Enteral Tube Feeding In Patients Research Articles

Enteral tube feeding in patients receiving dietary treatment for metabolic diseases: A retrospective analysis in a large French cohort

ContextA strictly controlled diet (often involving enteral tube feeding (ETF)) is part of the treatment of many inherited metabolic diseases (IMDs). ObjectiveTo describe the use of ETF in a large cohort of patients with IMDs. DesignA retrospective analysis of ETF in patients with urea cycle disorders (UCDs), organic aciduria (OA), maple syrup disease (MSUD), glycogen storage diseases (GSDs) or fatty acid oxidation disorders (FAODs) diagnosed before the age of 12 months. SettingThe reference center for IMDs at Necker Hospital (Paris, France). Results190 patients born between January 1991 and August 2017 were being treated for OA (n = 60), UCDs (n = 55), MSUD (n = 32), GSDs (n = 26) or FAODs (n = 17). Ninety-eight of these patients (52%) received ETF (OA subgroup: n = 40 (67%); UCDs: n = 12 (22%); MSUD: n = 9 (28%); GSDs: n = 23 (88%); FAODs: n = 14 (82%)). Indications for ETF were feeding difficulties in 64 (65%) patients, cessation of fasting in 39 (40%), and recurrent metabolic decompensation in 14 (14%). Complications of ETF were recorded in 48% of cases, more frequently with nasogastric tube (NGT) than with gastrostomy. Among patients in whom ETF was withdrawn, the mean duration of ETF was 5.9 (SD: 4.8) years (range: 0.6–19.8 years). The duration of ETF was found to vary from one disease subgroup to another (p = 0.051). While the longest median duration was found in the GSD subgroup (6.8 years), the shortest one was found in the UCD subgroup (0.9 years). ConclusionETF is an integral part of the dietary management of IMDs. The long duration of ETF and the specific risks of NGT highlights the potential value of gastrostomy.In this study at a French tertiary hospital, we documented the indications, modalities, duration and complications of enteral tube feeding in a cohort of patients with inherited metabolic diseases.

Glycemic Control During Enteral Tube Feeding in Patients with Diabetes Mellitus.

IntroductionAchieving good glycemic control during enteral tube feeding in patients with diabetes mellitus can be difficult. National guidelines emphasize the need for the early involvement of the dietitian and diabetes specialist nurse, regular capillary blood glucose (CBG) monitoring, and the avoidance of hypoglycemic events. We aimed to assess glycemic control in patients with diabetes during enteral tube feeding.Materials and methodsA retrospective study, involving patients with diabetes who had enteral tube feeding during their hospital stay from January to December 2016, was performed. Data included feed carbohydrate content, infusion rate and duration, involvement of dietitian and inpatient diabetes specialist nurse, capillary blood glucose monitoring, and documentation of hypoglycemic events.ResultsThere were 40 patient episodes. Mean (range) age: 67 (29-94) years, 60% were male, 97.5% had type 2 diabetes, and 60% were on oral hypoglycemic agents prior to admission. The average feed carbohydrate content was 14.6 g/dL and the average feed rate was 73 ml/hour. Dietitians and diabetes inpatient specialist nurses (DISNs) were involved in 100% and 75% of cases, respectively. During enteral tube feeding, capillary blood glucose was controlled using metformin, subcutaneous insulin, or intravenous insulin in 30%, 42.5%, and 15% of cases, respectively. Capillary blood glucose was checked four to six hourly in 100% of cases. The target capillary blood glucose range (6-12 mmol/L) was achieved in 40% of cases. The minimum capillary blood glucose value (median (interquartile range)) was 4.9 (3.9-6.2) mmol/L and the maximum value was 15.1 (11.9-18.8) mmol/L. Using these lower and upper quartile values for minimum and maximum values, respectively, revealed that 57.5% of patients had a capillary blood glucose range of 3.9-18.8 mmol/L. Two patients had hypoglycemic events requiring treatment.ConclusionsThis study demonstrated that despite adequate adherence to our trust's guidelines for glycemic control during enteral tube feeding in patients with diabetes, the target glycemic range was achieved in 40% of cases. The importance of the early involvement of the diabetes inpatient specialist nurse cannot be overemphasized. Early initiation and proactive (daily) dose up-titration of insulin are required to improve glycemic control during enteral tube feeding. A national audit tool for glycemic control and mortality data during enteral tube feeding is required.

