A review of the nursing care of enteral feeding tubes in critically ill adults: part I

Intensive and Critical Care Nursing (2004) 20, 330—343

ORIGINAL ARTICLE

A review of the nursing care of enteral feedingtubes in critically ill adults: part I

Teresa A. Williamsa,∗, Gavin D. Leslieb,1

a Royal Perth Hospital, PO Box X2213, Perth, WA 6847, Australiab Centre for Nursing Evidence Based Practice, Education and Research, Royal Perth Hospital, PO BoxX2213, Perth, WA 6847, Australia

Accepted 9 August 2004

KEYWORDSEnteral tube;Feeding;Intensive care

Summary Enteral tubes are frequently used in critically ill patients for feedingand gastric decompression. Many of the nursing guidelines to facilitate the careof patients with enteral tubes have not been based on current research, but onritual and opinion. Using a computerised literature search and an evidence-basedclassification system as described by the Joanna Briggs Institute for Evidence BasedNursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tubemanagement.Several nursing practices related to enteral tube management are described. Ev-

idence to support alternate methods of tube placement assessment other than ab-dominal X-ray was inconclusive. Enteral feeding should continue if gastric residualvolumes are not considered excessive, as feeding is often withheld unnecessarily.Frequency of checking gastric residual volumes is largely opinion based and variesconsiderably, but prokinetics that aid gastric emptying should be used if absorptionof feeds is problematic. Other recommendations include continuous rather thanintermittent feeding, semi-recumbent positioning to reduce the risk of airway aspi-ration and diligent artificial airway cuff management. Contamination of feeds canbe minimised by minimal, meticulous handling and the use of closed rather thanopen systems. Generally, there was little high quality evidence to support prac-tice recommendations leaving significant scope for further research by nurses in themanagement of patients with enteral tubes.© 2004 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +61 08 9224 2601;fax: +61 08 9224 3196.

E-mail addresses: [email protected](T.A. Williams), [email protected] (G.D. Leslie).1 Tel.: +61 08 9224 8081; fax: +61 08 9224 1958.

Introduction

Enteral tubes are frequently used in the criti-cally ill patient for gastric decompression, de-livery of medications and food substitutes. Al-though enteral feeding is beneficial, as with mosthealthcare interventions, there are risks and po-

0964-3397/$ — see front matter © 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2004.08.002

A review of the nursing care of enteral feeding tubes in critically ill adults 331

tential adverse events inherent with their clinicalapplication.

Nursing care of patients with enteral feedingtubes has often been based on ritual and opinionrather than current research (Booker et al., 2000;Edwards and Metheny, 2000; Metheny, 1993). Bestpractice is based on the highest levels of evidenceto facilitate the benefits and minimise the harm as-sociated with any therapy. The systematic and rig-orous approach to the analysis and grading of re-search findings in terms of level of evidence facili-tates the development of specific guidelines, stan-dards and recommendations to provide the bestpossible care for every patient. In part I of thistwo part paper, the current research findings forthe nursing care of critically ill patients with en-teral feeding tubes is reviewed. Nursing care of pa-tients to prevent aspiration is described. In part 2of this paper, nursing management and recommen-dations for implementing evidence-based protocolsfor tube and feeding management are discussed.

Data sources and levels of evidence

StsEtSavediaBM(

Background

Nursing management of patients with enteral feed-ing tubes has a key role in ensuring the successof enteral feeding (Marshall and West, 2004; Perry,1997). Enteral feeding benefits ICU patients by de-creasing catabolic response to injury, maintainingbowel mucosal integrity, decreasing translocationof gut bacteria, improving wound healing and re-ducing septic complications (Bower et al., 1995;Cerra et al., 1997; Galban et al., 2000; Hadfieldet al., 1995; Heyland et al., 1995; Heyland etal., 1996; King and Kudsk, 1997; Lipman, 1998;Moore et al., 1989; Romito, 1995; Sax, 1996). Al-though, some studies have demonstrated no clearbenefit of enteral nutrition over parenteral nutri-tion (Braunschweig et al., 2001; Lipman, 1998), ingeneral, enteral feeding is accepted to be safer,physiologically more compatible, associated withbetter patient outcomes, and more economicalthan parenteral nutrition, making it the preferredand most popular route for nutrient administration(Anonymous, 1994; ASPEN Board of Directors andthe Clinical Guidelines Task, 2002; Cerra et al.,1997; Frost and Bihari, 1997; Reignier et al., 2002;ScrCa

utnam1aos1

aticonesigneativecente timntstedmit

everal methods were used to identify relevant ar-icles for this review. A computerised literatureearch of online databases MEDLINE (1966—2003),MBASE (1966—2003), CINAHL (1982—1996), andhe Cochrane Library (1992—2003) was conducted.earches were restricted to the English language,dults and humans. Relevant abstracts were re-iewed and identified articles assessed. The ref-rence lists of all articles were examined for ad-itional papers not previously identified. The ev-dence base applied in classifying literature wasdapted from the recommendations of The Joannariggs Institute for Evidence Based Nursing andidwifery (The Joanna Briggs and Institute, 2002)Table 1).

