Introduction
VI. Reducing Contamination of Enteral Formulations
A. Complications related to contamination
1. Some degree of microbial contamination of formulations is almost inevitable during feedings. Contamination of enteral feedings may cause GI colonization, septicemia, nosocomial pneumonia, and diarrhea.69–75 Sources of contamination include formulation ingredients, mixing equipment, delivery systems, handling during assembly of the administration system, unsanitary formula prepa- ration areas and patient care units, health care providers, family members, and patients. Dangerous concentrations of organisms result from heavy initial contamination or inappropriately long hang times of the formulation or administration set.69Because infants are more susceptible to infection, guidelines for prepa- ration, storage, and administration of infant feedings are more conservative than those for children and adults.70
2. Hazard Analysis Critical Control Point (HACCP) is a systematic approach to minimizing the potential for contamination. It is important to identify critical points where contamination of enteral formulations may occur to reduce the possibilities for microbial contamination and/or food-borne disease. HACCP also aids in pro- viding safe and accurate nutrition products as mandated by the Joint Commission on Accreditation of Healthcare Organizations.
3. Reducing contamination during preparation.
a) When possible, formulations should be mixed, reconstituted, and diluted in a centralized location (eg, enteral formulary room or pharmacy). Mixing equipment must be cleaned meticulously.
b) In most instances, formulations can be reconstituted and diluted with tap water. However, in areas where the water supply is of questionable quality or in severely immunocompromised patients, it may be prudent to use distilled or sterile water.
c) Infant feedings require additional formulation preparation safeguards. Whenever possible, sterile ready-to-feed formu- lations or concentrated liquid formulations should be used.
Formulation powders should be weighed (not measured) and should be used only when no liquid forms are available.70For- mulations should always be prepared with sterile water.70 4. Formulations should be stored according to manufacturers’ rec-
ommendations.
a) Expired or damaged formula containers should be discarded.70 b) Unopened ready-to-feed formulations should be stored in a cool, dark place. They should not be stored in direct sunlight or near direct heat such as a radiator. Once opened, formula- tions may be stored in a refrigerator for up to 48 hours.71 c) Reconstituted or diluted formulations be stored in a refriger-
ator for a maximum of 24 hours.71
d) Additional guidelines for infant formulation storage include the following:
(1) Prepared infant formulations should be chilled to 40°F within 1 hour of preparation.70
(2) Opened ready-to-feed containers and prepared infant for- mulations should be stored in a refrigerator and used within 24 hours.70
(3) Human milk may be stored frozen in a home-style freezer for 3 months. It may be stored in a deep freeze (−20°C or
−4°F) for 12 months.70
(4) Fresh human milk may be stored in a refrigerator for 48 hours. Thawed or fortified human milk should be stored and used within 24 hours.70
5. Reducing contamination during administration a) Formulation hang time
(1) Canned, ready-to-use formulations generally can be hung for 8 to 12 hours at room temperature, but manufacturers’
guidelines should be followed. In general, it is best to fill the reservoir using clean technique as infrequently as hang time restrictions allow.
(2) Reconstituted powdered formulations generally can be hung for 4 to 6 hours at room temperature.
(3) Prefilled administration sets (bag/container) can generally be hung for 2 to 48 hours, or according to the manufac- turers’ recommendations.74
b) Administration set hang time
(1) Refillable sets (bag/container and tubing) can be used in a short-term care setting for about 24 hours.74
(2) It has been suggested that refillable administration sets (bags/containers and tubing) may be used for up to 72 hours in long-term care facilities; no differences in adverse effects (eg, fever, pneumonia, diarrhea, vomiting) were noted between delivery sets used for 24 versus 72 hours. How- ever, no bacterial counts were performed. Thus, use of refill- able delivery sets for longer than 24 hours in settings other than long-term care facilities requires further investigation.75 c) Infant feeding delivery guidelines
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74 A.S.P.E.N. Nutrition Support Practice Manual 2nd Ed. © 2005 A.S.P.E.N. www.nutritioncare.org.
(1) Hang times for human milk and infant formulas should not exceed 4 hours.70
(2) Syringe tubing should be changed every 4 hours in infants receiving continuous infusion feedings.70
(Enteral Formulations chapter from the 1st edition was contributed by Kelley Olree, Joseph Vitello, Jacqueline Sullivan, and Carol Kohn- Keeth)
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76 A.S.P.E.N. Nutrition Support Practice Manual 2nd Ed. © 2005 A.S.P.E.N. www.nutritioncare.org.
Linda Lord, NP, RN, MS, CNSN;
Michelle Harrington, MS, RD, CSP, CNSD, LDN
5
Enteral Nutrition
Implementation and Management
Introduction
When the gastrointestinal (GI) tract is functional, enteral feeding is the preferred route for nutrition support. This type of feeding provides many physiologic, metabolic, safety, and cost benefits over parenteral feedings.1Tube feedings can range from providing adjunctive support to providing complete nutrition therapy. Enteral feedings can be admin- istered and scheduled in a variety of ways. Practitioners who are famil- iar with these options can recommend regimens that accommodate each patient’s needs and lifestyle. Selection of the optimal enteral regimen depends on a number of factors, such as the patient’s nutritional and clinical status, GI function, age, and level of activity. Practitioners need to be aware of these factors so that enteral feedings can be administered successfully and safely. A well-tolerated enteral regimen that meets the patient’s needs can reduce the length of time that support is necessary and improve the disease treatment outcome; it can also assist in the growth and development of the pediatric patient.2
I. Benefits, Indications, and Contraindications for Enteral Feedings II. Implementation of Enteral Feedings
III. Monitoring and Management of Enteral Feedings IV. Complications and Management of Enteral Feedings
V. Transitioning from Enteral Nutrition Support References