Enteral Feeding for Adults

Artificial nutrition support should be considered for patients with functioning gastrointestinal tracts who are unable to meet their nutrition needs orally, either due to insufficient oral intake or because oral intake is unsafe. Ethical considerations should be given to the appropriateness of enteral feeding. Enteral feeding may be considered in those who have absent oral intake as a sole source of nutrition or to supplement an inadequate oral intake.

Decisions to start feeding, suitable route, content and management of nutritional support are best made by the multidisciplinary team directly responsible for patient care in consultation with the patient and their carers / family. Any discussions or decisions around enteral feeding should be clearly documented in the medical notes (see Appendix 1: Flowchart for decision making around Enteral feeding).

In cases other that nasogastric tube feeding, such as nasojejunal and gastrostomy feeding the patient should be referred the Gastroenterology Consultant.

Examples of patients suitable for enteral feeding are:

Further guidance on supporting people who have eating and drinking difficulties has been provided by the Royal College of Physicians on this link:

Supporting people who have eating and drinking difficulties (rcpjournals.org)

For patients being considered for enteral tube feeding should be assessed for their risk of refeeding syndrome.

Appendix 3 gives detail on the identification and management of those at risk of refeeding syndrome.

The current make of fine bore feeding tube we use in NHS Borders is the Nutricare – ISOSAF long term feeding tube.

Ryles tubes should not be used for enteral feeding but for gastric drainage only. These should only be left in situ for 7-10 days as the tube can become brittle and cause ulceration to the back of the throat and the gullet.

Other tubes such as a Trelumina tube or a naso-jejunal tube may also be used however these tubes would only be placed in endoscopy or in theatre and not on the ward.

1 Passing the Nasogastric / Orogastric Tube

Complete the 5 moments of hand hygiene before and after the procedure

Collect equipment i.e. nasogastric tube, 60mls syringe, pH indicator paper or strip, water to flush, hydrocolloid dressing cut to the correct size and transparent film to secure, glass of water or juice (if the patient doesn’t have swallowing difficulties).

Explain to the patient that you are going to pass the nasogastric tube

Check that the patient has not had any nasal surgery or has a septal deviation. Ask the patient to gently blow their nose clearing any mucus away. Offer oral hygiene.

Determine the length of tube to be inserted by measuring the tip of the tube from nose to ear and then measure from ear to xiphisternum. The patient should be sitting in an upright position. Note the mark on the tube or keep your fingers on the point measured (this is the NEX measurement and in adults is usually approx. 56-60cm)

Ensure end cap is firmly in place on the end of the tube, to prevent leakage of gastric contents

Select nostril that is clear, where possible alternate the nostril being used

Lubricate the tip of the tube using a water based solution and/or follow manufacturer’s guidelines

Insert the tip of the tube into the nostril and slide backwards along the floor of the nose

If there is any obstruction, pull tube back and turn it slightly and advance again. If obstruction is felt again try the other nostril

Once the tube reaches the nasopharynx, resistance may be felt. If so, get the patient to slightly lower his / her head, continue to gently advance the tube until the correct length is reached.

If at any time the patient starts coughing or their colour changes stop the procedure immediately and remove the tube

Secure Mefix (or similar) tape around the tube and nose and Tegaderm (or similar) to cheek.

Leave any guidewire in situ in case you are required to reposition at this stage.

The position of the tube should be confirmed by pH aspirate after passing it and prior to using it for administering any feed or medications

Document the position of the tube using the markers on the tube where it enters the nostril

2 Checking the position of a nasogastric/orogastric tube

Complete the 5 moments of hand hygiene before and after the procedure

Explain to the patient that you are going to check their tube

Note the position of the tube using the tube markers

Remove the end cap from the tube

Attach a 60ml syringe to the end of the tube unless contraindicated by manufacturer’s instructions

Aspirate the gastric contents from the patients’ stomach by gently pulling back on the plunger until a small amount of fluid appears in the syringe

Detach the syringe from the tube remembering to replace the end cap of the tube

Test the pH of the fluid using pH indicator paper or strip. The indicator paper or strip should change colour to read a pH of 5.5 or less.