Glycaemic control during enteral tube feeding in patients with diabetes who have had a stroke: a twice‐daily insulin regimen

AbstractUncontrolled hyperglycaemia has been a problem in patients with diabetes mellitus who have had a stroke and require enteral tube feeding in our hospital. There is a sustained glucose rise as opposed to the postprandial peaks of normal eating. In the absence of national guidelines, we tailored an insulin regimen for our inpatients. In this observational study we evaluated the effectiveness of this regimen for glycaemic control in these patients.Inpatients with diabetes receiving enteral feeding were given insulin twice daily. The initial dose was calculated from estimated carbohydrate‐to‐insulin ratio, feed carbohydrate concentration, infusion rate and duration, and adjusted according to capillary glucose (target range: 6–12mmol/L).Twenty‐four patients required enteral feeding; average age 72 years and weight 73.8kg. The median (range) feed carbohydrate concentration was 12.3(12.3–20.1)g/100ml; the final feed infusion rate 75(50–100)ml/hr; feed duration 20(10–24)hours/day; and carbohydrate‐to‐insulin ratio 10(6–10). Initial insulin doses ranged from 12–32units/day. Target capillary glucose range was achieved in 17 patients. Of the seven patients who did not achieve the target range, four pulled out their feeding tubes too early, one had hyperosmolar state, one died of aspiration pneumonia and one had a very complex feeding regimen. There were no hypoglycaemic events.This study has confirmed that a simple twice‐daily insulin regimen for patients with diabetes mellitus who require enteral tube feeding is safe and effective for most patients. The importance of frequent blood glucose monitoring in these patients cannot be over‐emphasised. Copyright © 2012 John Wiley & Sons.

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. Median survival from disease onset was 842 days [interquartile range (IQR) 573-1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443-1032), RIG 633 days (IQR 496-1039) and NGT 427 days (IQR 77-781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106-546) days, RIG 216 (IQR 83-383) days and NGT 28 (IQR 14-107) days. Survival between gastrostomy and NGT treated patients was significant (P < or = 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.

Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis

Enteral nutrition (EN) reduces infectious complications and mortality compared with parenteral nutrition (PN) in patients with predicted severe acute pancreatitis. However, to date the complications attributable to the administration of EN and PN in this patient group have not been comprehensively studied. The aim of the study was to systematically review the complications related to the use of nutrition in patients with predicted severe acute pancreatitis receiving EN v. PN. The Cochrane Library, MEDLINE and Scopus were searched. Randomised controlled trials (RCT) of EN v. PN in predicted severe acute pancreatitis were selected. Pooled estimates of complications were expressed as OR with corresponding 95 % CI. Data from five RCT were meta-analysed. Diarrhoea occurred in six of ninety-two (7 %) patients receiving PN and twenty-four of eighty-two (29 %) patients receiving EN (OR 0.20; 95 % CI 0.09, 0.43; P < 0.001). Hyperglycaemia developed in twenty-one of ninety-two (23 %) patients receiving PN and nine of eighty-two (11 %) receiving EN (OR 2.59; 95 % CI 1.13, 5.94; P = 0.03). Given a significant reduction in infectious complications and mortality associated with the use of EN over PN that has been consistently demonstrated in previous studies, the former should be the treatment of choice in acute pancreatitis. Further clinical studies should investigate the strategies to mitigate the complications of enteral tube feeding in patients with acute pancreatitis.

A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes

A cost-utility analysis was undertaken of enteral tube feeding (ETF) in patients with cerebrovascular accident (CVA). Mortality during ETF was established in nursing homes (n7007) or at home (n2888). Quality of life was measured (EuroQol) on a sub-sample (n25). Quality adjusted life years (QALYs) over 3 years and the cost/QALY were calculated. The cost/QALY (1 pound=1.482 euros; 30/06/05) for patients receiving ETF at home was 12,817 pounds (10,351 pounds-16,826 pounds using 95% CI for quality of life) and insensitive to the frequency of home visits (50-150% of the average frequency; 11,851 pounds-13,782 pounds), outcome of patients reverting to full oral feeding (0-100% survival; 11,023 pounds-14,440 pounds), and computed outcome of a 'control' group not given ETF (0.125-0.25 year survival; 12,991 pound-14,006 pounds). The cost/QALY in nursing homes (10,304 pounds-68,064 pounds) varied depending on the state contribution to non-medical costs and is above and below the threshold (30,000 pounds/QALY). The data suggest the cost-effectiveness of ETF in patients with CVA receiving ETF at home or in nursing homes, where the non-medical costs are paid privately, compares favourably with other interventions. The cost-effectiveness of ETF in nursing homes when the state pays all non-medical costs compares unfavourably with other treatments, raising economic, clinical, and ethical concerns.

Home enteral tube feeding in patients with inherited metabolic disorders: safety issues

Many children with inherited metabolic disorders (IMD), at risk of hypoglycaemia and metabolic decompensation, are dependent on long-term home overnight enteral tube feeding but its safety issues have not been evaluated. To identify common safety issues and carer pressures for patients with IMD on home enteral tube feeds (HETF). Thirty-four patients (53% male; median age 4.1, range: 1.2-15.8 years), with IMD on home continuous overnight tube feeds were recruited. They were all following specialized feeding regimens. A questionnaire, administered by face-to-face interview with carers identified family members involved in feeding, training they received; child safety issues; equipment reliability and carer night time disturbance. The principal problems were: carer sleep disturbance (100%); tube entanglement (71%); untrained secondary carers (71%); faulty pumps (50%); tube blockages (45%); faulty equipment (32%); and child tampering with pumps and feeding equipment (29%). Significant risks for children on HETF with IMD were identified, potentially leading to metabolic decompensation and hospitalization. The safety of feeding equipment, lack of training of extended family members and practical support for carers requires urgent attention.

Experiences with percutaneous endoscopic gastrostomy.

Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.