Adult Enteral Feeding guidelines

Full Title of Guideline: Adult Enteral Feeding guidelines – Section 9.0

Complications of Enteral feeding
Author (include email and role): Anne How (Therapy Service Manager in Dietetics)
anne.how@nuh.nhs.uk
Tracey Buchanan (Nutrition Nurse)
Tracey.Buchanan@nuh.nhs.uk
Division & Speciality: Clinical Support (Therapy Services)
Surgery (Nutrition)
Scope (Target audience, state if Trust Trust Wide
wide):
Review date (when this version goes out 01/04/2022
of date):
Explicit definition of patient group All adult patients who are being considered for or are
to which it applies (e.g. inclusion and receiving enteral nutrition
exclusion criteria, diagnosis):
Changes from previous version (not Structural changes
applicable if this is a new guideline, enter Some changes made in some sections based on recently
below if extensive): published NHS Improvement documents
Summary of evidence base this See references
guideline has been created from:
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

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Section Content Page
9.0 COMPLICATIONS OF Insertion related 2
ENTERAL FEEDING Tube related 3
Feeding related 3
Diarrhoea 3
Constipation 7
Regurgitation, nausea, vomiting or 7
aspiration
Management of unexpected 9
discontinuation of enteral feeding

9.0 COMPLICATIONS OF ENTERAL FEEDING

Complications can happen at any time whilst a feeding tube is in situ and/or used for
feeding so it is important that the patient is monitored closely throughout.
Complications can be categorised into 3 areas
 Insertion related
 Tube related
 Feeding related

9.1 INSERTION RELATED:

 Tube misplacement, eg into lungs or in the case of stomas into peritoneal

cavity

 Aspiration

 Tube removal, accidental or otherwise (see section 8.4 Management of

unexpected discontinuation of enteral feeding)

 Organ perforation (Oesophageal perforation for NG, small bowel for NJ and

colon/ small bowel/ liver for stoma)

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9.2 TUBE RELATED:

 Pulmonary aspiration and chest infection

 Tube blockage

 Tissue damage

 Special groups such as diabetics or patients absolutely dependent on regular

medication)

9.3 FEEDING RELATED:

 Diarrhoea

 Constipation

 Nausea and vomiting

 Regurgitation/ reflux

 Metabolic disturbances (rare) and usually occur in the early phase of feeding

in a patient who has been fasted for a prolonged period of time or in diabetic

patients, e.g. refeeding syndrome (see separate refeeding syndrome guideline

Prevention and Management of Refeeding Syndrome: Guidelines for Adults

(2014))

9.3.1 DIARRHOEA

Diarrhoea can be defined as “loose stools sufficient to inconvenience patients and/or

staff”, or “at least 3 loose stools /day for at least 2 days or a volume of >500ml of

stool for at least 2 days”.

Bowel frequency and stool form in patients receiving enteral tube feeds may be

different from when they were having diet orally, so it is important that patients,

carers and staff are aware of this. However, enteral tube feeding related diarrhoea

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occurs in up to 30% of enterally fed patients on medical and surgical wards and in

more than 80% of patients on intensive care units (Whelan and Schneider (2011),

Jack et al (2010), Stroud et al (2003), Ritz et al (2000).

The pathogenesis of diarrhoea in enterally tube fed patients is multifactorial. New or

pre-existing disease-related pathology e.g. colitis/enteritis, malabsorption, gut motility

disorders, should be excluded as potential causes in the first instance. Other causes

of enteral tube feeding related diarrhoea include infection, with C.difficile found in 20-

50% of patients with antibiotic related diarrhoea. See also Guidelines for the

management of C Diff. Patients on a tube feed are 9 times more likely to develop

C.difficile associated diarrhoea than non-tube fed patients (Bliss et al 1998).

9.3.1.1 MONITORING FOR DIARRHOEA:

Monitor stool type, frequency and volume on a Bristol Stool Chart, keep strict fluid

balance charts (paper rather than Eobs) and monitor electrolyte levels. IV fluid

replacement and electrolyte replacement should be given if required.

The diagnosis of C.difficile infection is via a diarrhoeal stool specimen. It is one

episode defined as either a stool loose enough to take the shape of a container used

to sample it, or as per the Bristol Stool Chart types 5-7. Specimens that are not type

5-7 will not be processed. Type 5-7 specimens of diarrhoea from in-patients over the

age of 16 years are routinely tested.

Best Practice
All patients with new onset diarrhoea must have enteric precautions in place (brown
special precautions card) and contact the Infection Prevention and Control Team.
Stool sample sent for microbial culture and sensitivity and C.difficile.