Table 1 Levels of evidence.

Level Description

Level I Evidence obtained from a systemLevel II Evidence obtained from at leastLevel III.1 Evidence obtained from well-deLevel III.2 Evidence obtained from compar

preferably from more than oneLevel III.3 Evidence obtained from multipl

results in uncontrolled experimeLevel IV Evidence from opinion of respec

studies, or reports of expert com

Reproduced from: The Joanna Briggs and Institute (2002).

ands, 1991). Enteral nutrition is recommended toommence as soon as possible after initial patientesuscitation (Alexander, 1999; Carr et al., 1996;erra et al., 1997; Kompan et al., 1999; Lewis etl., 2001; Taylor et al., 1999).A wide variety of enteral tubes are commonly

sed in ICU patients for the delivery of nutri-ion (Heyland et al., 1995). Tubes may be wide orarrow-bore, gastric or intestinal. Typically theyre inserted nasally but oropharyngeal placementay also be used. Wide bore tubes (e.g. 12 or4 Fr) placed into the stomach are easy to insertnd aspirate but may be poorly tolerated becausef pharyngitis, otitis, tracheal—oesophageal ero-ion and oesophageal sphincter incompetence (Fry,985). Narrow-bore tubes inserted into the stomach

review of all relevant randomized controlled trialsproperly designed randomized controlled triald controlled trials, not randomizedstudies such as cohort studies, case—control studies

re or research groupe series with or without the intervention. Dramatic

authorities, based on clinical experience, descriptivetees

332 T.A. Williams, G.D. Leslie

or small intestine increase patient tolerance, re-duce the risk of aspiration (Treloar and Stechmiller,1984) and improve delivery of nutrition, but are dif-ficult to aspirate, rupture, knot, block easily, andtend to migrate unnoticed out of position (Marcuardand Stegall, 1990; Powell et al., 1993; Treloar andStechmiller, 1984). Most patients commence feed-ing via a gastric tube (Preiser et al., 1999), whichis considered safe and efficient (Neumann and De-Legge, 2002), however, patients who develop gas-tric intolerance whilst being fed via this route maybe changed to an intestinal tube (Montejo et al.,2002).

Complications of enteral tubes and feeding

Complications occur with enteral feeding (Cerra etal., 1997) whatever type of tube is used (Table 2).The incidence of complications varies considerablyand is largely unknown.

Pulmonary aspiration of oropharyngeal or gastriccontents is an important complication reported tooccur in 0.8—95% of critically ill patients (Cataldi-Betcher et al., 1983; Winterbauer et al., 1981), al-

respiratory distress and may not be evident even toskilled clinicians (Arrowsmith, 1993; Elpern, 1997;Metheny et al., 1990). Critically ill patients with en-teral tubes are at greater risk for aspiration becauseof altered sensorium, sedative and narcotic med-ications, unstable physiological status and physi-cal disruptions of the gastrointestinal tract (Bookeret al., 2000). The enteral tube bypasses the pro-tective mechanisms of the oesophagus impingingon the lower oesophageal sphincter increasing therisk of gastro-oesophageal reflux (Cook and Kollef,1998; Ibanez et al., 1992; Orozco-Levi et al., 1995).Oropharyngeal secretions have been found to be theprincipal source of aspiration (Valles et al., 1995),however, migration of bacteria along the tube fromthe stomach to the upper airway may contaminateoral secretions and increase the risk of pneumo-nia from aspiration (Anonymous, 1996; Ewig et al.,1999; Inglis et al., 1993; Torres et al., 1992), al-though this process has been disputed (Bonten etal., 1994; de Latorre et al., 1995). Despite frequentsuctioning, small volumes of pharyngeal secretionsmay still be aspirated into the lower respiratorytract increasing the risk of nosocomial pneumonia(Finucane and Bynum, 1996). Risk factors associ-atas

a

ill pa

Stud

Cataof vepatieMullaTreloEisen

AdamCatauppeMontAdamCataAronCogo(198ValenMarcandMarv

though the true incidence is unknown due to lack ofdefinition standardisation (Neumann and DeLegge,2002) and silent aspiration. What is important iswhether the patient develops nosocomial pneumo-nia as a result of aspiration. Aspiration events areoften not accompanied by coughing or other signs of

Table 2 Complications of enteral feeding in critically

Complication

Pulmonary aspiration

Other pulmonary complications (pulmonary haem-orrhage, pneumothorax, pleural effusion, oe-sophageal perforation, pneumonitis)

Intolerance of feeding (such as high residual gastricvolumes, regurgitation, vomiting and diarrhoea)

