Routes of administration

The majority of patients need nutritional support for less than a month. For these patients the best method of enteral delivery is via a fine-bore nasogastric feeding tube. The most frequent complication (in <5% of patients) of these tubes is malposition when inserted, often into the trachea and bronchi. If this is not recognized, accidental intrapulmonary aspiration of feed may occur. This complication occurs most commonly in susceptible patients with altered swallowing, diminished gag reflex or who have had upper airway or

Figure 4.2. Stamm gastrostomy. An upper midline incision gives the best exposure and the catheter is placed laterally away from the incision. A Foley catheter is inserted into the gastric fundus through a double row of purse string sutures. The stomach around the tube anchored initially to the abdominal wall with sutures, becomes firmly adherent in about 10 days. Removal of the tube after this period is followed by rapid closure of the cutaneous orifice.

Figure 4.2. Stamm gastrostomy. An upper midline incision gives the best exposure and the catheter is placed laterally away from the incision. A Foley catheter is inserted into the gastric fundus through a double row of purse string sutures. The stomach around the tube anchored initially to the abdominal wall with sutures, becomes firmly adherent in about 10 days. Removal of the tube after this period is followed by rapid closure of the cutaneous orifice.

pharyngeal surgery. In patients who are alert and orientated, tube positioning may be confirmed by aspiration of gastric contents and auscultation of the epigastrum. If aspiration or auscultation is unsuccessful, radiograph confirmation of the position of the tube is essential, and must be undertaken routinely in all such susceptible patients. In some patients (e.g. diabetics with neuropathy, head injuries, postabdominal surgery and ITU/ventilated patients), nasogastric delivery of nutrients may not be appropriate because of increased risk of regurgitation and/or pulmonary aspiration of feed. All such patients and others with gastric atony or gastroparesis should be considered for postpyloric nasoduo-denal or nasojejunal feeding. For the surgical patient for whom postoperative nutritional support is anticipated, placement at laparotomy is advised. In other cases a fine-bore tube may be introduced pernasally and, if spontaneous passage has not occurred after 12-24 h, endoscopic or fluoro-scopic positioning is undertaken.

For longer-term feeding, pharyngostomy and oesophagos-tomy are used by some surgeons. Surgically placed gastros-tomies are used for long-term administration of feed for patients with progressive deglutition disorders (motor neurone disease, multiple sclerosis). Stamm gastrotomy (Fig. 4.2) is simple to perform as a temporary procedure. The removal of the tube is rapidly followed by closure of the cutaneous orifice. The percutaneous endoscopically-placed gastrostomy (PEG) is now the technique of choice for long-term administration of EN. This technique has a lower morbidity and mortality, when compared with the conventional surgical placement. A needle catheter jejunostomy is shown in

Fig. 4.3. Jejunostomy by Witzel technique (Fig. 4.4) uses a 14 or 16 F catheter and is less likely to be occluded by the feeding solution. Either may be inserted as a separate surgical procedure or concurrently at the time of abdominal surgery. Needle catheter jejunostomy has been recommended for patients:

• malnourished at the time of surgery;

• undergoing major upper GI surgery;

• who may receive adjuvant radio- or chemo-therapy after surgery;

• undergoing laparotomy after major trauma. Techniques of administration

Bolus feeding of enteral diets, where typically a volume of 200-400 ml of feed is instilled into the stomach via a nasogastric tube over a period ranging from 15min to 1h, was the standard method of administration for many years. This method has a high incidence of side-effects such as bloating and diarrhoea, in addition to which a considerable amount of nursing time is required and feeds may often be accidentally omitted. A continuous infusion either by gravity feed or by using a peristaltic pump is therefore the method of choice.

Starter regimens (diluting the feed or reducing the volume) limit the intake of diet in the first few days of feeding and thereby prolong the length of negative nitrogen balance. They should not therefore in general be used.

For those patients who are immobile or confined to bed, or with altered consciousness, the head of the bed should be elevated by 20° or 30° to help reduce the risk of regurgitation and pulmonary aspiration. In most adult patients with no other metabolic or fluid balance problems, between 2 and 2. 5l of diet are prescribed on a daily basis. This volume is infused from day 1.

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