What is nasogastric tube

Nasogastric tube is a long, flexible plastic tube inserted into a person’s nose and threaded into the stomach. A nasogastric tube tube may be used for treatments such as sucking excess fluids out of the stomach and delivering medicines. Nasogastric tube also can deliver fluid that contains nutrients directly into the stomach. This is called tube feeding. Nasogastric tube feeding can be on a schedule or it can be ongoing, with help from a pump.

Some people are also allowed to eat or drink through the mouth while the nasogastric tube is in place.

Inserting the nasogastric tube is not very pleasant, but it’s not painful. And in some people will likely need the nasogastric tube for only a short time.

Nasogastric tube is lubricated so it slides more easily. Then it’s placed through the nose, down the throat and the esophagus, and into the stomach. The esophagus connects the throat to the stomach. The person is asked to swallow, if able, to help the tube go down and get into the right place.

When a nasogastric tube is inserted, the person may have an X-ray taken to see if the tube is in the right place. Getting a nasogastric tube usually isn’t painful, but it may feel uncomfortable.

Types of nasogastric tube

There are several types of enteral feeding tubes. They are usually made of polyurethane or silicone. Feeding tube diameters are measured in French units (Fr). Each French unit is equivalent to 0.33 millimeters. Feeding tubes are usually denoted or classified by the site of placement.

1. Nasogastric tube
2. Nasoduodenal tube
3. Nasojejunal tube
4. Gastrostomy tube
5. Jejunostomy tube

Tubes can be placed:

• Manually
• Via endoscopy
• Surgically
• Interventional radiologically ¹

Nasoduodenal and Nasojejunal Tube

These are enteral feeding tubes placed with the tip in the duodenum or jejunum. Placement can be done at the bedside or with fluoroscopy guidance

Gastrostomy Tube

The feeding tube passes through the anterior abdominal wall into the gastric cavity. A gastrostomy tube is utilized for patients who require long-term feeding. It can be placed via endoscopy percutaneous endoscopic gastrostomy (PEG) ². Percutaneous endoscopic gastrostomy (PEG) tubes are for patients who require long-term nutritional support. PEG tube with jejunal extension is associated with tube dislocation and dysfunction ³. Gastrostomy feeding tube can also be placed radiologically or surgically or via endoscopy ⁴.

Jejunostomy Tube

This feeding tube passed through the anterior abdominal wall into the jejunum. It can be placed surgically or radiologically via extending through the pylorus into the jejunum. Endoscopically a percutaneous endoscopic gastrojejunostomy (PEGJ) can be placed. Placement of direct percutaneous endoscopic jejunostomy tubes is less commonly performed, but PEGJs are more robust and less likely to be dislocated ³.

Nasogastric tube indications

A nasogastric tube can be used for different kinds of treatments. For example, a nasogastric tube may be used to:

• Release pressure from the bowel if there is a blockage in the intestine.
• Deliver charcoal or other medicines into your body to treat poisoning.
• Pump the stomach clean in cases of poisoning.
• Diagnose and treat bleeding in the stomach.
• Deliver nutrients for tube feeding.

Nasogastric tube is mainly utilized for patients with no issues with vomiting, gastroesophageal reflux (GER), poor gastric emptying, and with no evidence of ileus, small or large bowel obstruction. Nasogastric tube is risky in patients with poor swallowing coordination or reflex. Fine bore 5 to 8 Fr nasogastric tube is usually recommended. If there is a need for nasogastric decompression, a larger bore nasogastric tube can be used. For patient’s safety, the recommendation is that a well-trained and qualified medical personnel places the feeding tube. After the placement, the position should be verified by auscultation or x-ray. Although not routinely recommended, an x-ray is used to confirm nasogastric tube placement for high-risk patient population, specifically, intensive care and neonatal patients. The National Patient Safety Agency advocates for the analysis of gastric aspirate with pH graded paper to confirm proper position. The pH should be less than 5.5 before feeding is started.

Nasogastric tube feeding

A nasogastric tube is a special tube that carries food and medicine to the stomach through the nose. A nasogastric tube for enteral nutrition is mainly used by patients who have a moderate-to-severe neurological impairment that might compromise the swallowing coordination and hence exposes the patients to the risk of aspiration. Healthcare professionals commonly use nasogastric tube feeding in patients with dysphagia. Patients with dysphagia sometimes cannot meet their daily nutritional needs even with modification of food texture and or consistency.