MechanicalBlocked feeding tubesInadvertant respiratory placement

Small bore tubes rupture, knot and block easily andtend to migrate unnoticed out of position

Nonocclusive bowel necrosis

ted with nosocomial pneumonia include organ sys-em failure, method of airway management, age,ntibiotic exposure, level of consciousness and po-itioning of the patient (Kearns et al., 2000).Intestinal feeding may be used for patients who

spirate frequently or with a higher risk of gastric

tients.

y/results

ldi-Betcher et al. (1983): 1%; Elpern et al. (1987): 77%ntilated patients; Esparza et al. (2001): 10% ofnts enterally fed; Metheny et al. (1986): 6% and 22%;n et al. (1992): 4%; Strong et al. (1992): 31—40%;ar and Stechmiller (1984): 0/30 (0%)berg (1991); Metheny et al. (1990)

and Batson (1997): 17% delivery interruption;ldi-Betcher et al. (1983): 6.2%; Mentec et al. (2001):r digestive disorder 46%; McClave et al. (1999): 45%;ejo (1999): 63%and Batson (1997): 14% delivery interruption

ldi-Betcher et al. (1983): 3%; Pinilla et al. (2001): 7%chick et al. (1984): 4 cases in 3 months; Dorsey andrdan (1985): 2 cases in 4 months; Harris and Huseby9): 5.4%; Metheny et al. (1990): 10 cases in 2 years;tine and Turner (1985): 0.3%uard and Stegall (1990); Powell et al. (1993); TreloarStechmiller (1984)in et al. (2000): 0.3% in ICU trauma patients


Table 3 Studies assessing intestinal vs. gastric feeding.

Study Design Results

Davies et al. (2002) exploredwhether nasojejunal feedingimproved tolerance of enteralnutrition by reducing gastricresidual volumes

Randomised, prospective, clinicalstudy of 73 ICU patients

Demonstrated jejunal feedingreduced gastric residual volumesand tended to improve feedingtolerance

De Jonghe et al. (2001) assessedthe amount of nutrients required,prescribed and delivered to criti-cally ill patients

Prospective cohort design in 51consecutive patients who receivednutritional support either enterallyor intravenously for 2 days

Inadequate delivery of enteralnutrition. Large volumes ofenterally fed nutrients wastedbecause of inadequate timing instopping and restarting enteralfeeding

Esparza et al. (2001) assessed thedifference in aspiration rates be-tween gastrically and transpylori-cally fed patients in the ICU

Prospective study in 54 critically illpatients

Clinical suspicion of aspiration wasinsensitive and detected only 60%of isotopically documentedaspirations. No difference inaspiration rates betweengastrically and transpylorically fedcritically ill patients

Heyland et al. (2001) determinedthe extent to which postpyloricfeeding reduces gastroesophagealregurgitation and pulmonary mi-croaspiration in critically ill pa-tients

Randomised trial with 33 patients Post pyloric feeding is associatedwith a significant reduction ingastro-oesophageal regurgitationand a trend toward lessmicroaspiration

Heyland et al. (2002) compared gas-tric with postpyloric feeding

Systematic review evaluated 10randomised controlled trials

Patients who regurgitated weremuch more likely to aspirate thanthose who did not regurgitate.Intestinal feeding moreadvantageous. Gastro-oesophagealregurgitation was reduced,nutrient delivery increased, targetnutrition met in shorter time andventilator-associated pneumoniareduced with intestinal feeding.Small sample size threatensinternal validity. Use of surrogateendpoint (>100 counts/min/g) maynot be clinically important

Kearns et al. (2000) investigated therate of ventilator acquired pneu-monia and adequacy of nutrientdelivery of gastric vs. small intes-tine feeding

Prospective, randomised,controlled trial. Medical ICU 44endotracheally intubated,mechanically ventilated patients

No clear difference in theincidence of ventilator acquiredpneumonia in small intestinecompared with gastric enteralnutrition. Small intestine feedingreceived higher calorie and proteinintakes

Kortbeek et al. (1999) evaluatedtranspyloric feeds in ventilatedtrauma patients

Randomised controlled trial ofduodenal vs. gastric feeds of 80patients

Length of stay and ventilator dayswere not significantly different.Transpyloric-duodenal feedssignificantly reduced the timerequired to achieve targetedenteric nutrition

McClave et al. (1999) evaluated fac-tors that impact on the delivery ofenteral tube feeding

Prospective study 44 medical ICUand coronary care units

Half the patients received theircaloric requirements—–underordering or frequent andoften inappropriate cessation offeeding


Table 3(Continued).

