Drug Administration Through an Enteral Feeding Tube

Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective

The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.

Recommendations for crushing Circadin® (melatonin) tablets for safe and reliable delivery via pediatric nasogastric tubes

Melatonin is an important drug in pediatric medicine which often requires delivery through a narrow bore nasogastric tube (e.g. FR6; 1300 µm internal diameter) for patients that cannot swallow tablets. Although Circadin® 2 mg tablets are often crushed for nasogastric delivery, there is an absence of evidence for the effectiveness of different methods for producing powders that can be administered without risk of blocking nasogastric tubes. Our aim was to develop a robust protocol for crushing Circadin tablets and suspending the powder for safe administration via paediatric nasogastric tubes. Circadin tablets were crushed using four different tablet crushers. For comparison, a pestle and mortar and tablespoon were also used to crush tablets as these techniques are also used in clinical practice. The particle size of powders resulting from different crushing maneuvers was evaluated using sieve analysis, laser diffraction and image-based sizing methods. For all the tablet crushers, five operations produced powders with irregular-shaped individual particles less than 500 µm diameter. A protocol termed 'King's 5-5-5' was developed for tablet crushers: powder obtained after 5 crushes was suspended in 5 mL water and delivered through NG tubes with pre and post-administration flushing with 5 mL water. This protocol is simple, low cost, uses readily available materials and enables the safe and reliable delivery of melatonin to paediatric patients without the fear of blocking nasogastric tubes.

Study of the More Suitable Drugs and Dosage Forms for Administration to Newborn Infants via Feeding Tube Using the Collection Rate as an Indicator

The dosages of drugs in newborn infants are small. Small dose necessitate consideration of the loss of drug when administered via feeding tube. In this study, we conducted a tube administration test for seven kinds of antiepileptic drugs and two kinds of potassium supplements using a neonatal feeding tube and investigated the drug loss using the collection rate. We also studied the differences in collection rates among different dosage forms and drugs to determine the more suitable dosage forms and drugs. We investigated three dosage forms: powder, fine granules or dry syrup (powdery form) drugs, powdery form drugs that have been pulverized (pulverized powdery forms), and pulverized tablets. Additionally, we investigated two potassium supplements to determine which was more suitable: potassium L-aspartate and potassium gluconate. For topiramate, only the powdery form caused tube obstructions; the collection rates of the pulverized powdery form and pulverized tablets were > 90%. All antiepileptic drugs other than topiramate that were tested had collection rates of about > 90%. Considering stability and pharmacokinetics, the more suitable dosage form for topiramate is pulverized tablets, whereas the more suitable dosage form for other antiepileptic drugs is powdery form. Collection rate of potassium gluconate was higher than that of potassium L-aspartate. The current study, which indicates that potassium gluconate powdery form is the more suitable drug, presents the more suitable dosage form and drug for administration via feeding tube to newborn infants. These results show that it is essential to evaluate passage through the tube using the collection rate.

Dispelling Myths and Unfounded Practices About Enteral Nutrition

Many protocols and steps in the process of enteral nutrition (EN) use are not overly supported with strong research and have been done the same way over many years without questioning the use of best-practices evidence. This article reports many of the myths and unfounded practices surrounding EN and attempts to refute those myths with current evidence. These practices include those about enteral access devices, formulas, enteral administration, and complications.

Enteral tube administration of oral chemotherapy drugs

Objective

Patients receiving oral chemotherapies face treatment interruptions if they require placement of an enteral tube for nutrition, potentially leading to adverse outcomes in cancer treatment. Enteral tube medication administration can provide a suitable alternative. The purpose of this review is to compile available data that describe enteral tube administration of oral chemotherapy agents. Data sources: A systematic evaluation of all Food and Drug Administration-approved oral chemotherapy agents through 31 July 2019 was conducted. Information on crushing or opening of the tablet or capsule, enteral tube administration, and extemporaneous formulations was compiled from the prescribing information, tertiary resources, and primary literature. Drug manufacturers were contacted for additional information. Data summary: A total of 87 oral chemotherapy agents were evaluated. Of the 87 drugs, 33 agents (37.9%) had information regarding enteral tube administration with only four drugs with nasogastric or gastric tube administration instructions in their prescribing information. The strength of evidence varied from non-peer reviewed data to complete evaluations of efficacy and safety. The majority of chemotherapies (62%) had no available data on enteral tube administration.

