Ask the Experts Use of Gastric Decompression Tubes With Small-Bowel Feeding Tubes
Q
My question is in relation to the clinical practice of having an orogastric or nasogastric tube hooked up to intermittent suction while the patient is being fed with a Keofeed tube (Kendall Medical) that is in the duodenum. Is this a proper practice? Is it not safe or is it incorrect to have an orogastric or nasogastric
Author Jan Powers is director of clinical nurse specialists and nursing research and a clinical specialist in the trauma intensive care unit at St Vincent Hospital in Indianapolis, Indiana. Corresponding author: Jan Powers, RN, PhD, CCRN, CCNS, CNRN, FCCM, St Vincent Hospital, 2001 W 86th St, Indianapolis, IN 46260 (e-mail: jmpowers@ stvincent.org). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 8092273 or (949) 362-2050 (ext 532); fax, (949) 3622049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014317
84
CriticalCareNurse
tube hooked up to intermittent or continuous suction to pull out bilious gastric fluid while the patient is being fed postpylorically with a Keofeed tube?
A
Jan M. Powers, RN, PhD, CCRN, CCNS, CNRN, replies:
This is a great question. Practices may vary depending on the accepted standards at each institution. The practice of gastric tube placement when feeding via the small bowel (duodenum or jejunum) should be individualized on the basis of the patient’s condition and needs. To address this question, one must consider some of the basic physiology of the intestinal system, guideline recommendations, and the patient’s condition. Nutrition in the intensive care unit (ICU) should be started within 24 to 48 hours of admission.1 Gastric feedings are often the initial method for enteral nutrition in hospitalized patients; however, small-bowel (postpyloric) feedings via the duodenum or jejunum may be necessary when gastric motility seems to be decreased, as evidenced by increased gastric residual volumes.
It is often difficult to attain goal nutrition in ICU patients because of decreased gastric motility, which is common and is related to their disease or injury.2 Studies have demonstrated intolerance to gastric feedings with high gastric residual volumes in 46% to 51% of enterally fed patients.3,4 This decrease in motility ranges from delayed gastric emptying to gastroparesis. Researchers in several studies5-12 have demonstrated decreased gastric motility and delayed gastric emptying related to mechanical ventilation, medications, hyperglycemia, traumatic brain injury, and increased intracranial pressure. Some of the more common medications that have been implicated in delayed gastric emptying include sedatives, opioid analgesics, and vasopressors,13 all of which are commonly used in the ICU. When feedings accumulate in the stomach as a result of decreased gastric motility, it may predispose patients to reflux and/or aspiration.2 Therefore, it may be necessary to feed patients via the small bowel, alleviating the need to withhold feedings because of increased gastric residual or because of procedures, thus making it easier to attain nutrition goals.
Vol 34, No. 3, JUNE 2014
Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
www.ccnonline.org
Even when patients are fed postpylorically directly into the small bowel, gastric secretions and saliva are still present in the stomach. Normal gastric secretions and saliva production can be anywhere from 2500 to 4000 mL per day.14-16 Air also may be present in the stomach and may need to be removed to decrease gastric distention. Because of this, it is often necessary to have an orogastric or nasogastric tube placed into the stomach and connected to intermittent suction to aspirate these secretions and decompress the stomach while simultaneously feeding patients postpylorically with a small-bowel feeding tube. Simultaneous small-bowel feeding and gastric drainage would be the ideal method of providing nutrition while simultaneously avoiding aspiration. Researchers in several studies17-19 have attempted to determine the best method of doing this with percutaneously placed dual tubes, yet there remains no recognized nationally accepted standard. For some patients, simultaneous gastric tubes may not be needed during small-bowel feedings. Smallbowel feedings may be used simply because the patient has impaired swallowing and increased risk of aspiration; with no decrease in gastric motility, they will not require simultaneous gastric decompression. Therefore, placement of an orogastric or nasogastric tube is probably not warranted in this situation. It is imperative that nurses assess and evaluate feeding tolerance when patients are fed via the
www.ccnonline.org
gastric route. This evaluation is typically done with a thorough abdominal assessment and checks of gastric residuals. When it is necessary to feed patients postpylorically via the small bowel, gastric tolerance still must be assessed. This assessment may be accomplished by monitoring patients for abdominal distension, nausea, and/or vomiting. However, it is also beneficial to place an orogastric or nasogastric tube to use with intermittent suction to aspirate any gastric secretions and decompress the stomach. If a gastric tube is not present in a patient being fed via the small bowel and the patient is exhibiting any signs of gastric distention, appears to be intolerant to feedings, or is at increased risk for aspiration, the nurse should discuss with the physician the possible need for gastric decompression while feeding the patient. CCN
6.
