Which nursing action is appropriate when providing care to a patient who is enteral feeding tube is clogged?

Enteral nutrition is nutrition delivered using the gut. This can refer to oral, gastric, or postpyloric feeds. There are many indications requiring a feeding tube to deliver nutrition or hydration. This is known as tube feeding, enteral feeding, or gavage. This activity reviews the indications, contraindications, and methodology of enteral feedings and highlights the role of the interprofessional team in the care of patients requiring enteral nutrition.

Objectives:

• Identify the anatomical of importance to enteric feeding.

• Describe the equipment required for enteric feeding.

• Summarize the potential complications of enteric feeding.

• Review a structured interprofessional team approach to provide effective care to and appropriate surveillance of patients requiring enteral nutrition.

Access free multiple choice questions on this topic.

Enteral nutrition is using the gastrointestinal tract to supply nutrients. This can be accomplished with feedings by mouth or through a feeding tube. 

Advantages of enteral nutrition over parenteral nutrition include: safety, effective, decreased risk of infection, decreased cost, prevents gut atrophy, and preserving the barrier function of the gut. 

Indications for Enteral Feeding

Enteral tube feeding is indicated in patients who cannot main adequate oral intake of food or nutrition to meet their metabolic demands. Healthcare professionals commonly use enteral feeding in patients with dysphagia. Patients with dysphagia sometimes cannot meet their daily nutritional needs even with modification of food texture and or consistency.

For enteral feeding to be successful, the GI tract should be accessible and functional. Inaccessible GI tracts, malabsorption, and severe GI losses might make enteral feeding a challenge. The alternative is parenteral feeding.

Indications

• Comatose patients on mechanical ventilation or with severe head injury

• A neuromuscular disorder affecting swallowing reflex: Parkinson disease, multiple sclerosis, cerebrovascular accident.

• Severe anorexia from chemotherapy, HIV, sepsis

• Upper GI obstruction esophageal stricture or tumor

• Conditions associated with increased metabolic and nutritional demands sepsis, cystic fibrosis and burns[1]

• Mental illness like dementia[2][3][4][5][6][7]

Enteral Nutrition in Critical Illness

In patients that are critically ill, there is overwhelming evidence that enteral feeding is the best approach for nutrition in critically ill patients. The GRADE system working group came up with the following recommendation based on the level of evidence 16.

• Enteral nutrition has been associated with an improvement in nutrition variables, a reduction in the length of hospital stay and a lower incidence of infection Level of Evidence A

• Critically ill patients who cannot tolerate oral feeding for greater than 72 hours should receive specialized nutritional support. Level of Evidence C

• Enteral nutrition is the preferred mode of feeding when compared to parenteral nutrition. Level of Evidence B

• Enteral nutrition should be started within 48 hours of admission Level of Evidence A

• It should provide between 25 to 30 kkal/kg per day. Level of Evidence C

• The goal caloric intake should be achieved within 48 to 72 hours. Level of Evidence C

• Enteral nutrition should be deferred until the patient is stable hemodynamically. Level of Evidence C

• The presence of flatus, the passage of stool or presence of bowel sound should not be a prerequisite for starting enteral nutrition. Level of Evidence B[7]

Caloric Consideration

Resting engery expenditure can be calculated using the indirect calorimetry. This method calculates the caloric requirements in patients requiring enteral feeding. When indirect calorimetry is not available, approximately 25 kcal/kg per day is the approximate energy requirement. Clinicians can calculate caloric intake for patients on mechanical ventilation by using the Penn State equation.[8]

Carbohydrate intake should be approximately 4 gm/kg per day with a target glucose level below 180 mg/dl. Lipid intake should be between 0.7 to 1.5 gm/kg per day. Amino acid should be adjusted to 1 to 1.8 g/kg per day with an adequate supply of micronutrients.[9]

It is highly recommended to start enteral feeding as early as possible in critically ill patients.[9][10][11]

Hypocaloric enteral intake is beneficial at the initial stage of critical illness as this can help to prevent hyperglycemia which is linked to a higher risk of mortality. Some authorities recommend around 80% of nutritional needs in the first 7 to 8 days of illness which can then be gradually increased during the phase of recovery.

Enteral nutrition is contraindicated in some special cases.