Conclusions

The results of this review suggest that there is limited data surrounding enteral tube administration of most oral chemotherapies, demonstrating the need for more studies to be conducted to provide more guidance to healthcare providers when administration via an enteral tube is needed in their patients.

Causes of nasoenteral tube obstruction in tertiary hospital patients

BACKGROUND/OBJECTIVES

Obstruction of the nasoenteral tube is one of the complications of enteral nutrition therapy, and its causes and frequency of occurrence are not well understood. To evaluate the causes of enteral nutrition feeding tube obstruction. To study the time elapsed between the beginning of the nutrition therapy and the obstruction of the tube.

SUBJECTS/METHODS

This was a retrospective cohort study of 1170 patients aged 18 years or older who were hospitalized at Sírio-Libanês Hospital between January 2015 and October 2017, and who were undergoing enteral nutrition therapy delivered using an infusion pump through a nasogastric or nasoenteral tube. The study population included 683 (58%) men and 487 (42%) women. The median age was 79 years. Of these, 1084 patients received enteral nutrition and medication through the feeding tube, and 86 received medication alone. Variables investigated as causes of feeding tube obstruction were the administration of medication through the tube, type of diet, and use of symbiotics.

RESULTS

Obstruction rates were 4% for up to 40 days of observation and 8% for the total observation time. The time for obstruction of 10% of the tubes in patients receiving rivaroxaban, linagliptin, metformin, and nystatin was 16, 19, 20, and 28 days, respectively.

CONCLUSIONS

The main cause of nasoenteral tube obstruction (odds ratio) was the combination of metformin (2.0), nystatin (3.1), linagliptin (4.3), rivaroxaban (2.4), and a high-protein diet (1.9). Overall, proper tube care and strict compliance with tubal drug delivery guidelines can result in low tube obstruction rates.

Registered nurses' knowledge and care practices regarding patients with dysphagia in Saudi Arabia

PURPOSE

The purpose of this paper is to assess the knowledge and practices of nursing staff caring for patients with dysphagia to determine any needs for further education programmes.

DESIGN/METHODOLOGY/APPROACH

A self-administered questionnaire with close-ended questions was completed by nurses at a tertiary hospital in Saudi Arabia to measure the depth of their dysphagia knowledge.

FINDINGS

From 316 potential participants, a sample of 174 nurses completed the questionnaire. The results revealed that the participants had partial theoretical and practical knowledge about nursing care for patients with dysphagia. Of interest, 78 per cent of the nurses reported that they had received less than 1 h of training in dysphagia, and only 4 per cent were aware of speech and language pathologists' role in dysphagia management.

PRACTICAL IMPLICATIONS

As the medical professionals who have the most contact with the patients, nurses have a central role in the care of patients with dysphagia. This study provides information that will guide strategies for in-service nurse education dysphagia programmes.

ORIGINALITY/VALUE

The estimated Saudi prevalence of dysphagia is high due to increased incidence of medical conditions commonly associated with dysphagia, such as stroke, cerebral palsy and traumatic brain injuries from traffic accidents. Nurses play a pivotal role in caring for these patients. However, little is known about the level of care patients with dysphagia require in Saudi hospital settings.

Accuracy of hydrocortisone dose administration via nasogastric tube

OBJECTIVE

Hydrocortisone via nasogastric (NG) tube is used in sick children with adrenal insufficiency; however, there is no licensed formulation for NG administration.

