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Approach to Oral and Enteral Nutrition (PN) in Adults

Topic 8
Module 8.5
Complications and Monitoring of EN
Matthias Pirlich
Learning Objectives

To understand the most important complications of EN;


To know how to prevent or counteract complications;
To know how to monitor patients on enteral nutritional support.

Contents
1. Gastrointestinal complications of EN
1.1 Diarrhoea
1.2 Nausea and vomiting
1.3 Constipation
2. Aspiration
3. Tube related complications
4. Metabolic complications
5. Monitoring of EN
Key Messages

Most complications of EN are the results of application errors;


Certain underlying diseases are associated with increased risk of specific complications;
Acceptance of EN can be enhanced by adequate monitoring / early recognition of complications
and modification of type of EN and application;
Careful monitoring of EN is especially important in intensive care, in elderly patients and in
patients with neurological impairment.

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1. Gastrointestinal Complications of EN
Enteral nutrition is a safe, effective and generally well tolerated approach of nutritional therapy in
patients with normal functioning gastrointestinal tract. Interruption of enteral nutrition is
frequently related to gastrointestinal complications. It is important to understand, that most
complications are the result of application errors. Complications of EN can be divided in
gastrointestinal, tube related and metabolic.

Table 1 Complications of enteral nutrition

1.1

Diarrhoea

Diarrhoea is a rather common gastrointestinal complication of EN. There is a wide range of


prevalence data for diarrhoea in the literature which is most likely explained by different
definitions used. The most common definition of diarrhoea is: stool mass > 200 mg/24 h or stool
frequency > 3 liquid portions per day. The prevalence of EN related diarrhoea is estimated to be 25
% on general wards and up to 60 % in ICU patients.
Reasons for diarrhoea can be bolus application or high delivery rate, high osmolality, bacterial
contamination or inadequate low temperature of the formula diet.

Figure 1 Reasons for diarrhoea during enteral nutrition

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The ideal temperature of the formula is 20 to 25 C. Furthermore, a number of medications (i.e.


macrolids, antacids, atropin, metoclopramide etc.) can cause diarrhoea. Before intolerance of EN is
considered, one must also exclude gastrointestinal infections and disturbances of nutrient
absorption (e.g. due to milk protein allergy, exocrine pancreatic insufficiency or lactose
intolerance,).
The work up of diarrhoea occurring under EN should include the following issues:
When bolus application has initially been performed switch to continuous application using an
electronic pump system. Continuous application of EN is generally better tolerated than bolus
application, even if the latter appears to be more physiologic;
Decrease the delivery rate (sometimes it is effective to decrease the delivery rate only for one
or two days and than increase the rate to the initial level). The maximum tolerated delivery
rate does usually not exceed 120 ml/h which is equivalent to the physiologic flux into the
duodenum;
Avoid bacterial contamination of the formula diet: change the drip line daily; review the
manufacturers guidelines for the use of the formula; when open systems are used, the formula
diet should be delivered within 6 to 10 hours; feeds should not made up in advance;
Review patients prescriptions regarding diarrhoea inducing drugs;
Exclude gastrointestinal infections (stool culture including; screening for clostridium difficile
toxin);
If malabsorption is suspected change to low molecular diets;
If diarrhoea persists change to soluble fibre containing EN formula.

1.2 Nausea and Vomiting


Many patients who receive enteral nutrition suffer from diseases which itself are associated with a
high risk of nausea and vomiting (e.g. cancer of the upper GI tract). Furthermore antineoplastic
therapy (i.e. radio- or chemotherapy) is a strong trigger for nausea and vomiting and requires a
consequent antiemetic therapy before EN is initiated. In some cancer patients nausea might be so
dominant that EN becomes impossible and total parenteral nutrition must be considered.
Delayed gastric emptying is the most common cause of nausea related to tube feeding and can be
accelerated by pain, ascites, immobilisation, sedatives, antibiotics etc.