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TABLE 1 CAUSES, PREVENTION AND TREATMENT OF DIARRHOEA IN
ENTERAL TUBE FEEDING (Blumenstein at al 2014)
Diarrhoea Causes Prevention/Treatment

Overflow diarrhoea. See constipation section for

Low albumin can cause gut oedema (there
is more water in the bowel due to osmotic
pressure).
Antibiotic therapy favors the growth of
C.diff, E.coli and Klebsiellae.
Chemotherapy/ Radiotherapy.
Fat malabsorption (particularly in
pancreatic insufficiency, biliary obstruction
or extensive ileal/ small bowel resection).
Lactose intolerance.
Feed rate too rapid (higher rate tolerance
issues more common in jejunally fed
patients).
Temperature of the feed
Bacterial/ microbial contamination of the
feed or equipment.
Medications.
prevention and treatment.
Treat the cause of the low albumin
i.e. sepsis.
Review the antibiotics. Guidelines
for the management of C Diff
Consider prescribing anti-
diarrhoeal medication if other
causes of diarrhoea have been
excluded (CDT –ve).
Dietitian review to consider
prescribing a medium chain
triglyceride (MCT) enteral feed.
Ensure use of low lactose or
lactose free feeds required.
Dietitian can advise as required.
Request a Dietitian review. In the
interim reduction in rate can be
considered.
Cold feed can cause diarrhoea.
Ensure enteral feeds are stored at
room temperature
Handle feed equipment
hygienically, change the giving sets
every 24hours
See table below for a list of
medications that can cause
diarrhoea.

9.3.1.2 FIBRE AND ENTERAL FEEDING:

The enteral feed per se is rarely the cause of enteral feeding related diarrhoea. In

patients receiving long term enteral feeding there may be some benefit in reviewing

the type of feed as fibre containing formulae can sometimes improve stool form. If

other causes, as described above, have been excluded then the dietitian should be

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contacted at the earliest opportunity to consider changes to the enteral feeding
regimen.
TABLE 2 SUMMARY OF THE DIARRHOEA GUIDANCE AFTER A STOOL
SAMPLE RESULT
If stool sample +ve
Treat according to Trust Guidelines
for the infection
Review tube or stoma management
to ensure that there is no cross
contamination of tubes or stomas
If stool sample –ve
Review medications – consider altering or
stopping:
 Laxatives
 Drugs with side-effect of diarrhoea
including
- Antibiotics
- Anti-hypertensives
- Oral magnesium/ phosphate
replacement
- Antacids -H2 blockers or proton pump
inhibitors ( PPI’s)
- Prokinetic agents
- Drugs containing active fillers i.e.
sorbitol
- Antiarrhythmics
- NSAIDs
Consider specific gastrointestinal causes
and seek help from the NST/ Dietitian
If no cause can be identified use anti-
diarrhoeals.
But NEVER use antidiarrhoeal agents in
patients with infective or bloody
diarrhoea. Seek Gastro review if this
occurs.
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9.3.2 MANAGEMENT OF CONSTIPATION IN ENTERALLY-FED PATIENTS:

Bowel frequency and stool form in patients being enterally fed may be different from

when they were having oral diet, and patients, carers and staff need to be aware of

this. Constipation is defined as difficulty in passing stools or incomplete or infrequent

passage of hard stools.

As with all patients, constipation is usually due to a combination of inadequate fluid

intake, dehydration, reduced mobility and drug side-effects. Clinical condition should

be reviewed to ensure no other explanation such as colonic pathology or motility

disorder.

Ensuring adequate fluid intake is of utmost importance in preventing and treating

constipation. Fibre-containing feeds can be beneficial and will usually be prescribed

by dietitians for long-term enteral feeding unless contra-indicated, but it is even more

important that sufficient fluid is provided if fibre is being used. The dietitian should be

contacted to review the fluid and fibre content of the feeding regimen.

Medication should be reviewed to identify and if appropriate stop any anti-diarrhoeal

drugs being prescribed. Consideration should also be given to stopping / altering

drugs where constipation is a side-effect, e.g. opiates.

Constipation should be treated in the usual way with laxatives and suppositories.

