NUTRITION SUPPORT CERTIFICATE

Administration of
Nutrition Support,
Part 2

Planned by the American Society of Health-System Pharmacists (ASHP) in collaboration with

the American Society for Parenteral and Enteral Nutrition (ASPEN).

©2022 American Society of Health-System Pharmacists, Inc. All rights reserved.

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 ADMINISTRATION OF
NUTRITION SUPPORT
PART 2
Todd W. Canada, Pharm.D., BCNSP, BCCCP,
FASHP, FTSHP, FASPEN
Univers ity of Texas MD Anders on
Canc er Center

NUT RI T I O N S UPPO RT
CE RT I FI CAT E

RELEVANT FINANCIAL
RELATIONSHIP DISCLOSURE
The following persons in control of this activity’s content have relevant financial
relationships:

 Andrew Mays: Fresenius Kabi, speaker

All other persons in control of content do not have any relevant financial
relationships with an ineligible company.

As defined by the Standards of Integrity and Independence definition of ineligible company. All relevant financial
relationships have been mitigated prior to the CPE activity.

NUT RIT IO N SUP P O RT

CE RT IF ICAT E
LEARNING OBJECTIVES

 Outline safe medication administration practices with concurrent enteral or

parenteral nutrition.
 Distinguish steps in managing total nutrient admixture vs. 2-in-1 parenteral
nutrition with separate lipid injectable emulsion infusions.

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KEY ABBREVIATIONS

 EN: enteral nutrition

 GI: gastrointestinal
 ILE: lipid injectable emulsion
 IV: intravenous
 PN: parenteral nutrition
 TNA: total nutrient admixture

NUT RIT IO N SUP P O RT

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SELF -ASSESSMENT #1

A 61-year-old male with Type 2 diabetes mellitus and benign prostatic hypertrophy
is admitted with urosepsis in the intensive care unit. He is an ill appearing male (80
kg, 5’10”) with a nasogastric tube placed. Which of the following medications would
be MOST appropriate to administer through his nasogastric tube?

A. Tamsulosin 0.4 mg daily

B. Doxazosin 2 mg daily
C. Metformin ER 2000 mg daily
D. Metformin ER 500 mg TID

NUT RIT IO N SUP P O RT

CE RT IF ICAT E

SELF -ASSESSMENT #2

A 55-year-old female with acute myelogenous leukemia and typhilitis is receiving

parenteral nutrition. She has multiple IV medications that the nurse is asking you
about Y-site compatibility with the PN. Which of the following medications would be
compatible to administer via Y-site with the PN?

A. Acyclovir
B. Amphotericin B
C. Ondansetron
D. Piperacillin/Tazobactam

NUT RIT IO N SUP P O RT

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SAFE MEDICATION PRACTICES
WITH EN
 Dependent on type of feeding tube used:
– Gastrostomy
– Transgastric jejunostomy
• Be aware the use of each lumen and avoid medication administration
into stomach when concerns about suctioning the medication before it
can be absorbed may occur (e.g., proton pump inhibitors)
 50% of patients experience ingredient-related diarrhea when using enteral access
tubes for medication administration (especially sorbitol-containing medications)
 Many liquid formulations of medications have osmolalities far exceeding that of the
GI tract
– Diarrhea, cramping, abdominal distention, and vomiting
NUT RIT IO N SUP P O RT
McIntyre CM et al. Am J Health-Syst Pharm. 2014; 71:549-56. CE RT IF ICAT E