3 If it is difficult to obtain aspirate:

Attempt to push the tube’s port away from the stomach wall. Insert 3-5ml of air via syringe, down the nasogastric tube. Try again to aspirate the tube and test with pH indicator paper or strip

Lie the patient on their left side to move gastric contents to the greater curvature of the stomach and then retry aspirating the tube

Ask the patient to take a small drink, if allowed, then try to aspirate the tube

Try advancing or pulling the tube back slightly

Ensure the tube is at the same position at the nostril, documented when passed initially

If it is still not possible to obtain an aspirate after waiting and change in position or there is clinical concern as to the tubes initial placement, then a chest x-ray can be obtained. NG tubes used in NHS Borders are fully radio opaque so can be x-rayed even if the guidewire has been removed.

4 If the aspirate is pH 6.0 or above

If the pH is 6.0 or above the position of the tube should be checked by a second competent person

If the aspirate of the tube is pH 6.0 or above, it may indicate that the tube is incorrectly placed in to the lung. Not all patients will cough when this happens. Do not feed and test the aspirate again in an hour.

Certain medications e.g. PPI inhibitors may raise the pH of the gastric contents. Do not feed and test the aspirate again in an hour.

If pH remains high, then a chest x-ray can be obtained. NG tubes used in NHS Borders are fully radio opaque so can be x-rayed even if the guidewire has been removed.

Once the tube is in the correct position remove the guide wire and close the port. Flush the tube with recommended amount of sterile water. All fine bore feeding tubes come with a patient record sticker which should be completed and placed in the unitary record.

Consideration should be given to whether nasogastric tubes are placed or replaced overnight as there may be reduced support available to accurately confirm placement, should ambiguity arise. If a consultant feels there is a clinical need to place an NG tube in these hours, then the decision and rationale must be clearly documented in the adult unitary record.

5 Frequency of checking nasogastric/orogastric tube placement

Check and document the tube position:

• Following the initial tube insertion
• Before commencement of each feed
• Before medications are administered
• Following evidence of tube displacement, e.g. loose tape, the visible tube appears longer or the position mark at the nostril has changed
• Following episodes of vomiting, retching or coughing
• If the patient develops signs of respiratory distress
• Oropharyngeal suction
• Patient is complaining of reflux of feed.

6 Frequency of changing nasogastric/orogastric tube

Tubes should not be re-used

Only tubes licensed for feeding should be used

Nutricare-ISOSAF nasogastric feeding tubes may be left in situ for >90 days if clinically necessary, following a clinical risk assessment. Routinely check tube performance, flow and any tube impairment. Discard and replace the tube upon performance and / or flow deterioration, and / or tube impairment.

7 Removal of the Nasogastric/orogastric tube

Explain the procedure to the patient

Place a towel or clinical sheet across their chest

Remove in 1 continuous motion

Offer the patient mouthwash (unless nil by mouth) or oral hygiene

Dispose of tube in normal clinical waste.

Insertion of a nasal bridle should be considered if an NG or NJ tube has been dislodged on at least 3 occasions or if the NG tube had to be placed endoscopically, radiologically or during surgery. Nasal bridles do not prevent a patient pulling the NG tube out through the nose and in some instances out of the clip that secures the bridle and the NG tube.

It is not always possible to place a nasal bridle. Contraindications include

Very confused patients who continue to pull at NG tube and cause trauma to nasal septum

Patients with facial or basal skull fractures

Patients with grossly deviated or perforated septum

Patients with structural deformity of the nose and nasopharynx

Patients with clotting disorders.