Absolute Contraindications

• Hemodynamic instability with poor end-organ perfusion. Enteral feeding in patients with bowel ischemia or necrosis can make a bad situation worse

• Active GI bleeding

• Small or large bowel obstruction

• Paralytic ileus secondary to electrolyte abnormalities, peritonitis

 Relative Contraindications

• Moderate to severe malabsorption

• Diverticular disease

• Fistula in the small bowel

• Short bowel disease in the early stages.

Special Cases

Acute Kidney Injury

In acute kidney injury (AKI), nutritional support is geared toward conserving the lean body mass, energy reserve, and preventing of malnutrition.

Patients with AKI and renal failure might be in a non-hypercatabolic or hypercatabolic state with excessive sodium, potassium, and phosphate load. In a non-hypercatabolic state, high-energy enteral nutrition with normal protein content and a low sodium, potassium and phosphate load is recommended.[12][13] In AKI with a hypercatabolic phase, a low protein (2 to 2.5g/kg per day), a low electrolyte enteral nutrition is recommended. Apart from monitoring electrolytes like sodium, potassium, phosphorus, and calcium, clinicians should pay special attention to micronutrients like zinc, selenium, thiamin, folic acid, and vitamins A, C, and D.

Acute Liver Failure and Liver Transplantation

Liver failure is associated with loss of the synthetic function of the liver. Liver failure patients also have an impaired ability to synthesize clotting factors. Enteral feeding should be approached with caution in patients with liver failure because of the inherent risk gastrointestinal bleeding from varices and coagulopathy. In acute liver failure, parenteral nutrition might be better if the gut is not viable and or if the risk of hepatic encephalopathy is high. If enteral feeding is used, a balanced mixture of energy supply from carbohydrate and protein is recommended. Caloric intake should be around 25 kcal/kg per day. Enteral feeds should contain an adequate quantity of potassium, magnesium, and zinc. In liver transplant patient, early enteral feeding via a transpyloric approach is recommended.[14]

Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS)

This is one of the most common reasons for admission into the intensive care unit (ICU). Daily protein intake should be around 1 to 1.8 g/kg per day. Use of high fat, low carbohydrate is not indicated. ALI and ARDS require an enteral diet rich in omega-3 fatty acid and antioxidants.[15]

Multiple Trauma

A patient who sustained multiple trauma should be started early enteral feeding. We recommend starting trauma patient should be started on a total caloric intake of about 25 to 30 kkal/kg per day. We also recommend arginine, omega in patients with multiple trauma.[16][17][18]

Abdominal Surgery

The nutritional needs of patients with abdominal surgeryare similar to the needs of other critically ill patients. Surgery causes both inflammatory and metabolic changes in the body. A post-surgical patient with malnutrition might have delayed wound healing and dehiscence and a decrease in immunological functions placing the patient at risk for infectious and cardiopulmonary complications. This can prolong hospital stay and cause a higher rate of mortality.[19]

Acute Pancreatitis

Inflammation of the pancreas can provoke a systemic inflammatory response syndrome. This causes a hypermetabolic, hyperdynamic, and catabolic state. Classically acute pancreatitis is treated with bowel rest and parenteral nutrition. It has been shown that this approach is associated with high morbidity and mortality. In acute pancreatitis, there is intestinal barrier dysfunction which is associated with multiple organ failure, pancreatic necrosis, and mortality. Based on these facts, the current recommendation is to start early enteral feeding via the jejunum within 48 hours of hospitalization.[20][21]

Types of Enteral Feeding Tubes

There are several types of enteral feeding tubes. They are usually made of polyurethane or silicone. Feeding tube diameters are measured in French units (Fr). Each French unit is equivalent to 0.33 millimeters. Feeding tubes are usually denoted or classified by the site of placement.

• Nasogastric tube

• Nasoduodenal tube

• Nasojejunal tube

• Gastrostomy tube

• Jejunostomy tube

• Gastrojejunal tube

Tubes can be placed:

• Manually

• Endoscopically 

• Surgically

• By interventional radiology [22]

Nasogastric Tube

Nasogastric tube (NG) is mainly utilized for patients with no issues with vomiting, gastroesophageal reflux (GER), poor gastric emptying, and with no evidence of ileus, small or large bowel obstruction. NG tube is risky in patients with poor swallowing coordination or reflex. Fine bore 5 to 8 Fr NG is usually recommended. If there is a need for nasogastric decompression, a larger bore NG can be used. For patient’s safety, the recommendation is that a well-trained and qualified medical personnel places the feeding tube. After the placement, the position should be verified by auscultation or x-ray. Although not routinely recommended, an x-ray is used to confirm NG tube placement for high-risk patient population, specifically, intensive care and neonatal patients. The National Patient Safety Agency advocates for the analysis of gastric aspirate with pH graded paper to confirm proper position. The pH should be less than 5.5 before feeding is started.

