Section 5b - Feeding Tubes

Question 1

What are feeding tubes used for?

Answer 1

To provide nutritional support to patients who cannot eat by mouth

Question 2

How are parenteral and enteral feeding different?

Answer 2

• Enteral feeding maintains both structural and functional integrity of the GI tract by preventing changes due to atrophy
• Enteral feeding is less expensive and risky
• Enteral feeding voids possible bacterial translocation and development of cholestasis is avoided since bile flow is maintained

Question 3

What determines the type of feeding tube that is used?

Answer 3

• Why the patient requires tube feeding

- Expected duration of treatment

Question 4

Where can a feeding tube be placed?

Answer 4

• Stomach
• Jejunum
• Occasionally duodenum

Question 5

What are the locations of dual lumens?

Answer 5

• One in stomach for passive decompression

- Other in the small bowel for nutrition

Question 6

What is a tube placed through the mouth called?

Answer 6

Orogastric

Question 7

What is a tube placed through the nose called?

Answer 7

Nasogastric

Question 8

Tubes that are placed surgically are called _____

Answer 8

Percutaneous

Question 9

When would a tube be placed in the stomach?

Answer 9

For patients who have a normal functioning GI tract from lower esophagus down

Question 10

When would a tube be placed in the upper duodenum or jejunum?

Answer 10

For patients w/

• Gastric emptying problems (gastroparesis)
• Non-functional upper GI tract
• Pancreatitis
• Severe gastroesophageal reflux disease
• At significant risk of aspiration

Question 11

What is important to note if the patient has a tube in their jejunum?

Answer 11

Need to provide food that is partly digested already

Question 12

What is the most common location for a feeding tube and why?

Answer 12

Stomach b/c more convenient and is able to tolerate enteral formulas which are hypertonic

Question 13

What is a side effect of jejunal feedings?

Answer 13

Abdominal cramping and diarrhea

Question 14

Which type of feeding tubes are used for short-term nutritional support?

Answer 14

Oral or nasal (percutaneous when these options are not possible)

Question 15

Which type of feeding tubes are used for long-term nutritional support?

Answer 15

Percutaneous

Question 16

What determines the size of feeding tube that is used?

Answer 16

• Nature of access
• Feeding supplement
• Patient

Question 17

What is the size of a small-bore?

Answer 17

Outer diameter is 5-12 French units

Question 18

What does 1 French unit equal?

Answer 18

0.33 mm

Question 19

What is the size of a large-bore?

Answer 19

Outer diameter is greater than 12 French units

Question 20

Which size of feeding tube is more common?

Answer 20

Small-bore, but has a greater risk of clogging

Question 21

What is the advantage to commercial products over home-prepared?

Answer 21

Commercial products contain vitamin and mineral supplementation and are sterile

Question 22

When should elemental (pre-digested) formulations be used?

Answer 22

Patients w/ severe small bowel absorptive dysfunction

Question 23

What determines feeding schedule?

Answer 23

Condition of the patient

Question 24

What are the 3 types of administration?

Answer 24

• Feeding syringe
• Gravity bag system
• Pump

Question 25

Can medications be given through enteral feeding tubes?

Answer 25

Yes if alternative drug delivery routes are not possible

Question 26

Should medication be mixed with formula?

Answer 26

No

Question 27

Should feeding and medication administration occur together?

Answer 27

No, feeding should be interrupted for medication administration and tube should be flushed w/ 15-30 mL of water before and after medication administration

Question 28

Is absorption better on an empty stomach?

Answer 28

Yes

Question 29

What should be done if medication needs to be taken on an empty stomach?

Answer 29

- Stop feeding 30 mins before administering drug to allow gastric emptying - Wait 30 mins after medication is given to allow time for drug absorption * *Only applicable to gastric feeding

Question 30

Can placement site affect drug absorption?

Answer 30

Yes

Question 31

What will occur if an opioid is given through a jejunal tube?

Answer 31

Will undergo extensive first-pass hepatic metabolism, and may show greater systemic effects

Question 32

Is gastric or jejunal access preferred?

Answer 32

Gastric

Question 33

Stomach is more tolerant than jejunum of ____ medications

Answer 33

Hypertonic

Question 34

Are liquid dose forms or enteral administration preferred and why?

Answer 34

- Liquid dose forms | - Readily absorbed and less likely to cause tube occlusion

Question 35

Drugs should be drawn up and dispensed only in ____ syringes

Answer 35

Oral (not parenteral)

Question 36

What are disadvantages to liquid dose forms?