Inserting a Nasal Bridle

NHS Borders use the AMT nasal bridle and the guidance below is provided for insertion of the AMT nasal bridle (a pictorial guide for insertion is included in with the bridle). Any alternative bridle should be inserted using the guidance enclosed.

The preferred position is to place the patient supine or sitting. The bridle may be placed before or after the nasal tube. Lubricate the probe, catheter and umbilical tape. Insert the blue probe into the nostril opposite the nasal tube until the 2^nd rib is at the bottom of nostril. Adjust for smaller patients

Insert the white bridle catheter into the opposite nostril to approximate the magnets. Pull back on the orange stylet about 1cm until the magnets connect. The ‘click of the magnets’ should be heard or felt. Equal lengths of both probes (minus the orange stylet) should be exposed.

If necessary, twist the probes to encourage contact between the magnets. If no contact has been made, then advance both the white catheter and the blue probe. Once contact has been made remove the orange stylet completely from the white catheter and dispose.

Slowly withdraw the blue probe and allow the white catheter to advance through the nose until only the cloth umbilical tape is in the nose.

Cut the catheter portion from the umbilical cord. If the nasal tube has not yet been inserted insert the tube now.

Use caution when handling the bridle clip near the patients’ mouth (consider covering mouth). Clip should be located approximately 1cm from the patients nose and should not touch the nostril.

Place the nasal tube into the channel or groove of the clip securely. Placing them flat put the 2 strands of the umbilical tape near the hinge of the clip.

Close the clip by folding over the plastic edge and firmly snapping it shut. Note the clip is difficult to reopen so ensure careful positioning of the nasal tube, umbilical tape and clip before closing. Depending on the rigidity of the tube will depend if more force is needed to close the clip.

After the clip is fully closed tie the 2 umbilical tape ends together creating a simple knot. Repeat 2-3 times.

The bridle may remain in place for the entire time the feeding tube is in situ. Make note of the date of insertion in the patients’ medical notes.

Removal of the Nasal Bridle

To remove the nasal bridle and tube cut only one strand of the umbilical tape. Gently remove the nasal tube and bridle out of the nose.

To remove only the bridle cut both ends of the umbilical tape and remove from the nose. The clip should remain in place.

CAUTION: Great care should be taken to prevent accidental swallowing as the tape can easily slide back into the nose.

Nasojejunal tubes are usually placed in theatre or in the endoscopy unit.

1: Confirmation of nasojejunal (NJ) tube position

The position of a NJ tube can only be confirmed radiologically. The pH of the small bowel is ≥ 6 so aspirate cannot be used to confirm the position of the tube.

The NJ tube should be secured with nasal fixation tape and secure residual tube firmly to cheek / neck. Patients with oily skin or who sweat a lot may require more frequent changing of this tape.

Nasal bridles may also be used to secure the NJ tube

2: Frequency of checking nasojejunal tube (NJ) position

Check the length of the external tubing daily and record the centimetre marking on the enteral feed record following tube placement and before and administering feed / water / medications

Observe patient for signs of abdominal distention, vomiting or aspiration as this could indicate tube migration back into the stomach.

There are a variety of gastrostomy tube types which can be held in place with either a bolster or a balloon. The aftercare of the different types of tubes may vary. In NHS Borders the tube most commonly placed is the 16Fr Corflo gastrostomy tube (bumper retained tube). If you are uncertain what type of tube your patient has contact your dietitian, GI nurse specialist or GI consultant.

Gastrostomy feeding tubes are classed as established when they have been in situ for more than 12 weeks.

1 Post PEG insertion procedure 

Following PEG insertion the patient will return to the ward. Please follow the Post-theraputic endoscopy observation instruction sheet which will be filed in the patient notes (see Appendix 9).

If there is pain on feeding, leakage of fluid around the tube, or new bleeding within first week of insertion, STOP FEED IMMEDIATELY and CONTACT a Gastroenterologist or Gastroenterology Nurse Specialist for urgent advice.