Figure 2 Reasons for impaired gastric emptying during EN


In ventilated patients a high PEEP might induce vomiting (with the risk of aspiration). In some
patients after initiating EN abdominal distension and nausea might occur only transiently.
The work up of nausea/vomiting occurring under EN should include the following issues:
In case of cancer / antineoplastic therapy: initiate adequate antiemetic / analgetic therapy
Exclude bowel obstruction (auscultation, x-ray abdomen)
Review patients prescriptions regarding nausea inducing drugs

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If delayed gastric emptying is considered: reduce delivery rate, try prokinetic drugs

1.3 Constipation
Constipation is a rare gastrointestinal complication of EN. Decreased fluid intake, the use of high
energy dense formulae and lack of dietary fibre are possible reasons for constipation associated
with EN. Furthermore, immobilisation and decreased bowel motility (as a result of sedatives or
opioids) may contribute to constipation.
The work up of constipation occurring under EN should include the following issues:
Review patients EN prescription ;
Increase fluid intake, reduce density of formula or switch to fibre containing formulae;
Exclude bowel obstruction (auscultation, x-ray abdomen);
If these steps fail consider stool softener (e.g. lactulose) or bowel stimulants.

2. Aspiration
Aspiration is the most critical complication of EN and may result in pneumonia and sepsis. Patients
with neurological impairment, decreased level of consciousness or with diminished gag reflexes are
at high risk of aspiration. Further risk factors are: postoperative or drug induced delayed gastric
emptying, high GI reflux, supine position or incompetent lower oesophageal sphincter.

Table 2 Problems of enteral nutrition during 1929 day in ICU patients

In ICU patients periodic measurement of gastric reflux is recommended (interruption of infusion for
several hours, gastric drainage). If the reflux is higher than 200 ml/ 6 h or 1 l / day the delivery rate
must be reduced or EN terminated. Although recommended by some authors the use of prokinetics
in the prevention of aspiration has not been proven.
In order to prevent aspiration in high risk patients the following issues should be considered:
Measure gastric reflux, adjust the delivery rate (prolong delivery period);
Prefer a semi-recumbent position (30-45);
Prefer nasojejunal instead of nasogastric tube feeding.

3. Tube Related Complications


A primary tube malposition can be diagnosed by adequate post-placement monitoring and requires
immediate correction. In patients with neurological impairment, decreased level of consciousness or
diminished gag reflexes it is not sufficient to monitor correct tube placement by auscultation of
insufflated air. The auscultation method can fail even in the hands of well experienced staff and
some fatal cases have been reported where erroneous infusion of large amounts of formula diet into
the lungs was not recognised by the patient (who might not even cough) nor by the staff. Therefore
radiological control of tube position is recommended.

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In patients with nasopharyngeal or facial injuries transnasal tube placement is contraindicated. In


contrast, oesophageal varices are not associated with increased risk of bleeding complications and,
thus, nasogastric tube feeding can be used even in advanced cirrhosis.
Other tube related complications such as necrosis or ulceration of the nasopharyngeal, oesophageal,
gastric or duodenal mucosa became very rare after introduction of the modern fine-bore tubes.
These are made from polyurethan or silicon. They are filiform (7 to 8 Ch, maximum 12 Ch), soft,
flexible and can be used for weeks. However, even with these modern and convenient fine-bore
tubes tolerance against nasogastric tubes is usually limited.
When long term EN (> 4 weeks) is anticipated, insertion of gastrostomy tube should be considered.
Local wound infections are the most common complication of percutaneous gastrostomies.

Figure 3 Complications of percutaneous endoscopic gastrostomy (PEG)


The infection rate can be reduced by preinterventional use of antibiotics (30 min before PEG
insertion use of 3rd generation cephalosporine or broad spectrum penicillin). This is recommended
especially in patients with impaired immune function or malignant diseases.
A frequent complication of all kinds of feeding tubes is tube obstruction. This can be avoided by
adequate flushing with water (40 ml or more) before and after feeding or whenever an interruption
of feeding is necessary. When fine-bore tubes are used flushing should be performed all 4 to 6 hours
even during feeding. However, clogging might also occur due to precipitates of administered
medication. Application of warm water, sodium bicarbonate or pancreatic enzymes is not always
successful in dislodging the tube, and, therefore, tube replacement might be necessary.

4. Metabolic Complications
Compared to parenteral nutrition EN is a more physiologic approach of nutritional support which is
reflected by a lower frequency and severity of metabolic complications. However, disturbances of
the hydration status might occur, if treatment focuses only on caloric intake and fluid balance is
ignored. Overhydration and dehydration are usually accompanied by hyponatraemia and
hypernatraemia, respectively, and are treated by fluid restriction or additional fluid gifts. A severe
form of dehydration is called the tube-feeding syndrome, where hyperosmolaric formula diet
causes diarrhoea and intestinal fluid losses, exsikkosis and renal function impairment. Such
disturbances can be avoided when adequate monitoring of EN is performed.
A further metabolic complication is the refeeding syndrome, which is the potentially life
threatening result of rapid and excessive food intake in severely malnourished subjects.

