General Guidelines for Enteral Support

1. Use appropriate-size feeding tube

2. Verify tube position before initiating feedings by radiological confirmation (KUB: abdominal film).

3. Specify tube type and feeding site (gastric vs. duodenal)

4. Specify formula by strength, category, and route

5. Initiate feedings at 20 cc/hour and advance by 20 cc/hour q 6 hours until goal rate is achieved

6. If receiving gastric feedings, monitor residuals q 4 hours; hold feedings if residuals are greater than 150 cc: hold for one hour and recheck, if less than 150 cc at time of recheck, restart at 1/2 of previous rate.

7. For increased residuals or GI intolerance (abdominal distension, etc.) administer Reglan 5-10 mg IVP q 6 hours.

8. Maintain Head of Bed (HOB) at least 30 degrees at all times.

9. Confirm gastric tube placement every 4 hours (via auscultation).

10. If there is any question regarding tube displacement, verify with a radiological exam before continuing feedings (i.e. KUB).

11. Review stress ulcer prophylaxis medications when patient is tolerating enteral nutrition

12. Monitor glucose levels with accuchecks q 6 hours and sliding scale insulin as necessary to maintain normoglycemia (Blood Glucose 80-110)

13. Monitor weight, fluid balance daily

14. Monitor electrolytes, Phosphate, Magnesium, Calcium, BUN, Cr, CBC, triglyceride

15. levels biweekly

16. Monitor liver function weekly

17. Monitor prealbumin and UUN baseline values, then q 1-2 weeks.

18. For drug administration:

19. 1. Flush tube with at least 30 cc H2O initially

    2. Flush tube after each medication - and each medication should be given separately

    3. Crush all tablets to a fine powder, except for enteric coated or sustained release

    4. Medications

    5. Dilute hyperosmolar or irritating medications

    6. Change to liquid formulations if possible.

20. TPN must be administered through a central venous catheter via a dedicated port, and with strict adherence to central line care and signs of infection.

Suggested Protocol

Prokinetic agents include: Reglan 5-10 mg IV or q 6 hrs x 4 doses Erythromycin 200 - 250 mg IV q 12 hrs