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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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)

9. GI Anatomy

10. 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?

11. Enteral Access Devices
Naso-gastric tube (NG)
Large bore tube 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

19. 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?

20. 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
ml/hr
Feeding Pumps: Delivers accurate continous volume

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

22. Enteral Products

23. 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

24. 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

25. 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®

26. 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

27. 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

28. 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®)

29. 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

30. 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

31. 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®

32. 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

33. 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?

34. 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

35. 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

36. 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)

37. 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: (unflavored)
Free water: Water 78%
100% RDI: 980mL (1470kcal)
Fiber : 8 g/L (soy fiber)

38. 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

39. 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

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

41. 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.” (
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.

42. 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

43. Enteral Products Product Kcal/ml Prot (g)/L
Peptamen Bariatric®
Isosource HN®
Isosource 1.5®
Impact Peptide®
Nutren 2.0®

44. 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
@ g/d protein (1.1 – 1.3g/kg/day)
@ 1500ml/day fluids
Which enteral product & rate best meets her needs?

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

46. 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 ® (1320ml)
Isosource 1.5® 45 (1080ml)
Impact Peptide® 45 (1080ml)
Nutren 2.0® 35 (840ml)
Beneprotein 2packets

47. 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

48. 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

49. 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

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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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!

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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 60ml of water for J-tube administration

65. 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

66. 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 = kcal/day
Protein requirements = 72-90g/d

67. 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® (1200ml)
Fibersource ® (1200ml)
Isosource 1.5® 40 (960ml)
Impact Peptide® 40 (960ml)
Nutren 2.0® 30 (720ml)

68. 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

69. ANY QUESTIONS