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Nutrition Care Subcommittee PRACTICE GUIDELINES: ENTERAL NUTRITION DELIVERY FOR THE ADULT PATIENT PURPOSE: To provide a “best practice” guideline for the management of enteral nutrition support in adult patients based upon current research. To standardize practice throughout the organization. I.

Candidates for Enteral Nutrition A. Who is a candidate for enteral feeds? 1. Functional GI tract and: 1. Neurological deficit prohibiting adequate intake 2. Mechanically ventilated 3. Increased nutrient needs unable to be met via p.o. intake 4. Oro-pharyngeal and esophageal deficits B. Who is NOT a candidate for enteral feeds? 1. Bowel obstruction 2. Small bowel ileus 3. Intractable diarrhea 4. Massive intestinal hemorrhage 5. Low perfusion states

II.

Feeding Tube Selection A. Short Term Selection criteria: for use in patients requiring nutrition support for < 6 weeks 1. NG Tube 2. OG Tube 3. Nasally-placed small bore feeding tube (gastric or post-pyloric placement) B. Long Term/Permanent Selection criteria: for use in patients requiring nutrition support for > 6 weeks 1. PEG 2. G-Tube 3. J-Tube 4. G-J Tube (e.g.: MICC)

III.

Feeding Tube Placement and Care (Short Term) A. Please refer to AACN Procedure Manual for Critical Care 4th Edition, Chapter 97, “Oro-gastric and Naso-gastric Tube Insertion, Care, and Removal”, page 681 B. Please refer to UMMC Clinical Practice Council Practice Guideline: Procedure for Small-Bore Feeding Tube Insertion (for post-pyloric placement)

IV.

Long Term/Permanent Feeding Tube Care A. Please refer to AACN Procedure Manual for Critical Care 4th Edition, Chapter 127, “Gastrostomy or Jejunostomy Tube Care”, page 883

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V.

Tube Identification A. Refer to UMMC policy regarding labeling of tubes (Policy: Medication Administration Process # Med-003 in Clinical Practice Manual) B. Document clearly tip (end) position of feeding tube (ie: post-pyloric, naso-jejunal vs nasogastric)

VI.

Formula Delivery A. Clean Technique • Wash hands prior to handling feedings and administration systems • Inspect for dents and expired product • Shake product to ensure proper mixing • Rinse top of cans with water before opening • Use clean technique • Assemble feeding systems on a clean, dry, disinfected surface. • Label feeding bag with patient name, product name, rate and time/date hung. Limit hang time of feeding to 8 hours • Note location of tube termination and document on flowsheet (ie post-pyloric, naso-jejunal) • Treat bag as a closed system (no additives without MD order) • If additives placed in formula bag, hang time decreases to 4 hours • Before adding additional tube feeding, let current formula completely run out from bag. Flush any remaining feeding from tubing. (coordinate with scheduled flush) • Change entire administration set every 24 hours • Discard all opened cans of formula that are not infused

VII. Method of Formula Delivery A. Continuous Feeding Schedule • Most appropriate feeding schedule for critically ill tube fed patients and only feeding delivery method for small bowel feedings • Formula infused continuously over ~ 24 hours via volumetric pump • As a supplement to oral intake may be infused nocturnally over 10-12 hours • Generally initiated at 20-40 ml/hour and advanced every 4-12 hours depending upon patient tolerance to goal rate • Fluid bolus usually provided every 4-6 hours to provide for additional fluid requirements B.

