Enteral feeding is now commonplace in the community and as such, healthcare practitioners working in the community should be aware of the National Institute for Health and Care Excellence’s (NICE) 2017 guideline. Entitled ‘Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition’, this guideline stipulates how one can prepare and give feeds, and use the equipment involved, so as to prevent infection or unwanted problems that may lead to hospital admission. The guideline also emphasises the importance of training in the care of enteral feeding tubes (NICE, 2017).
This article provides updated advice for using percutaneous endoscopic gastronomy (PEG), the choice on enteral tube feed, the need for communication between patients and their multidisciplinary team, and signs of complications to look out for (Palmer, 2021).
Enteral feeding: percutaneous endoscopic gastronomy
Percutaneous endoscopic gastrostomy (PEG) tubes are suitable for adults and children. They are a long-term, artificial enteral feeding tube that require endoscopic placement, allowing direct access to the stomach from outside the abdominal wall, whereby supplementation of nutrition, fluids, and medication can then be administered via this route (Haywood, 2012).
PEG tubes are usually made from flexible polyurethane and are approximately 35 cm in length, with a hollow lumen that allows for the passage of liquids (Haywood, 2012). On placement, the tube is held by a soft malleable silicone or airfilled foam sac retention bumper that lies against the anterior gastric wall, which keeps the tube from coming out of the stomach (Best, 2004).
The equipment used for giving feeds should be handled in an aseptic method so as to prevent contamination that could lead to infection/sepsis. Furthermore, feed-giving sets should be discarded after each feeding session (NICE, 2017). The entrance site of the feeding tube should be washed daily with water and dried thoroughly (NICE, 2017).
PEG tubes are inserted as a day case operation. The idea is that it should not fit too tightly (Best 2012), with preferably about 1 cm tube length from the abdominal wall (Haywood, 2012).
Choice of enteral tube feed
The British Association for Parental and Enteral Nutrition (BAPEN) (2016) indicates that the enteral feed is a sterile and tailored solution to an individual’s needs. It is often nutritionally complete in specified volumes, with a variety of feeds available for your patient, which the dietitian will be able to decide upon their thorough assessment of the patient. Most commercial feeds contain 1 to 2 calories per ml; some come with fibre, while others do not. There are three different categories of feed:
- Polymeric: whole protein feed, which is protein in the same form as it is found in an ordinary diet
- Pre-digested: peptide/semi-elemental/elemental feed, which contain protein broken down into smaller molecules (short peptides or free amino acids) and which contain carbohydrate that provides the majority of the energy in the person’s diet. The remainder of the feed consisting of fats as long or medium chain triglycerides
- Disease-specific or immune-enhancing: special formulations for people who have organ failure, which often contain nutrients that can modify the immune system (BAPEN 2016).
Communication and the multidisciplinary team
A healthcare professional looking after their patient in the community should ensure their patient and carer are kept fully informed. They must have access to appropriate sources of information in the correct format, language and ways appropriate and suitable to the individual’s requirements. NICE (2017) suggests that we must consider the patient’s cognition, gender, physical needs, culture and stage of life, and that they should be given the opportunity to discuss their diagnosis, treatment options, and all the relevant physical, psychological and social issues, encompassing a more holistic care giving of the patient. It is important to provide contact details of places that may help provide support, such as the relevant support groups, charities and voluntary organisations.
NICE (2017) guidelines state that everyone in the community setting with enteral feeding should have the support of a coordinated multidisciplinary team. This includes dietitians, district nurses, care home or homecare company nurses, GPs, community pharmacists and other allied healthcare professionals (for example, speech and language therapists). There should be close communication between the multidisciplinary team, patients and carers regarding the patient’s diagnoses, prescription, arrangements and potential complications or problems. There should be a care plan tailored individualistically to the patient’s needs, which would cover the overall aims and a monitoring plan.
It is essential that appropriate training is given to the patient and their carer regarding the management of the tube, and delivery system and regimen. This should also include an outline of procedures that relate to setting up the feed, using the feed pump, the likely risks and methods for troubleshooting common problems, provision of an instruction manual and if appropriate, visual aids (NICE, 2017).
It is also important to provide emergency telephone numbers of a healthcare professional who understands the needs and potential problems of people on home enteral tube feeding, the delivery of equipment, ancillaries and feed. Appropriate contact details for any homecare company involved should also be provided to the community patient who is receiving enteral nutrition (NICE, 2017).
Preparing and giving the feed
The feed can be given via a syringe, also known as bolus feeding, or can be given via an enteral pump. Specific enteral syringes must be used, which are usually purple and contain a female luer or catheter tip end (BAPEN, 2016). They can be used to administer feed, water or medications. Bolus feeding can then be given either by gravity with the plunger removed, or using the plunger. This will be indicated on the prescription by the dietitian. Pump feeding allows for a feeding rate to be set so that a specific amount is given over a set period of time at a certain rate. The rate is set according to what the patient is able to tolerate and in accordance with the patient’s daily routine. The pump can also be set to deliver boluses at a faster rate.
