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Administrator
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Registered: ‎02-22-2010
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Enteral Nutrition Webinar

[ Edited ]

Thanks for joining Matthew Wanat in his webinar, "Pharmacy Implications with Enteral Nutrition."

View the on-demand recording or download the slides.

 

Have a question for Matthew? Post it here and he will answer questions for a limited period of time.

Administrator
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Registered: ‎02-22-2010
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Re: Enteral Nutrition Webinar

Here are some questions from our live presentation:

Q: What's the best way to prevent clogging and, once a clog occurs, the best way to remedy it?

Q: When considering IV to PO conversions, how do you address the NG or alternative tube route if patients are on enteral feeding? What considerations are general (for all enteral products) and perhaps should be incorporated into IV-to-PO conversion policies?

Q: Is there data supporting pancreatic enzymes for enteral tube clogging events?

Q: At one time furosemide was contraindicated in post pyloric feedings.  Is this still the case?

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Registered: ‎04-12-2012
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Re: Enteral Nutrition Webinar

Tough subject and well handled by someone without much experience in the field. I hope to clarify some issues you presented, as this is a complicated subject, with few validated studies to support claims made regularly.

1.) You indicated that an Elemental diet would be ideal for patients havining low tolerance or fed into lower bowel. Elemental diets are not tolerated well in lower bowel due to high osmolarity. At my institution we do not use

2.) Post-pyloric feedings do not “require” continuous feeding. Some patients tolerate this and do better as intermittent feeding more closely resembles the natural diet. To improve outcome, it is always better to cycle feedings

3.) The current thinking, is if the gut works – use it. Adding TPN to enteral nutrition adds nothing. If you need more calories – give more enteral nutrition.Short term TPN is a waste of money without validated studies to support it.. One key issue is the number of interruptions to enteral for drug administration. The key is to increase rate to compensate for lost time.

4.) Hyper-osmolar liquid medications can be diluted with water to 300 mOsm to improve tolerance. Or the tablet may be crushed and mixed with water, which almost always results in tolerated osmolarity

5.) Phenytoin suspension is thick. Although one study did show it bound to tube, that study could not be reproduced. Bauer stated the drug binds to protein of diet – but the diet gets absorbed. The binding to diet does not change a drugs absorption. The tablet formulation has never been cited for having this interaction, only the suspension. Monitor levels is best answer, as holding TF will not change absorption.

6.) Not all fluoroquinolones are created equal. Ciprofloxacin suspension is poorly absorbed and easily affected by nutrients for delivery. Wrights study was in-vitro and could not see changes in absorption. But Wrights study showed no effect by Calcium and Magnesium – thus showing chelation was not the mechanism. Levofloxacin absorption is not altered by metals or nutrition.

7.) Warfarin does bind to nutrition – and it binds to the feeding tube. But the nutrition gets absorbed, not so much the feeding tube. Holding nutrition allows greater binding to tube. Better not to hold tube feedings. Monitor INR’s as nursing methods for administration are not consistent and the binding tube tubing is pH dependent.

8.) Creon is enteric coated and extended released pancreatic enzyme product. It takes 45 minutes to dissolve coatings with bicarbonate at 37°C. Warm water will work better. Much depends on what caused the clog. BTW Viokase is soon to be release back onto market as Viokace – same drug, different PI.

 

Mark Klang MS, RPh, BCNSP, PhD

Core Head, Research Pharmacy

Memorial Sloan-Kettering Cancer Center

1275 York AVe

New York, NY 10065

212-639-7574

klangm@mskcc.org

 

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Registered: ‎01-19-2011
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Re: Enteral Nutrition Webinar

Just an FYI: I found out that some enteral products are more viscous than others and require a certain size of feeding tube. The info can be found on the Ross/Abbott or Nestle websites under each specific product.  I would also like to agree with Mark Klang's statement that not all J-tube patients require continuous feedings--many do fine with bolus feedings.

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Registered: ‎04-11-2012

Re: Enteral Nutrition Webinar

Q: What's the best way to prevent clogging and, once a clog occurs, the best way to remedy it?

The best way to prevent clogging a feeding tube is frequent flushing of the feeding tube, and proper nursing administration (complete crushing of medications, using liquid forms when possible, etc). While there is no gold standard to remedy clogged feeding tubes, if flushing the feeding tube with water does not work we had have success with the pancrealipase/sodium bicarb method. The excerpt below is from the ASPEN core curriculum regarding feeding tube patency.

Maintaining Patency

Although not a life-threatening problem, occlusion of feeding tubes is a frequent occurrence that interrupts feeding, delays medication administration, interferes with attainment of nutritional goals, and can lead to loss of the access device. Numerous factors play a role in the development of clogged feeding tubes, including characteristics of the formula (concentrated, high protein, fiber-enriched), the feeding tube, and medication

administration. The simplest and most effective way to avoid clogging is to flush feeding tubes at regular intervals intervals with water. As discussed in Chapter 12, the use of acidic irrigants such as cranberry juice tend to promote clogging. Feeding tubes should be flushed at regular intervals according to institutional protocols and before and after medications are administered through the feeding tube.

Q: When considering IV to PO conversions, how do you address the NG or alternative tube route if patients are on enteral feeding? What considerations are general (for all enteral products) and perhaps should be incorporated into IV-to-PO conversion policies?

 

First would be to address the conversion factor and any dosage adjustments needed for conversion to enteral administration. Since medications are absorbed differently and there is no one site of absorption I don’t think a general policy can be adapted, it just relies on the pharmacist to research/know where critical meds are absorbed and follow levels/change to IV if absorption would be altered.

Q: Is there data supporting pancreatic enzymes for enteral tube clogging events?

 

There was a Meta-analysis published in 2011 that found very limited study data looking at agents for unclogging feeding tubes. Data appears to be limited with literature looking at pancreatic enzymes for unclogging feeding tubes, but many opinion pieces have been published and you can find several individual hospital policies describing the use of pancreatic enzymes on the web.

Ann Pharmacother. 2011 May;45(5):676-80. Epub 2011 Apr 26.

Q: At one time furosemide was contraindicated in post pyloric feedings.  Is this still the case?

I don’t think there is a contraindication to furosemide use post pylorically, but drug absorption has been shown in rat/animal models to be better absorbed in the proximal GI tract, and in humans bioavailability ranges from 40-65%. If providing medication administration further down (duodenum or jejunum), absorption may be impaired and it may require higher doses for the same diuretic effect. In critically ill patients, IV furosemide is typically used for a faster and more effacious dieresis.