What is the recommended protocol for bolus feedings in patients requiring nutritional support via a feeding tube?

From the Guidelines

Bolus feedings in patients requiring nutritional support via a feeding tube should be administered in volumes of 200-400 mL, 4-6 times daily, over a 15-60 minute period, as this approach is considered more physiological and mimics normal meal patterns. This recommendation is based on the most recent and highest quality study available, which suggests that bolus infusion procedure requires the division of total feed volume into four to six feeds throughout the day 1. The infusion volume is typically between 200 and 400 mL of feed administered over a 15-60 minute period, depending on the patient's nutrient needs and tolerance.

Key Considerations for Bolus Feedings

• Verify tube placement before each feeding to prevent complications
• Elevate the patient's head to at least 30 degrees to reduce aspiration risk
• Flush the tube with 30 mL of water before and after each feeding to prevent clogging
• Monitor for complications such as nausea, vomiting, diarrhea, or abdominal distension, and adjust the regimen if these occur
• Start with half-strength formula and gradually increase to full strength over 24-48 hours to improve tolerance

Benefits of Bolus Feedings

• Mimics normal meal patterns
• Requires less equipment than continuous feeding
• Suitable for ambulatory patients and those with stable gastrointestinal function
• Allows for greater autonomy and flexibility in daily activities

Potential Risks and Complications

• Dumping syndrome in some patients
• Nausea, vomiting, diarrhea, or abdominal distension
• Aspiration risk if tube placement is not verified or head elevation is not maintained

According to the most recent study, there is no evidence that bolus feeding predisposes to diarrhea, bloating, aspiration compared to continuous feeding 1. However, it is essential to monitor tolerance, especially during initial implementation, and adjust the regimen as needed to minimize potential complications.

From the Research

Bolus Feedings Protocol

• Bolus feeding involves administration of enteral nutrition (EN) over a 4- to 10-minute period using a syringe or gravity drip 2
• For medically stable patients with feeding tubes terminating in the stomach, bolus feeding is favored with respect to practical factors, such as cost, convenience, and patient mobility 2
• However, few studies have shown whether intermittent or bolus feeding is beneficial in a critical care setting at present 2
• Additional randomized controlled studies comparing intermittent with bolus feeding are required to determine the recommended protocol for bolus feedings in patients requiring nutritional support via a feeding tube 2

Enteral Feeding Routes

• Enteral feeding tubes can be used to administer medicines and provide nutrition directly into the gastrointestinal (GI) tract 3
• There are several routes that can be used for enteral feeding, including gastrostomy, post-pyloric, nasogastric, continuous pump, and bolus feeding 3
• Nurses and other healthcare professionals should be aware of the potential complications associated with enteral feeding, such as tube blockage and infection 3

Enteral Feeding Intolerance

• Enteral feeding intolerance (EFI) is a common feature in critically ill patients worldwide, but there is no clear, widely agreed-upon definition available 4
• A pragmatic definition of EFI may be useful in clinical practice, where a clinician has decided to reduce the amount of enteral nutrition specifically because features of gastrointestinal dysfunction appeared during enteral feeding 4
• The pathophysiological mechanisms of EFI are complex and may involve various factors, including gastroparesis/delayed gastric emptying 4

Medications and Enteral Feeding

• Metoclopramide is a medication that can be used to stimulate gastrointestinal smooth muscle and prevent vomiting induced by antineoplastic drugs 5
• Metoclopramide's effects on the gastrointestinal tract may be beneficial for patients undergoing enteral feeding, but its use should be carefully considered due to potential adverse effects 5

Fasting Times and Enteral Nutrition

• The American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine recommend minimizing fasting times prior to surgery, but guidelines for intubated patients in the intensive care unit are limited 6
• A scoping review found that institutions apply different fasting times depending on procedure types and feeding access for patients with cuffed endotracheal tubes prior to general anesthesia 6
• No aspiration events were witnessed during any operative procedure where a reduced fast was used, suggesting that limiting fasting times with cuffed endotracheal tubes may improve nutritional goals without additional complications 6