A continuous feed given by the enteral pump may be better tolerated due to the slow rate it is given at, and blood glucose levels can be improved through this consistent way of delivering the carbohydrate (BAPEN, 2016). There are pumps that can also be taken in a backpack, so there is some mobility for the patient, and the method also allows for overnight feeding. However, being attached for long periods to the pump may restrict movement and activity, and thus, reduce quality of life. A bolus feed mimics a normal pattern of eating, allows for greater mobility and activity, and allows greater flexibility with feeding times, as well as using less equipment (BAPEN, 2016). However, the large boluses may not be tolerated by the patient, who may struggle with its administration, as the plunger can be fairly difficult to push due to the high pressure. Syringes also need to be cleaned and stored after use, and this method is more labour intensive than giving a feed via a pump (BAPEN, 2016).
Feeds that do not need mixing or diluting should be provided, which can be given in a feeding session of up to 24 hours (NICE, 2017).
To prevent blockages, the feeding tube should be flushed with freshly drawn up tap water before and after feeding or giving medications, using enteral syringes (NICE, 2017). For patients who are immunosuppressed, the water should be boiled and then cooled, or sterile water should be used from a freshly opened container, so as to prevent further risk of infection (NICE, 2017).
Many feeds are already mixed. However, for those feeds that require mixing by the nurse or equivalent, only cooled, boiled water or fresh sterile water should be used to mix the feed, which can be prepared up to 24 hours in advance and kept in the fridge. Once mixed, the feeding session should last no more than 4 hours (NICE, 2017).
Red flag alerts
Healey et al (2010) developed red flag alerts to be aware of post-enteral tube insertion. These include:
- Severe pain that is not relieved by simple analgesia, or is made worse by using the tube
- Fresh bleeding (a small amount of bleeding is expected; avoid large thick dressings that disguise heavier bleeding) or gastric fluid or feed leaking from the wound site
- Sudden change in clinical observations
- Change in level of responsiveness or behaviour.
These symptoms are signs of complications and urgent medical attention should be sought if any of these appear. With good nursing care, many of the associated complications can be avoided, or promptly highlighted for investigation and management (Haywood, 2012).
Due to patients taking minimal or no oral intake, they are prone to complications such as a dry mouth, oral infection, and general discomfort. Good oral hygiene is important in the care of this type of patient so as to avoid infections and also to help reduce chest infections. Artificial saliva products can help to keep the mouth moist and comfortable for the patient and to prevent complications related to dry mouth.
To avoid reflux, always keep the patient upright or at a minimum of 30—45° angle. Also check the patient for abdominal distension, as this may be caused by constipation or obstruction; a stool chart should be kept, air going through the tube should be minimised, appropriateness of the feed should be reviewed, gut motility drugs may be required, gastric venting may be needed via a 60 ml open-ended syringe and the temperature of the feed may need to be checked (BAPEN, 2016). Diarhhoea can be caused by infection, medications, rate of feed, migration of feeding tube from the stomach to the small bowel, and poor tolerance to the feed. BAPEN (2016) recommends the following while investigation seeks to find the cause of the problem: electrolyte replacement; hydration; a temporary change or break in feeding; stool chart; stool culture; long-term changes to the feed to improve symptoms; review of any pre-existing bowel disorders; scan to check tube placement accuracy; medication review to reduce diarrhoea; review of hygiene practices around giving the feed; assessment for faecal impaction causing overflow; and consideration of malabsorption, including bile salt malabsorption. Constipation can occur and would usually be due to a lack of fluid, fibre, immobility or medications, and a stool chart needs to be well-documented, medical history reviewed, and a review of fibre and fluid intake as well as changes in mobility, are required (BAPEN, 2016).
Key points
- Percutaneous endoscopic gastronomy (PEG) tubes are inserted surgically in the hospital as a day case and managed throughout the wider multidisciplinary team in the community
- Patient and carer must be informed and trained, and factors such as cognition of the patient should be considered, to manage potential for risks and complications
- Some patients require more support than others in managing their PEG— the MDT should consider and manage this, and other factors through a tailored care plan
- Red flags may be seen post-insertion in the community, such as fresh bleeding and severe pain. Careful attention must be paid in the early days following insertion and urgent medical attention should be sought where these complications are observed
- Holistic care of the psychological and physical health of the patient should be given
- Stool chart can help in identifying patterns that link to complications such as constipation and diarrhoea
Conclusion
In conclusion, it is important to be mindful of the individual patient’s needs, their type of feed and prescription, their bowel habits and other indicators of feed tolerance, and to be knowledgeable of when it is important to review the patient. It is important to be aware of potential complications and how to respond when you recognise them. There are red flags and complications to look out for, and basic aseptic principles should always be followed as best as possible in the community, with only appropriately trained staff managing the PEG tube and the required nutritional input. Different feeds and their individual instructions as to their mixing and use, should be considered. Keeping the patient and carer trained and informed in managing the nutritional intake and avoiding complications are essential throughout the care of this type of patient in the community setting.