Healthcare professionals also use nasogastric tube feeding in patients who cannot maintain adequate oral intake of food or nutrition to meet their metabolic demands or patients who require additional nutritional supplementation. Using a nasogastric tube to deliver nutrition or supplement to a patient is known as tube feeding, enteral feeding, or gavage.

For nasogastric tube feeding to be successful, the gastrointestinal tract should be accessible and functional. Inaccessible gastrointestinal tracts, malabsorption, and severe gastrointestinal losses might make nasogastric tube feeding a challenge ⁵. The alternative is parenteral feeding.

Goals of nasogastric tube feeding

Patients that are critically ill are prone to go into a catabolic state of metabolism. This can cause the breakdown of protein in the body leading to a loss lean body mass. Proteins are the building block of enzymes and hormones in the body. The disbalance created by the breakdown of protein can cause wound dehiscence in surgical patients or impair the host response to infection.

Enteral nutrition serves the following purposes:

• Provision of adequate micronutrients and macronutrients to meet the metabolic demands of a sick patient
• Cut down on nitrogen deficit created by the catabolic state
• Avoid complication associated with enteral nutrition
• Modulation of the immunological and inflammatory response

Nasogastric tube feeding guidelines

British Society of Gastroenterology enteral tube feeding guidelines ⁶

Indications for enteral feeding

• Health care professionals should aim to provide adequate nutrition to every patient unless prolongation of life is not in the patient’s best interest.
• It should be hospital policy that the results of an admission nutritional screening are recorded in the notes of all patients with serious illness or those needing major surgery.
• Artificial nutrition support is needed when oral intake is absent or likely to be absent for a period >5–7 days. Earlier instigation may be needed in malnourished patients. Support may also be needed in patients with inadequate oral intake over longer periods.
• Decisions on route, content, and management of nutritional support are best made by multidisciplinary nutrition teams.
• Enteral tube feeding can be used in unconscious patients, those with swallowing disorders, and those with partial intestinal failure. It may be appropriate in some cases of anorexia nervosa.
• Early post pyloric enteral tube feeding is generally safe and effective in postoperative patients, even if there is apparent ileus.
• Early enteral tube feeding after major gastrointestinal surgery reduces infections and shortens length of stay
• In all post surgical patients not tolerating oral intake, enteral tube feeding should be considered within 1–2 days of surgery in the severely malnourished, 3–5 days of surgery in the moderately malnourished, and within seven days of surgery in the normally or over nourished.
• If there are specific contraindications to enteral tube feeding, parenteral feeding should be considered. If patients are taking >50% of estimated nutritional requirements, it may be appropriate to delay instigation of enteral tube feeding.
• Enteral tube feeding can be used for the support of patients with uncomplicated pancreatitis.

Ethical issues

• Enteral tube feeding should never be started without consideration of all related ethical issues and must be in a patient’s best interests (grade C).
• Enteral tube feeding is considered to be a medical treatment in law. Starting, stopping, or withholding such treatment is therefore a medical decision which is always made taking the wishes of the patient into account.
• In cases where a patient cannot express a wish regarding enteral tube feeding, the doctor must make decisions on enteral tube feeding in the patient’s best interest. Consulting widely with all carers and family is essential.

Access techniques

• Fine bore (5–8 French gauge) nasogastric (nasogastric) tubes should be used for enteral tube feeding unless there is a need for repeated gastric aspiration or administration of high viscosity feeds/drugs via the tube. Most fiber enriched feeds can be given via these fine bore tubes.
• Nasogastric tubes can be placed on the ward by experienced medical or nursing staff, without x rays to check position. Their position must be checked using pH testing prior to every use.
• The position of a nasojejunal (NJ) tube should be confirmed by x ray 8–12 hours after placement. Auscultation and pH aspiration techniques can be inconclusive.
• Nasogastric tube insertion should be avoided for three days after acute variceal bleeding and only fine bore tubes should be used.
• There is no evidence to support the use of weighted nasogastric tubes, in terms of either placement or maintenance of position.
• Long term nasogastric and nasojejunal (NJ) tubes should usually be changed every 4–6 weeks swapping them to the other nostril.
• Gastrostomy or jejunostomy feeding should be considered whenever patients are likely to require enteral tube feeding for more than 4–6 weeks and there is some evidence that these routes should be considered at 14 days.
• Suitability for gastrostomy placement should be assessed by an experienced gastroenterologist or member of a nutrition support team. Expert advice on the prognosis of swallowing difficulties may be needed.
• In patients with no risk of distal adhesions or strictures, gastrostomy tubes with rigid internal fixation devices can be removed by cutting them off close to the skin, pushing them into the stomach, and allowing them to pass spontaneously.

