Troubleshooting Common Nutrition Support Problems
We’ve all been there. You walk in to your patient’s room to find that tube feeding infusion is being held…again. What could it be this time? Before you have another conversation about gastric residual volumes, blood sugars, or diarrhea, arm yourself with the best solutions to help ensure your patients get what they need.
For Enteral Nutrition
The Problem: The patient is having “high” gastric residual volumes.
The Solution: First, find out what is meant by “high.” According to the 2016 ASPEN Critical Care Guidelines, any gastric residual less than 500 ml is not considered significant or an indication of intolerance. In fact, ASPEN suggests discontinuing regular monitoring of gastric residuals, as they are no longer considered to be a indication of tube feeding intolerance. Instead, look for abdominal distention or complaints of nausea as markers of intolerance. If there truly is an issue with intolerance, first recommend to add a prokinetic agent (like metoclopramide or erythromycin). If that doesn’t work, switch to a small bowel feeding tube, if possible.
The Problem: The patient is having diarrhea, so tube feeding is held.
The Solution: Tube feeding always seems to get blamed for a patient’s diarrhea. Instead of holding enteral nutrition, ASPEN recommends continuing infusion while investigating alternative causes. Recommend to check stool studies for infections, like C. diff, and review the patient’s medication list. Antibiotics, particularly the fluoroquinolones (ciprofloxacin, levofloxacin, etc.), are notorious for causing diarrhea. If the tube feeding does seem to be the true cause of the diarrhea, there are a few strategies to try. First, reduce the infusion rate, if possible, or change from bolus to continuous feeding. (Never bolus feed into a small bowel feeding tube!) You may also try adding soluble fiber or trial a fiber-containing formula.
The Problem: The feeding tube is clogged!
The Solution: Contrary to popular belief, remedies like using cranberry juice or cola to unclog the tube will likely be unsuccessful. Why? These acidic liquids may denature the proteins in the enteral formula and make the clog worse. (Think about how a liquid egg changes to a solid when it is exposed to heat. That change is due to denaturation of the proteins.) Instead, first try infusing warm (not hot) water into the tube and letting it sit for several minutes. If this is not successful, the best recommendation is to use a commercial unclogging kit, which often contains a small brush that resembles a mini pipe cleaner and a special solution that is pushed into the tube via a syringe.
For Parenteral Nutrition
The Problem: The patient’s blood sugars are very high.
The Solution: Just like with the gastric residual volume, investigate what is considered to be “high.” ASPEN recommends maintaining blood glucose below 180 mg/dl. Tight glucose control is generally considered to involve maintenance of blood glucose below 150 mg/dl. Speak with your physicians and discuss what their goals are, which may vary for each patient. Keep in mind that tight glucose control may increase the risks of hypoglycemia if the TPN is interrupted for some reason. Use caution when reducing the amount of dextrose in the TPN order, as this is where the bulk of calories from (unless you are able to reasonably replace these calories via the protein or lipid content). First, make sure you are not overfeeding the patient. Second, check the glucose infusion rate; it should not exceed 5 mg/kg/minute. Third, consider adding or increasing insulin dosage. Insulin can be added directly to the TPN bag, or long-acting insulins typically work well for 24-hour TPN infusions.
The Problem: The patient’s triglycerides or liver enzymes are elevated.
The Solution: TPN can put stress on a patient’s liver, which can be manifested in elevated liver enzymes. There are a few strategies to cope with this. First, reduce the lipid content, if possible. Often, lipids can be reasonably held for the first two weeks of TPN infusion. After this point, ASPEN recommends dosing a minimum of 100 grams per week to prevent essential fatty acid deficiency. Second, consider adding carnitine to the TPN bag. Carnitine is an amino acid that plays a role in fatty acid metabolism and may help reduce elevated liver enzymes. Third, try cycling the TPN infusion to give the liver a “break.” Fourth, add some sort of enteral feeding (either by mouth or via tube), if you can. Oftentimes, liver injury is caused by cholestasis. Stimulating the gut and allowing the gallbladder to release stored bile may help reduce liver enzymes. If the patient’s triglycerides become elevated above 400-500 mg/dl, make sure you are not overfeeding or providing excessive amounts of dextrose. If all else fails, you may need to consider holding lipids until serum triglyceride levels decrease below 500 mg/dl.
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