2 Care following initial stoma formation

Careful cleaning around the tube reduces the possibility of infection

Carry out hand hygiene in accordance to the 5 moments of hand hygiene principles.

Leave the external fixator in place for 14 days. There will be post insertion swelling causing the external fixator to possibly become too tight to the skin. If this occurs the gastroenterology nurse specialist, gastroenterologist or surgeon will loosen the external fixator if required.

Clean the skin around the stoma site and under the external fixator with sterile water or saline using sterile gauze that does not shed fibres. Continue this daily for 7 days post insertion. Always ensure that the surrounding skin and under the fixator is dried thoroughly.

If there is pain on feeding, leakage of fluid around the tube, or new bleeding within first week of insertion, STOP FEED IMMEDIATELY and CONTACT a Gastroenterologist or Gastroenterology Nurse Specialist for urgent advice.

3 Care of sutures following insertion of Radiological Inserted Gastrostomy

Around the stoma there will be two to four sutures in situ.

Please note that the gastrostomy tube is not held in place by the sutures. The sutures secure stomach wall to the abdominal wall to allow the stoma to be formed

These sutures should be removed seven days post procedure by a ward nurse.

Raise the metal fastener and cut the suture, then remove the disc and sponge.

Internal suture material will pass through the gastrointestinal tract.

Some bleeding is normal when removing sutures.

4 Daily stoma / tube care (after 7-14 days)

Clean the area with a clean cloth and soapy water, rinse and dry thoroughly.

Do not use moisturising creams or talcum powder around the stoma site.

Reposition the external fixator after cleaning, if appropriate. Leaving a 2-5mm gap between fixator and skin.

The external fixator should not be moved for the first 2 weeks post procedure (PEG tubes or tubes placed with pull through technique). Refer to the manufacturer’s guidelines.

Once a week, the external fixator should be moved and the tube should be moved in and out by a maximum of 10mm. This prevents “buried bumper syndrome”6, a rare but important complication in patients with a PEG tube

Rotate the tube 360^o and reposition the external fixator daily, leaving a space of at least 2mm to allow slight movement.

If you are unsure whether a tube should be rotated, check with the person who placed the tube or refer to the manufacturer’s guidelines.

Do not rotate the tube if the site is discharging, instead obtain a swab for culture.

5 Stoma problems – infection

Infection can be minimised by scrupulous hygiene of the stoma site.

Avoid occlusive dressings as these can encourage and trap moisture.

Obtain a swab for microbiology if any exudate or inflammation is present.

Treat with the appropriate systemic antibiotic as topical therapy may not always be effective. The infection is usually within the tract and not just superficial.

If a yeast is suspected (the tube can have a bubbled or bumpy appearance or cause a burst balloon or leaking feeding port) a gastric aspirate should be sent to microbiology and treatment guided by the microbiologist. Once the yeast is treated the tube should be replaced if it is degraded.

6 Stoma problems – Overgranulation

Insufficient rotation of the tube or movement of the tube within the tract can cause granulation tissue.

Check that the external fixator is not too loose or too tight. Correct positioning of the external retention device can reduce the risk of overgranulation.

Check for infection by taking a swab of the stoma site and treat accordingly.

Consider the use of a foam dressing and/or hydrocortisone cream. The dressing of choice should be used for a minimum of 2-weeks to determine if it has been effective.

A steroid-based, antibiotic or antifungal cream may be prescribed e.g. Maxitrol eye ointment, Fucidin H or Timodine

If no improvement after the above treatment seek specialist review.

7 Leakage around Gastrostomy site

Consider the following:

Check for infection by taking a swab of the stoma site and treat accordingly.

Check the internal fixator is against the inner gastric wall by gently pulling the tube outwards until resistance is felt, and ensuring the external fixator is close to the skin, leaving a space of about 2-5mm to allow slight movement.

For balloon-retained tubes, check the balloon is still patent and inflated.

