Martin | enteral medication administration

what is enteral nutrition?

refers to the system of providing nutrition directly into the GI tract by bypassing the oral cavity

when would enteral nutrition be indicated?

in patient’s who lack the ability to maintain oral intake

what are examples of patients who are indicated for enteral nutrition?

Neoplastic disease (chemo, radiation, oral/head/neck tumors)

Organ dysfunction (liver/renal disease, organ transplant)

Hypermetabolic states (TBI, burns, postoperative surgery, sepsis)

GI disease (IBD, short bowel, pancreatitis, GERD)

Neurologic impairment (coma, stroke, TBI)

anorexia complications, failure-to-thrive

what is the enteral nutrition process?

1.assess the patient

2.prescribe an regimen

3.review the order

4.procure, select/prepare, label, dispense EN

5.administer

6.monitor and reassess the patient

7.repeat

what are examples of short-term enteral access devices?

Nasogastric (NG)

Orogastric (OG)

what are examples of long-term enteral access devices?

Gastrostomy (G-tube)

Jejunostomy (J-tube)

Gastrojejunostomy) (GJ-tube)

what are considerations of enteral access devices?

what can cause a tube to clog?

-narrow tube diameter

-tube location

-insufficient water flushes

-formula contact with acidic fluid

-incorrect medication (thick suspension, enteric-coated, ER formulations)

how can we prevent clogs?

-largest diameter

-flush before and after feedings (adult 30+ mL, peds lowest volume necessary)

-flush before and after medication w/ 15 mL

-use an automatic flush pump

what is “water” with flushing tubes?

purified or sterile water

what is the role of the pharmacist in enteral feedings?

1.review medication formulations

2.determine the compatibility of the medication

3.assess the appropriateness of the medication route of administration

4.evaluate methods to optimize the medication regimen and prevent complications

what are preferred medication formulations w/ EN?

Liquids (avoid sugars, preservatives, thickening agents)

IR caps/tabs (crush)

what are medication formulations that we should avoid in EN?

enteric-coated (can clump and clog)

ER (crushed may result in erratic or toxic drug levels)

Sublingula/buccal tablets (erratic drug levels)

High-viscosity, high-osmolality (decreased delivery and may clog)

Hazardous (only crushed in a biological safety cabinet)

T/F

drugs requiring an acidic environment may have altered bsorption when given via J-tube

true, because they will have bypassed the acidic environment of the stomach

how should we administer phenytoin with enteral feeds?

hold the feed 1-2 hours before and after administration as enteral feeds may reduce absorption

how should we administer warfarin with enteral feeds?

the absorption may be variable, monitor INR

how should we administer fluoroquinolones with enteral feeds

2 hours before or 6 hours after

-may chelate w/ calcium and magnesium and clog

how should we administer levothyroxine with enteral feeds?

shouldn’t

these bind to enteral nutrition = reduced bioavailability and efficacy

what type of pill can we use for EN fluoroquinolones?

IR tablets

t/f

we can use fluoroquinolone suspensions

false, clogging risk due to high-osmolality and high-viscosity

what form of omeprazole can we use for EN?

oral packet for suspension

ODT or delayed-release

what form of lansoprazole can we use for EN?

delayed release oral capsule, ODT

can form of pantoprazole can we use for EN?

oral packet for suspension, delayed-release

t/f

we can use the oral capsule of levothyroxine for EN

false

how can we administer levothyroxine oral solution as EN?

hold tube feeding 1 hour before and up to 1 hour after

how can we administer levothyroxine oral tablet as EN?

hold tube feeding 1 hour before and after administration

how can we manage tube clogs?

1. instill warm water, apply a gentle back & forth motion

2. enzyme-based declogging solution (1 uncoated pancreatic enzyme + 325 mg NaHCO3 + 5mL water

3. mechanical declogging device

4. tube replacement

generally when can someone be switched from IV to PO?

when they have tolerated a full liquid diet for 24 hours

when there is a feeding tube in place

when they are receiving other oral/enteral medications

what are general exclusion to switching form IV to PO?

NPO

risk of aspiration

ileus/GI obstruction

severe/life-threatening infection

actively seizing