Enteral Nutrition Intolerance Management

(See Appendix A)

Vomiting

1. If no OG/NG tube in position, place one and initiate low wall suction.
2. Check existing OG/NG tube function and placement location.
3. If OG/NG tube is in proper position and functional, decrease tube feed rate by 50% and notify physician for further evaluation and work up.
4. Ensure patient is having normal bowel elimination.
5. If the patient is receiving gastric enteral feeding, consider placing the feeding tube post-pyloric.

Abdominal Distension (Mild to Moderate)

1. Perform history and physical exam.
2. Maintain current tube feed rate and do not advance.
3. Obtain portable abdominal x-ray to assess for small bowel obstruction or ileus.
4. Ensure patient is on bowel regimen to avoid constipation.
5. If distention persists >24hrs with no contraindication for continued tube feeds, switch to elemental formula.
6. If feeding while the patient is on low-dose vasopressors, any increase in distention should prompt holding tube feeds and consideration of bowel ischemia.

Severe

1. Perform history and physical exam.
2. Stop tube feed infusion.
3. Monitor fluid status.
4. Consider workup—CBC, lactate, ABG, Chem7, KUB, CT scan abdomen.
5. Check bladder pressure.

Diarrhea

1. If the patient develops Moderate (3–4 times/24 hrs or 400–600ml/24hrs) to severe diarrhea (>4 times/24hrs or > 600ml/24hrs) consider the following:
2. Review medication record for possible causes of new onset diarrhea.
3. Obtain abdominal x-ray to evaluate feeding tube location.
4. Consider working up patient for Clostridium difficile (C. diff.) infection. If evidence of C. diff. infection, treat with oral metronidazole or oral Vancomycin depending on severity. If utilized, antidiarrheal medications should be administered with great caution in the patient with C. diff. and should only be considered in the patient with a controlled or improving C. diff. infection.
5. Monitor fluid and electrolyte status.
6. Consider starting a soluble fiber supplement (e.g., guar gum, provide 1 pkg BID, increase to 1 pkg QID if stool consistency does not improve in 2-3 days).
7. If there is no evidence of C. diff. infection, consider giving 2 mg loperamide after each loose stool. An alternative is codeine 15 mg.

High OG/NG tube output

(> 1200 ml/24 hrs) with OG/NG tube to continuous suction and feeding via NJFT.

1. Stop tube feeds.
2. Obtain abdominal x-ray to determine location of OG/NG tube and NJFT.
3. Verify OG/NG tube is in the stomach. If tube is past pylorus, pull it back into stomach and resume tube feeds at previous rate.
4. Verify NJFT is in correct position. If NJFT is in the stomach take appropriate action to move the tube to the appropriate position. If NJFT is in the correct position, decrease tube feeds by 50% and assess patient’s overall condition.
5. Check NG/OG tube aspirate for glucose testing in lab.
6. If glucose > 110, hold tube feeds for 12 hours and re-evaluate.
7. If glucose negative, resume tube feeds at 50% previous rate.