From the Guidelines
To initiate tube feeding, start at a slow rate of 10-20 mL/hour and gradually increase by 10-20 mL/hour every 8-12 hours as tolerated until reaching the target rate, as recommended by the most recent guidelines 1. This approach is supported by the ESPEN practical guideline on home enteral nutrition, which suggests a graduated program of commencement of jejunal HEN feeds 1.
Key Considerations
- Start with a low flow rate (e.g., 10-20 mL/h) due to limited intestinal tolerance, as noted in the ESPEN guideline on clinical nutrition in surgery 1.
- Monitor for tolerance by checking for abdominal distension, nausea, vomiting, or diarrhea before each rate increase.
- If the patient shows signs of intolerance, maintain the current rate for an additional 8-12 hours before attempting another increase.
- For continuous feedings, once the target rate is reached, maintain it consistently.
- For intermittent feedings, gradually increase the volume while extending the feeding duration until the prescribed regimen is established.
Patient-Specific Factors
- Patients with prolonged NPO status or compromised gut function may require slower advancement schedules to prevent feeding intolerance, as suggested by the ESPEN guidelines on enteral nutrition: surgery including organ transplantation 1.
- The time to reach the target intake can be very different and may take five to seven days, as noted in the ESPEN guideline on clinical nutrition in surgery 1.
Gradual Increase Approach
- Begin at 20 mL/hour, then increase to 40 mL/hour after 8 hours, then to 60 mL/hour after another 8 hours, continuing this pattern until the prescribed goal rate (typically 50-100 mL/hour) is achieved.
- This gradual approach allows the gastrointestinal tract to adapt to the enteral nutrition, reducing the risk of complications such as dumping syndrome, diarrhea, or aspiration.
From the Research
Increasing Tube Feeding Starting Rate to Target Rate
To increase the tube feeding starting rate to the target rate, several strategies can be employed:
- Use of prokinetic agents such as metoclopramide or erythromycin to improve gastric emptying and reduce feeding intolerance 2, 3, 4
- Placement of post-pyloric feeding tubes to reduce the risk of aspiration and improve feeding tolerance 5, 3, 6
- Use of bedside nasointestinal tube placement techniques, such as the Cortrak system, to improve the success rate of post-pyloric tube placement 3
- Administration of intravenous metoclopramide prior to tube insertion to improve the success rate of blind bedside post-pyloric feeding tube placement 6
Prokinetic Agents
Prokinetic agents such as metoclopramide and erythromycin have been shown to improve gastric emptying and reduce feeding intolerance in critically ill patients:
- Metoclopramide has been shown to reduce feeding intolerance and improve gastric emptying in critically ill patients 2, 3, 4
- Erythromycin has been shown to increase the success rate of small-bowel tube placement and improve gastric emptying in critically ill patients 3, 4
Tube Placement Techniques
The use of post-pyloric feeding tubes and bedside nasointestinal tube placement techniques can improve the success rate of tube placement and reduce the risk of aspiration: