fact and comparison ngt

Hospital Pharmacy 225

FEATURED ARTICLE

Hospital PharmacyVolume 39, Number 3, pp 225–2372004 Wolters Kluwer Health, Inc.

Drug therapy may becomplicated in hospital-ized patients receivingnutrition via enteral

feeding tubes. Although oral nutri-tion is preferred, patients mayrequire enteral or parenteral nutri-tion if oral intake is inadequate orinadvisable. Patients with func-tional gastrointestinal (GI) tractsusually receive enteral nutritionthrough a feeding tube.1

Some medications may begiven through the enteral feedingtube. However, tube obstruction,increased toxicity, or reduced effi-

cacy may occur if an improperadministration method is used. Inone survey, 74% of hospital staffused at least two incorrect methodsto administer drugs via feedingtubes.2

This article describes anapproach to dosage form selectionand drug administration methodsin these patients. Appendix A sum-marizes medication administrationprocedures.

METHODS OF ENTERAL FEEDINGEnteral feeding tubes may be

inserted orally, nasally, or percuta-

neously, by manual insertion at thebedside, traditional surgical tech-niques, laparoscopy, endoscopy, orfluoroscopic guidance. Enteralnutrition formulas may be infusedinto the stomach, duodenum, orjejunum.3,4

Small-Bore TubesFlexible, small-bore nasoen-

teric (NE) tubes (ie, Dobhoff,Miller-Frederick) are commonlyused for short-term enteral feed-ings. These tubes can be placedinto the stomach or even the duo-denum at the bedside, or into theduodenum or jejunum using fluo-roscopy or endoscopy. These soft,small lumen tubes may help main-tain the competence of the loweresophageal sphincter, providing aphysical barrier between the nutri-ent solution and the bronchialtree.3,4 Tablets, pills, lozenges, andsome crushed dosage forms shouldnot be placed in the NE tubebecause they may clog the tube,necessitating replacement. Onlyliquid dosage forms should beplaced in the NE tube.5,6

The needle catheter jejunosto-my (NCJ) is another small-boretube used for enteral feeding. TheNCJ is inserted surgically, has asmaller bore than the NE tube, andclogs easily. Avoid administeringdrugs by this route whenever pos-sible.4 Because a procedure is need-ed for insertion, repeated replace-

*Drug Information Service, †Department of Surgery, ‡Nutrition Care Services: Uni-versity of Utah Hospitals and Clinics, Salt Lake City, Utah.

A Guide to Drug Therapy in Patients withEnteral Feeding Tubes: Dosage Form Selection

and Administration MethodsM. Christina Beckwith, PharmD,* Sarah S. Feddema, PharmD,*

Richard G. Barton, MD,† and Caran Graves, RD‡

Abstract — Drug therapy may be complicated in hospitalized patientsreceiving nutrition via enteral feeding tubes. Dosage form selection andappropriate administration methods are crucial in patients with feedingtubes. Although hospitalized patients receive nutritional support throughvarious routes, oral nutrition is preferred. Enteral or parenteral nutritionmay be used if oral intake is inadequate or inadvisable. Patients withfunctional gastrointestinal tracts usually receive enteral nutrition. Admin-istering oral medications through the enteral feeding tube can lead tocomplications like tube clogging or decreased drug activity. However,drug therapy need not be compromised in patients receiving enteral nutri-tion. Careful selection and preparation of dosage forms reduces the com-plications of medication administration. Flushing the feeding tube andscreening for drug incompatibilities decreases the incidence of tube clog-ging and replacement.

Key Words — critical care; drug administration; enteral nutrition

Hosp Pharm — 2004;39:225–237

226 Volume 39, March 2004

Guide to Drug Therapy in Patients with Enteral Feeding Tubes

Table 1. Potential Alternatives to Oral Administration of Medications.9,29,58-61

Route Some Medications Limitations of Route

Buccal Nicotine lozenge (Commit) Inappropriate in patients with mouth Testosterone buccal (Striant) injuries, mucosal injury or excoriation,

CNS impairment, dry mouth, excessive salivation, nausea, vomiting, reduced intestinalmotility, gastric suction, surgical resection, orswallowing difficulties.May cause mucosal irritation.Patient must avoid eating or drinking until medication dissolves completely.

Inhalation (inhalers, Albuterol, Nicotine, Zanamivir Only a few agents available.nebulization) Inappropriate in patients with

upper airway trauma.

Intramuscular Ampicillin/sulbactam, Dicyclomine, More expensive than oral treatment.Hydroxyzine, Lorazepam, Prednisolone Injections are an invasive procedure.