7.
8.
9.
10. 11.
12. 13.
14.
15.
16.
Financial Disclosures None reported.
17.
References 1. McClave SA, Martindale BG, Vanek VW, et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2009;33:277-316. 2. Metheny NA, Schallom ME, Edwards SJ. Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review. Heart Lung. 2004;33(3): 131-145. 3. Heyland, D, Cook DJ, Winder B, Brylowski I, Van demark H, Guyatt G. Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med. 1995;23:1055-1060. 4. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in the critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29: 1955-1961. 5. Dive A, Moulart M, Jonard P, Jamart J, Mahieu P. Gastroduodenal motility in mechanically ventilated critically ill patients:
18.
19.
a manometric study. Crit Care Med. 1994; 22(3):441-447. Garrick T, Mulvihill S, Buack S, MaedaHagiwara M, Tache Y. Intracerebroventricular pressure inhibits gastric antral and duodenal contractility but not acid secretion in conscious rabbits. Gastroenterology. 1988;95(1):26-31. DeMeo MT, Bruninga K. Physiology of the aerodigestive system and aberrations in that system resulting in aspiration. JPEN J Parenter Enteral Nutr. 2002;26(6 suppl):S9-S17. Dive A, Foret F, Jamart J, Bulpa P, Installe E. Effect of dopamine on gastrointestinal motility during critical illness. Intensive Care Med. 2000;26(7):901-907. Murphy DB, Sutton, JA, Prescott, LF, Murphy MB. Opioid-induced delay in gastric emptying: a peripheral mechanism in humans. Anesthesiology. 1997;87(4):765-770. Lewis TD. Morphine and gastroduodenal motility. Dig Dis Sci. 1999;44(1):2178-2186. Ritz MA, Fraser R, Edwards N, et al. Delayed gastric emptying in ventilated critically ill patients: measurement by 13 C-octanoic acid breath test. Crit Care Med. 2001;29:1744-1749. Kao CH, ChanLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998;93:1108-1112. Btaiche IF, Chan L-N, Pleva M, Kraft MD. Critical illness, gastrointestinal complication, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract. 2010;25(1):32-49. Ganong W. Gastrointestinal function: digestion and absorption. In: Nightingale JM, ed. Review of Medical Physiology. 22nd ed. New York, NY: Lange Medical Books/McGraw Hill; 2005:476. Nightingale JM. Normal intestinal anatomy and physiology. In: Intestinal Failure. London, England: Greenwich Medical Media Limited; 2001:18. Guyton AC, Hall JE. Secretory function of the alimentary tract. In: Textbook of Medical Physiology. 11th ed. Philadelphia, PA: Elsevier Inc; 2006:chapter 64. Faries MB, Rombeau JL. Use of gastrostomy and combined gastrojejunostomy tubes for enteral feeding. World J Surg. 1999;23:603-607. Lucey BC, Gervais DA, Titton RL, et al. Enteric feeding with gastric decompression: management with separate gastric accesses. AJR Am J Roentgenol. 2004;183:387-390. Gentilello LM, Cortes V, Castro M, Byers PM. Enteral nutrition with simultaneous gastric decompression in critically ill patients. Crit Care Med. 1993;21(3):392-395.
Ask the Experts Do you have a clinical, practical, or
legal question you’d like to have answered? Send it to us and we’ll pass it on to our Ask the Experts panel. Questions may be mailed to Ask the Experts, Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; or sent by e-mail to [email protected]. Questions of the greatest general interest will be answered in this department each and every issue.
