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Complications of Enteral Nutrition

Complications of Enteral Nutrition. Michele Port, P.Dt. Clinical Dietitian March 2014. Outline. Gastrointestinal Complications: Diarrhea Constipation Delayed gastric emptying Nausea and vomiting Abdominal distention Metabolic Complications Administrative Complications Case Study

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Complications of Enteral Nutrition

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  1. Complications of Enteral Nutrition Michele Port, P.Dt. Clinical Dietitian March 2014

  2. Outline • Gastrointestinal Complications: • Diarrhea • Constipation • Delayed gastric emptying • Nausea and vomiting • Abdominal distention • Metabolic Complications • Administrative Complications • Case Study • Conclusion

  3. Learning Objectives • Recognize various complications of enteral feeding and how to prevent and treat them. • Identify medications which often play a role in the diarrhea and constipation of enterally fed patients.

  4. Gastrointestinal Complications DIARRHEA • Incidence in tube fed patients: 2-63% of tube fed patients depends on definition • Common GI side effect in tube fed patient • Tube feeding formula usually blamed • Impact of diarrhea: • Fluid, electrolyte and acid-base disturbances • Inadequate nutrient intake which leads to malnutrition • Trace mineral deficiencies (Se, Zn) • Contamination of pressure ulcers and excoriation skin • Increases cost (Need rectal tube, cultures and linen changes)

  5. Gastrointestinal Complications DIARRHEA • Universal definition does not exist: • > 3 stools per day for 2 consecutive days OR > 500 mL stool every 8hr Mobarhan et al. 1995; Williams et al. 1998 • > 200g stool per day OR ≥ 3 or more liquid stools per day Bliss et al. 1992 • Studies on diarrhea in tube fed patients use different definitions • Clinically useful definition: Abnormal volume or stool consistency for an individual

  6. Gastrointestinal Complications DIARRHEA • What is patient’s normal stool consistency and frequency at home? • Measurement of stool volume • Using pad or bed pan under patient, weight of stool lg / mL stool • Rectal tube or fecal management device where stool can be quantified Boullata et al. , eds. 2010

  7. Gastrointestinal Complications DIARRHEA • Osmotic Diarrhea • Caused by osmotically active substances in intestines • The osmotic force pulls fluid into the intestinal lumen • Examples: Lactulose, sorbitol, magnesium, phosphate, hyperosmolar enteral formula • Secretory Diarrhea • Imbalance between absorption and secretion of electrolytes with a net water secretion in bowel lumen • Examples: C. difficile infection, enteroviruses, laxatives such as senna, colchicine Btaiche et al. 2010

  8. Gastrointestinal Complications DIARRHEA • Common Causes: • Medication • Antibiotic therapy • Hyperosmolar medications • Sorbitol: containing medications • Other (ex.: colchicine) • Infection • C. difficile • CMV: cytomegalovirus in post transplant or immunosuppressed pts

  9. Gastrointestinal Complications DIARRHEA • Common Causes: • Enteral formula contamination • Maldigestion or malabsorption • Steatorrhea • Bacterial overgrowth • Overflow diarrhea • Lactose intolerance • Severe hypoalbuminemia

  10. Gastrointestinal Complications DIARRHEA • Common causes medication-induced: • Antibiotic therapy • Non-infectious • Commonly cause diarrhea without causing CDAD (C. difficile associated diarrhea) • Infectious • C. difficile associated diarrhea (Ex.: Clindamycin, Ampicillin) • Oral electrolyte supplements (Ex.: Magnesium)

  11. Gastrointestinal Complications DIARRHEA • Common causes medication-induced: • Laxatives • Lactulose: Osmotic type diarrhea • Senna: Secretory type diarrhea • Prokinetics (Ex.: Maxeran, Erythromycin) • Hyperosmolar medications (Ex.: Liquid multivitamins, nystatin suspension, docusate syrup, kayexalate) • Can cause osmotic diarrhea, nausea, abdominal cramping if undiluted on administration via SB • Ex.: Cimetidine solution (Tagamet), furosemide (Lasix), doxycycline (Vibramycin), hydroxyzine (Vistaril), isoniazid, nortriptyline

