drug administration via feeding tubes in icu

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 - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

become liable for any adverse event


become liable for therapy failure


complications obstruction of feeding tubes cross-‐contamination

exposure to powders environmental contamination

(patients)

(HCP)


equipment

avoid handling or inhaling

cytotoxics agents hormones antibiotics

eg steroids!

personal protective


tubes


nasogastric feeding tube


duodenal-jejunal feeding tube

caveats: length & diameter Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

PEG/PEJ tubes

manage as nasal inserted Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

drugs formulations


soluble/effervescent tabs dispersible tablets buccal/sublingual tablets coated/uncoated tablets hard/soft gelatin capsules modified-‐release tablets

solid formulations


uncoated tablets

crush administered immediately do not mix powders Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

soluble tablets

dose adjustment is difficult allow complete dissolution


effervescent tablets

require large volumes produces CO2g when in water

caveats: gas & sediment Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

coated tablets

not crush nor break Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

coated tablets

if administered in small intestine tube may be crushed or coat removed Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

capsules (hard)

open & give content if not modified release Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

capsules (soft)

draw fluid with a syringe if not modified release complete dosing not guaranteed Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

buccal sublingual chewable cytotoxic agents hormones & enzymes

never to be crushed


alternative formulation alternative drug alternative route

never to be crushed …if essential


liquid formulations

preferable if available do not mix


liquid formulations suspensions solutions syrups elixirs linctus


liquid formulations

caveats co-‐solvents excipients viscosity granule size


paracetamol

high Na in soluble tablets oral liquids are hyperosmolar

(acetaminophen)


oral liquids are hyperosmolar

metoclopramide

dilute with at least an equal volume of water


do not use oral liquid tubes due to absorption into plastic tubing

diazepam


lactulose

dilute3 times before administration via ND/NJ/PEJ

dilute avoiding tube obstruction


drug -‐feed interactions

delayed -impaired reduced -augmented

absorption

bioavailability Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

drug -‐feed interactions

stop feeding before stop after flush tube

how long?


small syringe = high pressure

30-50 m l recommended

flush

may damage tube/mucosa use largest functional size


avoiding occlusions

reducing the formation &/or clearing debris built-‐up on inner wall

water flush effective


tap/sterile H2O

sterile H2O

water flush

for gastric tubes

beyond the stomach


pulsatile flush = turbulence within the inner lumen more effective cleaning

15-30 m l before 5-10 m l between each 15-30 m l after drug

water flush


sediment in syringe pediatric pts small bowel tubes

15-30 m l ? relates to lumen total volume

water flush

diameter & length! attention!


revise volumes take account in balance replace water with air

fluid restriction?


absorption affected by high-‐fibre containing feeds

digoxin

stop 2h before stop 2h after Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

isoniazid

rifampicin

stop 2h before stop 2h after

stop 2h before stop 1/2h after Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

bioavailability reduced to up 30% but no recommendations

furosemide


decreased absorption up to 75% if administered with feed absorption extremely poor via jejunal route


phenytoin


enteral feed delays but not decrease absorption


quinolone antibiotics


impair absorption by binding when containing


antacids

Al Mg Ca


levothyroxine

no documented interaction no feeding break required Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy


carbamazepine

impaired absorption


drug -‐device interactions

know administered drug know tubes in place

you have to


oral syringes

do not use devices compatible with IV ports & catheters

catheter tipped

Handbook of Drug Administration via Enteral Feeding Tubes


catheter-tipped syringes

do not measure liquid drugs: risk of excessive dosing owing to tip volume Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

dead-‐space volume is approximately 1–1.5 mL

catheter-tipped syringes


patency of feeding tubes

main cause of occlusion incorrect drug administration Velia Marta Antonini - I° department of Anesthesia & Intensive Care, Parma University Hospital - Italy

obstructed feeding tube

particle obstruction precipitate obstruction


food-‐drug drug-‐drug drug-‐device interactions

obstructed feeding tube


irrigation enzymes mechanical devices

unblock obstructed tube


Velia Marta Antonini Parma University Hospital

I° Department of Anesthesia and Intensive Care

thanks for attention

drug administration via feeding tubes in icu

Health & Medicine