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CLINICAL
GUIDELINES
ON
ENTERAL TUBE FEEDING
CONTENTS
EXECUTIVE SUMMARY3
I.INTRODUCTION5
A.INDICATIONS5
B.TIMING OF GIVING ENTERAL FEEDING6
II.ENTERAL FEEDING FORMULA7
A.CONTENT OF THE FORMULA7
B.SPECIFICATION OF THE FORMULA8
C.SELECTION OF FORMULA8
D.ADULT ENTERAL FORMULAS9
III.CALORIC REQUIREMENT11
A.CALORIE CALCULATION11
B.SIMPLE VERSION FOR HOSPITAL PATIENTS11
IV.NASOGASTRIC TUBE FEEDING IMPLEMENTATION12
A.SELECTION OF NASOGASTRIC TUBE12
B.SITE OF NUTRIENT DELIVERY12
C.NASOGASTRIC TUBE INSERTION12
D.METHODS OF TUBE PLACEMENT VERIFICATION13
E.PREPARATION FOR FEEDS14
F.TUBE FEEDING ADMINISTRATION15
G.DAILY NASOGASTRIC TUBE CARE16
H.DOCUMENTATION17
V.PEG TUBE FEEDING IMPLEMENTATION18
A.SELECTION OF PATIENT FOR PEG INSERTION18
B.PREPARATION OF PATIENT FOR PEG INSERTION18
C.POST OPERATIVE CARE OF PATIENT FOR PEG INSERTION19
D.MANAGEMENT OF PEG TUBE DISLODGMENT20
E.MANAGEMENT OF PEG EXIT WOUND INFECTION21
F.CHECKING BALLOON INTEGRITY OF THE PEG TUBE22
G.CHANGE OF PEG INITIAL TUBE24
H.CHANGE OF PEG REPLACEMENT TUBE25
I.CARE OF PEG IN THE COMMUNITY27
J.RESUME ORAL FEEDING AND TERMINATION OF PEG TUBE30
VI.MEDICATIONS ADMINISTRATION32
VII.COMMON PROBLEMS RELATED TO TUBE FEEDING33
A.COFFEE GROUND ASPIRATE33
B.TUBE CLOGGING33
C.TUBE DISLODGMENT33D.DIARRHOEA33
E.CONSTIPATION34
F.VOMITING34
VIII.REFERENCES35
IX.APENNDICES37
A.ALGORITHM: VERIFICATION OF TUBE PLACEMENT38
B.QUICK REFERENCE GUIDE39
C.APPLICATION OF TAPE FOR NG TUBE SECURAL40
D.CARE MAP FOR INSERTION OF PEG41
E.PEG TUBE BALLOON MAINTENANCE RECORD42
F.PEG CARD43
EXECUTIVE SUMMARY
Maintenance of hydration and nutrition constitute an important aspect of medical care of patients suffering from severe illnesses affecting the ability of oral intake. Therefore enteral tube feeding is an important treatment modality in hospital and long term care settings. The proper use of enteral feeding would ensure the safe delivery of nutrition to patients and able to improve their quality of life.
Nasogastric tube feeding is indicated to be the method of choice for patients with functional gastrointestinal tracts in view of low cost, simplicity and low incidence of complications. Therefore nasogastric tube feeding is widely used in most health care facilities. With the advent of the technique of Percutaneous Endsocopic Gastrotomy, the PEG is indicated where nasogastric or oral feeding is not possible or where extended enteral nutrition is required. The appropriate selection of the route of enteral tube feeding will able to offer the patients with the most optimal care.
In view of the importance of proper delivery of enteral tube feeding in elderly patients the Geriatric Subcommittee has convened a working group on enteral tube feeding in August 2001 to develop a set of clinical guidelines on enteral tube feeding for use in hospital settings and also for reference in residential and community care settings.
The working group consisted of members from Geriatric Subcommittee and nurse specialists from various hospitals. The present guidelines are based on existing literature with special reference to current practice in the local settings.
The guidelines attempt to address the issues related to the indications of enteral tube feeding, the selection of feeding formula, the selection of naso-gastric tube feeding and Percutaneous Endoscopic Gastrostomy Feeding. Special points has been made to the indications of the use of NG tube and PEG tube, the daily care of the tube feeding and management of complications related to the use of enteral tube feeding.
On behalf of the working group I would like to extend our thanks to all those who have contributed to the development of the guideline.
