in feeding tubes

Velia Marta Antonini, Parma University Hospital I Department of Anesthesia and Intensive Care

Administration via feeding tube often falls

outside license

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

 become liable

for any adverse event

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

 become liable

for therapy failure

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

 complications obstruction of feeding tubes cross-contamination (patients) (HCP) exposure to powders environmental contamination
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

personal protective equipment

avoid handling or inhaling cytotoxics agents hormones eg steroids! antibiotics

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

tubes

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

nasogastric
feeding tube

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

duodenal-jejunal feeding tube

caveats: length & diameter

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

PEG/PEJ

tubes

manage as nasal inserted

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

drugs
formulations

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

solid formulations
soluble/eervescent tabs dispersible tablets buccal/sublingual tablets coated/uncoated tablets hard/soft gelatin capsules modied-release tablets
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

uncoated tablets
crush administered immediately do not mix powders
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

soluble tablets
allow complete dissolution dose adjustment is dicult
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

effervescent tablets
require large volumes produces CO2g when in water caveats: gas & sediment
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

coated tablets

not crush nor break

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

coated tablets
if administered in small intestine tube may be crushed or coat removed
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

capsules (hard)

open & give content if not modied release

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

capsules (soft)
draw uid with a syringe if not modied release complete dosing not guaranteed
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

never

to be

crushed

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

buccal sublingual chewable cytotoxic agents hormones & enzymes

never

to be

if

essential

crushed

alternative formulation alternative drug alternative route

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

liquid formulations
preferable if available do not mix
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

liquid formulations
suspensions solutions syrups elixirs linctus

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

liquid formulations
caveats
co-solvents excipients viscosity granule size
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

paracetamol
(acetaminophen)

high Na in soluble tablets oral liquids are hyperosmolar

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

metoclopramide
oral liquids are hyperosmolar

dilute with at least an equal volume of water

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

diazepam

do not use oral liquid tubes due to absorption into plastic tubing
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

lactulose
dilute avoiding tube obstruction

dilute3 times before administration via ND/NJ/PEJ

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

drug -feed interactions

delayed -impaired absorption reduced -augmented bioavailability
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

drug -feed interactions

how long?

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

stop feeding before stop after flush tube

small syringe = high pressure may damage tube/mucosa use largest functional size
30-50 m l recommended
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

flush

water flush

eective

reducing the formation &/or clearing debris built-up on inner wall avoiding occlusions
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

water flush tap/sterile H2O sterile H2O

for gastric tubes

beyond the stomach

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

water flush
pulsatile ush = turbulence within the inner lumen more eective cleaning
15-30 m l before 5-10 m l between each drug 15-30 m l after
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

water flush
15-30 m l ? relates to lumen total volume

diameter & length!

attention!

sediment in syringe pediatric pts small bowel tubes

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

 revise volumes take account in balance replace water with air

fluid restriction?

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

digoxin

absorption aected by high-bre containing feeds

stop 2h before stop 2h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

isoniazid
stop 2h before stop 2h after

rifampicin

stop 2h before stop 1/2h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

furosemide

bioavailability reduced to up 30% but no recommendations

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

phenytoin

decreased absorption up to 75% if administered with feed absorption extremely poor via jejunal route stop 2h before stop 2h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

quinolone antibiotics

enteral feed delays but not decrease absorption

stop 1h before stop 2h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

antacids

impair absorption by binding when containing Al Mg Ca stop 1h before stop 1h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

levothyroxine

no documented interaction no feeding break required

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

carbamazepine
impaired absorption stop 2h before stop 2h after

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

drug -device interactions

you have to know administered drug know tubes in place

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

oral syringes
catheter tipped
Handbook of Drug Administration via Enteral Feeding Tubes

do not use devices compatible with IV ports & catheters

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

catheter-tipped syringes
do not measure liquid drugs: risk of excessive dosing owing to tip volume
Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

catheter-tipped syringes
dead-space volume is approximately 11.5 mL

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

patency

of feeding tubes

main cause of occlusion incorrect drug administration

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

obstructed

feeding tube

particle obstruction precipitate obstruction

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

obstructed

feeding tube

food-drug drug-drug drug-device interactions

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

unblock

obstructed tube
irrigation enzymes mechanical devices

Velia Marta Antonini, Parma University Hospital - I Department of Anesthesia and Intensive Care

thanks

for

attention

Velia Marta Antonini Parma University Hospital I Department of Anesthesia and Intensive Care