Nasoduodenal and Nasojejunal Tube

These are enteral feeding tubes placed with the tip in the duodenum or jejunum. Placement can be done at the bedside or with fluoroscopy guidance

Gastrostomy Tube

The feeding tube passes through the anterior abdominal wall into the gastric cavity. A gastrostomy tube is utilized for patients who require long-term feeding. It can be placed via endoscopy percutaneous endoscopic gastrostomy (PEG).[23][24] PEG tubes are for patients who require long-term nutritional support. PEG tube with jejunal extension is associated with tube dislocation and dysfunction.[24] Gastrostomy feeding tube can also be placed radiologically or surgically or via endoscopy.[25]

Jejunostomy Tube

This feeding tube passed through the anterior abdominal wall into the jejunum. It can be placed surgically or radiologically via extending through the pylorus into the jejunum. Endoscopically a percutaneous endoscopic gastrojejunostomy (PEGJ) can be placed. Placement of direct percutaneous endoscopic jejunostomy tubes is less commonly performed, but PEGJs are more robust and less likely to be dislocated.[24]

Nutritional Support Team

An interprofessional approach is the best way to manage patients who require enteral feeding using the current protocol and guidelines. A nutrition support team is made up of the physician, nurse, clinical pharmacist, and the nutritionist.[26] Provision of optimal enteral nutrition can be achieved by:

• Identification of patients at risk for malnutrition

• Performance of a comprehensive assessment of the patient's nutritional status

• Provision of a safe, adequate, and effective nutritional support

 Services that the nutrition support team can offer include:

• Consultation service for nutritional support

• Development of nutrition protocol for both medical and nursing staff

• Research and quality improvement projects in nutrition

• Staff education and development

Delivery Techniques

There are several modalities of delivery of enteral feeds. Traditionally, we usually start enteral feeding about 12 to 24 hours after placement of PEG. This is to allow for a better seal to develop at the site of insertion of the PEG tube.[26][27] More recent studies have shown that enteral feeding can be initiated from 3 to 4 hours after the insertion of the PEG.

Bolus Intermittent Feeding with a Bulb or Syringe

Enteral feeding is delivered in volumes of about 100 to 400 ml over 5 to 10 minutes. It is mostly used in ambulatory settings. The risk of aspiration is high.

Cyclic Intermittent Feeding

This method is used for patients in a semi-recumbent position. Enteral feeding is delivered via a pump or gravity. Enteral feedings are delivered over an 8- to 16-hour period

Intermittent Drip

This is popular for home enteral feeding. Approximately 1.5 to 2 liters of feeding can be delivered over an 8 to 16 hours period overnight. Feeding is delivered via gravity or pump.

Constant Infusion

This method is used for bedridden patients. Feeding is usually delivered via gravity or pump. The head is inclined at an angle of 45% to reduce aspiration or regurgitation.

Tube-Related

Mechanical complication

Tube placement for enteral feeding might cause mechanical complications. Some mechanical complication form tube feeding are listed below.

• Tube malposition

• Tube obstruction

• Accidental dislodgment of tube

• Breakage of the feeding tube

• Leakage of the feeding tube

• Erosion and ulceration near the site of insertion

• Intestinal obstruction

• Bleeding

Tube for enteral feeding can be inserted nasally, guided percutaneous application, or surgical technique.

Nasoenteral insertion is mostly done blindly by the bedside with about 0.5% to 16% mispositioning in the pleura, trachea or bronchial trees. This can cause the infusion of enteral feeds in the tracheobronchial tree causing a pulmonary abscess or pneumothorax.[28] Instillation of air or auscultation is not an accurate method of determining proper tube placement. The best confirmation is with radiography.[29][29] Failure of bedside nasoenteral tube placement is an indication for fluoroscopy or endoscopy-guided tube insertion.

