What are the guidelines for initiating and managing pump feeding in patients who require nutritional support?

Guidelines for Initiating and Managing Pump Feeding in Patients Requiring Nutritional Support

Pump feeding should be initiated in patients who require precise control of feeding rates, have feeding intolerance, require jejunal feeding, or need overnight feeding to maintain daytime activities and quality of life. 1

Indications for Pump Feeding

Pump feeding is indicated in the following clinical scenarios:

• Patients with post-pyloric feeding tubes (jejunal feeding)
• Administration of high-calorie feeds
• Poor feed tolerance requiring small volumes delivered over time
• Need for overnight feeding to maintain daytime activities
• Critically ill patients requiring early enteral nutrition
• Patients with severe pancreatitis

Route Selection

The route of administration should be determined based on:

• Gastric feeding: Suitable for most patients; allows for bolus or continuous feeding
• Post-pyloric feeding: Required when gastric feeding is contraindicated (high aspiration risk, gastroparesis, gastric outlet obstruction)

For patients undergoing major abdominal surgery:

• Placement of a nasojejunal tube or needle catheter jejunostomy is recommended for candidates requiring tube feeding 2
• For long-term enteral nutrition (>4 weeks), placement of a percutaneous tube (e.g., PEG) is recommended 2

Administration Methods

1. Continuous Infusion

• Preferred for critically ill patients and those with jejunal tubes
• Recommended for severe acute pancreatitis
• Delivered via pump over 24 hours

2. Cyclic/Intermittent Continuous Feeding

• Often used for overnight feeding to allow daytime activities
• Typically runs for 8-16 hours

3. Bolus Feeding

• Division of total feed volume into 4-6 feeds throughout the day
• Infusion volume typically between 200-400 mL over 15-60 minutes
• More physiological when delivered into the stomach 2
• Suitable for patients with nasogastric or gastrostomy tubes

4. Combined Approaches

• Overnight continuous feeding with daytime bolus feeding provides autonomy while meeting nutritional needs 2

Initiation Protocol

For Gastric Feeding:

• Feeding can be initiated within hours after gastrostomy insertion 2
• No need for water trials prior to commencing enteral nutrition via gastrostomy tube 2
• Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week 2

For Jejunal Feeding:

• Start with a low flow rate (10-20 mL/h) 2
• Increase the rate carefully based on individual tolerance
• May take 5-7 days to reach target intake 2
• Consider starting with 10 mL/h of 0.9% sodium chloride for the first 24 hours after tube insertion, followed by enteral nutrition at 10 mL/h for 24 hours, then increasing by 20 mL/h until target is reached 2

Feed Rate and Volume Guidelines

• Starting rate for pump feeding: 30 mL/h, gradually increasing based on tolerance 1
• Target energy intake:
  • Acute/initial phase of critical illness: 20-25 kcal/kg BW/day
  • Recovery phase: 25-30 kcal/kg BW/day 1
• If no specialized 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 2

Tube Management and Monitoring

• Flush tubes with at least 30 mL of water before and after feeds or every 4 hours during continuous feeding 2, 1
• For patients with doubtful gastrointestinal motility, aspirate the stomach every four hours; if aspirates exceed 200 mL, review feeding policy 2
• To minimize aspiration risk, keep patients propped up by 30° or more during feeding and for 30 minutes after feeding 2
• Monitor for signs of refeeding syndrome in malnourished patients (fluid, glucose, sodium, potassium, magnesium, calcium, and phosphate status) 2

Special Considerations

For Patients with Dementia:

• Tube feeding is suggested for a limited period in patients with mild or moderate dementia to overcome a crisis situation with markedly insufficient oral intake 2
• Tube feeding is not recommended for patients with severe dementia 2

For Post-Surgical Patients:

• Initiate tube feeding within 24 hours after surgery 2
• Adapt oral intake according to individual tolerance and type of surgery 2
• Consider placement of a percutaneous tube if long-term enteral nutrition (>4 weeks) is necessary 2

Complications and Management

• Diarrhea: Often related to concurrent medications (particularly antibiotics); consider fiber-containing feeds or 4-8 hour breaks in feeding 2
• Tube obstruction: Prevent with regular water flushing; if blockage occurs, attempt irrigation with water or cola 3
• Bacterial contamination: Avoid by using proper handling techniques and allowing breaks in feeding to let gastric pH fall 2

Transitioning to Home Enteral Nutrition

When discharging patients on enteral tube feeding:

• Ensure all community carers are fully informed
• Secure continuing prescription of feed and relevant equipment 2
• Provide education on tube management, feeding schedules, and complication recognition
• Consider mobile pumps in rucksacks to enhance patient mobility and independence 2

Regular reassessment of nutritional status during hospital stay and after discharge is essential for patients receiving nutritional support therapy 2.