Feed administration

• Giving enteral feed into the stomach rather than the small intestine permits the use of hypertonic feeds, higher feeding rates, and bolus feeding.
• Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week. Diluting feeds risks infection and osmolality difficulties.
• Both inadequate or excessive feeding may be harmful. Dietitians or other experts should be consulted on feed prescription.
• If no advice is available, 30 ml/kg/day of standard 1 kcal/ml feed is often appropriate but may be excessive in undernourished or metabolically unstable patients.
• When patients are discharged to the community on continuing enteral tube feeding, care must be taken to ensure all community carers are fully informed and that continuing prescription of feed and relevant equipment is in place.

Complications of enteral feeding

• Close monitoring of fluid, glucose, sodium, potassium, magnesium, calcium, and phosphate status is essential in the first few days after instigation of enteral tube feeding.
• Life threatening problems due to refeeding syndrome are particularly common in the very malnourished and there are also risks from over feeding shortly after major surgery or during major sepsis and/or multiorgan failure.
• To minimize aspiration, patients should be fed propped up by 30° or more and should be kept propped up for 30 minutes after feeding. Continuous feed should not be given overnight in patients who are at risk.
• Any drugs administered via an enteral tube feeding tube should be liquid and should be given separately from the feed with flushing of the tube before and after.
• Loosening and rotating a gastrostomy tube may prevent blockage through mucosal overgrowth and may reduce peristomal infections.
• In patients with doubtful gastrointestinal motility, the stomach should be aspirated every four hours. If aspirates exceed 200 ml, feeding policy should be reviewed.
• Continuous pump feeding can reduce gastrointestinal discomfort and may maximise levels of nutrition support when absorptive capacity is diminished. However, intermittent infusion should be initiated as soon as possible.
• Simultaneous use of other drugs, particularly antibiotics, is usually the cause of apparent enteral tube feeding related diarrhoea.
• Fibre containing feeds sometimes help with enteral tube feeding related diarrhoea, as will breaks in the feeding of 4–8 hours.
• Careful measures are needed to avoid bacterial contamination of feeds which can give rise to sepsis, pneumonia, and urinary tract infections, as well as gastrointestinal problems.
• Avoiding gastric acid suppression and allowing breaks in feeding to let gastric pH fall will help prevent bacterial overgrowth during enteral tube feeding.

Indications for nasogastric tube feeding

Nasogastric tube feeding is indicated in patients who cannot main adequate oral intake of food or nutrition to meet their metabolic demands. Healthcare professionals commonly use enteral feeding in patients with dysphagia. Patients with dysphagia sometimes cannot meet their daily nutritional needs even with modification of food texture and or consistency.

Indications for nasogastric tube feeding:

• Comatose patients on mechanical ventilation or with severe head injury
• A neuromuscular disorder affecting swallowing reflex: Parkinson disease, multiple sclerosis, cerebrovascular accident.
• Severe anorexia from chemotherapy, HIV, sepsis
• Upper gastrointestinal obstruction esophageal stricture or tumor
• Conditions associated with increased metabolic and nutritional demands sepsis, cystic fibrosis and burns ⁷
• Mental illness like dementia ⁸

Nasogastric tube feeding in critical illness

In patients that are critically ill, there is overwhelming evidence that enteral feeding is the best approach for nutrition in critically ill patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system working group came up with the following recommendation based on the level of evidence ⁹.

• Enteral nutrition has been associated with an improvement in nutrition variables, a reduction in the length of hospital stay and a lower incidence of infection.
• Critically ill patients who cannot tolerate oral feeding for greater than 72 hours should receive specialized nutritional support.
• Enteral nutrition is the preferred mode of feeding when compared to parenteral nutrition.
• Enteral nutrition should be started within 48 hours of admission
• It should provide between 25 to 30 kcal/kg per day.
• The goal caloric intake should be achieved within 48 to 72 hours.
• Enteral nutrition should be deferred until the patient is stable hemodynamically.
• The presence of flatus, the passage of stool or presence of bowel sound should not be a prerequisite for starting enteral nutrition ¹⁰.