Infectious Complications

• Infection at the site of tube insertion

• Aspiration pneumonia

• Ear and nasopharyngeal infection

• Infective gastroenteritis with diarrhea

• Peritonitis

Tube placement in enteral feeding is sometimes associated with infectious processes listed above. Aspiration pneumonia is reported in closed 89% of patients on enteral feeding with no clear benefit of nasoenteric feeding over nasogastric. Distal duodenal or jejunal feeding might prevent regurgitation of enteral feeds.[29]

Complications from the enteral feeding tube also depend on:

1. The size of the tube

2. The tube material

3. The diameter of the tube

Spark et al. critically reviewed pulmonary complications from nasoenteric tube placement. In 9931 cases of tube placement, there was 1.9% (187) malposition in the tracheobronchial tree. The 187 misplaced tubes resulted in 35 pneumothoraxes (18.7%) with at least 5 mortalities.[30]

Gastrointestinal Complications

Enteral feeding is associated with several GI complications

• Nausea and vomiting

• Diarrhea

• Constipation

• Cramps and bloating

• Regurgitation and aspiration 

Nausea

Nausea and vomiting are common after the initiation of enteral feeding about 20% to 30% incidence. Non-occlusive bowel necrosis and aspiration can also occur. This is associated with high mortality.[31][32]

Diarrhea

This is the most gastrointestinal complication seen in enteral feeding. Diarrhea occurs in about 30% of patients admitted to the medical or surgical wards and in about 80% in patients in the ICU.[27][33][34]

Diarrhea in enteral feeding is as a result of many factors. Using antibiotics and other medications in enteral feeding is a common cause of diarrhea. Medications like antacids, oral magnesium or phosphate, antacids, and prokinetic agents. Use of oral and intravenous antibiotics can also favor the growth of Clostridium difficile, Escherichia coli, and Klebsiella. The sorbitol-containing solution can also trigger profuse diarrhea in patients on enteral feeding. Use of fiber based on the result of meta-analysis has been found to be able to significantly reduce the incidence of enteral feeding associated diarrhea especially in high-risk patients both post-surgically and in the critically ill.

Constipation

This is a less common complication that is associated with enteral feeding. Constipation is more common in patients on long-term enteral feeds. Some studies suggest that use of fiber supplementation might help reduce the percentage of patients reporting constipation in enteral feeding.

Aspiration Pneumonia

This is a potentially life-threatening complication from enteral feeding. It occurs because of aspiration of oral secretion and or gastric with enteric secretions. Aspiration is more common when patients are fed via a nasogastric tube in a supine position.[35][36] The cause of aspiration pneumonia in enteral feeding are multifactorial.

• Gravitational backflow

• Lower esophageal sphincter impairment

• Infrequent contract of the esophagus

• The presence of a tube near the gastric cardia

• Impaired level of consciousness

• Poor gag and cough reflex is seen in neurologically impaired patients with stroke or dementia[37]

To prevent aspiration, place the enteral feeding tube about 40 cm distal to the ligament of Treitz. This applies to patients with a higher risk of aspiration.[38][39]

Metabolic Complications

Enteral feeding is associated with metabolic complications. A common complication seen in malnourished or undernourished patients is refeeding syndrome. This phenomenon was first described in Far East prisoners during the Second World War.[40][41][42]

Patients with anorexia nervosa, hyperemesis, alcoholism, and malabsorption syndrome like short bowel syndrome who are started on enteral feeding are prone to develop the re-feeding syndrome.

The pathophysiology of the refeeding syndrome is still poorly understood. In a period of starvation, the cellular membrane system downregulates with loss of intracellular potassium, phosphorus, magnesium, and calcium. The total body content of these ions is depleted. Intake of sodium and water by the cell is also increased. The sudden reversal of malnutrition with enteral feeding is due to an uptake of potassium, phosphorus, magnesium, and calcium back by the cell with simultaneous movement of water and sodium out of the cells. The undernourished kidney is also impaired and cannot handle the sodium and water load.

Hypophosphataemia is the hallmark of re-feeding syndrome. Hypophosphatemia can cause rhabdomyolysis, cardiac failure, arrhythmia, muscular weakness, leukocyte dysfunction, seizure, coma, and sudden death.[43]

The phenomenon is more common in enteral than parenteral feeding.[44]

Awareness of the syndrome is the key to treatment and prevention.