CriticalCareNurse
Vol 34, No. 3, JUNE 2014
Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
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Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
Use of Gastric Decompression Tubes With Small-Bowel Feeding Tubes Jan Powers Crit Care Nurse 2014, 34:84-85. doi: 10.4037/ccn2014317 © 2014 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
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Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
Q
My question is in relation to the clinical practice of having an orogastric or nasogastric tube hooked up to intermittent suction while the patient is being fed with a Keofeed tube (Kendall Medical) that is in the duodenum. Is this a proper practice? Is it not safe or is it incorrect to have an orogastric or nasogastric
Author Jan Powers is director of clinical nurse specialists and nursing research and a clinical specialist in the trauma intensive care unit at St Vincent Hospital in Indianapolis, Indiana. Corresponding author: Jan Powers, RN, PhD, CCRN, CCNS, CNRN, FCCM, St Vincent Hospital, 2001 W 86th St, Indianapolis, IN 46260 (e-mail: jmpowers@ stvincent.org). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 8092273 or (949) 362-2050 (ext 532); fax, (949) 3622049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014317
84
CriticalCareNurse
tube hooked up to intermittent or continuous suction to pull out bilious gastric fluid while the patient is being fed postpylorically with a Keofeed tube?
A
Jan M. Powers, RN, PhD, CCRN, CCNS, CNRN, replies:
This is a great question. Practices may vary depending on the accepted standards at each institution. The practice of gastric tube placement when feeding via the small bowel (duodenum or jejunum) should be individualized on the basis of the patient’s condition and needs. To address this question, one must consider some of the basic physiology of the intestinal system, guideline recommendations, and the patient’s condition. Nutrition in the intensive care unit (ICU) should be started within 24 to 48 hours of admission.1 Gastric feedings are often the initial method for enteral nutrition in hospitalized patients; however, small-bowel (postpyloric) feedings via the duodenum or jejunum may be necessary when gastric motility seems to be decreased, as evidenced by increased gastric residual volumes.
It is often difficult to attain goal nutrition in ICU patients because of decreased gastric motility, which is common and is related to their disease or injury.2 Studies have demonstrated intolerance to gastric feedings with high gastric residual volumes in 46% to 51% of enterally fed patients.3,4 This decrease in motility ranges from delayed gastric emptying to gastroparesis. Researchers in several studies5-12 have demonstrated decreased gastric motility and delayed gastric emptying related to mechanical ventilation, medications, hyperglycemia, traumatic brain injury, and increased intracranial pressure. Some of the more common medications that have been implicated in delayed gastric emptying include sedatives, opioid analgesics, and vasopressors,13 all of which are commonly used in the ICU. When feedings accumulate in the stomach as a result of decreased gastric motility, it may predispose patients to reflux and/or aspiration.2 Therefore, it may be necessary to feed patients via the small bowel, alleviating the need to withhold feedings because of increased gastric residual or because of procedures, thus making it easier to attain nutrition goals.
Vol 34, No. 3, JUNE 2014
Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
www.ccnonline.org
Even when patients are fed postpylorically directly into the small bowel, gastric secretions and saliva are still present in the stomach. Normal gastric secretions and saliva production can be anywhere from 2500 to 4000 mL per day.14-16 Air also may be present in the stomach and may need to be removed to decrease gastric distention. Because of this, it is often necessary to have an orogastric or nasogastric tube placed into the stomach and connected to intermittent suction to aspirate these secretions and decompress the stomach while simultaneously feeding patients postpylorically with a small-bowel feeding tube. Simultaneous small-bowel feeding and gastric drainage would be the ideal method of providing nutrition while simultaneously avoiding aspiration. Researchers in several studies17-19 have attempted to determine the best method of doing this with percutaneously placed dual tubes, yet there remains no recognized nationally accepted standard. For some patients, simultaneous gastric tubes may not be needed during small-bowel feedings. Smallbowel feedings may be used simply because the patient has impaired swallowing and increased risk of aspiration; with no decrease in gastric motility, they will not require simultaneous gastric decompression. Therefore, placement of an orogastric or nasogastric tube is probably not warranted in this situation. It is imperative that nurses assess and evaluate feeding tolerance when patients are fed via the
www.ccnonline.org
gastric route. This evaluation is typically done with a thorough abdominal assessment and checks of gastric residuals. When it is necessary to feed patients postpylorically via the small bowel, gastric tolerance still must be assessed. This assessment may be accomplished by monitoring patients for abdominal distension, nausea, and/or vomiting. However, it is also beneficial to place an orogastric or nasogastric tube to use with intermittent suction to aspirate any gastric secretions and decompress the stomach. If a gastric tube is not present in a patient being fed via the small bowel and the patient is exhibiting any signs of gastric distention, appears to be intolerant to feedings, or is at increased risk for aspiration, the nurse should discuss with the physician the possible need for gastric decompression while feeding the patient. CCN
6.