Study Design Results

Marik and Zaloga (2003) comparedgastric vs. post pyloric feeding

Systematic review andmeta-analysis of nine RCTs. Mixedgroup of critically ill patients (n =522), including medical,neurosurgical, and trauma ICUpatients

No demonstrated clinical benefitfrom post-pyloric vs. gastric tubefeeding. Incidences of pneumonia,ICU LOS, and mortality weresimilar between groups

Montecalvo et al. (1992) comparednutritional status, gastric coloni-sation, and rates of nosocomialpneumonia of gastric tube vs. je-junal tube feeding

Randomised, prospective study of38 medical/surgical ICU patients

Clinical nosocomial pneumonia intwo (10.5%) patients with gastrictubes, none in the jejunal tubegroup. Significantly higherproportion of nutrition and lowerrate of pneumonia in jejunal tubefed patients

Montejo et al. (2002) comparedthe incidence of enteral nutrition-related gastrointestinal complica-tions, the efficacy of diet adminis-tration, and the incidence of noso-comial pneumonia in patients fedin the stomach or in the jejunum

Prospective, randomisedmulticentre study. ICUs in 11teaching hospitals

Gastrointestinal complications lessfrequent in jejunal tube fedpatients. Accepted gastric residualvolumes of 300ml in the intestinaltube group

Neumann and DeLegge (2002) com-pared the outcomes of ICU pa-tients fed through a nasogastricvs. a nasal-small-bowel tube

Prospective study, 60 patientsrandomised to receive gastric orsmall-bowel tube feedings

No increase in aspiration or otheradverse outcomes in gastricfeeding compared withsmall-bowel feeding in the ICU

Spain et al. (1995) evaluated therate of transpyloric migration, theefficacy of adjunctive measures topromote passage, and the effecton pulmonary complications

Retrospective study of 74 patients Failed to demonstrate anyadvantages in nutrition fromintestinal tubes

Strong et al. (1992) assessed postpy-lorus delivery of enteral feedingbeing safer than intragastric de-livery

Retrospective study of 33 patients Failed to demonstrate anyadvantages in nutrition fromintestinal tubes

motility dysfunction (Kirby et al., 1995). Whetherintestinal tubes decrease the rate of aspiration re-mains controversial (Table 3). Comparing aspira-tion rates between transpyloric and gastric feed-ing, some investigators have found no differencein aspiration rates (Esparza et al., 2001; Kearnset al., 2000; Neumann and DeLegge, 2002; Spainet al., 1995; Strong et al., 1992) whilst other in-vestigators have found decreased aspiration rateswhich did not reach statistical significant (Heylandet al., 2001; Montecalvo et al., 1992). No differ-ence was observed in the rate of nosocomial pneu-monia (Kortbeek et al., 1999; Marik and Zaloga,2003; Montejo et al., 2002) in the ICU length ofstay or mortality in patients fed gastrically versuspostpylorically (Marik and Zaloga, 2003), althoughgastrointestinal complications were observed morefrequently in patients with gastric tubes (mainlylarger residual gastric volumes) (Montejo et al.,2002).

Rare complications include mesenteric is-chaemia, with abdominal pain, distension, in-creased nasogastric drainage or intestinal ileusseen with jejunal tubes (Lawlor et al., 1998; Raiet al., 1996; Schunn and Daly, 1995; Smith-Chobanand Max, 1988) and small bowel necrosis, whichhas been associated with a high mortality (Munshiet al., 2000).

Enteral feeding is often delayed or ceased be-cause of gastrointestinal intolerance (such as highresidual gastric volumes, regurgitation, vomitingand diarrhoea) and for stoppage for procedures(Adam and Batson, 1997; Heyland et al., 1995; Hey-land et al., 2003). Many critically ill patients haveimpaired gastric motility, often caused by medica-tions such as opioids or catecholamines, hypergly-caemia, increased intracranial pressure, decreasedgastric blood flow or the response to stress andpain (Montejo, 1999; Reignier et al., 2002). Stop-ping feeds because of the risk of gastrointestinal


complications may lead to underfeeding or loss ofother benefits afforded by early enteral feeding.Placement of intestinal tubes may be difficult andtime consuming, due to the technical expertiseand equipment that is required which may in turnfurther delay feeding (Maykel and Bistrian, 2002).Feeding via an intestinal tube has been reportedto provide a higher caloric intake than the gastricroute (Kearns et al., 2000; Kortbeek et al., 1999;Montecalvo et al., 1992; Montejo et al., 2002), al-though other investigators report no nutritional ad-vantages (Spain et al., 1995; Strong et al., 1992).Other reasons for not meeting nutritional needs in-clude fasting, procedures, staffing shortages, un-availability of feeds/equipment, low priorities forfeeding, variations in feed prescriptions (Adam andBatson, 1997; Briggs, 1996; De Jonghe et al., 2001;Marshall and West, 2004; McClave et al., 1999;Spain et al., 1999) and blockages in feeding tubes(Pinilla et al., 2001). Despite the risks and uncer-tainty of the best route of administration for en-teral feeds, diligent tube maintenance is clearly anursing responsibility essential to the administra-tion of enteral feeding.

