Introduction
X. Selection of Infusion Equipment 50,51
A. Times to use an infusion pump
1. Enteral infusion pumps are designed and used exclusively for delivery of tube feedings. A pump should be considered when a controlled volume or infusion rate is desired. Continuous drip feedings via pump may improve gastrointestinal tolerance and reduce the risk of aspiration associated with reflux.52Generally, postpyloric feedings require a pump.
2. Intravenous infusion pumps should not be used for enteral for- mulation delivery because of the risk of inadvertent connection of tube feeding to an IV site. In addition, IV pumps have unnec- essary alarms and are more costly than enteral pumps.
B. Pump selection. Issues to consider when selecting a pump include how easy the product is to use and who will be operating the pump (nurse, patient, or caregiver), the patient’s size and overall condi- tion (which can affect the ability to lift or move a pump), and the patient’s ambulation status.
C. Pumps for the outpatient
1. Pump requirements. Some special considerations with regard to pump selection are necessary for patients who receive feeds in the home setting.
a) Most pumps come with a built-in carrying handle and pole clamp. In the home setting, pumps should be portable or attached to a mobile pole. Some pumps are designed with shoulder straps or a carrying case for ease of transport, which is ideal for school or work.
b) All pumps have rechargeable batteries and run on AC power.
Pumps should have a battery life of at least 8 to 12 hours; some pumps have 24-hour batteries.
2. Reimbursement in the home-care setting varies greatly among payers. Most payers have very rigid criteria, and the necessity of a pump must be documented before reimbursement is approved.
D. Infusion pump mechanics 1. Fluid delivery mechanisms53
a) Rotary peristaltic devices. The pump insert is looped around the pump rotor. The pressure of the rotary mechanism against the tubing pulls the fluid out of the bag and through the adminis- tration set. The infusion rate is determined by the speed of the rotor. For the infusion rate to remain accurate, the rotor assem- bly must be installed and operating correctly, and the pump insert must be placed in accordance with the manufacturer’s instructions.
b) Cassette devices. These pump sets incorporate a measured- volume cassette that works with the pumping mechanism to deliver enteral fluid to the patient. These sets tend to be less susceptible to alarm conditions than rotary peristaltic devices.
Cassette devices may not deliver reconstituted powdered for- mulations accurately; manufacturers’ recommendations should be followed.
2. Infusion rates. All pump manufacturers claim an accuracy rate of
±10% of the selected flow rate. Formulation viscosity affects the accuracy of the flow rate. Adding a powdered protein supplement to a ready-to-feed formulation may also reduce the expected infu- sion rate.54Institutions should evaluate the delivery accuracy of the
pump and follow manufacturers’ instructions for their selection of enteral formulations. Administration sets and tubing should have a safety feature preventing free flow of the formulation.
3. Automatic flush systems. Some manufacturers provide pumps with automatic flush systems. These pumps combine infusion of the enteral formulation with programmable water flushes. The flush feature can be turned off if manual flushing is desired.55 4. Pump alarms. Most pumps come with an adjustable alarm con-
trol. Troubleshooting guidelines are usually located on the side of the pump.
a) Low battery power. When this alarm sounds, battery operation should be stopped. Ideally, the pump should be plugged in to an electrical outlet whenever feasible, not only to provide elec- tricity to run the pump but also to recharge the battery. The bat- tery is primarily a backup system in case of a power outage and for use when transporting the patient.
b) Flow obstruction alarm. An alarm sounds when fluid is not being administered because of an empty bag, kinked tubing, an occluded feeding tube, or an overfilled drip chamber.
c) Dose-delivered feature. An alarm sounds when a preset dose has been delivered.
d) Free-flow alarm or runaway alarm. An alarm sounds when the measured rate exceeds the set rate by some percentage.
e) Set out alarm. An alarm alerts the user if the pump set has not been seated correctly in the set slot.
E. Cleaning and maintenance. The pump should be of a simple design and have as few crevices as possible, because residue and dirt may build up, creating an environment for microbial growth. Pumps should be unplugged and cleaned weekly with a mild soap and warm water. When spills occur, the pump should not be immersed in water.
F. Pump servicing. With use, the rotor mechanism may wear and no longer exert correct pressure, resulting in inaccurate volume deliv- ery. The pump should be serviced on a schedule recommended by the manufacturer.
G. Administration sets. Enteral pumps should have dedicated admin- istration sets that are incompatible with the patient’s IV infusion line. Some manufacturers have developed tubing that prevents free flow of the formulation when the set is disconnected from the pump.
To minimize microbial contamination of the enteral formulation, the tubing set is usually changed every 24 hours.
(Enteral Access and Infusion Equipment chapter in the 1st edition was contributed by Donald F. Kirby, Gayle Minard, and Carol Kohn-Keeth) R E F E R E N C E S
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Introduction
Numerous commercially prepared enteral formulations are available and include standard formulations and specialty products designed to provide nutrition support for specific disease states. It is important to choose formulations that deliver the most beneficial and cost-effective enteral nutrition support. The formulations can be grouped by compo- sition to facilitate formula selection. Once a formulation has been cho- sen, the compounding (if necessary) and delivery must be undertaken in a manner that will avoid potential infectious complications.
I. Composition and Characteristics of Enteral Formulations II. Adult Enteral Formulations
III. Pediatric Enteral Formulations IV. Infant Enteral Formulations
V. Preterm Infant Enteral Formulations
VI. Reducing Contamination of Enteral Formulations References