7.
8.
9.
10. 11.
12. 13.
14.
15.
16.
Financial Disclosures None reported.
17.
References 1. McClave SA, Martindale BG, Vanek VW, et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2009;33:277-316. 2. Metheny NA, Schallom ME, Edwards SJ. Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review. Heart Lung. 2004;33(3): 131-145. 3. Heyland, D, Cook DJ, Winder B, Brylowski I, Van demark H, Guyatt G. Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med. 1995;23:1055-1060. 4. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in the critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29: 1955-1961. 5. Dive A, Moulart M, Jonard P, Jamart J, Mahieu P. Gastroduodenal motility in mechanically ventilated critically ill patients:
18.
19.
a manometric study. Crit Care Med. 1994; 22(3):441-447. Garrick T, Mulvihill S, Buack S, MaedaHagiwara M, Tache Y. Intracerebroventricular pressure inhibits gastric antral and duodenal contractility but not acid secretion in conscious rabbits. Gastroenterology. 1988;95(1):26-31. DeMeo MT, Bruninga K. Physiology of the aerodigestive system and aberrations in that system resulting in aspiration. JPEN J Parenter Enteral Nutr. 2002;26(6 suppl):S9-S17. Dive A, Foret F, Jamart J, Bulpa P, Installe E. Effect of dopamine on gastrointestinal motility during critical illness. Intensive Care Med. 2000;26(7):901-907. Murphy DB, Sutton, JA, Prescott, LF, Murphy MB. Opioid-induced delay in gastric emptying: a peripheral mechanism in humans. Anesthesiology. 1997;87(4):765-770. Lewis TD. Morphine and gastroduodenal motility. Dig Dis Sci. 1999;44(1):2178-2186. Ritz MA, Fraser R, Edwards N, et al. Delayed gastric emptying in ventilated critically ill patients: measurement by 13 C-octanoic acid breath test. Crit Care Med. 2001;29:1744-1749. Kao CH, ChanLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998;93:1108-1112. Btaiche IF, Chan L-N, Pleva M, Kraft MD. Critical illness, gastrointestinal complication, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract. 2010;25(1):32-49. Ganong W. Gastrointestinal function: digestion and absorption. In: Nightingale JM, ed. Review of Medical Physiology. 22nd ed. New York, NY: Lange Medical Books/McGraw Hill; 2005:476. Nightingale JM. Normal intestinal anatomy and physiology. In: Intestinal Failure. London, England: Greenwich Medical Media Limited; 2001:18. Guyton AC, Hall JE. Secretory function of the alimentary tract. In: Textbook of Medical Physiology. 11th ed. Philadelphia, PA: Elsevier Inc; 2006:chapter 64. Faries MB, Rombeau JL. Use of gastrostomy and combined gastrojejunostomy tubes for enteral feeding. World J Surg. 1999;23:603-607. Lucey BC, Gervais DA, Titton RL, et al. Enteric feeding with gastric decompression: management with separate gastric accesses. AJR Am J Roentgenol. 2004;183:387-390. Gentilello LM, Cortes V, Castro M, Byers PM. Enteral nutrition with simultaneous gastric decompression in critically ill patients. Crit Care Med. 1993;21(3):392-395.
Ask the Experts Do you have a clinical, practical, or
legal question you’d like to have answered? Send it to us and we’ll pass it on to our Ask the Experts panel. Questions may be mailed to Ask the Experts, Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; or sent by e-mail to [email protected]. Questions of the greatest general interest will be answered in this department each and every issue.
CriticalCareNurse
Vol 34, No. 3, JUNE 2014
Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
85
Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
Use of Gastric Decompression Tubes With Small-Bowel Feeding Tubes Jan Powers Crit Care Nurse 2014, 34:84-85. doi: 10.4037/ccn2014317 © 2014 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
E-mail alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at RUTGERS UNIVERSITY on June 5, 2015
