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Topic 8
Module 8.5
Complications and Monitoring of EN
Matthias Pirlich
Learning Objectives
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
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.
1.1
Diarrhoea
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.
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.
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.
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.
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
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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.
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cirrhosis after bleeding from esophageal varices ? A randomized controlled study. Dig. Dis Sci
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multicenter study. Crit Care Med 1999; 27: 1447-1453.