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Implementing Enteral Nutrition Therapy: Enteral Access. Objectives. To describe the benefits of enteral nutrition therapy To review indications and contraindications of enteral nutrition To describe access routes for enteral nutrition infusion

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Presentation Transcript
  • To describe the benefits of enteral nutrition therapy
  • To review indications and contraindications of enteral nutrition
  • To describe access routes for enteral nutrition infusion
  • To describe the advantages and disadvantages of various enteral access routes
enteral nutrition therapy benefits
Enteral Nutrition Therapy: Benefits
  • Maintains gastrointestinal structure and function
  • Reduces translocation of toxins and possibly bacteria
  • Less expensive than parenteral nutrition therapy
  • Fewer complications
enteral nutrition indications
Enteral Nutrition: Indications
  • Patients unable or unwilling to consume adequate nutrition to meet metabolic requirements alone or with assistance
  • Complement insufficient intake or increased demand
enteral nutrition indications1
Enteral Nutrition: Indications

Requires total or partial GI tract function

  • Anorexia
  • Apoplexy
  • Coma
  • Sepsis
  • Trauma/surgery
  • Transition from parenteral nutrition
enteral nutrition contraindications
Enteral Nutrition: Contraindications


  • Complete bowel obstruction
  • Severe small bowel ileus with abdominal distention
  • Complete inability to absorb nutrients through the GI tract
enteral nutrition contraindications1
Enteral Nutrition: Contraindications


  • Severe postprandial pain
  • Short bowel syndrome
  • Intractable vomiting
  • Severe diarrhea
gastric access
Gastric Access

Gastric Route Preferred

  • Adequate gastric motility
  • Minimum risk of aspiration

Gastric Route Contraindicated

  • Delayed gastric emptying (gastroparesis)
  • High risk for aspiration
gastric access1
Gastric Access

Gastric Route Advantages

  • Normal reservoir for food
  • Easy access
  • Tolerates high osmotic loads
  • Tolerates intermittent feedings
  • Gastric acid destroys contaminants
  • Can be placed by nurses
gastric feeding techniques
Gastric Feeding Techniques

Rugeles S, et al. Universitas Medica 1993;34(I):19-23

nasogastric tubes
Nasogastric Tubes

8 Fr, stylet,opaquebolus, 45"

12 Fr,opaque, 36"

12 Fr,clear, 36"

nasogastric tube disadvantages
Nasogastric Tube: Disadvantages
  • Short-term use only
  • Higher risk for aspiration
  • Difficult to confirm position
  • Small bore
  • Nasopharyngeal trauma/irritation
  • Accidental tube displacement
percutaneous endoscopic gastrostomy peg tubes
Percutaneous Endoscopic Gastrostomy: PEG Tubes



Minard G. Nutr Clin Prac 1994;9:172-182

percutaneous endoscopic gastrostomy advantages
Percutaneous Endoscopic Gastrostomy: Advantages
  • The same as for surgical gastrostomy
  • No surgery / less invasive
  • Minimal sedation
  • Direct visualization
  • < 30 minutes to place tube
  • Lower costs
percutaneous endoscopic gastrostomy placement criteria
Percutaneous Endoscopic Gastrostomy: Placement Criteria
  • Adequate passage for endoscope
  • Ease in identifying safe site
  • Ease in determining a safe tract
  • Functioning GI tract
  • Absence of ascites / morbid obesity

Stellato TA, et al. Ann Surg 1984;200:46-50Lee M, et al. Clin Radiol 1991;44:332-334

surgical gastrostomy
Surgical Gastrostomy
  • Performed in operating room
  • Indicated when PEG is contraindicated or during other surgical procedures
  • Requires general anesthesia and full surgical team
  • In observation during recovery
  • More expensive than PEG
post pyloric access
Post-pyloric Access

Indications for post-pyloric route

  • Patient at risk for bronchial aspiration, gastric reflux
  • Gastric feeding contraindicated

– Gastric motility disorders; e.g., gastroparesis

– Upper GI tract condition; e.g., carcinoma, stricture, fistula

post pyloric access1


  • Small bore tubes, prone to obstruction
  • Tubes can be dislodged into stomach
  • Difficult to maintain long term
  • Potential for dumping syndrome
  • Requires infusion pump
  • Advantages
  • Allows earlier post-op feeding
  • Lower risk of aspiration
Post-pyloric Access

Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387

post pyloric feeding techniques

Long Term


– Percutaneous endoscopic jejunostomy or through the PEG tube

– Surgical jejunostomy

Short Term


– Nasoduodenal

– Nasojejunal

Post-pyloric Feeding Techniques

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875

nasal access tubes
Nasal Access: Tubes


Nasoduodenal / Jejunal

  • Easy
  • Short term
  • Y-Port
  • Small bore
  • Weighted tip
  • Metal guidewire
post pyloric enteral nutrition indications
Post-pyloric Enteral Nutrition: Indications
  • History / risk of reflux or aspiration
  • Gastric motility disorders
  • Upper GI tract fistulae
  • Acute pancreatitis
post pyloric enteral nutrition advantages
Post-pyloric Enteral Nutrition:Advantages
  • Easily accessible
  • Less invasive
  • Lower risk of aspiration
  • Manual, fluoroscopic, or endoscopic placement
post pyloric enteral nutrition disadvantages
Post-pyloric Enteral Nutrition:Disadvantages
  • Placement can be difficult to achieve and maintain
  • Requires x-ray confirmation
  • Short term use only
  • Nasopharyngeal trauma / irritation
  • Small bore tube
jejunostomy feeding indications
Jejunostomy Feeding: Indications
  • Feeding contraindicated for upper GI tract
  • Gastric motility disorders
  • History / risk of reflux or aspiration
nutrition by jejunostomy disadvantages
Nutrition by Jejunostomy: Disadvantages
  • Small bore tube
  • Placement can be difficult to achieve and maintain
  • Difficult to maintain for long term
percutaneous endoscopic jejunostomy
Percutaneous Endoscopic Jejunostomy
  • Tube placed with or without existing PEG
  • Requires endoscopy
  • Placed distal to Ligament of Treitz

Bumpers HL, et al. Surg Endosc 1994;8:121-123

choosing the feeding site

Can the GI tract be used?



Parenteral Nutrition

Tube feeding for more than 6 weeks?



Nasoenteric Tube

Enterostomy Tube

Risk for pulmonary aspiration?





Nasogastric Tube

Nasoduodenalor nasojejunal tube



Choosing the Feeding Site
  • Enteral nutrition should always be the first option considered
  • Gastric access is the first choice
  • Use post-pyloric route if gastric access not possible
  • Nasogastric route should be used for short term feedings
  • Surgical or percutaneous enterostomies should be the choice for long term cases and for laparotomy patients