Dr. Leung Man Fuk (Convenor), Consultant Geriatrician, Department of M&G UCH
Dr. Derrick Au, Consultant Geriatrician, Department of Rehabilitation KH
Dr. Au Si Yan, Consultant Geriatrician, Department of M&G TMH
Miss Alice Choi, WM, Department of Geriatrics FYKH
Miss Fung Suk Yee, Becky, NO, Department of M&G TMH
Dr. Kong Tak Kwan, Consultant Geriatrician, Department of M&G PMH
Miss Ada Lau, NS, Department of M&G UCH
Miss Law Po Chun, Alice, RN, Department of M&G TPH
Miss Patricia Lee, NS, Department of M&G SH
Miss Imelda Leung, NO, Department of M&EC TPH
Miss Anita Ling, NO, Department of M&G KWH
Miss Tammi Lo, NS (Geriatrics), CND PMH
Miss Rebecca Poon, NS, Department of Geriatrics RHTSK
Dr. Shea Tat Ming, Paul, Asso Consultant, Division of Geriatrics, Department of Medicine QEH
Dr. Yung Cho Yiu, Consultant Geriatrician, Department of M&G UCH
Prepared by Dr. Leung Man Fuk
August 2002
INTRODUCTION
Patient should be considered for enteral feeding when they are unable to safely and comfortably take adequate nutrition orally, having a functioning GI tract, and wish to have the intervention.
INDICATIONS
As a temporary measure
a. to tide over acute illness causing insufficient volitional intake
confusion
acute stroke
depression
anorexia caused by systemic illness
b. to meet increased energy demand as in the following conditions
* pressure sores
* peri-operative periods
* burns
* mechanical ventilation
* multiple trauma
* sepsis
Permanent measure in
a. neuromuscular dysphagia
* stroke
* brain injury
* Parkinson disease
* demyelinating disease
* GBS
* MND
* Polymyositis
b. chronic anorexia
* chronic illness
* dementia?
c. overcoming mechanical obstruction
* neoplasm
* post-radiation
* surgery
?Demented patients tend to struggle with feeding tube which may need physical or chemical restraining. The decision on permanent enteral tube feeding in the demented older persons needs careful discussion with the close relatives about the balance of survival prolongation and the suffering induced.......（后略) ......
CLINICAL
GUIDELINES
ON
ENTERAL TUBE FEEDING
CONTENTS
EXECUTIVE SUMMARY3
I.INTRODUCTION5
A.INDICATIONS5
B.TIMING OF GIVING ENTERAL FEEDING6
II.ENTERAL FEEDING FORMULA7
A.CONTENT OF THE FORMULA7
B.SPECIFICATION OF THE FORMULA8
C.SELECTION OF FORMULA8
D.ADULT ENTERAL FORMULAS9
III.CALORIC REQUIREMENT11
A.CALORIE CALCULATION11
B.SIMPLE VERSION FOR HOSPITAL PATIENTS11
IV.NASOGASTRIC TUBE FEEDING IMPLEMENTATION12
A.SELECTION OF NASOGASTRIC TUBE12
B.SITE OF NUTRIENT DELIVERY12
C.NASOGASTRIC TUBE INSERTION12
D.METHODS OF TUBE PLACEMENT VERIFICATION13
E.PREPARATION FOR FEEDS14
F.TUBE FEEDING ADMINISTRATION15
G.DAILY NASOGASTRIC TUBE CARE16
H.DOCUMENTATION17
V.PEG TUBE FEEDING IMPLEMENTATION18
A.SELECTION OF PATIENT FOR PEG INSERTION18
B.PREPARATION OF PATIENT FOR PEG INSERTION18
C.POST OPERATIVE CARE OF PATIENT FOR PEG INSERTION19
D.MANAGEMENT OF PEG TUBE DISLODGMENT20
E.MANAGEMENT OF PEG EXIT WOUND INFECTION21
F.CHECKING BALLOON INTEGRITY OF THE PEG TUBE22
G.CHANGE OF PEG INITIAL TUBE24
H.CHANGE OF PEG REPLACEMENT TUBE25
I.CARE OF PEG IN THE COMMUNITY27
J.RESUME ORAL FEEDING AND TERMINATION OF PEG TUBE30
VI.MEDICATIONS ADMINISTRATION32
VII.COMMON PROBLEMS RELATED TO TUBE FEEDING33
A.COFFEE GROUND ASPIRATE33
B.TUBE CLOGGING33
C.TUBE DISLODGMENT33D.DIARRHOEA33
E.CONSTIPATION34
F.VOMITING34
VIII.REFERENCES35
IX.APENNDICES37
A.ALGORITHM: VERIFICATION OF TUBE PLACEMENT38
B.QUICK REFERENCE GUIDE39
C.APPLICATION OF TAPE FOR NG TUBE SECURAL40
D.CARE MAP FOR INSERTION OF PEG41
E.PEG TUBE BALLOON MAINTENANCE RECORD42
F.PEG CARD43
EXECUTIVE SUMMARY
Maintenance of hydration and nutrition constitute an important aspect of medical care of patients suffering from severe illnesses affecting the ability of oral intake. Therefore enteral tube feeding is an important treatment modality in hospital and long term care settings. The proper use of enteral feeding would ensure the safe delivery of nutrition to patients and able to improve their quality of life.