Intermittent Gravity Drip Feeding Schedule • Intermittent feeding schedules are appropriate for non-critically ill patients and can only be utilized in patients being fed gastrically. Jejunal/small bowel feedings should never be delivered as intermittent gravity drip feeds. Patients who require long-term tube feedings generally utilize this feeding regimen. • Formula is infused intermittently throughout the day, often timed to mimic a meal schedule (breakfast, lunch, dinner and HS snack) • Formula is delivered via a feeding bag and tubing equipped with a roller clamp

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• • • •

Each feeding generally consists of 240- 480 ml formula infused via gravity drip over a minimum of 30-60 minutes Patients should be positioned with head elevation at a minimum of 45 – 90 degrees during and for 30 minutes following a feeding The feeding tube is flushed before and after each feeding. Additional free water can be provided between meals. Gastric residual volumes (GRV) should be checked prior to each feeding (in patients with gastric tubes) and if GRV is greater than 250 ml, the feeding should be delayed 1 hour and a thorough GI assessment completed

C. Modular Components- DO NOT MIX MODULAR COMPONENTS INTO ENTERAL FEEDING FORMULAS •

Prosource , No Carb - Single serving liquid protein supplement- 15 grams protein each - Flush tube with 30 ml water − Mix each packet Prosource with 30 ml tap water (subtract water from routine fluid flush or bolus) − Deliver Prosource bolus via syringe − Flush tube with 30 ml water

•

Arginaid − Mix each packet Arginaid powder with 60 ml water in styrofoam cup with spoon, mix until fully dissolved − Flush feeding tube with 30 ml water − Deliver Arginaid bolus via syringe − Flush tube with 30 ml water

• GlutaSolve − Flush feeding tube with 15 ml water − Mix each packet GlutaSolve with 60 ml warm water for 20 seconds in a styrofoam cup with spoon and infuse immediately via syringe − Flush feeding tube with 15 ml water D. Formula Delivery for Special Populations 1. Guidelines for all patients at UMMC and Shock Trauma undergoing HBO treatment and receiving enteral nutrition support A. Non Insulin Drip Requiring Enteral Nutrition Support Patient a) All patients receiving tube feedings NOT on an insulin drip should be sent to the HBO chamber with the tube feedings infusing b) Prior to diving the tube feedings will be disconnected. (The tube feeding pole, pump and formula will remain outside the diving chamber until the treatment is complete due to pump incompatibility). Tube feeding infusion is restarted once patient removed from the chamber. c) RD will adjust the tube feeding formula goal rate for diving as follows: o QD treatments calculate feedings on 21-hours/day infusions. NutritionCare Subcommittee/Revised October 2007

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o BID treatments calculate feedings on 18-hours/day infusions. o Monitor patient tolerance to increased infusion rates o Discuss with service RD. B. Insulin Drip Requiring Enteral Nutrition Support Patient *Goal is to maintain glucose control as per unit protocol. (For additional information, refer to Hyperglycemia Management Guidelines) a) All patients receiving tube feedings and on an insulin drip should leave the unit for HBO treatment with the tube feeding and insulin drip infusing. b) In HBO prior to diving, decrease the insulin drip rate by 50%. Disconnect the tube feeding (The tube feeding pole, pump, and formula will remain outside the diving chamber until patient’s treatment is complete due to pump incompatibility). Check finger glucose mid way through the dive. (~45minutes) and at completion of treatment Document glucose on flow sheet and adjust insulin drip per insulin drip guidelines. Tube feeding should be restarted once patient removed from the chamber prior to transfer back to the patient care unit. Document all changes on flow sheets c) Upon return to room, check finger stick, document on flow sheets, adjust insulin drip per insulin drip guidelines. 2. Guidelines for all patients at UMMC and Shock Trauma undergoing Hemodialysis and Enteral Nutrition Support  Continuous enteral feedings should continue during hemodialysis treatment unless otherwise ordered by the physician a) Transport patients to dialysis with pump, pole and adequate tube feeding product for duration of treatment b) Document enteral feeds infused on flow sheet during dialysis c) Follow aspiration precaution guidelines VIII.