SAFE MEDICATION PRACTICES

WITH EN, CONT.
 Nasoduodenal
 Nasojejunal
 Jejunostomy
– Significant risk of drug-nutrient interactions as both food (enteral nutrition)
and medications are administered concurrently
– Post-pyloric administration assumes the medication can be absorbed where
it enters the GI tract
• Intestinal site of absorption of most medications is lacking
• Potential increased toxicity due to lack of degradation from gastric acid
or decreased first-pass metabolism (e.g., azathioprine)
• Treatment failure
NUT RIT IO N SUP P O RT
McIntyre CM et al. Am J Health-Syst Pharm. 2014; 71:549-56. CE RT IF ICAT E
SAFE MEDICATION PRACTICES
WITH EN, CONT.
 Nasoduodenal
 Nasojejunal
 Jejunostomy
– Avoid use of aspirin and ferrous sulfate post-pylorically
• Require gastric acid for absorption and can only be administered into the
stomach
– Increased absorption has occurred post-pylorically for:
• Ciprofloxacin, fluconazole, pravastatin, zinc, azathioprine
– Decreased absorption has occurred post-pylorically for:
• Allopurinol, baclofen, calcium, gabapentin, sirolimus
NUT RIT IO N SUP P O RT
McIntyre CM et al. Am J Health-Syst Pharm. 2014; 71:549-56. CE RT IF ICAT E

SAFE MEDICATION PRACTICES

WITH EN, CONT.
 Avoid solid dosage form medications resulting in a significant change in absorption
of the active ingredient if opened (e.g., capsule) or crushed (e.g., tablet)
– Immediate release products only
 Evaluate each medication for its inherent solubility and release characteristics
– Consider alternative dosage form, drug or route of administration
• Enteric coated or extended/sustained release especially
– May lead to occluded feeding tube
– Increased drug toxicity if crushed
 Do not add medication directly to an enteral feeding formula

NUT RIT IO N SUP P O RT

Boulatta JI et al. JPEN J Parenter Enteral Nutr. 2017; 41(1):15-103. CE RT IF ICAT E
SAFE MEDICATION PRACTICES
WITH EN, CONT.
 Only crush simple compressed tablets to fine powder and mix with purified water
 Only open hard gelatin capsules and mix powder containing the immediate release
medication with purified water
 Provide feeding tube irrigation around the timing of drug administration
– Prior to medication administration, stop the enteral feeding and flush the tube
with at least 15 mL water
– Administer the medication using a clean ENFIT syringe
– Flush the tube again with at least 15 mL water
– Repeat with the next medication
– Restart the enteral feeding in a timely manner
NUT RIT IO N SUP P O RT
Boulatta JI et al. JPEN J Parenter Enteral Nutr. 2017; 41(1):15-103. CE RT IF ICAT E

SAFE MEDICATION PRACTICES

WITH EN, CONT.
 Enteral feeding tubes with an internal diameter equal to or greater than 10 French
are best for administering crushed or dissolved solid dosage medications
– Tubes less than 10 French require medications in a liquid formulation with
few residual solids (e.g., homogeneous)
• Smaller tube sizes are prone to clogging
 Institute for Safe Medication Practices resource:
– Do Not Crush list

NUT RIT IO N SUP P O RT

Boulatta JI et al. JPEN J Parenter Enteral Nutr. 2017; 41(1):15-103. CE RT IF ICAT E
SAFE MEDICATION PRACTICES
WITH PN
 Venous access device determines parenteral drug compatibility in the setting of
PN
– Single lumen catheters are the greatest challenge as separate IV
administration of other medications with PN is not always possible
• If simultaneous IV administration with PN is inevitable, utilize available IV
drug compatibility resources (e.g., Handbook of Injectable Drugs)
• Y-site administration has limited published resources with PN
– 106 drugs evaluated with 83 deemed compatible
– Incompatible drugs included: acyclovir, amphotericin B, haloperidol,
heparin, lorazepam, ondansetron
• Contact manufacturer(s) for new PN or ILE product compatibility
NUT RIT IO N SUP P O RT
Trissel LA et al. JPEN J Parenter Enteral Nutr. 1999; 23(2):67-74. CE RT IF ICAT E

