Enteral Nutrition Support Therapy for Adults
Manual of Clinical Nutrition Management B- 44 Copyright © 2013 Compass Group, Inc.
Refer to the ASPEN Enteral Nutrition Practice Recommendations or organization-specific
interdisciplinary enteral nutrition monitoring protocol and policy as needed (52).
Formula delivery guidelines:
Irrigate the tube every 4 hours with 20 to 30 mL of warm sterile water or saline to ensure patency for
continuous feeding (52). Also, irrigate the tube before and after each intermittent feeding or medication
administration (2,52).
To reduce bacterial contamination, flush water through the bag and tube every 8 hours before adding
new formula when an open system is in place.
Avoid putting food and beverages into the tube (eg, juice, milk, and soda).
Flush tube with purified sterile water or saline before and immediately after the administration of
medicines to avoid clogging the tube (52).
To reduce the risk of contamination and infection, the feeding bag should be properly labeled, and tubing
should be changed every 24 hours or as specified by the manufacturer (52).
Refer to organization-specific interdisciplinary enteral nutrition monitoring protocol and policy as
needed.
Patient Monitoring Guidelines
Refer to the Academy’s Critical Illness Evidence-Based Nutrition Practice Guideline, the ASPEN Enteral Nutrition
Practice Recommendations, the ASPEN Guidelines for Nutrition Support Therapy in the Adult Critically Ill
Patient, and the Morrison Nutrition Practice Guideline – Enteral Nutrition (3,5,52,55,56). Also refer to organization-
specific interdisciplinary enteral nutrition monitoring protocols as needed. Guidelines for patient monitoring
and avoidance of complications associated with the delivery of enteral nutrition are described below.
Patients with nasoenteric tubes:
Provide mouth and nose care every 8 hours to prevent parotitis and skin breakdown around the nose.
Verify the placement of a nasoenteric tube prior to feeding initiation and every 4 to 8 hours thereafter, or
as specified by the organization’s protocol (52).
Avoidance of intestinal hypoxia and bowel necrosis (4,15,56):
Assess bowel sounds every 8 hours.
Feed into the small bowel (postpyloric position).
Administer feeding in patients who are adequately fluid resuscitated and have a sustained mean arterial
pressure of at least 70 mm Hg, and are at steady or decreasing dos of vasoactive agents.
Use iso-osmolar, low residue formulations, initiated at 10 – 20 ml/hr and advance the feedings when
tolerance is demonstrated.
Assess the need to hold feedings if the patient experiences a sudden period of hypotension (mean arterial
pressure < 60 - 70 mm Hg), if the dosages of pressor agents (eg, dobutamine, norepinephrine, and
epinephrine) are increased, or if the need for ventilatory support is increased (3, 56).
Assess the need to hold feedings if the patient develops increased nasogastric output, abdominal
distention, or abdominal pain.
Avoidance of gastrointestinal intolerance and aspiration (3,5,52,57):
Recommendations from the North American Summit on Aspiration in the Critically Ill state that feeding
ideally should be into the small bowel with the tube tip at or below the ligament of Treitz when two or
more risk factors for aspiration are present (4,5,57). These risk factors include: prior aspiration, decreased
level of consciousness, neuromuscular disease, structural abnormalities of the aerodigestive tract,
endotracheal intubation, vomiting, persistently high gastric residual volumes (GRVs), and the need for a
supine position (57). ASPEN guidelines also suggest that patients at high risk for aspiration receive a
continuous infusion to decrease intolerance to gastric feeding (5). The Academy of Nutrition and Dietetics
recommends small bowel feeding tube placement for critically ill mechanically ventilated patients
requiring enteral nutrition (Grade II) (3). Some large research studies with ventilator-associated pneumonia
(VAP) as a primary outcome suggest that small bowel enteral nutrition vs. gastric enteral nutrition
reduces VAP (Grade II) (3).
Use a 50-mL or 60-mL syringe to check GRVs in nasogastric-fed or gastrostomy-fed patients before each
intermittent or bolus feeding (52). Feeding tubes with a diameter smaller than 10 French may be
unreliable in determining residuals (58,59). The GRV should be checked before bolus feedings,