Injections may be painful; patients may be anxious about “shots.”Drug absorption is slower than with IV administration.Inappropriate in immunosuppressed patients or patients with increased bleeding tendency.Must be given by trained staff.

Intravenous Dexamethasone, Digoxin, More expensive than oral treatment.Enalaprilat, Hydromorphone, Injections are an invasive procedure.Methotrexate, Morphine, Phenytoin, Must be given by trained staff.Promethazine

Rectal (enemas, Acetaminophen, Aspirin, Bisacodyl, Administration may be embarrassing for patient.suppositories) Caffeine/ergotamine, Lactulose, Inappropriate in patients with cardiac

Mesalamine, Morphine, Prochlorperazine, diseases, immunosuppression, rectal surgery,Promethazine, Sodium polystyrene sulfonate or increased bleeding tendency.

Subcutaneous Fentanyl, Hydromorphone, Morphine More expensive than oral treatment.Injections are an invasive procedure and may cause local tissue damage.Injections may be painful; patients may be anxious about “shots.”Drug absorption is slower than with IV or IM administration.Inappropriate in immunosuppressed patients or patients with increased bleeding tendency.Must be given by trained staff.

Sublingual Isosorbide, Nitroglyerin Inappropriate in patients with mouth injuries, mucosal injury or excoriation, CNS impairment,dry mouth, excessive salivation, nausea, vomit-ing, reduced intestinal motility, gastric suction,surgical resection, or swallowing difficulties.Patient must avoid eating or drinking until med-ication dissolves completely.

Transdermal (patches, Clonidine, Estradiol, Fentanyl, Inappropriate in patients with skin irritation, ointment) Nicotine, Nitroglycerin rashes, or open lesions.

May cause skin irritation, redness, rashes, pruri-tus, or allergic contact dermatitis.May leave residue (oil, paste) on the skin or maystain clothing.


ment of NE/NCJ tubes mayincrease hospital costs, patient dis-comfort, and infection risk.

Large-Bore TubesSeveral types of large-bore

tubes may be used for enteral feed-ings, including nasogastric (NG)and orogastric (OG) tubes (ie,Salem sump), as well as tubes thatcross the body wall, such as gas-trostomy (G) or jejunostomy (J)tubes.7 These tubes may be placedusing open or laparoscopic surgicaltechniques, endoscopically, orunder fluoroscopy.

Compared with NE or NCJtubes, large-bore tubes are lesslikely to clog. Nasogastric tubesare also stiffer than NE tubes andmay be inserted at the bedside.Because tube insertion is relativelyeasier, tube replacement costs arelower for NG tubes than for NE orNCJ tubes.3,4

Although NG tubes, includingthe Salem sump, may be used forenteral nutrition, their main pur-pose is to suction gastric contentsin patients with impaired GI tractfunction (eg, gastric stasis, ileus,bowel obstruction).3,4 These tubesare stiffer than NE tubes and mayincrease aspiration risk by compro-mising swallowing and reducingthe integrity of the loweresophageal sphincter.3,4 In general,stiff, large-bore NG tubes shouldnot be used as feeding tubes whenother options exist. One possibleexception may be in the intensivecare unit, where patients are oftenintubated and closely monitored;in such cases, it may be unaccept-able to risk transporting patients toplace a more traditional feedingtube.

Because the primary purposeof an NG tube is to suction gastriccontents, it is important to remem-ber that any medications giventhrough the tube may be suctioned


Table 2. Oral Dosage Forms That Should Not be Crushed13

Drug and Dosage Form Reason

Acetaminophen: Arthritis Bayer Time Release, Sustained-releaseTylenol Extended Relief

Acetazolamide: Diamox Sequels Sustained-release

Albuterol: Volmax, Proventil Repetabs Sustained-release

Aspirin, enteric-coated: various, ASA Enseals, Enteric-coatedAscriptin, Bayer Enteric-coated, Bayer Low Adult, Bayer Regular Strength, Easpirin, Ecotrin, ZORprin

Benzphetamine: Bontril SR, Prelu-2 Sustained-release

Bisacodyl: various, Carter’s Little Pills, Dulcolax Enteric-coated

Brompheniramine: Lodrane LD, Respahist Sustained-release

Bupropion: Wellbutrin SR, Zyban Sustained-release

Carbamazepine: Carbatrol, Tegretol XR Sustained-release

Carbidopa/Levodopa: Sinemet CR Sustained-release

Carbinoxamine/pseudoephedrine: Carbiset-TR Sustained-release

Cefaclor: Cefaclor CR Sustained-release

Cefuroxime: Ceftin Taste

Charcoal, activated/simethicone: Charcoal Plus Enteric-coated

Chlorpheniramine: Chlorpheniramine Sustained-releaseMaleate Time Release, Chlor-Trimeton, Dallergy, Dallergy-JR, Deconamine SR, Extendryl JR, Extendryl S-R, Pannaz