MANAGING PN WITH SEPARATE

ILE INFUSIONS
 Possible threats to inadvertent PN administrations
– Both PN and separate ILE on same IV pole
• Using 2 separate pumps increases risk for rate error
– Double check of pump settings needed by 2nd nurse prior to start of
infusions
– Inadequate room lighting
• Routinely trace lines back to source
– Lines confused despite color differences of IV products
– Confusion of rates of PN and separate ILE
– Omission of in-line filter placement
NUT RIT IO N SUP P O RT
Simmons D et al. Nutr Clin Pract. 2011; 26(3):286-93. CE RT IF ICAT E
ADVANTAGES AND
DISADVANTAGES OF TNA
Advantages Disadvantages
  Pharmacy preparation and nursing  Macronutrients limited to one
administration time manufacturer
 Only one infusion pump required  Cannot see particulate matter
  risk of touch contamination  Cannot infuse ILE through a 0.22
micron in-line filter
  Rate of microbial growth vs. ILE – Requires 1.2 micron in-line filter
alone as for all PN formulations
 Improved oxidation of lipids  Risk of ILE instability

NUT RIT IO N SUP P O RT

Derenski K et al. Nutr Clin Pract. 2016; 31(5):578-95. CE RT IF ICAT E

PRE-CPOE PN SAFETY
IMPLICATIONS
Percentage of PN Errors
 Prospective, observational study in
a large teaching hospital with a 50
39.2
nutrition support team; 4730 PN 40 35.1
prescriptions reviewed and 74 30 24.3
errors observed: 20
– 63% transcription and 10
1.4
preparation errors 0
– 35.1% administration errors
 8% contributed to or resulted in
temporary patient harm
 15.6 errors/1000 PN prescriptions Steps in PN process
NUT RIT IO N SUP P O RT
Sacks GS et al. Pharmacotherapy. 2009; 29:966-74. CE RT IF ICAT E
POST-CPOE PN SAFETY
IMPLICATIONS
Percentage of PN Errors
 Observational study in a 350-bed 95
urban pediatric hospital, 84,503 100
prescriptions for PN reviewed and 80
230 errors observed: 60
– 95% related to administration 40
– 9.1% contributed to or 20
3 0 2
resulted in temporary patient 0
harm
– 2.7 errors/1000 PN
prescriptions
Steps in PN process
NUT RIT IO N SUP P O RT
MacKay M et al. Nutr Clin Pract. 2016; 31:195-206. CE RT IF ICAT E

SELF -ASSESSMENT #1

A 61-year-old male with Type 2 diabetes mellitus and benign prostatic hypertrophy
is admitted with urosepsis in the intensive care unit. He is an ill appearing male (80
kg, 5’10”) with a nasogastric tube placed. Which of the following medications would
be MOST appropriate to administer through his nasogastric tube?

A. Tamsulosin 0.4 mg daily

B. Doxazosin 2 mg daily
C. Metformin ER 2000 mg daily
D. Metformin ER 500 mg TID

NUT RIT IO N SUP P O RT

CE RT IF ICAT E
SELF -ASSESSMENT #1

A 61-year-old male with Type 2 diabetes mellitus and benign prostatic hypertrophy
is admitted with urosepsis in the intensive care unit. He is an ill appearing male (80
kg, 5’10”) with a nasogastric tube placed. Which of the following medications would
be MOST appropriate to administer through his nasogastric tube?

A. Tamsulosin 0.4 mg daily

B. Doxazosin 2 mg daily
C. Metformin ER 2000 mg daily
D. Metformin ER 500 mg TID

NUT RIT IO N SUP P O RT

CE RT IF ICAT E

SELF -ASSESSMENT #2

A 55-year-old female with acute myelogenous leukemia and typhilitis is receiving

parenteral nutrition. She has multiple IV medications that the nurse is asking you
about Y-site compatibility with the PN. Which of the following medications would be
compatible to administer via Y-site with the PN?

A. Acyclovir
B. Amphotericin B
C. Ondansetron
D. Piperacillin/Tazobactam

NUT RIT IO N SUP P O RT

CE RT IF ICAT E
SELF -ASSESSMENT #2

A 55-year-old female with acute myelogenous leukemia and typhilitis is receiving

parenteral nutrition. She has multiple IV medications that the nurse is asking you
about Y-site compatibility with the PN. Which of the following medications would be
compatible to administer via Y-site with the PN?