Patients at Risk for Re-feeding Syndrome

• Chronic alcoholism

• Anorexia nervosa

• Postoperative patients

• Elderly patients

• Prolonged fasting

• Morbid obesity associated with profound weight loss

• Malabsorption syndrome: Cystic fibrosis, inflammatory bowel disease, and short bowel syndrome[45]

To manage refeeding syndrome, the cardiovascular status of the patient should be monitored closely preferably in the ICU. Judicious monitoring of electrolytes and micronutrients should also be implemented.

Goal caloric intake should target about 50% to 75% of daily requirements.

Body Weight

• Less than 7 years: 80 to 100kcal/kg body weight per day

• Seven to 10 years: 80 to 100kcal/kg body weight per day

• Eleven to 14 years: 60 kcal/kg body weight per day

• Fifteen to 18 years: 50kcal/kg body weight per day

• Older than 18 years: 25 kcal/kg body weight per day, an average of 1000 kcal per day initially

• Thiamine, riboflavin, folic acid, and pyridoxine should be supplemented including fat-soluble vitamin A, D, E, and K.

Minerals

Sodium should be restricted, I mmol/kg of body weight per day or 1.5 g per day, but adequate amount of phosphorus, magnesium, and potassium should be given.

Magnesium (0.8 to 1.6mmol/L)

For hypomagnesemia, start 0.5 mmol/kg per day over 24 hours, then 0.25 mmol/kg of body weight per day for 5 days

Maintenance 0.2 mmol/kg per day intravenous or 0.5 mmol/kg per day oral

Hypophosphatemia

A normal range is 0.85 per 1.40mmol/L

For mild hypophosphatemia (0.6 to 0.85 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day

For moderate hypophosphatemia (0.3 to 0.6 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day

In severe hypophosphatemia, less than 0.3 mmol/L, give IV sodium or potassium phosphate 0.8 mmol/kg of body weight in half normal saline over 12 to 24 hours.[46][47]

Complications Associated with PEG Placement

Peristomal Wound Infection

Wound infection occurs after PEG placement with an incidence of about 3 to 70%. Wound site infection can be caused by the technique of placement, obesity, malnutrition, steroid, or immunosuppressive therapy. Prophylactic antimicrobial therapy has been shown to reduce the incidence of wound infection after placement of PEG. First-generation cephalosporins or penicillin gives adequate coverage.[48][49][50]

Clogged Feeding Tube

The incidence of clogging of feeding tubes can be as high as 25%. Clogging occurs when very thick feeds and medications are delivered through a relatively thin feeding tube. Repeated gastric aspiration is discouraged since the low pH of gastric fluid can promote protein coagulation.[51] Feeding tube should be flushed with about 40 to 50 mL of water after delivering thick feeds or medications. A clogged feeding tube can also be cleared mechanically using various endoscopic catheters, braided quid wires or plastic brushes.

Peristomal Leakage

This is also a complication of PEG tube placement for enteral feeding. Several factors can contribute to leakage. Excessive pulling and tugging, increased gastric secretion are factors that inhibit wound healing like malnutrition, diabetes, and immunodeficiency. This can be prevented by using antisecretory agents like proton pump inhibitors (PPI). Skin protectant and barrier creams can also be used.

Bleeding

The incidence of bleeding is about 2.5% after placement of PEG.[52][53] This might be secondary to mucosal tear or damage to a local vessel. Risk factor for bleeding includes the use of antiplatelet or anticoagulation therapy. Based on current recommendation aspirin can be continued in a high-risk patient. Warfarin is recommended to be discontinued, and unfractionated heparin can be used as a bridge.[53]

Colonic Fistulae

Misplacement of PEG for enteral feeding might lead to the formation of gastrocolic, colocutaneous and gastro colocutaneous fistulae. A gastrocolic fistula is a connection between the wall of the stomach and the colon. Gastro colocutaneous fistula is an epithelial connection between the wall of the stomach, colon and the skin that can occur because of iatrogenic puncture or direct erosion of the PEG into the wall of the colon and the skin.[54][31][55][56][57]

To prevent colonic misplacement, the gastroscope should be transilluminated through the anterior abdominal wall, and the endoscopically visible imprint of a finger or needle on the is considered a “condition sine qua non” before introducing the needle through the stomach.[58] Clinically the presence of a fistula is associated with watery diarrhea around the site of the PEG or the presence of stool around the site of insertion of the PEG. In rare instances, fistulae formation can cause peritonitis, infection or fasciitis.injection of contrast into the PEG can establish the diagnosis. Management can be conservative with the removal of PEG and awaiting the spontaneous closure of fistulae. For more severe cases, endoscopic intervention or invasive laparotomy with colonic exploration might be necessary.