Special cases

Acute Kidney Injury

In acute kidney injury (AKI), nutritional support is geared toward conserving the lean body mass, energy reserve, and preventing of malnutrition.

Patients with acute kidney injury (AKI) and renal failure might be in a non-hypercatabolic or hypercatabolic state with excessive sodium, potassium, and phosphate load. In a non-hypercatabolic state, high-energy enteral nutrition with normal protein content and a low sodium, potassium and phosphate load is recommended ¹¹. In acute kidney injury with a hypercatabolic phase, a low protein (2 to 2.5g/kg per day), a low electrolyte enteral nutrition is recommended. Apart from monitoring electrolytes like sodium, potassium, phosphorus, and calcium, clinicians should pay special attention to micronutrients like zinc, selenium, thiamin, folic acid, and vitamins A, C, and D.

Acute Liver Failure and Liver Transplantation

Liver failure is associated with loss of the synthetic function of the liver. Liver failure patients also have an impaired ability to synthesize clotting factors. Enteral feeding should be approached with caution in patients with liver failure because of the inherent risk gastrointestinal bleeding from varices and coagulopathy. In acute liver failure, parenteral nutrition might be better if the gut is not viable and or if the risk of hepatic encephalopathy is high. If enteral feeding is used, a balanced mixture of energy supply from carbohydrate and protein is recommended. Caloric intake should be around 25 kcal/kg per day. Enteral feeds should contain an adequate quantity of potassium, magnesium, and zinc. In liver transplant patient, early enteral feeding via a transpyloric approach is recommended ¹².

Acute Lung Injury and Acute Respiratory Distress Syndrome (ARDS)

This is one of the most common reasons for admission into the intensive care unit (ICU). Daily protein intake should be around 1 to 1.8 g/kg per day. Use of high fat, low carbohydrate is not indicated. Acute Lung Injury and Acute Respiratory Distress Syndrome (ARDS) require an enteral diet rich in omega-3 fatty acid and antioxidants ¹³.

Multiple Trauma

A patient who sustained multiple trauma should be started early enteral feeding. We recommend starting trauma patient should be started on a total caloric intake of about 25 to 30 kkal/kg per day. We also recommend arginine, omega in patients with multiple trauma ¹⁴.

Abdominal Surgery

The nutritional needs of patients with abdominal surgeryare similar to the needs of other critically ill patients. Surgery causes both inflammatory and metabolic changes in the body. A post-surgical patient with malnutrition might have delayed wound healing and dehiscence and a decrease in immunological functions placing the patient at risk for infectious and cardiopulmonary complications. This can prolong hospital stay and cause a higher rate of mortality ¹⁵.

Acute Pancreatitis

Inflammation of the pancreas can provoke a systemic inflammatory response syndrome. This causes a hypermetabolic, hyperdynamic, and catabolic state. Classically acute pancreatitis is treated with bowel rest and parenteral nutrition. It has been shown that this approach is associated with high morbidity and mortality. In acute pancreatitis, there is intestinal barrier dysfunction which is associated with multiple organ failure, pancreatic necrosis, and mortality. Based on these facts, the current recommendation is to start early enteral feeding via the jejunum within 48 hours of hospitalization ¹⁶.

Caloric Consideration

Energy consumption is calculated using the indirect calorimetry method. This is the best method to calculat the caloric requirements in patients requiring enteral feeding. When indirect calorimetry is not available, approximately 25 kcal/kg per day is the approximate energy requirement. Clinicians can calculate caloric intake for patients on mechanical ventilation by using the Penn State equation ¹⁷.

Goal caloric intake should target about 50% to 75% of daily requirements.

Carbohydrate intake should be approximately 4 gm/kg per day with a target glucose level below 180 mg/dl. Lipid intake should be between 0.7 to 1.5 gm/kg per day. Amino acid should be adjusted to 1 to 1.8 g/kg per day with an adequate supply of micronutrients ¹⁸.

It is highly recommended to start enteral feeding as early as possible in critically ill patients ¹⁹.

Hypocaloric enteral intake is beneficial at the initial stage of critical illness as this can help to prevent hyperglycemia which is linked to a higher risk of mortality. Some authorities recommend around 80% of nutritional needs in the first 7 to 8 days of illness which can then be gradually increased during the phase of recovery.