A. Acyclovir
B. Amphotericin B
C. Ondansetron
D. Piperacillin/Tazobactam

NUT RIT IO N SUP P O RT

CE RT IF ICAT E

CONCLUSIONS

 Safe use of medication administration via an enteral feeding tube requires:

– Knowledge of proximal end of tube in GI tract for drug absorption
– Osmolality of medication and use of other excipients such as sorbitol
– Dosage form that is immediate release
– Adequate flushing of the feeding tube before and after medication
 Safe use of medication administration via Y-site with PN requires:
– Confirmed drug compatibility (e.g., Handbook of Injectable Drugs)
– Other IV site or enteral options if no compatibility information exists
 Use of PN with separate ILE infusion increases the risk of administration errors

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REFERENCES

 Boullata JI, Carrera AL, Harvey L et al. A.S.P.E.N. safe practices for enteral nutrition
therapy. JPEN J Parenter Enteral Nutr. 2017; 41(1):15-103.
 Derenski K, Catlin J, Allen L. Parenteral nutrition basics for the clinician caring for the adult
patient. Nutr Clin Pract. 2016; 31(5):578-95.
 MacKay M, Anderson C, Boehme S et al. Frequency and severity of parenteral nutrition
medication errors at a large children’s hospital after implementation of electronic ordering
and compounding. Nutr Clin Pract. 2016; 31(2):195-206.
 McIntyre CM, Monk HM. Medication absorption considerations in patients with postpyloric
enteral feeding tubes. Am J Health-Syst Pharm. 2014; 71(7):549-56.
 Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related
to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy.
2009; 29(8):966-74.

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REFERENCES, CONT.

 Simmons D, Symes L, Guenter P et al. Tubing misconnections: Normalization of deviance.

Nutr Clin Pract. 2011; 26(3):286-93.
 Trissel LA, Gilbert DL, Martinez JF et al. Compatibility of medications with 3-in-1 parenteral
nutrition admixtures. JPEN J Parenter Enteral Nutr. 1999; 23(2):67-74.

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NUT RI T I O N S UPPO RT
CE RT I FI CAT E
 Todd W. Canada, Pharm.D., BCNSP, BCCCP, FASHP, FTSHP, FASPEN
Clinical Pharmacy Services Manager
Nutrition Support Team Coordinator
University of Texas MD Anderson Cancer Center
Houston, Texas

Todd W. Canada serves as a clinical pharmacy services manager and

nutrition support team coordinator for the University of Texas MD
Anderson Cancer Center in Houston, Texas. He received his B.S. in Pharmacy
from the University of Oklahoma Health Sciences Center and his post-
baccalaureate Pharm.D. from the University of Texas Health Science Center
at San Antonio.

Dr. Canada completed a specialized residency in Critical Care / Nutrition Support at the University of
Tennessee-Memphis and has been board certified in nutrition support since 1996 and critical care since
2016. Dr. Canada has previously served on the Board of Pharmaceutical Specialties – Nutrition Support
Specialty Council and the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of
Directors. He was the recipient of the ASPEN Distinguished Nutrition Support Pharmacist Service Award
in 2011 and Stanley Serlick Safety Award in 2017.
Relevant Financial Relationship Disclosure
In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing
Education, ASHP requires that all individuals in control of content disclose all financial relationships with
ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship
with ineligible company in any dollar amount in the past 24 months and the educational content that the
individual controls is related to the business lines or products of the ineligible company.
An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services
consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed
to the activity audience.

The following persons in control of this activity’s content have relevant financial relationships:
• Phil Ayers: Fresenius Kabi, consultant and speaker
• David Evans: Fresenius Kabi, consultant and speaker; Abbott Laboratories, consultant and speaker;
CVS/OptionCare, consultant; Alcresta, consultant and speaker
• Andrew Mays: Fresenius Kabi, speaker
• Jay Mirtallo: Fresenius Kabi, consultant
• Kris Mogensen: Baxter, speaker; ThriveRx, advisory board; Pfizer, advisory board

All other persons in control of content do not have any relevant financial relationships with an ineligible company.

As required by the Standards of Integrity and Independence in Accredited Continuing Education definition of ineligible
company, all relevant financial relationships have been mitigated prior to the CPE activity.

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