  12. Gastrointestinal Complications DIARRHEA • Common causes medication-induced: • Sorbitol: Containing medications • Sorbitol: a sugar alcohol used as a sweetener in oral medications • May cause osmotic diarrhea and abdominal cramps or bloating • Inactive ingredient in liquid medications, amounts often not listed on label or package insert • Acid-suppressive medications (Ex.: Proton-pump inhibitor ) • Chemotherapeutic drugs • Other: colchicine Boullata J et al. 2010, Btaiche IF, et al. 2010, Malone A, et al. 2007

  13. Gastrointestinal Complications DIARRHEA • Common causes: • Infection • Need stool assay to rule out C. difficile associated diarrhea • Enteroviruses: Rotavirus, norwalk • CMV colitis in immunosuppressed • Contamination of enteral feeding solution • Needs to ensure gloves are clean when handling enteral spike sets/ tubing for open tube feeding formulas • All equipment to prepare enteral feeding must be clean • Open tube feeding formula needs to be refrigerated and formula discarded after 24hr. Label with date and time opened

  14. Gastrointestinal Complications DIARRHEA • Common causes: • Contamination of enteral feeding solution • Only 4hr of feeding should be hung at one time for open feeding systems • Feeding bags and tubing should be washed after each intermittent feeding and discarded after 24hr • Closed feeding systems need to be labelled with date and time when bag spiked and discarded after 48hr

  15. Gastrointestinal Complications DIARRHEA • Common causes: • Maldigestion / Malabsorption • Definition • Maldigestion: Impaired breakdown at nutrients • Malabsorption: Defective mucosal uptake and absorption from bowel • Diarrhea, weight loss, steatorrhea (fat malabsorption)

  16. Gastrointestinal Complications DIARRHEA • Common causes: • Maldigestion / Malabsorption • Celiac disease • Short bowel syndrome • Resection of terminal ileum • Human immunodeficiency virus • Pancreatic insufficiency • Inflammatory bowel disease • Protein-losing gastroenteropathies • GVHD of gut

  17. Gastrointestinal Complications DIARRHEA • Common causes: • Maldigestion / Malabsorption • Past medical history part of nutrition assessment • When interviewing patient / family ask regarding usual bowel habits • Medications which affect bowel movements. Lactulose, Imodium, herbal teas • Tests • Look at stool - fat floating on top? • Steatocrit to assess fecal fat content • Check B12, folate, vitamin A level Malone et al. 2007

  18. Gastrointestinal Complications DIARRHEA • Common causes: • Bacterial overgrowth • Diagnosed by distal duodenal or jejunal aspirates, high serum folate (de novo synthesis) or hydrogen-methane breath tests • Chronic diarrhea with minimal steatorrhea • Associated with achlorhydria, bile acid deficiency, dysmotility (pseudo obstruction, diabetic neuropathy, narcotics) • Overflow diarrhea • Occurs in chronic-care immobilized patients • Liquid flowing around hard feces • Volume of stool not large usually

  19. Gastrointestinal Complications DIARRHEA • Common causes: • Lactose intolerance • Majority of commercial tube feeding formulas are lactose free • Patient on food and tube feeding may be receiving lactose in diet • Severe hypoalbuminemia • Decreases oncotic gradient across bowel wall • May be due to malnutrition, stress, fluid overload • Edematous bowel • Patient with anasarca likely has edema of the bowel also • Diarrhea often improves with fluid removal such as continuous dialysis

  20. Gastrointestinal Complications DIARRHEA • Treatment • Rule out C. difficile associated diarrhea • Medication review with pharmacist • Discontinue medications suspected of causing diarrhea if possible • Sorbitol-containing oral liquid medications should be discontinued and replaced with tablets • Mg or K-elixir given via tube should be given IV to see if it makes a difference • Review antibiotic use • Dilute drugs introduced into jejunum to avoid dumping-like syndrome Btaiche IF, et al. 2010

  21. Gastrointestinal Complications DIARRHEA • Treatment • Review medical / surgical history • Is patient with pancreatic insufficiency on a high fat formula (ex.: renal formula) without pancreatic enzymes? • Use a lower fat formula or a formula with 50%-70% of fat as MCT • Steatorrhea • Use lower fat formula • Severe GVHD of gut: consider parenteral nutrition until diarrhea decreases, use trophic feeding at low rate if tolerated • Extensive SB resection • Trial of elemental formula (low fat) or semi-elemental formula (protein in peptides, at least 50% fat in form of MCT)