Ciprofloxacin: Cipro Taste

Dexbrompheniramine: Sustained-releaseDrixoral various, Disophrol Chronotab

Dexchlorpheniramine Sustained-release

Dextroamphetamine: Dexedrine Spansule Sustained-release

Diclofenac/misoprostol: Arthrotec Enteric-coated

Diethylpropion Sustained-release

Diflunisal: Dolobid Irritant

Diltiazem: Cardizem CD, Cardizem LA Sustained-release Cardizem SR, Cartia XT, Dilacor XR, Tiazac

Dimenhydrinate: Triptone Sustained-release

Diosman: Baros Effervescent

Dirithromycin: Dynabac Enteric-coated

Disopyramide: Norpace CR Sustained-release

Divalproex sodium: Depakote ER Sustained-release

Divalproex sodium: Depakote Sprinkle, Depakote Enteric-coated

Enalapril: Lexxel Sustained-release

Ergocalciferol: Drisdol (capsule) Liquid-filled capsule

Ergoloid mesylate: Hydergine LC Liquid-filled capsule

Ergotamine: Ergomar Sublingual product

(continued)



out, preventing absorption.8

Clamping the NG tube for at least30 minutes after drug administra-tion increases absorption if the GItract is functioning.6 However,many patients with GI tract dys-function cannot tolerate long peri-ods of tube clamping.8

MEDICATION ADMINISTRATION PLAN

The key to managing medica-tions in enterally fed patients is tofocus on prioritizing therapeuticgoals. First, temporarily discontin-ue medications that are not imme-diately necessary (eg, hormonereplacement therapy).9 Second,consider giving medications by analternate route, such as transder-mal, rectal, inhaled, intramuscular,subcutaneous, buccal, sublingual,or intravenous. The appropriate-ness of each route should beassessed based on the patient’s clin-ical status and medication needs(see Table 1).

Third, when products are notavailable in alternate dosageforms, consider using another drugwith similar pharmacologic effects.For example, transdermal fentanylcould be used for pain instead oforal morphine. Dosage or frequen-cy adjustments may be necessarywhen changing administrationroutes, especially if patients areswitched from one agent to anoth-er (eg, morphine to fentanyl).9

ENTERAL ADMINISTRATION OF MEDICATIONS

Medications may be given viathe feeding tube if necessary.9,10

However, clinicians must first eval-uate tube type, tube location in theGI tract, site of drug action andabsorption, and the effects of foodon drug absorption.

For example, antacids, bis-muth, and sucralfate act locally inthe stomach and are not suitable



Erythromycin: E.E.S, E-Mycin, Eryc Enteric-coatedEry-tab, Erythromycin base

Esomeprazole: Nexium Sustained-release

Etodolac: Lodine XL Sustained-release

Felodipine: Plendil Sustained-release

Ferrous fumarate: Ferro-Sequels Sustained-release

Ferrous sulfate: Slow-FE, Slow-FE Folic Sustained-release

Ferrous sulfate Enteric-coated

Fexofenadine: Allegra-D Sustained-release

Fiber: Perdiem Fiber Therapy Wax-coated

Finasteride: Propecia, Proscar Teratogenic

Fluoxetine: Prozac Weekly Delayed-release

Ganciclovir: Cytovene Irritant

Glipizide: Glucotrol XL Sustained-release

Guaifenesin: Breonesin, Entex LA, Sustained-releaseEntex PSE, Guaifed, Guaifed-PD, Guaifenex LA, Guaifenex PSE, Humabid DM, Humabid DM Sprinkle, Humibid LA, Humibid Sprinkle, Muco-Fen-DM, Nasatab LA, PanMist Jr., LA, Profen II, Quibron-T SR, Respa various, Respaire SR, Sudal, Syn-RX, Touro (various)

Hyoscyamine: Cystospaz-M, Levbid, Sustained-releaseLevsinex Timecaps

Indomethacin: Indocin SR Sustained-release

Isosorbide Dinitrate: Dilatrate-SR, Sublingual productIsosorbide dinitrate sublingual