Pneumoperitoneum

This can occur in about 8% to 18% of PEG tube placement.[59][60][61][26] This is a relatively benign condition that does not warrant any intervention.

Clinical significance cannot be overemphasized. Utilization of the gut to provide nutrients helps in the maintenance of the gut integrity, stimulation, and modulation of the immunological properties of the GI tract.[62]

To improve the outcome in enteral feeding requires an interprofessional approach. Enteral feeding requires coordination amongst the nutritional support team.

The nutrition support team is made up of:

• Clinician

• Nutrition nurse specialist

• Dietician

• Pharmacist

The clinician coordinates and directs the care related to enteral feeding. The clinician determines the optimal feeding regimen for the patient

A nutrition nurse specialist is primarily responsible for educating the patient on the use of the feeding tube. The nurse also supervises the care of the tube and notifies the clinician if there any complications that develop.

The dietician manages the evaluation of the nutritional requirements including the calculation of the daily caloric need and the optimal fluid requirements.

The pharmacist provides the enteral feed and can mix and compounds parenteral nutrition. The pharmacist advises on the compatibility of nutrients and interaction.

Other ancillary staff includes the social worker, physical, occupational and speech therapists, and a case manager to help arrange home supplies.[63]

Review Questions

1.

Mainous MR, Block EF, Deitch EA. Nutritional support of the gut: how and why. New Horiz. 1994 May;2(2):193-201. [PubMed: 7922444]

2.

Volpe A, Malakounides G. Feeding tubes in children. Curr Opin Pediatr. 2018 Oct;30(5):665-670. [PubMed: 30004947]

3.

Scott R, Bowling TE. Enteral tube feeding in adults. J R Coll Physicians Edinb. 2015 Mar;45(1):49-54. [PubMed: 25874832]

4.

Tuna M, Latifi R, El-Menyar A, Al Thani H. Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications. Eur J Trauma Emerg Surg. 2013 Jun;39(3):235-42. [PubMed: 26815229]

5.

Holmes S. Enteral nutrition: an overview. 2012 May 30-Jun 5Nurs Stand. 26(39):41-6. [PubMed: 22787992]

6.

Pennington CR, Powell-Tuck J, Shaffer J. Review article: artificial nutritional support for improved patient care. Aliment Pharmacol Ther. 1995 Oct;9(5):471-81. [PubMed: 8580266]

7.

Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin Gastroenterol. 1988 Oct;2(4):815-47. [PubMed: 3149904]

8.

Frankenfield D, Smith JS, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN J Parenter Enteral Nutr. 2004 Jul-Aug;28(4):259-64. [PubMed: 15291408]

9.

Bonet Saris A, Márquez Vácaro JA, Serón Arbeloa C., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): macro-and micronutrient requirements]. Med Intensiva. 2011 Nov;35 Suppl 1:17-21. [PubMed: 22309747]

10.

Fernández Ortega EJ, Ordóñez González FJ, Blesa Malpica AL. [Nutritional support in the critically ill patient: to whom, how, and when?]. Nutr Hosp. 2005 Jun;20 Suppl 2:9-12. [PubMed: 15981841]

11.

Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009 Aug;28(4):387-400. [PubMed: 19505748]

12.

López Martínez J, Sánchez-Izquierdo Riera JA, Jiménez Jiménez FJ., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): acute renal failure]. Med Intensiva. 2011 Nov;35 Suppl 1:22-7. [PubMed: 22309748]

13.

Fiaccadori E, Cremaschi E. Nutritional assessment and support in acute kidney injury. Curr Opin Crit Care. 2009 Dec;15(6):474-80. [PubMed: 19812486]

14.

Montejo González JC, Mesejo A, Bonet Saris A., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): liver failure and transplantation]. Med Intensiva. 2011 Nov;35 Suppl 1:28-32. [PubMed: 22309749]

15.

Grau Carmona T, López Martínez J, Vila García B., Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary units. Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: respiratory failure. Nutr Hosp. 2011 Nov;26 Suppl 2:37-40. [PubMed: 22411517]

16.