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Wide variation exists in the literature as to whatconstitutes an excessive gastric residual volume.The value that is considered to be acceptable orexcessive (Table 4 ) has not been established by con-trolled trials and is often based on opinion (McClaveet al., 1992; Metheny, 1993; Pinilla et al., 2001).Measuring residual gastric volumes is an imprecisemethod of determining gastric emptying and up-per digestive functioning (Alston, 2001; Chapmanet al., 2000), with the volume of salivary and gas-tric secretions often not taken into account. In ad-dition, gastric residual volume and the presence ofbowel sounds may not correlate with gastric emp-tying (Goldhill et al., 1997). Having high residualgastric volumes does not always imply gastric sta-sis (Jooste et al., 1999) suggesting the rationale forusing gastric residual volumes is flawed (Burd andLentz, 2001; McClave and Snider, 2002). The cur-rent practice of stopping enteral feeding if gastricresidual volumes are less than 400—500ml is notphysiologically or clinically appropriate (Lin and VanCitters, 1997). Decreasing the designated thresholdof gastric residual volume at which feeds shouldbe withheld does not decrease the risk of aspira-tion (Lukan et al., 2002; McClave and Snider, 2002;P

crsbCeputt1rcepicrta52cesaeme

educing the risk of aspiration

esidual gastric volumes

urses frequently assess gastro-intestinal functiony checking gastric residual volumes, listening forowel sounds and observing for abdominal disten-ion in an attempt to reduce the risk and severityf aspiration (Beattie et al., 1996; Eisenberg, 1994;olliet et al., 1998; Kirby et al., 1995). The presencef bowel sounds to confirm gastrointestinal functions questionable (Anonymous, 1994). High residualolumes may indicate delayed gastric emptying, in-olerance to enteral feeding and increase the risk ofegurgitation and aspiration (McClave et al., 1992;etheny, 1993). Many conditions decrease gastricotility, including drugs such as opioids, surgery,rauma, shock and respiratory failure (Bosscha etl., 1998; Dive et al., 1994; Tarling et al., 1997).The measuring of gastric residual volume by as-

iration with a syringe is a popular approach, al-hough this has not been validated (Chapman et al.,000). Using a mobile gamma camera, scintigraphy,s noninvasive, well tolerated, and may not inter-ere with nursing care (Horowitz and Dent, 1991),owever, its use in ICU is impractical (Chapman etl., 2000). Methods that may be used in the futurenclude continuous monitoring of oesophageal tone,lectrogastrograms and tonometry (Alston, 2001).

inilla et al., 2001; Powell et al., 1993).Despite few randomised controlled trials being

onducted regarding the management of gastricesidual volumes (Booker et al., 2000), current re-earch supports continuation of feeding if possi-le (Davies et al., 2002; Jolliet et al., 1998; Mc-lave and Snider, 2002; Mentec et al., 2001). El-vated residual volumes should alert clinicians tootential problems, but a single high gastric resid-al volume should not result in automatic cessa-ion of feeding. Feeding should continue whilsthe patient is closely monitored (McClave et al.,992). Cessation of enteral feeding due to highesidual volumes is a frequent avoidable actionontributing to inadequate caloric intake (Spaint al., 1999). It has been recommended that onlyatients demonstrating overt regurgitation, vomit-ng or aspiration should have their feeds abruptlyeased (McClave and Snider, 2002). If gastric aspi-ates exceed 500ml, then it has been recommendedhat feeds should be withheld and the patient re-ssessed (McClave et al., 2002). Gastric aspirates of00ml or less should be returned. If the aspirate is00—500ml, careful bedside assessment using a de-ision algorithm to manage enteral nutrition deliv-ry is recommended (McClave et al., 2002). Feedinghould continue whilst reducing the rate of feedingnd administering prokinetics considered (Mentect al., 2001). Further studies are needed to deter-ine the amount of gastric residual volume that isxcessive.


Table 4 Studies investigating gastric residual volumes.

Study Design Comments

Burd and Lentz (2001) estimatedgastric volume

Mathematical model Evaluation of gastric residual volume isan unreliable method to monitor feedingintolerance

Cohen et al. (2000) assessed theeffect of continuing enteralnutrition in patients with anelevated gastric residual volumebut normal gastric emptying bythe paracetamol absorption test

Prospective study of 32 criticallyill patients

25% of patients with high gastric residualvolumes (greater than 150ml or morethan twice the hourly nutritionaladministration rate) had normalparacetamol absorption tests for gastricempting

Davies et al. (2002) comparednasojejunal to nasogastricfeeding in critically ill patients

Prospective study Accepted gastric residual volumes of250ml more than the amount deliveredsince the previous gastric aspirationbefore ceasing feeding. Complicationswere rare and they had a much higherrate of tolerated enteral nutrition whencompared to other studies

Goldhill et al. (1997) investigatedthe absorption of cisapride, andits effect on gastric emptyingand the usefulness of clinicalsigns of gastric emptying

RCT involving 27 patients Large variation in gastric emptying wasobserved. The volume of gastric aspirateand the presence of bowel sounds did notcorrelate with gastric emptying

Jolliet et al. (1998) assessed asimple approach to optimiseenteral nutrition modalitieswith practical application.

