Preventing respiratory complications of tube feedings: evidence-based practice.

The most dreaded complication of tube feedings is tracheobronchial aspiration of gastric contents. Strong evidence indicates that most critically ill tube-fed patients receiving mechanical ventilation aspirate gastric contents at least once during their early days of tube feeding. Those who aspirate frequently are about 4 times more likely to have pneumonia develop than are those who aspirate infrequently. Although a patient's illness might not be modifiable, some risk factors for aspiration can be controlled; among these are malpositioned feeding tubes, improper feeding site, large gastric volume, and supine position. A review of current research-based information to support modification of these risk factors is provided.     

Assuring successful home enteral feedings

As increased numbers of acutely and chronically ill patients are cared for in the home environment, the need for high-tech services such as enteral feedings will increase. This article has outlined some areas to be considered in order to assure a successful tube-feeding experience for patient, family, and caregivers. As new information becomes available from home health research, clinical practices will need to be revised and refined to incorporate this new data. It is evident that current practices in the area of enteral feeding as well as other high-tech areas are somewhat arbitrary and that many critical questions about policies and procedures remain unanswered. It is to be hoped that clinicians and administrators of home health agencies will continue to collaborate with nursing faculty to engage in and promote research and study of these areas and share their findings with others. Only in this way can all home care patients be assured of the highest quality care.     

Enteral feedings with comfort and safety

Patients who are unable to eat by mouth can be fed in a manner that maintains the structural and functional integrity of the gastrointestinal tract. The appropriate choice of type of feeding tube to use is based on the reasons patients need to be tube fed and the expected duration of need for the tube. Once the tubes are placed, verification of placement is critical for safe use. Patients, family caregivers, and staff must assess for potential complications. Misplacement is the most common problem of feeding tubes. Life-threatening complications can include "refeed syndrome" and "buried bumper syndrome." Additional threats include contaminated tube feeding and inappropriate medication administration. Feeding too rapidly into the small intestine can cause necrosis of the small bowel. To maintain patient comfort, site care is critical. Nasogastric tubes can cause permanent deformity of the nares. Gastric drainage on the skin can cause painful excoriation that is difficult to manage. With careful monitoring of tube feedings, positive nutritional status can be achieved. A positive nutritional status assists in promoting health and immune function.     

Effect of acidified enteral feedings on gastric colonization in the critically ill patient.

OBJECTIVE: To evaluate the effect of acidified enteral nutritional formulas (feedings) on gastric colonization and pH in critically ill patients. DESIGN: Randomized, double-blind trial of three groups: a) regular feedings into the stomach; b) regular feedings into the duodenum; and c) acidified feedings into the stomach. Nasogastric aspirates for gastric pH and microbiological determinations were obtained daily for a mean of 5 days after feeding began. SETTING: ICU at a tertiary care hospital. PATIENTS: Thirty-one patients indicated to receive enteral feedings before day 4 in the ICU were randomized. Seven patients had their feedings discontinued because of intolerance, accidental extubation, or tolerance of oral supplementation. One patient received the wrong feedings and was dropped from the study. A total of 23 patients finished the study. They were mostly trauma (n = 15) or neurosurgical (n = 6) patients. The average age was 40 yrs (range 15 to 71). INTERVENTIONS: An enteral formula with a pH of 6.5 was used as the control feeding. Hydrochloric acid was added to the control feeding to titrate the pH to 3.5 and this acidified enteral formula was given to the experimental group. All patients received continuous enteral feedings via an 8-Fr feeding tube. MAIN RESULTS: Seven of eight patients receiving the acidified feedings were sterile (no microbial growth) on receiving feedings compared with five of 15 of those patients receiving regular feedings (p = .027). For those patients initially colonized, four of four patients receiving acidified feedings immediately became sterile and remained so. Only two of ten patients receiving regular feedings remained sterile (p = .021). The mean gastric pH of the acidified group was 3.2 compared with the group receiving regular feedings into the stomach (pH = 4.7) and the group receiving regular feedings into the duodenum (pH = 3.8) (p < .01). There was no evidence of gastrointestinal bleeding in any patient. CONCLUSIONS: Acidified enteral feedings are effective in eliminating and preventing gastric colonization in critically ill patients. Further investigation is needed to assess its effect on nosocomial infection rates.