9.3.3 MANAGEMENT OF ENTERALLY-FED PATIENTS WITH REGURGITATION,

NAUSEA, VOMITING OR ASPIRATION:

Regurgitation is defined as “the return to the mouth of food already present in the

oesophagus or stomach”. A patient with an enteral tube feed may report

regurgitation or staff may see feed in a patient’s mouth or when they cough, or hear

gurgling sounds. Regurgitation and vomiting can both lead to secondary aspiration,

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particularly in patients with an unsafe swallow. Both nasogastric and gastrostomy

feeding can be associated with the risk of secondary aspiration as can jejunal

feedings if the tubes become displaced.

TABLE 3: MANAGEMENT OF ENTERALLY-FED PATIENTS WITH

REGURGITATION, NAUSEA, VOMITING OR ASPIRATION:

Nausea, vomiting or regurgitation of feed

Check administration of feeding regimen:

 Are appropriate infection control measures being followed e.g. correct

hanging time, use-by date of feed, feed stored at the correct temperature (see

section on Administration of feeds

 Correct feed type and rate or bolus size

 Tube position checked – also re-check NG or NJ position after any

episode of vomiting

Patient position – at 30-45° during feeding and for thirty minutes afterwards

Review medications

 Consider stopping / altering those with nausea or vomiting as side-effect

 Consider trialling pro-kinetics and / or anti-emetics

Consider clinical cause including gastrointestinal condition, infection, constipation,

treat as necessary

Bacterial feed contamination can also cause gastrointestinal related problems and so

it is vital to prevent microbial contamination when setting up enteral feeds, by using

closed enteral feeding systems whenever possible and following guidance when

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setting up enteral feeds

Monitor hydration status, fluid balance and electrolyte levels.

Consider IV fluids and electrolytes. Consider if the route of medications needs to be

altered

Contact dietitian and/or Nutrition Support Team and / or Gastro Team for further

advice

9.4 MANAGEMENT OF UNEXPECTED DISCONTINUATION OF ENTERAL

FEEDING:

Unexpected discontinuation of enteral feeding by tube or stoma may occur and for

some patients this can have serious metabolic and or nutritional consequences. If

unexpected discontinuation occurs the following steps should be taken:

1. Check that the patient’s environment is safe

2. Displaced tubes removed and disposed of

3. Partially displaced NG tubes may be left in situ until review by someone

competent in replacement unless the patient is in distress when the tube

should be removed

4. Running pumps switched off

5. Hanging feeds disposed of

6. Can the feed be re-established within the next 2 hours?

If feed cannot be restarted in 2 hours, consider the following:

1. Is the patient on insulin or oral hypoglycaemic agents? If so please monitor

BMs hourly until review by the medical team and request review within 2

hours. If feeding cannot be re-established the medical team will decide

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 whether the patient needs to be converted onto sliding scale insulin or if it is

sufficient to stop or reduce their diabetic medication

2. Is the patient dependent on the tube or stoma for their medication? If so

request a review by medical team before next drugs are due to determine

which if any drugs need to be given by another route until enteral access is re-

established

3. Is the patient dependent on the tube or stoma for hydration? If so request a

review by the medical team within 4 hours so that parenteral or subcutaneous

fluids can be prescribed until enteral access is re-established

4. Is this route of enteral feeding access being lost recurrently (eg NG tubes

being pulled out)? If it is discuss the most appropriate route of feeding access

with the patient’s medical team. Assess and document the reason for

discontinuation of the feed and the actions you have taken in the patient’s

record

Adherence to the guidelines above should minimise these problems. Should they

occur, contact the nutrition team.

References

Bliss DZ, Johnson S, Savik K, Clabots CR, Willard K, Gerding DN. (1998) Acquisition
of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized
patients receiving tube feeding. Ann Inter n Med. ;129:1012–1019.

Blumenstein I, Shastri YM, and Stein J 2014Gastroenteric tube feeding:

Techniques, problems and solutions World J Gastroenterol.; 20(26): 8505–8524.

Jack L, Coyer F, Courtney M, Venkatesh B.(2010) Diarrhoea risk factors in enterally

tube fed critically ill patients: a retrospective audit. Intensive Crit Care Nurs.;26:327–
334.

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Ritz MA, Fraser R, Tam W, Dent J.(2000) Impacts and patterns of disturbed
gastrointestinal function in critically ill patients. Am J Gastroenterol. 2000;95:3044–
3052.

Stroud M, Duncan H, Nightingale J.(2003) Guidelines for enteral feeding in adult

hospital patients. Gut.;52 Suppl 7:vii1–vii12.

Whelan K, Schneider SM. (2011) Mechanisms, prevention, and management of

diarrhea in enteral nutrition. Curr Opin Gastroenterol. 2011;27:152–159.

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