Monitoring, Complication Prevention/Management A. General Monitoring: 1. Blood glucose • Where applicable, follow Hyperglycemia Management Guidelines • Goal glucose level: Per unit target 2. Weight • Minimum twice weekly weight q Sunday and Wednesday • Weigh patient in am 3. Intake/Output 4. Oral Care (Refer to CPC Practice Guidelines: Oral Care and Prevention of Aspiration Pneumonia). 5. GI Exam • To include evaluation of distention, tenderness, firmness, presence of bowel sound, nausea, vomiting, flatus, stool (volume and characteristic)

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B. Monitoring Specific to Aspiration Prevention 1. Tube Position • OGT/NGT placement should be confirmed a. q shift b. after severe coughing c. after vomiting or retching d. if mark at exit site of tube is in a different position or not visible e. if a question exists regarding placement, feeding and medication delivery should be held until placement confirmed 2. Head of bed elevation • minimum 30 – 45 degrees for continuous feedings via gastric route • 45 – 90 degrees during and 30 minutes after intermittent feedings • Hold all tube feeding if HOB needs to be lower because of hemodynamic instability. • Hold gastric feedings if HOB decreased for bedside procedures. 3. Frequent suctioning in ventilated patients. 4. Check gastric residuals (GRV) • Do not check residuals in post pyloric feeding tubes or jejunal feeding tubes

• Check gastric residual volumes q 6 hrs (use 60 ml syringe w/Luer tip). • Gastric residual volume should be checked in all gastrically fed patients regardless of • • • •

type of feeding tube (NGT, OGT, Gastric Corpak/Keofeed, PEG) All residual volumes must be documented on the flow sheet even if residual volume is “0” ml If GRV < 250 ml- re-feed aspirate and continue tube feedings in patients without other clinical changes If GRV 250 – 350 ml- re-feed aspirate in patients without clinical changes or change in GI exam. Hold tube feedings for 1 hour and re-check residual volume. If GRV > 350 ml or patient experiences emesis- hold tube feeding, discard aspirate, notify physician and document on flow sheets

**Algorithm for residual volume management below

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Adult Gastric Residual Volume (GRV) Algorithm

Check GRV every 6 hours if patient receiving gastric tube feeding (TF) and document all

If GRV 250-350 ml

If GRV < 250 ml

•Refeed aspirate to patient •Continue TF

IF If GRV GRV > > 350 350 ml, ml, or or if patient has if patient has emesisemesis

•Return aspirate to patient, in the absence of change in clinical condition or GI exam •Hold TF 1 hour and recheck GRV

If GRV < 250 ml

If GRV ≥ 250 ml

•Stop TF •Discard aspirate/emesis •Notify MD •Monitor clinical condition(pressors, hemodynamic instability) •Monitor GI exam (firm, distended, N/V) •Consider promotility agent (e.g.metoclopramide) •Verify tube placement & assess

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Recheck GRV in 4 hours

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C. Complication Management 1. Tube occlusion • Attach a 20 to 60 ml syringe to end of feeding tube and aspirate as much fluid as possible. Fill syringe with warm water (Do not use carbonated beverages or fruit juice). Instill using manual pressure for one minute; use a back-and-forth motion with the plunger. Clamp the tube for 5 to 15 minutes. Try to aspirate or flush the tube. Repeat as needed. • If above fails, crush the Minimicrospheres from 1 capsule of Creon 10 or formulary pancreatic enzymes with 1 (324 mg) tablet sodium bicarbonate. Dissolve in 5 mls warm water and inject into feeding tube. Cap tube and wait 5-15 minutes. Uncap and attempt to flush tube. Repeat as needed. 2. Nausea/Vomiting • Notify MD • Hold gastric feedings for emesis • Verify tube placement • Assure head of bed elevation • Assess for change in clinical status • Evaluate changes in GI exam − new onset distention − constipation • Medication profile review • Evaluate possible etiology of symptoms − Following suctioning − Following medication administration − Pain induced − Too rapid feeding delivery − Large volume fluid bolus • Consider anti-emetics and/or promotility agents if other causes ruled out • Discuss with R.D. if unresolved 3.

Aspiration of feeding formula • Immediate discontinuation of feeding and begin gastric decompression if able • Notify MD • Verify tube placement, HOB elevation • Assess for changes in GI exam • Discuss need for promotility agents and/or post pyloric feedings

4.

