General Considerations: Daily weights, inputs and outputs, nasoduodenal feeding tube. Head-of-bed at 30° while enteral feeding and 2 hours after completion.
Enteral Bolus Feeding: Give 50-100 mL of enteral solution (Pulmocare, Jevity, Vivonex, Osmolite, Vital HN) q3h. Increase amount in 50 mL steps to max of 250-300 mL q3-4h; 30 kcal of nonprotein calories/kg/d and 1.5 gm protein/kg/d. Before each feeding measure residual volume, and delay feeding by 1h if >100 mL. Flush tube with 100 cc of water after each bolus. Continuous enteral infusion: Initial enteral solution (Pulmocare, Jevity, Vivonex, Osmolite) 30 mL/hr. Measure residual volume q1h for 12h then tid; hold feeding for 1h if >100 mL. Increase rate by 25-50 mL/hr at 24 hr intervals as tolerated until final rate of 50-100 mL/hr. Three tablespoonfuls of protein powder (Promix) may be added to each 500 cc of solution. Flush tube with 100 cc water q8h. Special Medications:
-Metoclopramide (Reglan) 10-20 mg PO or in J-tube q6h OR -Cisapride (Propulsid) 10-20 mg via nasogastric tube qid (concurrent use with macrolide antibiotics or azole antifungals may result in prolongation of QT interval) OR
-Erythromycin 125 mg IV or via nasogastric tube q8h. -Cimetidine (Tagamet) 400 mg PO bid OR -Ranitidine (Zantac)150 mg PO bid. Symptomatic Medications:
-Loperamide (Imodium) 2-4 mg PO/J-tube q6h prn, max 16 mg/d OR -Diphenoxylate/atropine (Lomotil) 1-2 tabs or 5-10 mL (2.5 mg/5 mL) PO/J-
tube q4-6h prn, max 12 tabs/d OR -Kaopectate 30 cc PO or in J-tube q8h. Extras: CXR, plain abdominal x-ray for tube placement, nutrition consult. Labs:
Daily labs: SMA7, osmolality, CBC, cholesterol, triglyceride. SMA-12 Weekly Labs when indicated: Protein, Mg, INR/PTT, 24h urine nitrogen and creatinine. Pre-albumin, retinol-binding protein.
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