  22. Gastrointestinal Complications DIARRHEA • Treatment • Review medical / surgical history • Irritable bowel syndrome (IBS) • High fructose corn syrup, fructooligosaccharides (FOS), galactooligosaccharides and inulin can cause diarrhea, pain and bloating in IBS patients Barrett, et al. 2009

  23. Gastrointestinal Complications DIARRHEA • Treatment • Enteral Formula • Trial of formula with fibre • In ICU patients: use soluble fibre but only when hemodynamically stable and fully resuscitated • Soluble fibre is fermented to SCFA • SCFA are absorbed in the colon pulling water and electrolytes with them McClave et al. 2009; Btaiche, et al. 2010

  24. Gastrointestinal Complications DIARRHEA • Treatment • If feeding with a hypertonic formula consider trial with an isotonic formula • Decrease rate temporarily • Avoid intermittent feeds

  25. Gastrointestinal Complications DIARRHEA • Treatment • Fiber supplements may help • Pectin (Certo): for diarrhea every 4-8 hr • Mix 30mL pectin with 100 mL warm water, syringe into feeding tube and flush well with 60mL water • Benefiber (Novartis) (Inulin) • Rounded 1 tsp (312g) provides 3g fibre, mix 1-2 tsp benefiber with ½ cup (125mL) water • Clearly fibre (Inulin) • 3.2g sachet provides 3g fibre

  26. Gastrointestinal Complications DIARRHEA • Treatment • Antimotility agents (loperamide, lomotil) • Loperamide: lower risk of central nervous system adverse effects • Slows intestinal motility • Contraindicated in C. difficile diarrhea and may aggravate toxic megacolon • Use only when all other causes of diarrhea have been addressed • Cholestyramine • An insoluble ion exchange resin that binds bile acids in intestines • May be beneficial in diarrhea due to bile acid malabsorption, Ex.: cholestasis, short bowel syndrome, terminal ileum resection

  27. Gastrointestinal Complications DIARRHEA • Treatment • Fluid and electrolyte replacement to replace GI losses • Chronic diarrhea can lead to micronutrient deficiencies especially selenium and zinc, may require supplements

  28. Gastrointestinal Complications CONSTIPATION • Clinical definition: accumulation of excess waste in colon • Can identify this with abdominal X-ray, able to rule out ileus or obstruction • Causes of constipation • Immobility • Neurological disorders • Dehydration • Inadequate fibre in enteral nutrition • Excessive fibre in enteral nutrition • Some medications (Ex.: sedatives, analgesics, opioids) gut motility • Acute colonic pseudo obstruction (Ex.: Ogilvie’s syndrome) • GI motility disorders

  29. Gastrointestinal Complications CONSTIPATION • Consequences • Delayed transit time • Vomiting • Abdo. distension • Risk of perforation • Bacterial overgrowth • Prolonged ventilator dependence in ICU patients • Electrolyte disturbances • Severe hypokalemia and hypomagnesemia may result in  bowel motility • Severe hypokalemia may result in paralytic ileus

  30. Gastrointestinal Complications CONSTIPATION • Treatment and Prevention • Use a bowel regimen when you start enteral feedings • Calculate the fluid requirement for a patient that is on enteral feeding: • 30-40 mL/kg OR 1 mL/Kcal (minimumfor adults) • Use fibre-containing enteral feeding with adequate fluid. Avoid formula with fibre if fluid restricted • Medication review: Medication-induced dysmotility?

  31. Gastrointestinal Complications CONSTIPATION • Treatment and Prevention • Laxatives • Emollients (Ex.: Sodium docusate) • Maintain soft fecal texture • Onset of action: 1-3 days • Not likely beneficial after stools harden • Osmotics (Ex.: Lactulose) • Non absorbable sugar • Onset of action: 1-3 days • Stimulants (Ex.: Senna, bisacodyl) • Increase lower GI motility and anal sphincter tone • Onset of action: 6-12 hr after oral dose

  32. Gastrointestinal Complications CAUSES OF DELAYED GASTRIC EMPTYING • Causes of delayed gastric emptying • Hypotension • Hypokalemia • Sepsis • Medication(anesthesia, opioids, anti-cholinergics) • Diabetes mellitus (gastroparesis) • Rapid infusion of formula or cold formula • Formula infusion • High fat feeding formula • Hyperglycemia