Nasogastric tube feeding delivery techniques

There are several modalities of delivery of enteral feeds.

Bolus Intermittent Feeding with a Bulb or Syringe

• Enteral feeding is delivered in volumes of about 100 to 400 ml over 5 to 10 minutes. It is mostly used in ambulatory settings. The risk of aspiration is high.

Cyclic Intermittent Feeding

• This method is used for patients in a semi-recumbent position. Enteral feeding is delivered via a pump or gravity. Enteral feedings are delivered over an 8- to 16-hour period

Intermittent Drip

• This is popular for home enteral feeding. Approximately 1.5 to 2 liters of feeding can be delivered over an 8 to 16 hours period overnight. Feeding is delivered via gravity or pump.

Constant Infusion

• This method is used for bedridden patients. Feeding is usually delivered via gravity or pump. The head is inclined at an angle of 45% to reduce aspiration or regurgitation.

Nasogastric tube feeding contraindications

Enteral nutrition is contraindicated in some special cases.

Absolute contraindications

• Hemodynamic instability with poor end-organ perfusion. Enteral feeding in patients with bowel ischemia or necrosis can make a bad situation worse
• Active gastrointestinal bleeding
• Small or large bowel obstruction
• Paralytic ileus secondary to electrolyte abnormalities, peritonitis

Relative contraindications

• Moderate to severe malabsorption
• Diverticular disease
• Fistula in the small bowel
• Short bowel disease in the early stages.

Nasogastric tube complications

Tube-Related

Mechanical complication

Tube placement for enteral feeding might cause mechanical complications. Some mechanical complication form tube feeding are listed below.

• Tube malposition
• Tube obstruction
• Accidental dislodgment of tube
• Breakage of the feeding tube
• Leakage of the feeding tube
• Erosion and ulceration near the site of insertion
• Intestinal obstruction
• Bleeding

Nasogastric tube insertion is mostly done blindly by the bedside with about 0.5% to 16% mispositioning in the pleura, trachea or bronchial trees. This can cause the infusion of enteral feeds in the tracheobronchial tree causing a pulmonary abscess or pneumothorax ²⁰. Instillation of air or auscultation is not an accurate method of determining proper tube placement. The best confirmation is with radiography ²¹. Failure of bedside nasoenteral tube placement is an indication for fluoroscopy or endoscopy-guided tube insertion.

Infectious Complications

• Infection at the site of tube insertion
• Aspiration pneumonia
• Ear and nasopharyngeal infection
• Infective gastroenteritis with diarrhea
• Peritonitis

Tube placement in enteral feeding is sometimes associated with infectious processes listed above. Aspiration pneumonia is reported in closed 89% of patients on enteral feeding with no clear benefit of nasoenteric feeding over nasogastric. Distal duodenal or jejunal feeding might prevent regurgitation of enteral feeds ²¹.

Complications from the enteral feeding tube also depend on:

1. The size of the tube
2. The tube material
3. The diameter of the tube

Spark et al ²². critically reviewed pulmonary complications from nasoenteric tube placement. In 9931 cases of tube placement, there was 1.9% (187) malposition in the tracheobronchial tree. The 187 misplaced tubes resulted in 35 pneumothoraxes (18.7%) with at least 5 mortalities.

Gastrointestinal Complications

Enteral feeding is associated with several gastrointestinal complications

• Nausea and vomiting
• Diarrhea
• Constipation
• Cramps and bloating
• Regurgitation and aspiration

Nausea

Nausea and vomiting are common after the initiation of enteral feeding about 20% to 30% incidence. Non-occlusive bowel necrosis and aspiration can also occur. This is associated with high mortality ²³.

Diarrhea

This is the most gastrointestinal complication seen in enteral feeding. Diarrhea occurs in about 30% of patients admitted to the medical or surgical wards and in about 80% in patients in the ICU ²⁴.

Diarrhea in enteral feeding is as a result of many factors. Using antibiotics and other medications in enteral feeding is a common cause of diarrhea. Medications like antacids, oral magnesium or phosphate, antacids, and prokinetic agents. Use of oral and intravenous antibiotics can also favor the growth of Clostridium difficile, Escherichia coli, and Klebsiella. The sorbitol-containing solution can also trigger profuse diarrhea in patients on enteral feeding. Use of fiber based on the result of meta-analysis has been found to be able to significantly reduce the incidence of enteral feeding associated diarrhea especially in high-risk patients both post-surgically and in the critically ill.