Constipation- greater than 3 days without bowel movement • Evaluate provision of enteral fluid boluses

• Evaluate need for bowel regimen •

− Stool softener, laxatives, enemas Evaluate MAR for medications prone to decrease bowel motility (e.g.: Morphine)

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5.

Acute/New-Onset Diarrhea- Greater than 5 liquid stools/day or a volume greater than 1500 ml/day • Quantify stool output

• Notify MD for possible stool cultures (i.e. C. difficile ) • Evaluate medication profile (see medication section for high osmolality medication list) • Discuss with RD for further evaluation if above does not improve diarrhea Blue dye is no longer recommended for routine use in enterally fed patients. Case reports have associated negative patient outcomes caused by the systemic absorption of blue dye in critically ill enterally fed patients. Special Considerations with postpyloric and jejunal feeding tubes. Due to their small diameter, additional diligence is required to prevent tube occlusion. Feeding tubes should be flushed a minimum of 4 – 6 hours to maintain patency. Do not obtain residual volumes from these tubes Administer medications in liquid form whenever available IX.

Medications Delivery with Enteral Feedings A. • • • • • •

•

•

General considerations NO MEDICATION SHOULD BE MIXED DIRECTLY WITH FEEDING FORMULA. Identify where the tip of tube is prior to medication delivery as drug absorption can be affected by its location. Flush tube with 15-30 ml tap water before and after administering medications and with 5 ml between multiple doses being administered consecutively. If a medication is to be delivered on an empty stomach, check gastric residual before medication delivery. Use only water to flush feeding tubes as other liquids not only significantly increase osmolality but also may result in tube occlusion. When possible, the elixir, emulsion, solution, or suspension (except for ciprofloxacin and clarithromycin suspensions) should be used. Notify the pharmacy that the medication is for delivery via feeding tube and liquid medications can be sent, if available. - medications available in liquid form include: acetaminophen, ibuprofen, ferrous sulfate, furosemide, docusate, metoclopramide, diphenhydramine, multiple vitamins, valproic acid, potassium chloride, digoxin, tacrolimus, sirolimus, and calcium carbonate. Administer medications as liquids. Many tablets can be crushed. Crush the tablet into a fine powder and mix with 15-30 ml of room temperature tap water. - Confirm with the pharmacy which medications can be crushed or opened. Certain medications such as enteric coated, extended release, sustained release, or timed-release drugs should NOT be crushed or opened to administer via feeding tube. Sublingual or buccal tablets should NOT be delivered via feeding tube.

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• • •

B.

Administer each medication separately and flush tube with 5 ml of water after each consecutively administered medication. Liquid medications are easier to administer, but may be hypertonic and cause gastrointestinal distress. Dilute hypertonic liquid medications with water. - Liquid medications can be up to 6000 mOsm whereas GI tract secretions are 300 mOsm (see below) *****Always flush tube between medications and Never mix medications together into “cocktails” as these mixtures may cause precipitates, occlude feeding tubes or compromise patient safety because the efficacy of the medication may be affected.

Preparation of Medication 1. Crushing Tablets • Crush tablets as finely as possible. Mix powder with 15-60 ml tap water depending on tube diameter. If tablet is uncovered, wrap in clean paper towel before crushing. 2. Thick Liquids • Dilute with 15-30 ml of water. Very concentrated liquids should be diluted with 30-60 ml. 3. LIQUID-FILLED/SOFT GELATIN CAPSULES (e.g. Vit. E, calcitriol) • Use one of 2 methods: - A pinhole can be poked in one end of the capsule and the contents can be squeezed out and reconstituted with 10-15 ml of tap water. - Preferably, the entire capsule can be dissolved in 15-30 ml of warm tap water; it may take up to 1 hour for the capsule to dissolve. 4. Dilution • Dilute medications that should be given with meals to avoid GI irritation. • Dilute hypertonic or irritating medications with at least 15-30 ml of water to avoid GI irritation. - This formula can be used to calculate the exact amount of water needed to bring the osmolality of the hypertonic liquid medication down to isotonic levels: -

Final volume = volume of liquid med x mOsm of liquid med desired mOsm (300-500) -

Example: a dilution with 30 ml of water can reduce a 10 ml amount of medication with an osmolality of 2000 mOsm/kg to 500 mOsm/kg.

