Medication and Tube Feeding

Question 1

What are feeding tubes used for?

Answer 1

They are used to provide nutritional support to patients who cannot eat by mouth

Question 2

What makes feeding tubes different from parenteral feeding?

Answer 2

Unlike parenteral feeding, enteral feeding maintains both structural and functional integrity of the GI tract by preventing changes due to atrophy, is less expensive and risky, voids possible bacterial translocation and since bile flow is maintained, development on cholestasis is avoided

Question 3

How do we choose the type of feeding tube?

Answer 3

The type of feeding tube is based on why the patient requires tube feeding and the expected duration of the treatment

Question 4

Where is a feeding tube placed?

Answer 4

Tubes may be placed in the stomach, jejunum or occasionally the duodenum
Some have dual lumens; one in the stomach for passive decompression and the other in the small bowel for nutrition
Tubes placed through the mouth or nose is referred to as a orgastric or nasogastric respectively
Those placed surgically are referred to as percutaneous and one common type is referred to as a percutaneous endoscopic gastrostomy (PEG) tube

Question 5

Why would we place a tube in the stomach?

Answer 5

Tubes placed in the stomach is appropriate for patients who have a normal functioning GI tract from the lower esophagus down
The stomach is usually used because it is more convenient and able to tolerate enteral formulas which are hypertonic

Question 6

Why would we place a tube in the duodenum or jejunum?

Answer 6

Those place into the upper duodenum or jejunum are appropriate for patients with gastric emptying problems, a non-function upper GI tract or patients at significant risk of aspiration
Jejunal feedings may cause abdominal cramping and diarrhea

Question 7

Why would we use a small bowel tube?

Answer 7

Small bowel access may be necessary for patient with pancreatitis, gastroparesis (delayed gastric emptying) or severe gastroesophageal reflux disease

Question 8

When would we use oral or nasal placement?

Answer 8

For short-term nutritional support, oral or nasal placement is used. For long term or when nasal or oral placement is not possible, we use percutaneous placement

Question 9

What are the sizes of feeding tubes?

Answer 9

Feeding tubes may come in a variety of sizes and size selection based on the nature of access, feeding supplement and patient
Outer diameter is often measured in French units (1 French unit = 0.33 mm) and are often designated as small-bore (5-12 French) or large-bore (12 or over French)
Generally small-bore tubes are used for feeding as more comfortable but greater risk of clogging

Question 10

How do we meet the nutritional needs of the patient?

Answer 10

One or two enteral formulations can meet most patients’ needs
Specialty products may be useful in certain disease state
Includes lactose-free, fibre-containing, elemental
Also modular products such as pulmonary or liver formulas
Although some have clear clinical indications (e.g., lactose-free) advantages of others less clear

Question 11

What is the problem with using home prepared feedings vs commercially prepared?

Answer 11

Commercial products contain vitamin and mineral supplementation and are sterile
Home-prepared feedings are not sterile and may not be nutritionally complete

Question 12

When do we use elemental formulations?

Answer 12

Use of elemental (pre-digested) formulations should be reserved for patients with severe small bowel absorptive dysfunctions

Question 13

Describe the feeding schedule

Answer 13

Administration may be intermittent or continuous
Feeding schedule is dependent on the condition of the patient. Administration may be done with a feeding syringe, a gravity bag system or a pump

Question 14

Can medications be given through enteral feeding tubes?

Answer 14

If medications are required and alternative routes of drug delivery are not options, then the medications may be given through enteral feeding tubes
Ideally, the medication should not be mixed with formula and feeding should be interrupted for medication administration and the tube should be flushed before and after medication administration

Question 15

What should be done if medication needs to be taken on an empty stomach?

Answer 15

Some medications should be taken on an empty stomach
Possible suggestion is to stop feeding 30 minutes before administering the drug to allow gastric emptying then wait another 30 minutes after the medication is given allowing time for drug absorption
This is only applicable to gastric feeding

Question 16

When administering mediations through a feeding tube, tube size and placement site must be considered. Explain

Answer 16

Smaller diameter tubes may be prone to clogging with some medications
Placement of site may affect drug absorption
If the stomach is the target drug action and absorption, medications such as antacids will be ineffective if the tube is placed in the small bowel, by-passing the stomach

Question 17

How can a tube placed in the jejunum affect medication administration?

Answer 17

Medications like opioids which undergo extensive first-pass hepatic metabolism may show greater systemic effects
May also result in incomplete or unpredictable drug absorption since beyond the section of the GI tract where most absorption takes place
Care should be taken with drugs having a narrow therapeutic window when the feeding tube is placed in the jejunum

Question 18

Why is gastric access preferred over jejunal?

Answer 18

Tubes are usually larger and less prone to clogging
Stomach is more tolerant of hypertonic medications
Gastric feedings are usually intermittent so feeding and medication may be given at separate times
Drug absorption is more predictable with gastric placement

Question 19

When are liquid dose forms preferred?

Answer 19

Preferred for enteral administration because they are readily absorbed and are less likely to cause tube occlusion
It is important to ensure that the drugs are drawn up and dispensed only in oral syringes and not in parenteral synergies in order to avoid accidental injection of the oral product

Question 20

Why can liquid dose forms be problematic?

Answer 20

They are usually for children so large volume of the product needed to achieve an adult dosage and volume may not be tolerated by the patient
Adjustments in dose or frequency may be necessary especially when switching from an extended or controlled-release product to a liquid preparation which is usually immediate release

Question 21

What is the problem with hypertonic liquid dose forms?

Answer 21

Hypertonic liquid preparations