The French Gauge of the tube may be incorrect. Discuss with a specialist e.g. Gastrointestinal Nurse Specialist or Gastro Intestinal Consultant.

Consider the use of barrier preparation e.g. Cavilon, in conjunction with a foam dressing such as Allevyn Non-Adhesive.

8 Frequency of changing tubes

When a tube has been placed, document the approximate date for the next replacement. Check the manufacturers’ recommendation. As a guide the following should apply:

Gastrostomy tube with internal retention bolster: change if required or clinically indicated.

Balloon gastrostomy tubes: 3-6 months

Low profile devices (internal retention bolster): approximately 24 months

Balloon replacement low profile device: 3-6 months

The life span of a tube can vary depending on medications and stomach acidity.

7.9 What to do when a gastrostomy tube falls out

If a gastrostomy tube falls out in the BGH refer to gastroenterology.

Patients in the community with established balloon retained feeding tubes should have a spare tube or enPlug that can be inserted to maintain the gastrostomy tract.

If a gastrostomy tube falls out then it should be replaced or an enPlug be inserted as soon as practicable, preferably within 6 hours, or the stoma will start to close.

Family members and carers may be trained to reinsert the gastrostomy tube if appropriate.

If there is any problem reinserting the tube, then the patient must come to A&E at the BGH.  Spare balloon tubes can be located in the GI nurses endoscopy treatment room and will be accessible by A&E out-of-hours. Position of the tube can be confirmed by gastric aspirate <5.5. If there are any concerns about tube position arrange an x-ray, ‘pegogram’ or CT with contrast to confirm tube position. Once the position of the tube has been confirmed feed as per regimen.

If a displaced tube is less than 2 weeks old the risk of disrupting the tract with leakage of feed or gastric contents into the peritoneum is greatest.

If a displaced tube has a tract less than 12 weeks old only an experienced member of the GI team should attempt to gently replace the tube. Feeding should not be attempted through any tube until a contrast study has been completed to ensure the tube is in the correct position

10 Fasting prior to and after permanent Gastrostomy tube removal

There is no evidence to suggest that fasting is required before or after permanent gastrostomy tube removal but it may be appropriate for the patient to fast for 4 hours before the tube is removed.

Consider the needs of the patient but do not remove the tube just after food or drink.

11 Frequency of checking the balloon in balloon-retained tubes

The water in balloon retained gastrostomy tubes should be checked weekly.

Remove old water from the balloon using a luer slip syringe.

Report any changes in water volume or water colour.

For inpatients replace the water with sterile water and for patients in their own home replace with cooled boiled water using a separate sterile luer slip syringe.

Ideally check the balloon on the same day each week.

Ensure that the balloon port is kept clean.

12 Unable to remove water from balloon

Check that Luer Slip syringe is attached firmly to the balloon port.

Try again, and if unsuccessful refer to community nurse/nutricia nurse. Possible onward referral to GI team at BGH may be required.

13 Other Problems

Parents / carers should be aware of the need to report problems of vomiting, diarrhoea, constipation, abdominal distension, cramps, nausea or dehydration, weight loss or rapid weight gain; these factors may indicate a need to alter the patients feeding regimen, dietary intake, medication regime or may indicate that a medical assessment is required by a Gastroenterology Consultant or GP.

Leakage of feed/gastric contents around the gastrostomy tube and onto the skin at the gastrostomy site will cause skin redness, excoriation and breakdown as the gastric acid contents burn the skin:

check balloon is properly inflated

pull gently on the tube until resistance is met and secure the external fixator

Yeast infections - swab site and treat as per local policy

If the patient is having problems with recurrent burst balloons or leaking valve ports a gastric aspirate should be taken and sent to check for the presence of yeasts and treated as appropriate NB. If patient takes Domperidone, they cannot have Fluconazole, but high dose Nystatin

Replacing the Corflo PEG Y-adaptor

NHS Borders uses Corflo gastrostomy tubes as its standard gastrostomy tube. Occasionally the Y shaped end of the tube can split and needs to be replaced. This can avoid the need to replace the gastrostomy tube.