Answer 36

- Usually made for children, so large volumes of product are needed for adult dosage and volume may not be tolerated by patient - Adjustments in dose and frequency may be necessary especially when switching from extended or controlled-release product to liquid preparation which is usually immediate release

Question 37

Many liquid preparations are _____ or contain large amounts of ______

Answer 37

- Hypertonic | - Sorbitol

Question 38

Why are hypertonic medications better tolerated in stomach?

Answer 38

- Stomach can dilute hypertonic substances w/ gastric juices before transferring contents into duodenum - If given too rapidly may be "dumped" into small intestine resulting in osmotic diarrhea

Question 39

When can hypertonic medications be administered into the small intestine?

Answer 39

When diluted w/ 10-30 mL STERILE water

Question 40

What are some side effects to adminstration of hypertonic medication into small intestine?

Answer 40

- Bloating - Nausea - Cramping - Diarrhea

Question 41

What is sorbitol used for and what are some side effects?

Answer 41

- Sweetening agent | - 10-20 g daily may cause an osmotic laxative effect => cramping and diarrhea

Question 42

Why aren't syrup dose forms frequently used w/ feeding tubes?

Answer 42

Usually acidic, and most enteral feeding formulas will coagulate if exposed to acidic environment

Question 43

When can syrup dose forms be used w/ feeding tubes?

Answer 43

If the feeding formula and syrup do not come into contact b/c tube may become clogged or blocked

Question 44

What can be done w/ immediate-release tablets that need to be administered through a feeding tube?

Answer 44

May be crushed, including those that are sugar or film coated, then mixed w/ 15-30 mL water

Question 45

What can be done w/ hard gelatin capsules that need to be administered through a feeding tube?

Answer 45

Opened and contents are dispersed in 10-15 mL of water

Question 46

What can be done w/ liquid-filled soft gelatin capsules that need to be administered through a feeding tube?

Answer 46

- Pierced w/ needle and contents squeezed out | - May result in under-dosing

Question 47

Can enteric-coated products be crushed and why?

Answer 47

No b/c adverse effects may occur or drugs effectiveness may be reduced

Question 48

What happens if extended or controlled-release tablets are crushed?

Answer 48

It destroys delivery mechanism and may result in potentially toxic peaks and low troughs

Question 49

What happens if a sublingual preparation is administered enterally?

Answer 49

May result in reduced drug absorption and lack of efficacy

Question 50

Can injectable formulations be used orally?

Answer 50

Yes, but must consider stability in gastric acid (hypertonic products may induce osmotic diarrhea and cost is usually high)

Question 51

What are some side effects to adding medication directly to an enteral formula?

Answer 51

- Physical incompatibilities - Decreased drug absorption - Increased risk of tube occlusions - Potential microbial contamination

Question 52

Which type of formulas will be more affected if medication is added?

Answer 52

Formulas containing protein will be more affected than those containing free aa's or hydrolyzed protein

Question 53

What should be done if multiple medications need to be given through a feeding tube?

Answer 53

- Give each separately | - Feeding tube should be irrigated w/ 5-10 mL of water (sterile if into jejunum) btwn each medication

Question 54

Why should the tube be flushed?

Answer 54

- To reduce risk of tube occlusion | - Ensures total drug delivery and avoidance of contact btwn feeding formula and medication

Question 55

Should liquid medications that are highly concentrated or viscous by diluted and why?

Answer 55

Yes to reduce medication osmolality and prevent tube occlusions

Question 56

What is an example of a drug that is not very compatible w/ enteral feeding?

Answer 56

- Phenytoin - Showed a 70% decrease in bioavailability when administered w/ enteral feeding - Drug may bind w/ components in the feeding and avoid absorption

Question 57

What can be done if phenytoin must be administered through a feeding tube?

Answer 57

Hold feeding formulas for 1 hour before and 2 hours after medication dosing

Question 58

Why are proton-pump inhibitors prolembatic to feeding tubes?

Answer 58

Are highly unstable in acidic environments and are inactivated by gastric acid

Question 59

What should capsule contents be mixed w/?

Answer 59

- Apple or orange juice b/c they protect the enteric-coated granules so they remain intact in stomach until reaching the small intestine - Mixing w/ water causes clumping

Question 60

What are some problems associated w/ bedside modification?

Answer 60

- Taste - Acid stability - Over-dosing when controlled-release products are used