Bolus Feeding Schedules for an 84-Year-Old, 68-kg Man Two Months Post-Abdominal Surgery
For this patient receiving Jevity 1.5 via gastrostomy tube, I recommend either a three-times-daily schedule (475 mL per feed at 08:00,13:00,18:00) or a four-times-daily schedule (355 mL per feed at 08:00,12:00,16:00,20:00), with the choice depending on gastric tolerance—use the three-times schedule if the patient tolerates larger volumes well, or the four-times schedule if he experiences early satiety or delayed gastric emptying. 1
Calculating Total Daily Volume Requirements
Caloric and Protein Targets
- This 68-kg patient requires 1,700–2,040 kcal/day (25–30 kcal/kg/day) and 68–102 g protein/day (1.0–1.5 g/kg/day). 1
- Jevity 1.5 provides 1.5 kcal/mL and approximately 0.06 g protein/mL. 1
- To deliver approximately 2,130 kcal and 85 g protein, the patient needs 1,420 mL of Jevity 1.5 per day. 1
Fluid Requirements
- Total fluid requirement is 1,700–2,040 mL/day (25–30 mL/kg/day). 1
- Jevity 1.5 is approximately 85% water, so 1,420 mL provides roughly 1,207 mL of free water. 1
- Additional 400–500 mL of free water flushes are needed to meet total fluid goals. 1
Three-Times-Daily Bolus Schedule
Volume and Timing
- 475 mL of Jevity 1.5 at 08:00,13:00, and 18:00 (total 1,425 mL/day). 1
- Administer each bolus over 30–45 minutes by gravity or slow syringe to prevent dumping syndrome and abdominal distension. 1
- Never deliver faster than 15 minutes per bolus—rapid administration in elderly patients precipitates dumping syndrome, hypotension, and aspiration risk. 1
Water Flush Protocol
- Give 150 mL of free water after each feed (50 mL × 3 = 150 mL total), plus an additional 250–300 mL distributed throughout the day to reach the 400–500 mL supplemental water target. 1
- Flush the tube with 30–50 mL of fresh tap water, cooled boiled water, or sterile water before and after each feed to maintain patency. 1, 2
Advantages of This Schedule
- Larger bolus volumes mimic normal meal patterns, supporting physiological satiety cues and improving quality of life. 1
- Fewer feeding interruptions allow greater participation in daily activities and mobility. 1
- Appropriate for patients with good gastric tolerance at two months post-operative. 1
Four-Times-Daily Bolus Schedule
Volume and Timing
- 355 mL of Jevity 1.5 at 08:00,12:00,16:00, and 20:00 (total 1,420 mL/day). 1
- Administer each bolus over 20–30 minutes by gravity or slow syringe. 1
- Again, never exceed 15 minutes per bolus to avoid complications. 1
Water Flush Protocol
- Give 30–40 mL of free water after each feed (120–160 mL total from post-feed flushes), plus an additional 240–340 mL distributed throughout the day to reach the 400–500 mL supplemental water target. 1
- Flush the tube with 30–50 mL of water before and after each feed. 1, 2
Advantages of This Schedule
- Smaller bolus volumes reduce gastric distension and dumping symptoms. 1
- Better tolerated in patients with delayed gastric emptying or early satiety. 1
- More gradual nutrient delivery may enhance absorption when gastrointestinal function is compromised. 1
Administration Technique (Both Schedules)
Patient Positioning
- Keep the patient upright or with head of bed elevated ≥30° during feeding and for at least 30 minutes afterward to minimize aspiration risk. 1, 3
Formula Preparation
- Use Jevity 1.5 at full strength—do not dilute the formula, as dilution increases infection risk, alters osmolality, and reduces nutrient delivery without clinical benefit. 1
- Employ only commercially prepared Jevity 1.5; home-blended feeds carry higher infection rates and inadequate micronutrient content. 1
Tube Maintenance
- Flush with fresh water before and after each feed and medication administration to prevent blockage. 1, 2
- Do not use carbonated drinks, pineapple juice, or acidic solutions for flushing, as they degrade tube material. 2
- If the tube becomes blocked, attempt flushing with warm water first, then an alkaline solution of pancreatic enzymes if warm water fails. 2
- Loosen and rotate the gastrostomy tube weekly to prevent mucosal overgrowth. 1
Monitoring and Safety Checks
Gastric Residual Volumes
- Check gastric residuals every 4 hours initially; if residual volume exceeds 200 mL, hold the feeding and reassess tolerance. 1, 3
- Residuals >500 mL per 6 hours indicate high risk of intolerance and may require transition to post-pyloric (jejunal) feeding. 3
Electrolyte Monitoring
- Monitor Na⁺, K⁺, Mg²⁺, Ca²⁺, and PO₄³⁻ closely during the first few days after any change in feeding regimen to detect early disturbances and prevent refeeding syndrome. 1
- Although refeeding syndrome risk is lower at two months post-operative, patients with prior malnutrition should still be monitored. 1
Micronutrient Surveillance
- After gastrointestinal surgery, routinely monitor serum levels of vitamin B₁₂ (especially if terminal ileum resected), iron, calcium, and vitamin D, as absorption may be compromised. 1
Signs of Intolerance
- Watch for abdominal distension, nausea, vomiting, and diarrhea. 1
- If diarrhea occurs, first evaluate medication side effects (e.g., antibiotics) rather than attributing it to the formula. 1
Fluid Status
- Monitor for signs of fluid overload (peripheral edema, weight gain >1 kg/day, dyspnea) in elderly or post-surgical patients. 1
- Conversely, watch for dehydration (fatigue, confusion, electrolyte disturbances) if supplemental water is inadequate. 1
Common Pitfalls and How to Avoid Them
- Rapid bolus delivery in elderly patients can precipitate dumping syndrome, hypotension, and aspiration—strict adherence to the 20–45 minute administration window is essential. 1
- Avoid overnight bolus feeding in individuals with any aspiration risk, as nocturnal feeding increases aspiration events. 1
- Do not eliminate water flushes entirely, even when supplemental water intake is adequate; flushes are essential for tube patency and to prevent medication residue buildup. 1
- Never apply suction to gastrostomy tubes during routine care, as this can cause mucosal damage. 2
Summary Tables
Three-Times-Daily Schedule
| Time | Jevity 1.5 Volume | Duration | Water Flush After Feed |
|---|---|---|---|
| 08:00 | 475 mL | 30–45 min | 50 mL |
| 13:00 | 475 mL | 30–45 min | 50 mL |
| 18:00 | 475 mL | 30–45 min | 50 mL |
| Total | 1,425 mL | 150 mL (plus 250–300 mL additional throughout day) |
Four-Times-Daily Schedule
| Time | Jevity 1.5 Volume | Duration | Water Flush After Feed |
|---|---|---|---|
| 08:00 | 355 mL | 20–30 min | 30–40 mL |
| 12:00 | 355 mL | 20–30 min | 30–40 mL |
| 16:00 | 355 mL | 20–30 min | 30–40 mL |
| 20:00 | 355 mL | 20–30 min | 30–40 mL |
| Total | 1,420 mL | 120–160 mL (plus 240–340 mL additional throughout day) |