  33. Gastrointestinal Complications CAUSES OF DELAYED GASTRIC EMPTYING • Treatment • Duodenal or jejunal feeding • Prokinetic agents (Ex.: Maxeran, erythromycin) • Low fat feeding formula • Check residual volume every 4hr and assess tolerance • Follow feeding algorithm

  34. Gastrointestinal Complications NAUSEA and VOMITING • Nausea may be caused by high enteral feeding rate or volume or medications • Treat with antiemetics • Decrease rate or volume • Review medications • Vomiting may be caused by GI obstructions, medications, delayed gastric emptying • Hold enteral nutrition if GI obstruction • Use antiemetics • Hold feeds x 1hr then reassess

  35. Gastrointestinal Complications ABDOMINAL DISTENTION • Abdominal Distention • Causes • GI ileus • Obstruction • Obstipation • Ascites • Lactose intolerance • Rapid infusion of enteral formula • Infusion of cold formula • Rule out ileus or obstruction, do abdominal Xray

  36. Metabolic Complications Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

  37. Metabolic Complications Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

  38. Metabolic Complications Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

  39. Metabolic Complications Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

  40. Metabolic Complications Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

  41. Refeeding Syndrome • Occurs when severely malnourished patients are refed • Acute intracellular shifts of electrolytes as cell anabolism is stimulated • Results in decreased circulating levels of K+, Mg, phos • Can cause hematologic, neuromuscular, cardiac and respiratory dysfunction • Prevention / Treatment: • Identify patients at risk • Correct electrolytes before starting EN • For the first day limit energy provided to 25% of requirements and progress gradually over 3-5 days to 100% of energy requirement • Supplement with thiamine 100mg/day X 3-5 days • Monitor for signs of fluid retention • Monitor electrolytes daily until at mantenenace and replete low levels

  42. Administrative Complications ASPIRATION • Tube feeding, gastric secretions, or oral secretion enter the lungs • A severe complication of enteral feeding • Risk factors • supine position • regurgitation • vomiting • delayed gastric emptying • decreased level of consciousness • patient pulling out nasoduodenal tube while feeding is running • poor oral hygiene • mechanical ventilation • neurological disease

  43. Administrative Complications ASPIRATION • Progression from aspiration of tube feeding formula to pneumonia depends on the amount, acidity of formula, and the microbial content and the health of the patient • To decrease aspiration risk • HoB 30-45oif not contraindicated • Small bowel feeding tubes • Motility agents • Ex.: Metoclopramide: ineffective in head-injured patients, Erythromycin • Oral Hygiene • Chlorhexidine mouthwash should be used twice daily to  VAP risk in mechanically ventilated patients

  44. Case Study 66 year old male, post liver transplant 2009 with recurrent HCV on liver bx admitted to hospital due to cholangitis due to stones and needs surgery to remove one of the stones. Transferred to ICU with respiratory failure, anasarca, hyponatremia, hyperkalemia, C. difficile diarrhea and AKI with anuria and  Cr. Intubated, ventilated, bronchoscopy performed. Found gastric fluid in lungs, vocal cords which didn’t close. Aspiration pneumonia diagnosed. Continuous veno-venous hemodialysis will be started. The patient had a PEG inserted 2 weeks before ICU admission due to inadequate food intake. (He had pulled out 3-4 nasoduodenal tubes) He was also eating some food. (200-300Kcal per day)

  45. Case Study Case Study • Abdomen: • Non-tender • CT scan of abdo: nothing acute • Diarrhea but not copious amounts • GU: • High potassium treated with kayexalate • On CVVHDF, urea, Cr, K, phos decreasing • Still anasarca

  46. Case Study Problems: • Aspiration: • Gastric contents seen on bronchoscopy • Vocal cords not closing • Diarrhea • C. Difficile • Electrolyte abnormalities • Acute kidney injury (AKI) • Likely not related to tube feeds • Overhydration • Treated with continous dialysis

  47. Case Study Should you use PEG for feeding?

  48. Case Study • Decision at morning rounds to use PEG until PEG/J can be arranged through radiology • Promotility drug initially (despite diarrhea) • Check residuals every 4hr

  49. Case Study Which formula? • On continuous dialysis with DNFL 100 • If anasarca likely has gut edema and may have decreased absorption • History of C. difficile diarrhea diagnosed and treated X 5 days

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