Literature review by the workinggroup on nutrition and metabolismof the European Society forIntensive Care Medicine

Rrate of feeding should be decreased ifgastric residual volumes were greaterthan 300ml

Jooste et al. (1999) assessed theeffect of metoclopramide ongastric motility in critically illpatients

Prospective, controlled,single-blind cross-over trial in 10patients

High residual gastric volume did notalways imply gastric stasis.Metoclopramide effective prokineticagent

Lin and Van Citters (1997) testedhypothesis that gastric residualvolume increases with slowergastric emptying and fasterformula delivery but reaches aplateau volume

Computer simulation modelling Practice of stopping enteral feeding ifgastric residual volumes were less than400—500ml not physiologically orclinically appropriate

McClave et al. (1992) investigatedthe gastric residual volume thatindicates intolerance orinadequate gastric emptying

Assessed 20 healthy normalvolunteers, 8 stable patients withgastrostomy tubes and 10critically ill patients prospectivelyfor 8 h while receiving enteralnutrition

Wide range of residual volumes (even upto 400ml) were seen with no obviousintolerance such as regurgitation.Residual volumes were higher with higherfeeding rates. Should be wary whenresidual volumes exceed 200ml. Smallsample size and narrow sampling timeframe (6 h following fasting for 2 h)threaten the internal validity of thisstudy. Rate of feeding may not beappropriate for patients who have beenfasting

McClave and Snider (2002)summarised results from studiesthat evaluated the practice,interpretation, and impact onpatient outcome from use ofgastric residual volume

Systematic review Use of gastric residual volumes as amarker of impending clinicaldeterioration is limited by the fact thatthe timing of increases in GRV isunpredictable and high GRVs do notcorrelate independently to adverseoutcome. Practice of GRV may in factimpede delivery of ETF by promotinginappropriate cessation and reducingpotential infusion time


Table 4 (Continued.)


Mentec et al. (2001) investigatedthe frequency of and riskfactors for increased gastricresidual volume and upperdigestive intolerance (definedas vomiting or increased gastricresidual volumes) and theircomplications

Prospective observational study in153 patients receiving nasogastrictube feeding. Aspirate wasreturned to the patient unless itexceeded 500ml

High residual gastric volumes werefrequent, occurred early and morefrequent in patients receivingcatecholamines or sedation. High residualgastric volumes were an early marker ofupper digestive intolerance, which wasassociated with a higher incidence ofnosocomial pneumonia, longer stays inthe intensive care unit and a higher ICUmortality rate. Rather than discontinuefeeding, the investigators recommendedmore aggressive use of prokinetics

Spain et al. (1999) determinedwhether the use of an infusionprotocol could improve thedelivery of enteral tube feedingin ICU

Prospective study, 31 patients inthe protocol group with 44patients in the control group

Cessation of enteral feeding due to highresidual volumes was a frequentavoidable problem contributing toinadequate caloric intake

Tarling et al. (1997) described therange and factors that mayaffect gastric emptying in thecritically ill patient using aparacetamol absorption test

Validation study of 27 ICU patients Observed a wide range of volumes ingastric emptying. Over 50% of patients ina validation sample had normal gastricresidual volumes despite abnormalparacetamol absorption tests for gastricemptying

Enhancing gastric motility by the use of proki-netic agents, with differing pharmacological prop-erties, have been supported by randomised trials(Boivin and Levy, 2001; Booth et al., 2002; Chap-man et al., 2000; Heyland et al., 1996; Jooste etal., 1999; MacLaren et al., 2000; Spapen et al.,1995; Yavagal et al., 2000). Metoclopramide is aselective dopamine-2 receptor antagonist that en-hances cholinergic induced peristaltic contractil-ity of the upper gastrointestinal tract (MacLaren etal., 2000). Cisapride acts by selectively enhancingcholinergic motor activity throughout the gastroin-testinal tract (MacLaren et al., 2000). Eythromycinenhances motilin release from the duodenal ente-rochromaffin cells (MacLaren et al., 2000). A sys-tematic review of promotility drugs concluded thatprokinetics are effective in promoting gastric emp-tying in ICU patients (Booth et al., 2002; MacLarenet al., 2000). Introducing prokinetic agents earlyhas been suggested when the pre feeding residualvolume exceeds 20ml or during feeding if resid-ual volumes exceed 100ml, (Mentec et al., 2001).Mandatory use of prokinetics reduces the incidenceof enteral feeding intolerance (Pinilla et al., 2001).Whether these drugs improve the amount of nutri-t2av