DRUG Acetaminophen elixir Aminophylline liquid Digoxin elixir Diphenoxylate suspension Ferrous sulfate liquid Furosemide solution Metoclopramide Multivitamin liquid Phenytoin sodium suspension Potassium chloride liquid NutritionCare Subcommittee/Revised October 2007

(Average) mOsm/kg 5,400 450 1,350 8,800 4,700 2,050 8,350 ~5,700 1,500-2,000 3,000-4,350 9

Theophylline elixir

C.

6,550

Specific Medication considerations: 1. Liquid Antacids • Administer into feeding tubes with the tip placed in the stomach only. • Avoid giving via feeding tubes < 10 french in size. • Aluminum containing antacids (e.g. Amphogel/ aluminum hydroxide, Maalox, Mylanta) should be given 15 minutes after all other medications have been administered. • Preferably, give the antacid following a feed (bolus or intermittently fed patients) and flush the tube with 10-15 ml of warm water prior to administration. 2. Bulk-forming Medications- (methylcellulose, polycarbophil Metamucil, psyllium, cholestyramine) • Avoid giving via tube, especially small bore feeding tubes, as they clog easily. 3. Antibiotic Agents • Clarithromycin and ciprofloxacin suspensions should NOT be administered via feeding tubes as they clog easily. Used crushed ciprofloxacin tablets for medication administration via feeding tubes. 4. Gastrointestinal Agents • Esomeprazole may be administered by opening and mixing the contents of the capsule with 25-50 ml of water or apple juice and giving immediately. Then flush the tube with 15 ml of water. • Sucralfate should be administered into feeding tubes with the tip placed in the stomach only. • Pancreatic enzymes (Creon, pancretin, Pancrease, pancrelipase) should be administered by opening and mixing the contents of the capsule with 10-15 ml of apple or cranberry juice and given immediately followed by flushing the tube with the juice. Then flush the tube with 15 ml of water.

5. Carbamazepine • This suspension should NOT be given along with other medications or diluted with other liquids. 6. Phenytoin • Hold tube feeds 1 hour before and 1 hour after dosing. • Dilute phenytoin suspension with 30ml of water. • Monitor blood levels of phenytoin. • Phenytoin can not be delivered via J tube. 7. Ciprofloxacin • Hold tube feeds for 1 hour before and 2 hours after dose is administered. 8. Moxifloxacin • Hold tube feeds for 2 hours before and 2 hours after dose is administered.

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X: Documentation Requirements: A. Patient/Family Education 1. Explain procedure for enteral nutrition 2. If possible, teach patient to report signs/symptoms of intolerance such as nausea, abdominal cramping, abdominal fullness 3. Discuss patient’s need for long term nutrition support if appropriate B. Aspiration Precautions 1. HOB Elevation 2. Gastric Residual Volumes (GRV)/frequency/times/appearance C. Fluid bolus (fluid and volume) D. Weight E. Feeding prescription F. Feeding formula, rate, total volume delivered over 24 hours G. Feeding hold with reason H. Tube insertion I. Confirmation of tube placement minimum of q shift (naso-gastric) J. Feeding tube type and tip placement K. GI exam including bowel sounds, tenderness, distention, flatus, nausea, vomiting, stooling (character, volume, frequency) XI: Where To Document EachNursing Flowsheet- Floor: • Patient/Family Education- Computer charting or on paper form

• Aspiration Precautions- HOB elevation- Last Line under Nutrition Section (page 2) • Gastric Residual Volumes/Appearance- Designated area in Nutrition Section (page 2) • Feeding Prescription and Fluid bolus volume and frequency- (page 2) In “Diet” line under Nutrition Section • Actual Tube Feeding formula, rate and fluid bolus delivered- (page 6) Intake Section

