger tube and dilution of the stomach for less irritation If there is gastric intolerance of the medication, it has to be finely crushed and mixed with @ 60ml of water for J-tube administration

Case Ms Johnson, 82 yo, 66”, 56kg, with diabetes, gastro paresis, and vomiting, now has a PEG/J How would maintain the feeding tube so it does not get clogged? Flush feeding tubes with15-30ml of water before and after each medication If the J-tube clogs, attempt to flush with hot water to dissolve the drug or food

Extra Case Example Sally Sue lives in the Rest Easy Nursing Home. She is bed ridden with stage III decubitus ulcers. She receives continuous tube feeding and drug therapy via a PEG Sally Sue is 45kg, 5’1”, 78yo PEE = 1380-1500kcal/day Protein requirements = 72-90g/d

Case - Answer PEE = 1380-1500kcal/day Protein requirements = 59-72g/d Which of the following choices provides optimal enteral nutrition therapy. Rate Total Protein Product ml/hr (Kcal/d) (Gm/d) Isosource HN® 50 (1200ml) 1440 64 Fibersource ® 50 (1200ml) 1440 65 Isosource 1.5® 40 (960ml) 1440 65 Impact Peptide® 40 (960ml) 1440 90 Nutren 2.0® 30 (720ml) 1440 58

Objectives Describe the advantages of EN over PN Describe the various enteral access devises and their GI locations Describe the major differences in the available enteral products Calculate a 24 hour infusion of enteral nutrition to meet a patients nutritional needs Describe how medications are administered in various feeding tube Describe why certain medications can NOT be administered in a feeding tube

ANY QUESTIONS