Isosorbide Dinitrate: Imdur, Isosorbide CR, Sustained-release

Isotretinoin: Accutane Irritant

Isradipine: Dynacirc CR Sustained-release

Lansoprazole: Prevacid Sustained-release

Lithium: Eskalith CR, Lithobid Sustained-release

Loratadine: Claritin-D, Claritin-D 24 hour Sustained-release

Magnesium chloride: Slow-Mag Sustained-release

Mesalamine: Pentasa Sustained-release

Mesalamine: Asacol Enteric-coated

Methylphenidate: Ritalin SR Sustained-release

Metoprolol: Toprol XL Sustained-release

Morphine: Kadian, MS Contin, Oramorph SR Sustained-release

Multiple vitamins: Mi-Cebrin T, Optilets 500 Enteric-coated

Multiple vitamins: Feocyte, Fumatinic, ICaps Plus, Sustained-releaseICaps Time Release

(continued)



for administration via intestinalfeeding tubes.9,10 Bioavailabilitymay increase with intrajejunaladministration of drugs withextensive first-pass metabolism,such as opioids, tricyclics, betablockers, or nitrates. Buccal andsublingual dosage forms may beineffective when given enterally.For drugs that require administra-tion on an empty stomach, stopenteral feeding for 30 minutesbefore and after dosing if the tubeis placed in the stomach.9,10

The use of liquid dosage formsis preferred whenever possible.Liquid preparations for oral or IVuse may be substituted for soliddosage forms.3,6,7 Many tablets maybe crushed to a fine powder,mixed to a slurry in water, andgiven through large-bore feedingtubes. The contents of most cap-sules may be administered in thesame manner.3

Regardless of which dosageform is used, the feeding tubeshould be flushed with at least 30mL of water before and afteradministration to clear any resid-ual medication.3,6,7 In general, med-ications should not be added to theenteral formula, both to reduce therisk of microbial contaminationand to avoid drug–nutrient incom-patibilities.11,12

Many oral products shouldnot be crushed (see Table 2). Sus-tained-release, enteric-coated, ormicroencapsulated productsshould neither be crushed norgiven through feeding tubes asintact tablets or capsules.13 Crush-ing destroys the sustained-releaseproperties of sustained-releasetablets and microencapsulateddrugs, resulting in erratic bloodlevels. Enteric coatings do notcrush well but break into smallchunks that bond together whenmoist, clogging the tube.13

Because aerosolized particles



Mycophenolate: Cellcept Teratogenic

Naproxen: Naprelan Sustained-release

Niacin: Slo-Niacin Sustained-release

Nicardipine: Cardene SR Sustained-release

Nicotinic acid: Nicotinic acid extended-release Sustained-release

Nifedipine: Adalat CC, Procardia XL Sustained-release

Nifedipine: Procardia Delays absorption

Nisoldipine: Sular Sustained-release

Nitroglycerin: Nitroglyn, Nitro-Time Sustained-release

Nitroglycerin: Nitrostat Sublingual product

Omeprazole: Prilosec Delayed-release

Orphenadrine citrate: Norflex Sustained-release

Oxybutynin: Ditropan XL Sustained-release

Oxycodone: Oxycontin Sustained-release

Pancreatic enzymes: Creon 10, Creon 20, Enteric-coatedPancrease, Pancrease MT, Ultrase, Ultrase MT

Pantoprazole: Protonix Sustained-release

Papaverine: Papaverine Sustained Action, Sustained-release

Pentoxyfylline: Trental Sustained-release

Phendimetrazine Sustained-release

Piroxicam: Feldene Irritant

Potassium citrate: Urocit K Wax-coated

Potassium supplements: K-Dur, Sustained-releaseKlor-Con/EF, Klotrix, K-Tab, Micro K

Potassium supplements: K-Lyte, K-Lyte CL, Effervescent productK-Lyte DS

Procainamide: Procanbid, Procainamide hydrochloride SR, Pronestyl SR Sustained-release

Propranolol: Betachron, Inderal LA Sustained-release

Pseudoephedrine: Disophrol Chronotab, Sustained-releaseSudafed 12 hour

Pyridostigmine: Mestinon Timespan Sustained-release

Quinidine gluconate: Various Sustained-release

Rabeprazole: Aciphex Sustained-release

Riboflavin: Iberet 500 Sustained-release

Sodium Valproate: Depakote ER Sustained-release

Sulfasalazine: Azulfidine EN-tabs Enteric-coated

Tamsulosin: Flomax Sustained-release

Theophylline derivatives: Choledyl SA, Sustained-releaseSlo-bid Gyrocaps, Theo-24, Theochron, Uniphyl

Venlafaxine: Effexor XR Sustained-release

Verapamil: Calan SR, Covera HS, Verelan Sustained-release


may be harmful to hospital staff,avoid crushing drugs with terato-genic, carcinogenic, or cytotoxicproperties, such as antineoplastics,hormones, and prostaglandinanalogs. Cross-contaminationfrom the tablet crushing device isalso possible; avoid crushing med-ications that commonly causeallergic reactions.9,10