• • • • • •

Tube Feeding holds/Reason- (page 1) Additional Notes section Tube insertion- (page 1) Additional notes section Feeding tube type and tip placement- (page 2) Nutrition Section “GI Access/Care” Confirmation of tube placement (NGT)- (page 2) Nutrition Section “GI Access/Care” GI Exam- (page 4) Assessment Section “GI” Weight- (page 6) Designated area

Nursing Flowsheet –ICU: • Patient/Family Education- Computer charting

• Aspiration Precautions- HOB elevation- (page 1) Designated area • Gastric Residual Volumes/Appearance- (page 4) “Tube feeding residual” • Feeding Prescription and Fluid bolus volume and frequency- (page 4) “Meal assistance” NutritionCare Subcommittee/Revised October 2007

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• • • • • • •

Actual Tube Feeding formula, rate and fluid bolus delivered- (page 3) Intake Section Tube Feeding holds/Reason- (page 6) “GI” Tube insertion- (page 6) “GI” or (page 8) Feeding tube type and tip placement- (page 6) “GI- Feeding tube Type/Location” Confirmation of tube placement (NGT)- (page 6) “GI- Feeding tube Type/Location” GI Exam- (page 6) Assessment Section “GI” Weight- (page 3) Designated area

Nursing Flowsheet- Trauma: • Pt/Family Education Documentation-Complete the Pt/Family Education Documentation Form

• • • • • • • • • •

Aspiration Precautions-HOB (page 7)“GI” section Gastric Residual Volume: (page 3) “output” section above or on “OGT/NGT” line Feeding Bag Label: (page 8) under “care documentation” Fluid Bolus (page3) “intake” section below “PO/Enteral” Weight: (page 1) “Weight” box Feeding Prescription: (page 1) “Nutrition” box Feeding Formula, rate, and total: (page 3) “intake” section with “PO/Enteral” line Confirmation of tube placement and insertion: (page 7) “GI” section Feeding tube type and tip location: (page 5) “Label” section GI exam: (page 7) “GI” section

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Enteral Practice Guideline Reference List Au Yeung S, Ensom M. Phenytoin and enteral feedings: does the evidence support an interaction? Ann Pharmacother 34(7-8):896-905 Jul-Aug, 2000. Bankhead R, Fang J. Enteral Access Devices IN The ASPEN Nutrition Support Core Curriculum: A Case Based Approach/The Adult Patient. Gottschlich, MM (ed): ASPEN, Silver Spring, Maryland, 2007. Carvalho MLR, Morais TA, Amaral DF, Sigulem DM. Hazard analysis and critical control point system approach in the evaluation of environmental and procedural sources of contamination of enteral feeding in three hospitals. JPEN 24:296-303, 2000. Drugdex Drug Evaluations. Levodopa. Resource on world wide web: http://micromedex.com, June 2003. Drugdex Drug Evaluations. Levothyroxine. Resource on world wide web: http://micromedex.com, July 2003. Engle K, Hannawa T. Techniques for administering oral medications to critical care patients receiving continuous enteral nutrition. Am J Health-Syst Pharm 56:1441-4, 1999. FDA Public Health Advisory: Reports of blue discoloration and death in patients receiving enteral feedings tinted with the dye, FD&C Blue No. 1. http://www.cfsan.fda.gov. FDA website for USDA/NACMCF: HACCP; http://vm.cfsan.fda.gov/~comm/nacmcfp.html . Heyland DK, Khaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill patients. JPEN 27:5:255-73, 2003. Johnson D, Roach A. Esomeprazole pellets are stable following in vitro suspension in common beverages. Am J Gastroenterol. 97(9 suppl):S20 Abstract 59, 2002. Koch K. Improving Pharmaceutical Care: Active Monitoring of Phenytoin and Tube Feedings to Reduce ADR’s. P&T, Aug 1995 520-31. Kreymann KG, Berger MM, Deutz NEP, et al. ESPEN guidelines on enteral nutrition: intensive care. Clinical Nutrition 25:210-33, 2006.