Patients who are in the community should have a spare PEG end and they or their carers will often be trained in how to replace them.

Appendix 8 details how to replace the Y PEG adaptor

If a spare PEG end is required in the BGH they can be found in the GI Nurses endoscopy treatment room and will be accessible by A&E out of hours.

Surgical jejunostomy type of tube varies and are not usually placed at NHS Borders. They are placed at surgical laparotomy or laparoscopically. There is usually an external fixator sutured to the skin. These sutures do become loose and should either be re-sutured or if not practical the external fixator should be secured to the skin with Tegaderm or similar.

Jejunostomy Daily Stoma Care

Check length of external tubing daily and record centimetre marking.

Ensure security of external fixator and sutures

Site should be cleaned daily with a clean cloth and water and dried thoroughly.

Avoid the use of dressings unless exudate present

Reposition the external fixator after cleaning stoma site.

1 Hand Hygiene

Before or after providing enteral tube care, feed or medication administration the 5 moments of hand hygiene should be completed.

Employees suffering from infected wounds, skin infections, sore throats, diarrhoea / vomiting must be excluded from enteral tube feeding and advice sought from infection control (in the first instance) or occupational health.

Non-sterile, non-powdered gloves and an apron should be worn.

If a patient is managing their own enteral feeding tube then it is not necessary for them to wear gloves but hand hygiene should be carried out.

Family (informal) carers in the home situation are not required to wear protective clothing but should be aware that: careful hand hygiene is important, cuts and sores on hands and forearms must be covered with a waterproof dressing, carers should not handle enteral feeds if they have skin infections, diarrhoea or vomiting. In such situations medical advice should be sought.

Minimal handling and aseptic technique should be used to connect the administration system to the enteral feeding tube.

2 Giving sets, syringes and extension sets

Items marked ‘single use’ should not be reused

Items marked ‘single patient use’ can be reused in a specific patient if the manufacturers cleaning instructions are followed.

Giving sets can be used for 24h when using a sterile system. Once disconnected from the feed they should be left attached to the used feed bag with the end cap on until reconnected to the next feed bag. If feed is not sterile giving sets should not be used for more than 4 hours.

Reusable oral / enteral syringes can be re-used up to 84 times (potentially 28 days). Refer to manufacturers cleaning guidance.

Extension sets for PEG or button tubes should be changed fortnightly and should not be thrown out. Refer to manufacturers guidelines for cleaning instructions. For patients with longer inpatient stays these may be required to be brought in from home.

3 The use of water in enteral feeding

In the hospital setting sterile water should be used and bottles of sterile water should be changed every 24 hours. Bottles of sterile water should be single patient use.

In the community freshly drawn tap water can be used if a patient if fed into their stomach i.e. NG or gastrostomy fed.

In the community, patients with an NJ tube or jejunostomy tube should use cooled boiled water.

If a patient has a private water supply cooled boiled water should be used.

If a community patient is immunocompromised cooled boiled water should be used.

Cooled boiled water should be used to replace the water in balloon retained devices.

Patients should have a jug identified for this purpose. The jug should be washed between uses with hot soapy water and allowed to air dry.

If more than the required volume of water is prepared it should be stored in a clean contained with a lid and refrigerated. It should be allowed to return to room temperature before being used.

Cooled boiled water should be discarded after 24 hours.

4 Decanting feed

• Where possible decanting enteral feeds should be avoided by using ready to hang sterile feeds to reduce the risk of contamination.
• If feed is required to be decanted the required volume should be decanted into a feed container.
• Once decanted the feed should not be hung for more than 4 hours before being discarded.
• If any feed is left in the original bottle this can be stored refrigerated for up to 24h (but should be brought to room temperature before being administered down an enteral feeding tube)

5 Pump cleaning

• The pump should be cleaned before and after every episode of use.
• Consult manufacturers instructions regarding how to do this.