Constipation

This is a less common complication that is associated with enteral feeding. Constipation is more common in patients on long-term enteral feeds. Some studies suggest that use of fiber supplementation might help reduce the percentage of patients reporting constipation in enteral feeding.

Aspiration Pneumonia

This is a potentially life-threatening complication from enteral feeding. It occurs because of aspiration of oral secretion and or gastric with enteric secretions. Aspiration is more common when patients are fed via a nasogastric tube in a supine position ²⁵. The cause of aspiration pneumonia in enteral feeding are multifactorial.

• Gravitational backflow
• Lower esophageal sphincter impairment
• Infrequent contract of the esophagus
• The presence of a tube near the gastric cardia
• Impaired level of consciousness
• Poor gag and cough reflex is seen in neurologically impaired patients with stroke or dementia ²⁶

To prevent aspiration, place the enteral feeding tube about 40 cm distal to the ligament of Treitz. This applies to patients with a higher risk of aspiration ²⁷.

Metabolic Complications

Enteral feeding is associated with metabolic complications. A common complication seen in malnourished or undernourished patients is refeeding syndrome. This phenomenon was first described in Far East prisoners during the Second World War ²⁸.

Patients with anorexia nervosa, hyperemesis, alcoholism, and malabsorption syndrome like short bowel syndrome who are started on enteral feeding are prone to develop the re-feeding syndrome.

The pathophysiology of the refeeding syndrome is still poorly understood. In a period of starvation, the cellular membrane system downregulates with loss of intracellular potassium, phosphorus, magnesium, and calcium. The total body content of these ions is depleted. Intake of sodium and water by the cell is also increased. The sudden reversal of malnutrition with enteral feeding is due to an uptake of potassium, phosphorus, magnesium, and calcium back by the cell with simultaneous movement of water and sodium out of the cells. The undernourished kidney is also impaired and cannot handle the sodium and water load.

Hypophosphataemia is the hallmark of re-feeding syndrome. Hypophosphatemia can cause rhabdomyolysis, cardiac failure, arrhythmia, muscular weakness, leukocyte dysfunction, seizure, coma, and sudden death ²⁹.

The phenomenon is more common in enteral than parenteral feeding ³⁰.

Awareness of the syndrome is the key to treatment and prevention.

Patients at Risk for Re-feeding Syndrome

• Chronic alcoholism
• Anorexia nervosa
• Postoperative patients
• Elderly patients
• Prolonged fasting
• Morbid obesity associated with profound weight loss
• Malabsorption syndrome: Cystic fibrosis, inflammatory bowel disease, and short bowel syndrome ³¹

To manage refeeding syndrome, the cardiovascular status of the patient should be monitored closely preferably in the ICU. Judicious monitoring of electrolytes and micronutrients should also be implemented.

Goal caloric intake should target about 50% to 75% of daily requirements.

Body Weight

• Less than 7 years: 80 to 100kcal/kg body weight per day
• Seven to 10 years: 80 to 100kcal/kg body weight per day
• Eleven to 14 years: 60 kcal/kg body weight per day
• Fifteen to 18 years: 50kcal/kg body weight per day
• Older than 18 years: 25 kcal/kg body weight per day, an average of 1000 kcal per day initially
• Thiamine, riboflavin, folic acid, and pyridoxine should be supplemented including fat-soluble vitamin A, D, E, and K.

Minerals

Sodium should be restricted, I mmol/kg of body weight per day or 1.5 g per day, but adequate amount of phosphorus, magnesium, and potassium should be given.

Magnesium (0.8 to 1.6mmol/L)

• For hypomagnesemia, start 0.5 mmol/kg per day over 24 hours, then 0.25 mmol/kg of body weight per day for 5 days
• Maintenance 0.2 mmol/kg per day intravenous or 0.5 mmol/kg per day oral

Hypophosphatemia

• A normal range is 0.85 per 1.40mmol/L
• For mild hypophosphatemia (0.6 to 0.85 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day
• For moderate hypophosphatemia (0.3 to 0.6 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day
• In severe hypophosphatemia, less than 0.3 mmol/L, give IV sodium or potassium phosphate 0.8 mmol/kg of body weight in half normal saline over 12 to 24 hours ³²

Nasogastric tube feeding care instructions

Follow your doctor’s instructions for use and care of the nasogastric feeding tube. You’ll learn to take good care of the tubing and the skin around the nostrils so that the skin doesn’t get irritated.