METHODS

We investigated hydrocortisone recovery after passage through NG tubes in vitro for three formulations: liquid suspension, crushed tablets mixed with water, and hydrocortisone granules designed for oral administration to children. Cortisol was measured by LC-MS/MS.

RESULTS

Hydrocortisone content was variable and recovery low after preparation in syringe and prior to passage through NG tubes. For doses, 0.5 and 2.0 mg mean percentage recovery was as follows: liquid suspension 57% and 58%; crushed tablets 46% and 30%; and hydrocortisone granules 78% and 71%. Flushing the administering syringe increased recovery. Hydrocortisone recovery after passage with flushing through 6-12Fr gauge NG tubes was variable: liquid suspension 61%-92%, crushed tablets 40%-174%, hydrocortisone granules 61%-92%. Administration of hydrocortisone granules occluded 6 and 8Fr NG tubes; however, administration using a sampling needle to prevent granules being administered gave a recovery of 74%-98%.

CONCLUSIONS

The administration of hydrocortisone through NG tubes is possible; however, current methods deliver a variable dose of hydrocortisone, generally less than that prescribed. Attention should be placed on the technique used to optimize drug delivery such as flushing of the administering syringe. Hydrocortisone granules block small NG tubes but behaved as well as the commonly used liquid suspension when prepared with a filtering needle that filters out granules.

Enteral Access Devices: Types, Function, Care, and Challenges

Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.

Intensive care unit nurses' knowledge of medication administration via enteral tubes

BACKGROUND

Medication administration via enteral tubes is a complex and key application for which nurses in intensive care units are responsible.

AIM

The aim of this study was to evaluate drug administrations via enteral tubes by nurses in intensive care units.

METHODS

This research was conducted using a descriptive and cross-sectional research design. The study was conducted with 289 nurses at intensive care units in hospitals in İzmir, Turkey. The data of the study were collected with the 'Sociodemographic Information Form' and the 'Enteral Medication Administrations Questionnaire', which was designed in accordance with the literature and consists of questions on interventions before, during and following medication administrations via enteral tubes.

RESULTS

It was found that more than half the nurses (62.3%) use nasogastric tubes for medication administrations and that all of them use the enteral way for the administration of medications in the form of tablets, while 58.8% use this method to administer the medications in the form of enteric-coated tablets. It was determined that approximately half the nurses (52.6%) apply more than one medication separately, and a majority (84.1%) use tap water to wash the enteral tube.

CONCLUSIONS

Enteral medication administration practices are inconsistent. Some nurses use unsafe practices and may therefore compromise patient care.

RELEVANCE TO CLINICAL PRACTICE

Conduction of education programmes on medication administration via enteral tubes for intensive care unit nurses is important in improving nurses' knowledge.

Effects of sharing information on drug administration errors in pediatric wards: a pre-post intervention study

BACKGROUND AND PURPOSE

Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.

PATIENTS AND METHODS

This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.

RESULTS

A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.

CONCLUSION

This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Drug administration via enteral feeding tubes in residential care facilities for individuals with intellectual disability: an observational study

BACKGROUND

The administration of oral medication to patients with an enteral feeding tube (EFT) is challenging. Compliance to guidelines concerning medication administration via EFT has been investigated extensively in the hospital setting. However, studies in residential care facilities (RCFs) for individuals with intellectual disability (ID) are very limited. Therefore, the present study aimed to collect direct observational data on drug administration practices to residents with EFT in multiple RCFs.

METHOD

This cross-sectional, observational study was conducted in six Belgian RCFs for individuals with ID. Observations of medication preparation and administration through EFT were carried out in two randomly selected units per participating RCF, on 2 days per unit during all daytime drug rounds, using a direct observation method. Afterwards, the recorded observations were compared with international guidelines on drug preparation and administration through EFT.