Blesa Malpica AL, García de Lorenzo y Mateos A, Robles González A., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. Med Intensiva. 2011 Nov;35 Suppl 1:68-71. [PubMed: 22309757]

17.

Wernerman J. Glutamine and acute illness. Curr Opin Crit Care. 2003 Aug;9(4):279-85. [PubMed: 12883282]

18.

Marik PE, Zaloga GP. Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive Care Med. 2008 Nov;34(11):1980-90. [PubMed: 18626628]

19.

Sánchez Álvarez C, Zabarte Martínez de Aguirre M, Bordejé Laguna L., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): gastrointestinal surgery]. Med Intensiva. 2011 Nov;35 Suppl 1:42-7. [PubMed: 22309752]

20.

Bordejé Laguna L, Lorencio Cárdenas C, Acosta Escribano J., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): severe acute pancreatitis]. Med Intensiva. 2011 Nov;35 Suppl 1:33-7. [PubMed: 22309750]

21.

Gopalan S, Khanna S. Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care. 2003 May;6(3):313-7. [PubMed: 12690265]

22.

Marks JM, Ponsky JL. Access routes for enteral nutrition. Gastroenterologist. 1995 Jun;3(2):130-40. [PubMed: 7640944]

23.

Engelke M, Grund KE, Schilling D, Beilenhoff U, Kern-Waechter E, Engelke O, Stebner F, Kugler C. [Comparison of safety insertion techniques of percutaneous endoscopic gastrostomy in nurses and physicians - a non-randomized interventional pilot study on a simulation model]. Z Gastroenterol. 2018 Mar;56(3):239-248. [PubMed: 29113003]

24.

DiSario JA. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20(3):605-30. [PubMed: 16782532]

25.

Byrne KR, Fang JC. Endoscopic placement of enteral feeding catheters. Curr Opin Gastroenterol. 2006 Sep;22(5):546-50. [PubMed: 16891888]

26.

Bischoff SC, Kester L, Meier R, Radziwill R, Schwab D, Thul P., Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8. Ger Med Sci. 2009 Nov 18;7:Doc20. [PMC free article: PMC2795381] [PubMed: 20049081]

27.

Majid HA, Emery PW, Whelan K. Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians. Nutr Clin Pract. 2012 Apr;27(2):252-60. [PubMed: 22223668]

28.

Halloran O, Grecu B, Sinha A. Methods and complications of nasoenteral intubation. JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):61-6. [PubMed: 20978245]

29.

Levy H. Nasogastric and nasoenteric feeding tubes. Gastrointest Endosc Clin N Am. 1998 Jul;8(3):529-49. [PubMed: 9654567]

30.

Sparks DA, Chase DM, Coughlin LM, Perry E. Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5):625-9. [PubMed: 21799186]

31.

Hull MA, Rawlings J, Murray FE, Field J, McIntyre AS, Mahida YR, Hawkey CJ, Allison SP. Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet. 1993 Apr 03;341(8849):869-72. [PubMed: 8096573]

32.

Marvin RG, McKinley BA, McQuiggan M, Cocanour CS, Moore FA. Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection. Am J Surg. 2000 Jan;179(1):7-12. [PubMed: 10737569]

33.

Jack L, Coyer F, Courtney M, Venkatesh B. Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit. Intensive Crit Care Nurs. 2010 Dec;26(6):327-34. [PubMed: 21087731]

34.

Ritz MA, Fraser R, Tam W, Dent J. Impacts and patterns of disturbed gastrointestinal function in critically ill patients. Am J Gastroenterol. 2000 Nov;95(11):3044-52. [PubMed: 11095317]

35.

NAGLER R, SPIRO HM. PERSISTENT GASTROESOPHAGEAL REFLUX INDUCED DURING PROLONGED GASTRIC INTUBATION. N Engl J Med. 1963 Sep 05;269:495-500. [PubMed: 14043246]

36.

Gomes GF, Pisani JC, Macedo ED, Campos AC. The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care. 2003 May;6(3):327-33. [PubMed: 12690267]

37.

Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract. 2010 Feb;25(1):16-25. [PubMed: 20130154]

38.

Silk DB. The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN J Parenter Enteral Nutr. 2011 May;35(3):303-7. [PubMed: 21393640]

39.

