Enteral tubes: administration of medication via (PICU)

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Objectives

The purpose of this guideline is to:

  • To establish clear guidance on how to administer medicines via an enteral feeding tube
  • To establish clear guidance on which medicines can be administered via a trans-pyloric feeding tube. 

Audience

All medical and nursing staff involved in the placement, care and use of enteral feeding tubes should be familiar with this guideline BEFORE administering medicines to patients.

Introduction

Administering medicines via enteral feeding tubes is a process that can change the way medicines are absorbed and handled by the body. There are some medicines that are more affected than others.

There are also some issues around the licensing of medicines that are crushed, opened or otherwise changed to facilitate administration down an enteral feeding tube. As such, the ORAL route should always be used in preference to enteral feeding tubes.

This is often not possible in critical care environments when children are heavily sedated, with endo-tracheal tubes in situ rendering oral administration of medications unsafe. It is thus essential that oral medicines are administered via enteral feeding tubes. 

Administration

Action

Rationale

1. Stop enteral feed before administering medication

  • Medicines and enteral feeds must never be mixed, except where advised by a pharmacist.
  • Drugs can interact with the ingredients of the feed causing blockages, or reducing nutrients available to the patient.

2. Flush the enteral feeding tube thoroughly before administering medication

  • Inadequate flushing of enteral tubes is the most common cause of tube blockage. The flush should be sufficient to clear the entire feeding tube (ie twice the volume of the deadspace.)

3. Prepare and administer each medicine separately – do not mix medicines

  • Medicines can be incompatible with each other.

4. Use fresh equipment for each medicine. Where equipment is reused, clean thoroughly before and after use to avoid cross contamination

  • Medicines can be incompatible with each other.

5. Administer each medicine using a separate enteral syringe. Consult local guideline for syringe choice

  • Intravenous syringes must NOT be used due to the risk of inadvertent intravenous administration of enteral medicines.

6. Flush the enteral feeding tube thoroughly after each medication is administered

  • This will prevent medicines interacting with each other in the enteral feeding tube
  • This will reduce the incidence of tube blockage.

7. Restart feed as directed

  • The presence of feed can sometimes reduce the absorption of medicine (eg Phenytoin, Ciprofloxacin.)

 

Preparing medicines for administration

Soluble tablets:

  • Dissolve the required number of tablets in a suitable volume of sterile potable water.
  • If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
  • If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Tablets:

  • Crush the tablet in a tablet crusher
  • Mix the resultant powder with an appropriate volume of sterile potable water
  • If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
  • If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Capsules:

  • Carefully open the capsule and allow its contents to fall into a suitable container
  • Disperse this powder with an appropriate volume of sterile potable water
  • If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
  • If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Liquids (including injectable products):

  • Shake the bottle well (for at least 15 seconds)
  • Draw up the required volume for the dose
  • Thick liquids should be diluted with 2 to 3 times the volume with sterile potable water. This makes them less likely to “clog” in the tube. 

DO NOT flush enteral tubes with the same syringe used to administer the dose as enteral syringes have a “dead-space” which is accounted for on the graduations.

Medicines NOT suitable for administration via enteral tubes

Enteric coated medicines (denoted e/c on packaging, label or in the BNF.)

  • Modified Release medicines (denoted CR, MR, SR, XL, LA, Once-Weekly on packaging, label or in the BNF.)
  • Cytotoxic medicines
  • Hormones
  • Tablets designed for administration sub-lingually, buccally, or that should be chewed 
Post-Pyloric Feeding Tubes (NJ, OJ, PEJ)

Most medicines are absorbed jejuno-ileally thus there are few restrictions on what can be given via a post-pyloric feeding tube. However, these tubes tend to be much narrower than gastric feeding tubes, and thus are more prone to blockage.

FLUSHING is the single most important factor in ensuring post-pyloric tube maintenance.

Drugs NOT Suitable for Post-Pyloric Feeding Tubes:

Proton Pump Inhibitors
Omeprazole, lansoprazole, esomeprazole and others (see BNF)

  • Antacid products
    Gaviscon ®, Gaviscon Infant ®, ranitidine, sucralfate
  • Fluconazole
    Absorbed pre-pylorically and in the duodenum. Higher doses required if administered via the jejunum.
  • Ciprofloxacin
    Absorbed in the duodenum which is bypassed by a jejunal feeding tube.
Algorithm

References
  1. Smyth, J (ed.) The NEWT Guidelines Betsi Cadwaladr University Local Health Board (East), 2014
  1. Fair, R; Proctor, B (eds.) Administering Medicines Through Enteral Feeding Tubes The Royal Hospitals NHS Trust (Belfast) 2005
  1. White, R; Bradnam, V (eds.) Handbook of Drug Administration via Enteral Feeding Tubes Pharmaceutical Press (Oxon.) 2006
  1. BAPEN Administering Drugs Via Enteral Feeding Tubes - A Practical Guide. 2004
Editorial Information

Last reviewed: 01 December 2009

Next review: 01 December 2012

Author(s): Adam Sutherland