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Figure 4 The refeeding syndrome


The refeeding syndrome is associated with hypophosphataemia, hypokalaemia, hypomagnesaemia,
thiamine deficiency and fluid retention and can finally result in cardiac arrhythmias and congestive
cardiac failure. Milder forms of the refeeding syndrome are probably not so uncommon and might be
identified by hypophosphataemia.
Patient groups with increased risk for the refeeding syndrome are: patients with severe chronic
malnutrition, undernourished children, anorexia nervosa, chronic alcoholics and prolonged fasting
(hunger strikers). In order to prevent the refeeding syndrome in patients at risk it is important to
perform a close monitoring of vital functions, fluid balance, plasma and urinary electrolytes, heart
rate, ventilatory functions and blood gases. Before onset of nutritional support electrolyte and fluid
deficiencies must be corrected. Nutritional support has to be started with reduced amount of
energy (less than 50 % of planned energy intake, about 500-1000 kcal/day) while the patients needs
for fluid and electrolytes should be infused separately. Energy intake is gradually increased over a
week until daily nutritional requirements are met. Additional potassium and phosphate should be
given to prevent deficiency.

5. Monitoring of EN
It is important to monitor EN for two reasons: 1. to monitor the patients progress if enteral feeding
is to be successful and adequate for the patients needs; and 2. to recognize possible (metabolic)
complications early.

Figure 5 Monitoring of enteral nutrition

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Monitoring of EN should consider the following issues:


Feed administration: Check delivery rates at intervals to ensure even flow. Aspirate periodically
to check stomach emptying; if necessary measure gastric reflux.
Fluid balance: Fluid balance charts must be strictly maintained throughout enteral feeding.
Check hydration status clinically; in patients with diarrhoea, fever or other unphysiologic fluid
losses assess urinary output daily.
Laboratory tests: serum urea, electrolytes and glucose must be monitored daily, blood calcium,
magnesium and phosphate levels twice weekly until feeding is well established. Keep in mind
that many cancer patients have insulin resistance and might develop diabetes mellitus under
EN. Serum albumin should be measured initially and then at weekly intervals
Nutritional status: weigh patient daily until feeding is well established, then weigh patient
weekly. If available perform analysis of body composition by bioelectrical impedance analysis or
by anthropometry every second week. A good functional outcome measure of tube feeding is
hand grip strength which can easily be performed every week.

Summary
In this module diagnosis and treatment of gastrointestinal, tube related and metabolic
complications of EN are highlighted. Most complications of EN are results of application errors and
can be avoided by an adequate approach and monitoring.

References
1. Adam S, Batson S: A study of problems associated with the delivery of enteral feed in critically
ill patients in five ICUs in the UK. Intensive Care Med 1997; 23: 261-266.
2. American Gastroenterological Association Medical Position Statement: Guidelines for the use of
enteral nutrition. Gastroenterology 1995; 108: 180.
3. Bodoky G, Kent-Smith L. Complications of enteral nutrition. In Sobotka L (Ed), Basics in Clinical
Nutrition, 3rd Edition, Galn 2004.
4. DeLedinghen V, Beau P, Mannant PR, et al. Early feeding or enteral nutrition in patients with
cirrhosis after bleeding from esophageal varices ? A randomized controlled study. Dig. Dis Sci
1997; 42: 536-541.
5. Lser C, Flsch UR. Guidelines for treatment with percutaneous endoscopic gastrostomy.
German Society of Digestive and Metabolic Disease. Z. Gastroenterol 1996; 34: 404-408.
6. Maier-Dobersberger T, Lochs H. Enteral supplementation of phosphate does not prevent
hypophosphataemia during refeeding of cachectic patients. JPEN 1994; 18: 182.
7. Marinella MA. The refeeding syndrome and hypophosphataemia. Nutr Rev 2003; 61: 320.
8. Montecalvo MA, Steger KA, Farber HW et al. Nutritional outcome and pneumonia in critical care
patients randomized to gastric versus jejunal tube feelings. The Critical Care Research Team.
Crit Care Med 1992; 20: 1377-1387.
9. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: A
multicenter study. Crit Care Med 1999; 27: 1447-1453.

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