RESULTS

In total, 862 drug preparations and 268 administrations in 48 residents with EFT were witnessed. Mixing together multiple drugs, not diluting liquid formulations with at least an equal amount of water, not shaking suspensions/emulsions before use, and not selecting the most appropriate dosage form were the most common deviations from medication preparation guideline recommendations. For medication administration, not flushing the EFT with at least 15 mL water was the most common deviation. We also observed high variability in working methods regarding medication preparation and administration via EFT, even between staff members of the same unit.

CONCLUSION

This study found that current guidelines concerning medication preparation and administration through EFT are often not followed in Belgian RCFs for individuals with ID. Further research aimed at understanding why current guidelines are not followed seems warranted.

Nonoral feeding for children and youth with developmental or acquired disabilities

The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.

Drug administration via enteral tubing: an unresolved but increasing challenge

The number of patients with serious impairments of the swallowing function will continue to increase in the coming decades. Problems related to enteral feeding and drug administration to patients with swallowing issues is a growing concern of physicians, compounding pharmacists and nurses. The lack of information on the impact of compounding by mixing with liquid or food and/or administering through enteral or intestinal feeding tubes on the drug product safety and efficacy is problematic. In addition, there is a lack of appropriate alternative dosage forms of drugs for these routes of administration. As patients with swallowing issues represent a significant and growing patient population that is vulnerable and in need of effective drug therapy, the issue needs urgent attention by all stakeholders involved in healthcare provision. Incremental improvements at the different stages in the process, from product development to the patients' well-being are required to assure safe and effective drug therapy to an important patient population.

Errors of oral medication administration in a patient with enteral feeding tube

Enteral feeding tube is employed for feeding of critically ill patients who are unable to eat. In the cases of oral medication administration to enterally fed patients, some potential errors could happen. We report a 53-year-old man who was admitted to intensive care unit (ICU) of a teaching hospital due to the post-CPR hypoxemic encephalopathy. The patient was intubated and underwent mechanical ventilation. A nasogastric (NG) tube was used as the enteral route for nutrition and administration of oral medications. Oral medications were crushed then dissolved in tap water and were given to the patient through NG tube. In present article we report several medication errors occurred during enterally drug administration, including errors in dosage form selection, methods of oral medication administration and drug interactions and incompatibility with nutrition formula. These errors could reduce the effects of drugs and lead to unsuccessful treatment of patient and also could increase the risk of potential adverse drug reactions. Potential leading causes of these errors include lack of drug knowledge among physicians, inadequate training of nurses and lack of pharmacists participation in medical settings.

Clinical nutrition and drug interactions

A drug's plasma level, pharmacological effects or side effects, elimination, physicochemical properties or stability could be changed by interactions of drug-drug or drug-nutrition products in patients who receive enteral or parenteral nutritional support. As a result, patients might experience ineffective outcomes or unexpected effects of therapy (such as drug toxicity, embolism). Stability or incompatibility problems between parenteral nutrition admixtures and drugs might lead to alterations in expected therapeutic responses from drug and/or parenteral nutrition, occlusion in venous catheter or symptoms or mortality due to infusion of composed particles. Compatibilities between parenteral nutrition and drugs are not always guaranteed in clinical practice. Although the list of compatibility or incompatibilities of drugs are published for the use of clinicians in their practices, factors such as composition of parenteral nutrition admixture, drug concentration, contact time in catheter, temperature of the environment and exposure to light could change the status of compatibilities between drugs and nutrition admixtures. There could be substantial clinical changes occurring in the patient's nutritional status and pharmacological effects of drugs due to interactions between enteral nutrition and drugs. Drug toxicity and ineffective nutritional support might occur as a result of those predictable interactions. Although administration of drugs via feeding tube is a complex and problematic route for drug usage, it is possible to minimise the risk of tube occlusion, decreased effects of drug and drug toxicity by using an appropriate technique. Therefore, it is important to consider pharmacological dosage forms of drugs while administering drugs via a feeding tube. In conclusion, since the pharmacists are well-experienced and more knowledgeable professionals in drugs and drug usage compared to other healthcare providers, it is suggested that provision of information and drug counselling by pharmacists in terms of detection and prevention of problems (such as interactions, stability, incompatibility) related with enteral/parenteral nutrition and drugs are invaluable in clinical practice.