Follow any specific instructions your doctor or nurse gives you. Use the information below as a reminder of what to do.

These instructions will be based on your age and weight. Your doctor or nurse will:

• Teach you how to check the position of the tube before the start of a feeding.
• Tell you what feeding formula and fluids to put through the tube.
• Tell you how often to give a feeding and how fast the feeding should be.
• Explain what to do if the tube is blocked or comes out.
• Always wash your hands before handling the tube and formula. Wash the top of the can of formula before you open it.
• Flush the tube with plain water after each feeding to keep it clean. Do not put anything other than formula or water through the tube unless your doctor has told you to.
• Check your nose often to make sure the tube isn’t causing soreness. Also make sure the tape is still holding the tube in place.
• Talk to your doctor if you vomit or have diarrhea or bloating during feeding. Your doctor may have you slow down the rate of feeding.

What to expect at home

If you or your child has an nasogastric tube, try to keep your child from touching or pulling on the tube.

After your nurse teaches you how to flush the tube and perform skin care around the nose, set up a daily routine for these tasks.

Flushing the nasogastric tube

Flushing the nasogastric tube helps release any formula stuck to the inside of the tube. Flush the tube after each feeding, or as often as your nurse recommends.

1. First, wash your hands well with soap and water.
2. After the feeding is finished, add warm water to the feeding syringe and let it flow by gravity.
3. If the water does not go through, try changing positions a bit or attach the plunger to the syringe, and gently push the plunger part-way. DO NOT press all the way down or press fast.
4. Remove the syringe.
5. Close the nasogastric tube cap.

Taking care of the skin

Follow these general guidelines:

• Clean the skin around the tube with warm water and a clean washcloth after each feeding. Remove any crust or secretions in the nose.
• When removing a bandage or dressing from the nose, loosen it first with a bit of mineral oil or other lubricant. Then gently remove the bandage or dressing. Afterward, wash the mineral oil off the nose.
• If you notice redness or irritation, try putting the tube in the other nostril, if your nurse taught you how to do this.

Nasogastric suction

Nasogastric suction also called gastric lavage or bowel obstruction – suction, is a procedure to empty the contents of your stomach.

Nasogastric suction may be done to:

• Remove poisons, harmful materials, or excess medicines from the stomach
• Clean the stomach before an upper endoscopy (EGD) if you have been vomiting blood
• Collect stomach acid
• Relieve pressure if you have a blockage in the intestines

A tube is inserted through your nose or mouth, down the food pipe (esophagus), and into the stomach. Your throat may be numbed with medicine to reduce irritation and gagging caused by the tube.

Stomach contents can be removed using suction right away or after spraying water through the tube.

In an emergency, such as when a person has swallowed poison or is vomiting blood, no preparation is needed for gastric suction.

If gastric suction is being done for testing, your health care provider may ask you not to eat overnight or to stop taking certain medicines.

Nasogastric suction risks may include:

• Breathing in contents from the stomach (this is called aspiration)
• Hole (perforation) in the esophagus
• Placing the tube into the airway (windpipe) instead of the esophagus
• Minor bleeding