White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009;13(6):R187. [PMC free article: PMC2811894] [PubMed: 19930728]

40.

SCHNITKER MA, MATTMAN PE, BLISS TL. A clinical study of malnutrition in Japanese prisoners of war. Ann Intern Med. 1951 Jul;35(1):69-96. [PubMed: 14847450]

41.

KEYS A. The residues of malnutrition and starvation. Science. 1950 Sep 29;112(2909):371-3. [PubMed: 14781769]

42.

Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr Rev. 2003 Sep;61(9):320-3. [PubMed: 14552069]

43.

Terlevich A, Hearing SD, Woltersdorf WW, Smyth C, Reid D, McCullagh E, Day A, Probert CS. Refeeding syndrome: effective and safe treatment with Phosphates Polyfusor. Aliment Pharmacol Ther. 2003 May 15;17(10):1325-9. [PubMed: 12755846]

44.

Zeki S, Culkin A, Gabe SM, Nightingale JM. Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients. Clin Nutr. 2011 Jun;30(3):365-8. [PubMed: 21256638]

45.

Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008 Jun 28;336(7659):1495-8. [PMC free article: PMC2440847] [PubMed: 18583681]

46.

Marinella MA. Refeeding syndrome in cancer patients. Int J Clin Pract. 2008 Mar;62(3):460-5. [PubMed: 18218007]

47.

Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition. 2001 Jul-Aug;17(7-8):632-7. [PubMed: 11448586]

48.

Safadi BY, Marks JM, Ponsky JL. Percutaneous endoscopic gastrostomy. Gastrointest Endosc Clin N Am. 1998 Jul;8(3):551-68. [PubMed: 9654568]

49.

Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005571. [PubMed: 17054265]

50.

Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther. 2007 Mar 15;25(6):647-56. [PubMed: 17311597]

51.

Powell KS, Marcuard SP, Farrior ES, Gallagher ML. Aspirating gastric residuals causes occlusion of small-bore feeding tubes. JPEN J Parenter Enteral Nutr. 1993 May-Jun;17(3):243-6. [PubMed: 8505829]

52.

Amann W, Mischinger HJ, Berger A, Rosanelli G, Schweiger W, Werkgartner G, Fruhwirth J, Hauser H. Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients. Surg Endosc. 1997 Jul;11(7):741-4. [PubMed: 9214323]

53.

ASGE Standards of Practice Committee. Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Lichtenstein DR, Maple JT, Shen B, Strohmeyer L, Baron T, Dominitz JA. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009 Dec;70(6):1060-70. [PubMed: 19889407]

54.

Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987 Jul;93(1):48-52. [PubMed: 3108063]

55.

Berger SA, Zarling EJ. Colocutaneous fistula following migration of PEG tube. Gastrointest Endosc. 1991 Jan-Feb;37(1):86-8. [PubMed: 1900799]

56.

Guloglu R, Taviloglu K, Alimoglu O. Colon injury following percutaneous endoscopic gastrostomy tube insertion. J Laparoendosc Adv Surg Tech A. 2003 Feb;13(1):69-72. [PubMed: 12676027]

57.

Friedmann R, Feldman H, Sonnenblick M. Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature. JPEN J Parenter Enteral Nutr. 2007 Nov-Dec;31(6):469-76. [PubMed: 17947601]

58.

Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. World J Surg. 1989 Mar-Apr;13(2):165-70. [PubMed: 2499128]

59.

Wiesen AJ, Sideridis K, Fernandes A, Hines J, Indaram A, Weinstein L, Davidoff S, Bank S. True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study. Gastrointest Endosc. 2006 Dec;64(6):886-9. [PubMed: 17140892]

60.

Nazarian A, Cross W, Kowdley GC. Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. Am Surg. 2012 May;78(5):591-4. [PubMed: 22546133]

61.

Blum CA, Selander C, Ruddy JM, Leon S. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. Am Surg. 2009 Jan;75(1):39-43. [PubMed: 19213395]

62.

Kudsk KA. Beneficial effect of enteral feeding. Gastrointest Endosc Clin N Am. 2007 Oct;17(4):647-62. [PMC free article: PMC2121657] [PubMed: 17967372]

63.

Nightingale J. Nutrition support teams: how they work, are set up and maintained. Frontline Gastroenterol. 2010 Oct;1(3):171-177. [PMC free article: PMC5517177] [PubMed: 28839571]