Nasogastric tube feeding is indicated to be the method of choice for patients with functional gastrointestinal tracts in view of low cost, simplicity and low incidence of complications. Therefore nasogastric tube feeding is widely used in most health care facilities. With the advent of the technique of Percutaneous Endsocopic Gastrotomy, the PEG is indicated where nasogastric or oral feeding is not possible or where extended enteral nutrition is required. The appropriate selection of the route of enteral tube feeding will able to offer the patients with the most optimal care.
In view of the importance of proper delivery of enteral tube feeding in elderly patients the Geriatric Subcommittee has convened a working group on enteral tube feeding in August 2001 to develop a set of clinical guidelines on enteral tube feeding for use in hospital settings and also for reference in residential and community care settings.
The working group consisted of members from Geriatric Subcommittee and nurse specialists from various hospitals. The present guidelines are based on existing literature with special reference to current practice in the local settings.
The guidelines attempt to address the issues related to the indications of enteral tube feeding, the selection of feeding formula, the selection of naso-gastric tube feeding and Percutaneous Endoscopic Gastrostomy Feeding. Special points has been made to the indications of the use of NG tube and PEG tube, the daily care of the tube feeding and management of complications related to the use of enteral tube feeding.
On behalf of the working group I would like to extend our thanks to all those who have contributed to the development of the guideline.
Dr. Leung Man Fuk (Convenor), Consultant Geriatrician, Department of M&G UCH
Dr. Derrick Au, Consultant Geriatrician, Department of Rehabilitation KH
Dr. Au Si Yan, Consultant Geriatrician, Department of M&G TMH
Miss Alice Choi, WM, Department of Geriatrics FYKH
Miss Fung Suk Yee, Becky, NO, Department of M&G TMH
Dr. Kong Tak Kwan, Consultant Geriatrician, Department of M&G PMH
Miss Ada Lau, NS, Department of M&G UCH
Miss Law Po Chun, Alice, RN, Department of M&G TPH
Miss Patricia Lee, NS, Department of M&G SH
Miss Imelda Leung, NO, Department of M&EC TPH
Miss Anita Ling, NO, Department of M&G KWH
Miss Tammi Lo, NS (Geriatrics), CND PMH
Miss Rebecca Poon, NS, Department of Geriatrics RHTSK
Dr. Shea Tat Ming, Paul, Asso Consultant, Division of Geriatrics, Department of Medicine QEH
Dr. Yung Cho Yiu, Consultant Geriatrician, Department of M&G UCH
Prepared by Dr. Leung Man Fuk
August 2002
INTRODUCTION
Patient should be considered for enteral feeding when they are unable to safely and comfortably take adequate nutrition orally, having a functioning GI tract, and wish to have the intervention.
INDICATIONS
As a temporary measure
a. to tide over acute illness causing insufficient volitional intake
confusion
acute stroke
depression
anorexia caused by systemic illness
b. to meet increased energy demand as in the following conditions
* pressure sores
* peri-operative periods
* burns
* mechanical ventilation
* multiple trauma
* sepsis
Permanent measure in
a. neuromuscular dysphagia
* stroke
* brain injury
* Parkinson disease
* demyelinating disease
* GBS
* MND
* Polymyositis
b. chronic anorexia
* chronic illness
* dementia?
c. overcoming mechanical obstruction
* neoplasm
* post-radiation
* surgery
?Demented patients tend to struggle with feeding tube which may need physical or chemical restraining. The decision on permanent enteral tube feeding in the demented older persons needs careful discussion with the close relatives about the balance of survival prolongation and the suffering induced.......（后略) ......
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