Nutritional options in the critically ill patient (Proceedings) - Veterinary Healthcare


Nutritional options in the critically ill patient (Proceedings)


Possible Complications of Enteral Nutrition

Kinking is common with small diameter tubes. Use care looping the tube when bandaging and don't bandage too tightly.

Clogging of the tube is a very common complication. The tube must be flushed a minimum of once every 6 hours. Always use commercial liquid diets in all small tubes (less than 10 Fr). Diets must be properly blenderized when using E tube or G tube. Use the largest bore tube possible. Tubes can often be unclogged with water, carbonated beverages, pancreatic enzymes, or meat tenderizer. Flush with smaller syringes to build up higher pressure in tube. Passing an angiographic wire down the lumen can be tried if other methods fail. Take radiographs to look for internal kinking if unclogging is unsuccessful.

Infection is a less common but more serious complication of feeding tubes. Mild wound infections can be treated locally with gentle cleaning with antibacterial solution. Warm compressing daily may be helpful as well. Avoid systemic antibiotics unless systemically ill.

Necrotizing fasciitis occurs when bacteria travel along fascial planes. This is a possibly fatal complication. Early warning signs include swelling, inflammation around the tube and in dependent areas near the tube, fluid or crepitus under the skin, and fever. This complication requires aggressive surgical debridement.

Tube dislodgement is common with nasal tubes, and an Elizabethan collar may be needed. Dislodgment is also common with vomiting. You may choose to avoid passing the tube through lower esophageal sphincter, especially in cats, as this may trigger vomiting. Early dislodgement of gastrostomy or jejunostomy tubes can lead to peritonitis.

Aspiration is common in humans. Always confirm placement of a tube with a radiograph. Monitor for moist lung sounds, areas of dullness on auscultation or percussion of the lungs, coughing or fever. Discontinue feeding, provide oxygen if necessary, and take chest radiographs. Transtracheal wash may help identify infectious agents.

Vomiting can be related to placement of the tube, the feeding process, the underlying disease, or a hyperosmolar diet. Avoid placing nasal and esophageal tubes into the stomach unless necessary, as this may trigger vomiting. Feed food at room temperature and don't feed too rapidly. Consider switching to a lower fat diet or diluting the diet with water. Consider suctioning the tube prior to feeding. Refrigerate all enteral diets after opening, and discard any opened diets after 24 hours.

Diarrhea is usually related more to the underlying disease. Liquid diets can often result in a liquid stool. Don't discontinue feeding unless absolutely necessary.

Refeeding syndrome occurs secondary to severe hypophosphatemia as malnourished patients receive aggressive nutritional support. It is characterized by acute cardiopulmonary decompensation leading to death. Refeeding leads to fluid retention, increases in heart rate, blood pressure, and oxygen consumption that may cause the demands on the heart to exceed supply. Increased carbon dioxide production leads to respiratory distress, CNS dysfunction (including seizures), diarrhea, red blood cell dysfunction and leukocyte dysfunction.

References available upon request.


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