• The term blended diet can apply to anything other than water or commercial enteral formula being given via an enteral feeding tube. It can vary between a small amount of, for example fruit juice being given alongside a commercial enteral formula to meeting an individuals’ nutritional requirements.
• Blended diets are relatively new and therefore research in this area is currently limited. The BDA Use of Blended diet with Enteral Feeding Practice toolkit (2021) recommends a shared decision making approach to care, in line with current NICE guidance. The shared decision should be clearly documented in the individuals’ record by the dietitian and the MDT.
• Fine bore tubes may be more likely to get blocked and therefore be less suitable for blended diets. Due to lack of stomach acid jejunal feeding may also increase the risk of infection so be less suitable for blended diets.
• The dietitian should work with the individual, their carers or family to ensure the nutritional adequacy of the blended diet.
• Good food safety and food hygiene is key to avoiding any food borne infections and families / carers should be educated in this to minimise risks of infection for the individual.
• Blended diets may be able to be gravity fed for thinner consistencies however thicker consistencies may need to be slowly plunged.
• Blended diets may be difficult to facilitate in a hospital setting but care providers should work together to explore the possibility of blended diet provision for inpatients.

Monitoring of patients on enteral feeding will depend on the duration, type of feeding and also will depend on the disease process and whether someone is acutely unwell or stable.

Effective monitoring will help to ensure that nutrition support is provided safely, complications are detected early and nutritional goals are met and/ or reviewed.

Monitoring of a patient on enteral feeding should be multidisciplinary and the frequency of the need for monitoring will be determined by some of the parameters listed above.

The table below shows suggested monitoring and responsibilities.

• Once a discharge date and destination for a patient on enteral feeding is known this should be communicated to the dietitian.
• For patients, carers or care home staff requiring training, the dietitian will co-ordinate with the Nutricia nursing team to advise who needs trained and what training is required.
• The dietitian will advise what discharge supplies of enteral feed and equipment is needed.
• For patients being transferred to a community hospital with ongoing NG feeding, a clear plan of care must be in place. This should include documentation of the plan if the tube is to become displaced/dislodged and if to progress to a longer term feeding tube.
• For patients being transferred out of area the dietitian will communicate with the dietetic team in the area they are transferring to.
• Any patients on enteral feeding transferring into NHS Borders should have care handed over from the existing dietitian to the NHS Borders dietitian.

• Enteral feeding tubes should be removed after death
• NG and NJ tubes can be removed by gently pulling them
• If a gastrostomy tube has a balloon retention device the balloon should be deflated and the tube gently pulled out.
• If a gastrostomy tube has a bumper retention device the external part of the tube should be cut at skin level and the stoma covered with a waterproof dressing.

AEF Guidelines Appendix 1

AEF Guidelines Appendix 2

AEF Guidelines Appendix 3

AEF Guidelines Appendix 4

AEF Guidelines Appendix 5

AEF Guidelines Appendix 6

AEF Guidelines Appendix 7

AEF Guidelines Appendix 8

AEF Guidelines Appendix 9

AEF Guidelines Appendix 10

Key Points

• Rigorous medication review is essential when a patient requires enteral tube feeding to simplify and minimise drug regimens
• Contact the ward pharmacist to review current oral medication for administration via enteral feeding tube administration
• Drugs should only put down enteral feeding tubes as a last resort. There may be little information to support via this route. The prescriber takes responsibility for this ‘off-license’ use.
• Patient response to drugs administered via enteral feeding tubes can be unpredictable. Drugs may have a lesser or greater therapeutic effect than when given via the oral route. The onset and duration of effect may be affected. Side effects, particularly those involving the gastrointestinal system, are likely to be exacerbated. The side effects of drugs given by an unlicensed route are also the responsibility of the prescriber.
• Nasogastric and nasojejunal feeding tubes deliver feed and drugs into the stomach and jejunum respectively. These tubes are long, fine bore tubes, with a large surface area for potential drug absorption and may easily block due to their small bore. PEG and Jejunostomy tubes are shorter with a larger bore.
• A minimum 50ml syringe should be used for drug administration via an enteral feeding tube to avoid rupturing the feeding tube with rapid administration with a smaller syringe.

