What are the best practices for increasing the rate of enteral feedings?

From the Guidelines

To increase the rate of enteral feedings safely and effectively, start with a low initial rate (typically 10-20 mL/hour) and advance gradually by 10-20 mL/hour every 8-12 hours as tolerated until reaching the target rate. This approach is supported by the most recent and highest quality study, which emphasizes the importance of individualized and gradual advancement of enteral feedings to minimize complications and maximize nutrient delivery 1.

Key Considerations

• Implement a prokinetic agent such as metoclopramide (10 mg IV/PO every 6 hours) or erythromycin (250 mg IV/PO every 6 hours) if feeding intolerance occurs, as recommended by the ESPEN guideline 1 and the Canadian Clinical Practice Guidelines 1.
• Position patients with the head of bed elevated at 30-45 degrees to reduce aspiration risk, a strategy supported by the Surviving Sepsis Campaign 1.
• Use continuous rather than bolus feedings for patients with high aspiration risk or feeding intolerance, as suggested by the ESPEN practical guideline 1.
• Monitor for tolerance by checking gastric residual volumes (holding feeds if >250-500 mL), assessing for abdominal distention, vomiting, or diarrhea, in line with the recommendations from the Canadian Clinical Practice Guidelines 1 and the ESPEN guideline 1.
• Consider post-pyloric feeding tube placement if persistent gastric feeding intolerance occurs despite prokinetic agents, as recommended by the ESPEN practical guideline 1 and the Canadian Clinical Practice Guidelines 1.

Formula Selection and Hydration

• Start with isotonic formulas (300-310 mOsm/kg) before advancing to more concentrated formulas, to minimize the risk of feeding intolerance and complications.
• Maintain proper hydration alongside enteral nutrition and implement a bowel regimen to prevent constipation, as emphasized by the ESPEN practical guideline 1 and the Canadian Clinical Practice Guidelines 1.

By following these guidelines and considering the individual needs and tolerance of each patient, healthcare providers can optimize the rate of enteral feedings, minimize complications, and improve patient outcomes, as supported by the evidence from the ESPEN guideline 1, the Surviving Sepsis Campaign 1, and the Canadian Clinical Practice Guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Best Practices for Increasing the Rate of Enteral Feedings

To increase the rate of enteral feedings, several best practices can be employed:

• Use a controller pump to administer continuous feedings at a constant rate or to administer formulas that are viscous 2
• Flush feeding tubes with water every 4 hours during continuous feedings, after giving intermittent feedings, after giving medications, and after checking for gastric residuals 2
• Select feedings that contain appropriate nutrient sources, caloric density, and osmolality; handle feedings in a way that minimizes bacterial contamination 2
• Consider using prokinetic medications such as erythromycin or metoclopramide to improve gastrointestinal mobility and enteral feed migration and absorption 3, 4, 5
• Use a combination of prokinetic medications, such as erythromycin and metoclopramide, for patients who do not respond to single-drug therapy 4
• Consider using bedside nasointestinal tube placement, such as the Cortrak system, to improve enteral nutrition delivery and reduce delayed gastric emptying 6

Monitoring and Assessment

Regular monitoring and assessment are crucial to ensure the safe and effective administration of enteral feedings:

• Monitor patients' vital signs, fluid intake and output, and weight on a daily basis 2
• Check urine sugar and acetone levels every 6 hours (until stable) 2
• Determine serum electrolytes, blood urea nitrogen, and glucose levels daily, until serum levels stabilize 2
• Perform weekly measurements of trace elements to ensure adequate mineral replacement 2
• Assess patients' nutritional status and adjust enteral feedings as needed to ensure adequate nutrition 2

Troubleshooting Common Issues

Common issues that may arise during enteral feedings include:

• Diarrhea: assess for concomitant drug therapy, malnutrition, hypoalbuminemia, formula-related factors, and bacterial contamination 2
• Tube obstruction: attempt to irrigate the tube with water or cola 2
• Gastric feeding intolerance: consider using prokinetic medications or adjusting the rate of enteral feedings 3, 4, 5