The frequency of checking gastric residual vol-umes varies from 2 to 24 hourly (Arrowsmith,1993; Bowers, 1996; Cataldi-Betcher et al., 1983;Goodwin, 1996), and is opinion based. Aspirationregimes include 4 hourly on the first day of feed-ing and then 8 hourly (Fellows et al., 2000); 3 to 4hourly when feeding was commenced then checkingdaily once full volume and tolerance is established(Goodwin, 1996; Jolliet et al., 1998; Kleibeuker andBoersma-van Ek, 1991); and 4 to 12 hourly (Edwardsand Metheny, 2000; Metheny, 1993; Payne-James,1992). The risk of aspiration during continuous na-sogastric tube feeding has been reported as great-est during the first few hours of administration(Kleibeuker and Boersma-van Ek, 1991). It may benecessary to monitor residuals more closely duringthe early phase of feeding, and then less frequentlyonce feeding is established. In patients with estab-lished feeding and where volume of aspirate is nota problem, consideration may be given to less fre-quent aspirations (Fellows et al., 2000). Althoughthere are no established guidelines indicating howoften enteral tubes should be aspirated, most insti-tutions follow some type of protocol although com-pliance issues have been identified (Breach and Sal-d

ga

ion patients receive is not proven (Pinilla et al.,001). There are concerns regarding their safetynd lack of effect on clinical outcomes such as sur-ival (Booth et al., 2002).

anha, 1988; Sands, 1991).Discarding gastric aspirate may result in loss of

astric fluid and electrolytes (Cataldi-Betcher etl., 1983) but reduces the potential for contami-


Table 5 Studies investigating return of gastric aspirates.


Booker et al. (2000) studied theeffects of discarding vs. returninggastric residual volumes on bodyweight, electrolyte levels, andcomplications associated withtube feeding

Randomised controlled trial, 35patients but only 18 sets of useabledata obtained

No significant differences betweenthe discard group or return group.Both groups had substantialnumbers of complications,including feeding delays due tohigh gastric residual volumes (7 inthe discard group and 8 in thereturn group). Although electrolytelevels did not differ significantlybetween the 2 groups, potassiumlevels tended to be lower in thediscard group. Small sample size,many data being collectedretrospectively and the effect offluid intake and output not beingmeasured that may have influencedelectrolyte status threatenedinternal validity

McClave and Snider (2002)summarised results from studiesthat evaluated the practice,interpretation, and impact onpatient outcome from use ofgastric residual volume

Systematic review Recommended that aspirates bereturned

nation during the aspiration process and cloggingof enteral tubes when aspirate is returned. A RCTfound no significant differences in outcomes be-tween the discard group or return group (Booker etal., 2000), although potassium levels tended to belower in the discard group (Table 5). Small samplesize, many data being collected retrospectively andthe effect of fluid intake and output that may haveinfluenced electrolyte status not being measured,threatened study internal validity.

Patient positioning during enteral feeding

Continuous feeding increases the risk of aspira-tion as the oesophageal sphincter remains open,therefore, nursing the patient at a minimum of30—45◦ elevation has been recommended to re-duce this risk (Table 6) (Arrowsmith, 1993; Bow-ers, 1996; Drakulovic et al., 1999; Elpern, 1997;Ibanez et al., 1992; Kirby et al., 1995; Kollef, 1993;Orozco-Levi et al., 1995; Potts et al., 1993; TheJoanna Briggs and Institute, 2002; Torres et al.,1992; Treloar and Stechmiller, 1984). Some inves-tigators believe that elevating the head of the beddoes not prevent aspiration (Elpern et al., 1987),

during those times when a patient has to lie flat(Metheny, 1993).

Management of artificial airways

Patients with artificial airways are at risk of aspira-tion. Decreased elevation of the larynx, obstructionby the cuff of the artificial airway, decreased sensa-tion of the larynx, reduced reflexes due to chronicairway diversion and uncoordinated laryngeal clo-sure due to chronic upper airway bypass have beennoted with the use of artificial airways (Goodwin,1996). Tracheostomy tube cuffs do not prevent as-piration, even when properly inflated (Elpern etal., 1987; Koeman et al., 2001). Whilst trial basedevidence is lacking, a cuff pressure maintained at20—25 cmH2O and regular oropharyngeal suctioningto the back of the mouth in intubated patients hasbeen well supported by expert opinion to minimisethe risk of aspiration (Elpern, 1997).

Mouth care

The risk for aspiration pneumonia is decreased byugp

however, the semi-recumbent position may reducethe risk. Because the head up position is diffi-cult to achieve at all times, aspiration may occur

p to 60% in patients receiving aggressive oral hy-iene/decontamination (Koeman et al., 2001; Ter-enning et al., 2001; Yoneyama et al., 2002). Pa-


Table 6 Studies evaluating patient position in patients receiving enteral nutrition.