Documentation

• All staff are responsible for documenting care plans in the Adult Unitary Record. All medicines that the patient is currently taking should be clearly documented. The pharmacist should annotate the kardex to show how to administer drugs via enteral tubes along with documenting this in the patients care records. Clear communication should be made that the patient required medications via enteral feeding tubes via discharge letter and community pharmacy.

Directions for administration of liquids

Liquids are the preferred formulation for the administration via the enteral feeding tubes when available. It is not usually necessary to dilute liquid medications with water just prior to administration unless very thick.

Enteral feeding tubes should be flushed with a minimum 30ml water prior to and following administration of medication. If multiple medications are being administered 5-10ml water should be flushed through the tube between each medication.

Syrups: These are viscous and hyperosmolar so it is best to dilute the syrup with the same volume of water. If there are multiple drugs to be administered it is preferable to administer the syrup last. Following administration ensure the tube is flushed with a minimum 30ml water flush.

Suspensions: The majority of suspensions are suitable for administration via enteral feeding tubes but some such as lansoprazole may block the tube. A clinical pharmacist can advise on this.

Directions for administration of tablets

Crushing standard release tablets

• Crush the tablet in a tablet crusher
• Add 15-30ml water to the mortar and mix with the powder just before administration
• Draw up the solution with an enteral syringe. Administer the solution via the enteral tube
• Rinse out the mortar with 15-30ml water and add the remaining solution to the tube. Flush the tube with a minimum 30ml water.
• Care should be taken when crushing drugs which have a high incidence of allergic reactions e.g antibiotics and chlorpromazine
• Don’t crush cytotoxic, prostaglandin or hormone antagonist preparations. Seek advice from pharmacy.

Sugar coated and film coated tablets

• These tablets are usually coated to improve appearance or to mask unpleasant taste. Administer as a standard release table (see steps above)
• The presence of a coating may make crushing difficult and increase the probability of the drug blocking the tube. Ensure that the coating is well crushed and the tube is flushed well with water.

Dispersible/ Disintegrating tablets

Tablets may disintegrate in water without crushing even if not classed as a dispersible tablet. For either type of tablet, it should be prepared as follows

• Place intact tablet into the barrel of an enteral syringe. Replace the plunger and draw up 15-30ml water
• Allow the tablet to disperse
• Shake well and administer down the enteral feeding tube.
• Flush tube with minimum 30ml water

Effervescent tablets

Tablets will effervesce and disperse in water. The resulting gases need to be allowed to escape. Prepare as follows

• Pour 50ml water into a beaker. Add the tablet to the water
• Wait for the effervescent reaction to finish
• Swirl the solution and draw it all up into a 60ml enteral syringe. Administer the dose down the enteral feeding tube
• Flush the tube post dose with minimum 30ml water.

Directions for the administration of capsules

For dry powder hard gelatin capsules

• Gently ease open the two halves of the capsule to release the powder. Add the powder to the pestle.
• Mix the powder with 15-30ml water
• Draw up the solution in an enteral syringe and administer the solution though the enteral feeding tube
• Rinse out the beaker and administer through the tube
• Flush the tube with minimum 30ml water

Modified release capsules

• Ask a pharmacist for advice as it may be necessary to change preparation

Soft gelatin capsules containing liquid

• Pinprick one end of the capsule
• Drain the contents with an enteral syringe and administer through the enteral feeding tube
• Flush the tube post administration with minimum 30ml water
• NB some of the drug may adhere to the soft gelatin capsule and may result in a sub therapeutic dose