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Lacy C, Armstrong L, et al. Drug Information Handbook 2003-2004, 11th edition, Lexi-Comp INC. Hudson (Cleveland) 2003. Lefton J. Management of common gastrointestinal complications in tube-fed patients. Support Line 24(1): 1924, 2002 Levindale Geriatric Home & Hospital, Dept of Food and Nutrition HACCP Plan for Enteral Feeding and Administration 11/99. Lin HC, Van Citters GW. Stopping enteral feeding for arbitrary gastric residual volume may not be physiologically sound: results of a computer simulation model. JPEN 21:286 - 289, 1997. McClave SA, DeMeo MT, DeLegge MH et al. North American summit on aspiration in the critically ill patient: concensus statement. JPEN Nov-Dec 26(6 Suppl):S80-5, 2002. McClave SA, Snider HL. Clinical use of gastric residual volumes as a monitor for patients on enteral tube feedings. JPEN 26:S43 - S50, 2002. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN 16:99 - 105, 1992. Malone A, Seres D, Lord L. Complications of Enteral Nutrition IN The ASPEN Nutrition Support Core Curriculum: A Case Based Approach/The Adult Patient. Gottschlich, MM (ed): ASPEN, Silver Spring, Maryland, 2007. Maloney, JP, Ryan TA, Brasel KJ et al. Food dye use in enteral feedings: a review and a call for a moratorium. NCP 17: 168-181, 2002. Marion M, McGiness C. Overview of Enteral Nutrition IN The ASPEN Nutrition Support Core Curriculum: A Case Based Approach/The Adult Patient. Gottschlich, MM (ed): ASPEN, Silver Spring, Maryland, 2007. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors and complications. Crit Care Med 29(10):1955-1961, 2001. Mitchell J. Oral dosage forms that should not be crushed: 2000 update. Hospital Pharmacy 35(5):553-7, 2000. Montejo J. Enteral nutrition-related gastrointestinal complications in critically ill patients: A multicenter study. Crit Care Med 27(8): 1447-1453, 1999. Nestle Clinical Nutrition: The Seven Steps of HACCP, 2000. Oliveira MR, Batista CRV, Aidoo KE. Application of hazard analysis critical control points system to enteral tube feeding in hospital. The British Dietetic Association J Hum Nutr Dietet 14:397-403, 2001. Parrish, CR. Enteral feeding: the art and science. NCP18: 76-85, 2003. Pinilla JC, Samphire J, Arnold C, Liu L, Thiessen B. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. JPEN 25:81 - 86, 2001

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Robinson D, Higginson I, Macklin B, et al. Influence of protein containing meals on the pharmacokinetics of levodopa in healthy volunteers. Br J Clin Pharmac 31: 413-7, 1991. Schmidt L, Dalhoff K. Food-Drug Interactions. Drugs 62(10):1481-1502, 2002. Smith Becker D, Ashley J. HACCP, Implications for enteral feeding .Today's Dietitian, October 2002. Sostek M, Blychert E, et al. An in vitro study of the administration of esomeprazole enteric-coated pellets through naso-gastric and gastrostomy tubes. Am J Gastroenterol 97(9 suppl):S3-4 Abstract 9, 2002. Tube Feeding: Practical Guidelines and Nursing Protocols. Guenter, P and Silkroski, M (eds): ASPEN Publication, Gaithersburg, Maryland, 2001. University of Maryland Medical Center Formulary, 2007. Van Den Bernt PMLA, Cusell MBI, Overbeeke PW et al. Quality improvement of oral medication administration in patients with enteral feeding tubes. Qual Safe Health Care 15:44-7, 2007. Williams T, Leslie G. A review of the nursing care of enteral feeding tubes in critically ill adults: part II. Intensive and Critical Care Nursing 21:5-15, 2005.

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