1. Marks JM, Ponsky JL. Access routes for enteral nutrition. Gastroenterologist. 1995 Jun;3(2):130-40[↩]
2. Engelke M, Grund KE, Schilling D, Beilenhoff U, Kern-Waechter E, Engelke O, Stebner F, Kugler C. [Comparison of safety insertion techniques of percutaneous endoscopic gastrostomy in nurses and physicians – a non-randomized interventional pilot study on a simulation model]. Z Gastroenterol. 2018 Mar;56(3):239-248[↩]
3. DiSario JA. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20(3):605-30[↩][↩]
4. Byrne KR, Fang JC. Endoscopic placement of enteral feeding catheters. Curr. Opin. Gastroenterol. 2006 Sep;22(5):546-50[↩]
5. Adeyinka A, Valentine M. Enteric Feedings. [Updated 2019 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532876[↩]
6. Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut 2003;52:vii1-vii12. https://gut.bmj.com/content/52/suppl_7/vii1[↩]
7. Mainous MR, Block EF, Deitch EA. Nutritional support of the gut: how and why. New Horiz. 1994 May;2(2):193-201[↩]
8. Volpe A, Malakounides G. Feeding tubes in children. Curr. Opin. Pediatr. 2018 Oct;30(5):665-670[↩]
9. Guyatt Gordon H, Oxman Andrew D, Vist Gunn E, Kunz Regina, Falck-Ytter Yngve, Alonso-Coello Pablo et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations BMJ 2008; 336 :924 https://www.bmj.com/content/336/7650/924[↩]
10. Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin. Gastroenterol. 1988 Oct;2(4):815-47[↩]
11. López Martínez J, Sánchez-Izquierdo Riera JA, Jiménez Jiménez FJ., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): acute renal failure]. Med Intensiva. 2011 Nov;35 Suppl 1:22-7[↩]
12. Montejo González JC, Mesejo A, Bonet Saris A., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): liver failure and transplantation]. Med Intensiva. 2011 Nov;35 Suppl 1:28-32[↩]
13. Grau Carmona T, López Martínez J, Vila García B., Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary units. Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: respiratory failure. Nutr Hosp. 2011 Nov;26 Suppl 2:37-40[↩]
14. Blesa Malpica AL, García de Lorenzo y Mateos A, Robles González A., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. Med Intensiva. 2011 Nov;35 Suppl 1:68-71[↩]
15. Sánchez Álvarez C, Zabarte Martínez de Aguirre M, Bordejé Laguna L., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): gastrointestinal surgery]. Med Intensiva. 2011 Nov;35 Suppl 1:42-7[↩]
16. Bordejé Laguna L, Lorencio Cárdenas C, Acosta Escribano J., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): severe acute pancreatitis]. Med Intensiva. 2011 Nov;35 Suppl 1:33-7[↩]
17. Frankenfield D, Smith JS, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN J Parenter Enteral Nutr. 2004 Jul-Aug;28(4):259-64[↩]
18. Bonet Saris A, Márquez Vácaro JA, Serón Arbeloa C., Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): macro-and micronutrient requirements]. Med Intensiva. 2011 Nov;35 Suppl 1:17-21[↩]
19. Fernández Ortega EJ, Ordóñez González FJ, Blesa Malpica AL. [Nutritional support in the critically ill patient: to whom, how, and when?]. Nutr Hosp. 2005 Jun;20 Suppl 2:9-12[↩]
20. Halloran O, Grecu B, Sinha A. Methods and complications of nasoenteral intubation. JPEN J Parenter Enteral Nutr. 2011 Jan;35(1):61-6[↩]
21. Levy H. Nasogastric and nasoenteric feeding tubes. Gastrointest. Endosc. Clin. N. Am. 1998 Jul;8(3):529-49[↩][↩]
22. Sparks DA, Chase DM, Coughlin LM, Perry E. Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5):625-9[↩]
23. Hull MA, Rawlings J, Murray FE, Field J, McIntyre AS, Mahida YR, Hawkey CJ, Allison SP. Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet. 1993 Apr 03;341(8849):869-72[↩]
24. Majid HA, Emery PW, Whelan K. Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians. Nutr Clin Pract. 2012 Apr;27(2):252-60[↩]
25. NAGLER R, SPIRO HM. PERSISTENT GASTROESOPHAGEAL REFLUX INDUCED DURING PROLONGED GASTRIC INTUBATION. N. Engl. J. Med. 1963 Sep 05;269:495-500[↩]
26. Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract. 2010 Feb;25(1):16-25[↩]
27. Silk DB. The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN J Parenter Enteral Nutr. 2011 May;35(3):303-7[↩]
28. Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr. Rev. 2003 Sep;61(9):320-3[↩]
29. Terlevich A, Hearing SD, Woltersdorf WW, Smyth C, Reid D, McCullagh E, Day A, Probert CS. Refeeding syndrome: effective and safe treatment with Phosphates Polyfusor. Aliment. Pharmacol. Ther. 2003 May 15;17(10):1325-9[↩]
30. Zeki S, Culkin A, Gabe SM, Nightingale JM. Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients. Clin Nutr. 2011 Jun;30(3):365-8[↩]
31. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008 Jun 28;336(7659):1495-8[↩]
32. Marinella MA. Refeeding syndrome in cancer patients. Int. J. Clin. Pract. 2008 Mar;62(3):460-5[↩]