Pancreatic enzyme replacement therapy for enterally fed patients with cystic fibrosis

Administration of pancreatic enzymes (pancrelipase) to adult patients with cystic fibrosis when receiving enteral nutrition through a feeding tube is challenging. A number of techniques for preparing and administering the drug may result in complications that include feeding tube occlusion and inadequate enzyme delivery to the patient. A series of inpatient encounters is described.

Pharmaceutical and safety considerations of tablet crushing in patients undergoing enteral intubation

Medication in patients undergoing enteral intubation addresses various challenging issues considering safety and treatment efficiency. Ideally, other routes of administration (i.e. intravenous or intramuscular routes) or especially dedicated formulations should be used. However, in absence of liquid dosage form, tablets or pills must be crushed and suspended in a vehicle before administration. The administration of oral dosage forms by enteral tube is usually performed by the nursing staff facing (i) pharmaceutical relevance of crushing, (ii) loss and concomitant aero-contamination of drug substance, (iii) drug-nutriment interactions and (iv) enteral feeding tube clogging. In the present study, different combinations of either open or confined crushing and suspending protocols were compared by taking into account the crushing yield, the stability and granulometry of the solid oral form suspension and finally the extend of aerosol contamination during crushing and suspending. All protocols exhibited comparable crushing efficiency and suspending properties, but significantly higher aerosolisation of tablet particles was observed in both open crushing and suspending protocol. Therefore, both confined crushing and suspending protocol constitutes an efficient, time saving and safe alternative to the absence of available liquid dosage form for intubated patients.

[Drug's administration via feeding tubes: evaluation of practices in an intensive care unit of a Tunisian hospital]

INTRODUCTION

Drugs' administration via feeding tubes is a potential source of iatrogenic events for the intensive care patients because of the problem of not adapted galenic forms.

OBJECTIVES

We analyzed the prescriptions of patients with enteral feedings to determine if the galenic forms were compatible with administration via feeding tubes. We also observed and analyzed the methods of drugs passage by nurses.

PATIENTS AND METHODS

We analyzed 30 prescriptions of patients with enteral feedings in the intensive care unit of Habib Bourguiba Sfax hospital, by a prospective and exhaustive way. We also, observed and evaluated the practices of preparation and administration of drugs to these patients via feeding tube by nurses.

RESULTS

Only 12% of drugs were liquids. Eighty-eight percent of the drugs were pulverised and capsule open before administration. The galenic form was not in conformity for 20% of drugs because of the prohibition to crushing tablet or opening capsule (gastroresistant form was dissolved), or because of the administration of a parenteral form (risk of irritation). Among 78 drugs administered by 10 different nurses, the time between passage of the drug and enteral nutrition were not respected for 59% of the observations. The drugs were managed in mixture for 90% of the observations. The gloves were not worn in 80% of observations. No rinsing is made between consecutive administrations and before administration.

CONCLUSION

This study shows that it is possible to reduce risk of administration errors in the intensive care unit and to facilitate the administration of drug via feeding tube by prescribing liquid oral form or soluble solid oral form. It also shows the need for cooperation with the pharmacist in order to adapt the galenic forms and to redact protocol of administration.

An overview of intestine and multivisceral transplantation

Intestine transplantation remains a formidable clinical and immunologic challenge. With newer immunosuppressive agents and accumulated experience, the survival outcomes for these patients are improving. The relationship of recipient preexisting conditions with the risk of postoperative events clearly emphasize the necessity of early referral of patients with intestinal failure to expert transplant program before the onset of life-threatening complications.30 With increased awareness and knowledge regarding referral criteria, transplant criteria, optimal time for transplantation, and medication regiments, improved patient outcomes after intestine and multivisceral transplant will be achieved.