Study Results

Drakulovic et al. (1999) The frequency of suspected and microbiologically confirmed pneumonia wassignificantly less in patients randomised to the semi-recumbent position

Elpern et al. (1987) The upright position was used 80% of the time in 31 intubated patients and anaspiration rate of 27% was observed

Ibanez et al. (1992) Randomised controlled trials demonstrated greater gastro-oesophageal refluxin patients with orotracheal intubation and naso gastric tube. Semirecumbencydoes not prevent GER, but there is less incidence than in the supine position

Kollef (1993) Three times increased risk of nosocomial pneumonia during the first 24 h ofmechanical ventilation in cohort of patients nursed supine

Orozco-Levi et al. (1995) Prospective, randomised crossover design studies observed that the supinebody position had a higher rate of pulmonary aspiration but clinicallysignificant aspiration was not observed. Higher radioactive counts oftechnetium sulphur colloid, instilled into the stomach, in endobronchialsecretions in patients nursed supine

Potts et al. (1993) Patients with clinically significant aspiration were fed supine 98% of the time,patients who did not aspirate being fed supine only 21% of the time

Torres et al. (1992) Prospective, randomised crossover design studies observed that the supinebody position had a higher rate of pulmonary aspiration but clinicallysignificant aspiration was not observed. Higher radioactive counts oftechnetium sulphur colloid, instilled into the stomach, in endobronchialsecretions in patients nursed supine

Treloar and Stechmiller (1984) Zero incidence of aspiration when the head of the bed was elevated by 30—45◦

tients should receive regular mouth care (McClaveet al., 2002) but antiseptic solutions should be usedin preference to antimicrobials to decrease the pos-sibility of antimicrobial resistance (DeRiso et al.,1996).

Continuous versus intermittent feeding

Continuous feeding delivered via a peristaltic pumpis considered to reduce the risk of aspiration be-

Table 7 Continuous vs. intermittent feeding.


McKinlay et al. (2001) compared theeffect of recent changes in systemdesign on the levels and incidenceof bacterial contamination in en-teral tube feeds

Randomised study of 34neurological ICU patients

No differences in bowel activity,evidence of aspiration or meetingcaloric targets were found

McKinlay et al. (1995) compared thelevels and types of microorgan-isms present in residual nutrientcontainers and giving sets

Randomised study of 18 traumapatients

Continuous feeding facilitatednutrient delivery with lessgastrointestinal complications

Spilker et al. (1996) evaluatedthe effect of intermittent enteral

13 patients converted fromcontinuous to intermittent feeding

No significant differences werefound between the 2 groups

cause of the assured constant delivery volume andsmaller volumes in the stomach at any one time(Ciocon et al., 1992; Kocan and Hickisch, 1986;Steevens et al., 2002). Intermittent feeding sup-posedly allows pH to restore itself between bolusesof food thus minimising gastric colonisation. How-ever, critically ill patients have higher than normalpH (Metheny et al., 1997). Studies evaluating in-termittent feeding have design and methodologicalflaws. Although no significant differences have beenfound between continuous and intermittent feeding

feeding on gastric pH and gastricmicrobial growth in mechanicallyventilated patients


(Elpern, 1997; McKinlay et al., 2001; Spilker et al.,1996) (Table 7) continuous feeding has been rec-ommended (McClave et al., 2002; Metheny et al.,2002) on the basis it facilitates nutrient deliverywith less gastrointestinal complications (McKinlayet al., 1995).

Conclusion

When patients are unable to feed normally, theuse of enteral tubes for nutrition delivery pro-vide the best alternative mode of sustenance. How-ever, their use is not without risk. Of all compli-cations from enteral feeding tubes, pulmonary as-piration represents one of the most frequent andproblematic issues. Nursing measures to minimisethis risk include regular checking of gastric resid-ual volumes, continuous rather than intermittentfeeding, semi-recumbent positioning to reduce therisk of airway aspiration, good oral hygiene prac-tices and diligent artificial airway cuff manage-ment. Frequency of checking gastric residual vol-umes is largely opinion based and varies consid-

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Bower RH, Cerra FB, Bershadsky B, Licari JJ, Hoyt DB, Jensen GL,et al. Early enteral administration of a formula (impact) sup-plemented with arginine, nucleotides, and fish oil in inten-sive care unit patients: results of a multicenter, prospective,randomized, clinical trial. Crit Care Med 1995;23(3):436—49.

Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral comparedwith parenteral nutrition: a meta-analysis. Am J Clin Nutr2001;74(4):534—42.

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B

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C

C

C

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D

D

erably, but prokinetics that aid gastric emptyingshould be used if absorption of feeds is problem-atic. In part two of this paper, other nursing man-agement issues are discussed and recommendationsfor enteral tube placement, care and maintenanceare described.

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Documents

A review of the nursing care of enteral feeding tubes in critically ill adults: part I