The pellets inside somemicroencapsulated products maybe poured down the large-boreenteral feeding tube after beingremoved from the capsule, provid-ed that the pellets are not crushed.Medications that may be given inthis manner include diltiazem(Cardizem CD, Cardizem SR), fer-rous gluconate (Fergon), nizatidine(Axid), pancreatic enzymes(Creon, Pancrease, Pancrease MT),theophylline (many genericbrands), and verapamil (Vere-lan).6,13

Cromolyn (Gastrocrom) cap-sules may be administered byopening the capsule and dissolvingthe contents in water before pour-ing the mixture down the feedingtube. Liquid contents of softgelatin capsules (acetazolamide,nifedipine) may be aspirated fromthe capsule and given via the feed-ing tube as immediate-releasedosage forms, provided that thecapsule contents are completelyremoved.6,13

Proton-Pump InhibitorsThe proton pump inhibitors

(PPIs) present a special dilemma.Because the active drugs are acid-labile and undergo gastric degrada-tion, the products are formulatedto reduce the amount of drug lostto hydrolysis. Omeprazole(Prilosec), lansoprazole (Prevacid),and esomeprazole (Nexium) areformulated as delayed-release cap-sules containing enteric-coateddrug granules.14–17 Gastric acid dis-

solves the delayed-release capsuleduring transit of the dosage form.The enteric-coated granules aredelivered to the small intestine, thebase-labile coating dissolves, anddrug is absorbed.14–17 Pantoprazole(Protonix) and rabeprazole (Aci-phex) are formulated as enteric-coated, delayed-release tablets; thecoating dissolves in the stomachand drug is absorbed in the intes-tine.18,19

Several studies have evaluatedmethods for giving omeprazoleand lansoprazole through enteraltubes.20–22 Crushing the enteric-coated granules results in tubeclogging from the enteric coat-ing.14–16 Instead the granules shouldbe mixed with an appropriate dilu-ent, such as apple or orange juice,to ensure that maximal amounts ofdrug reach the duodenum. Toaccomplish this, different methodsmust be used depending on thetype of feeding tube in place and itslocation in the GI tract (see Appen-dix A).20–24

In patients with a large-boreNG or G tube (18 French or larg-er), mix the intact granules withacidic fruit juice, pour the mixturedown the tube, then flush withadditional juice. The fruit juiceprotects the base-labile granulesuntil they reach the small intestine,ensuring maximal drug delivery.Suitable juices include apple, cran-berry, grape, orange, pineapple,prune, tomato, and V-8juice.14–16,20–24

In patients with an intestinalfeeding tube, give oral PPI suspen-sions. Oral suspensions of lanso-prazole 3 mg/mL or omeprazole 2mg/mL may be prepared by dis-solving the unencapsulated, intactgranules in sodium bicarbonate8.4% solution.14–16,20–24 Because theintact granules dissolve incom-pletely in acidic fruit juice, oralsuspensions may also be used in

patients with small-bore G tubes(less than 18 French), although theamount of drug absorbed may bereduced. For maximal effective-ness, give oral PPI suspensions intothe intestine and intact granulesinto the stomach.20,21,25

Lansoprazole is also availableas a packet of granules that aremixed with water before adminis-tration to form a suspension.26

However, this product is notappropriate for administration viaenteral tubes. The formulationcontains xanthan gum, an ingredi-ent that increases the suspension’sviscosity and causes it to expandwithin the feeding tube, increasingthe risk of tube blockage.27

There is no information aboutadministering esomeprazole (Nexi-um), pantoprazole (Protonix), orrabeprazole (Aciphex) via feedingtubes. Because esomeprazole is for-mulated similarly to omeprazoleand lansoprazole, it may be rea-sonable to give esomeprazoleeither as intact granules or an oralsuspension.17 Because pantoprazoleand rabeprazole are enteric-coatedtablets and cannot be split,chewed, or crushed, these medica-tions cannot be administered viafeeding tubes.18,19

LaxativesBulk-forming laxatives, such

as methylcellulose or psyllium(Metamucil), should not be givenvia feeding tubes.6,15 These prod-ucts form a semisolid mass thatmay occlude the feeding tube whenmixed with less than 250 mL fluid.Even when mixed properly, theresultant viscous solutions mayblock feeding tubes. In one study,clogging occurred in 33% ofpatients given psyllium via theenteral feeding tube, necessitatingtube replacement.11 Similarly,cholestyramine (Questran), a bileacid sequestrant, may clog small-



bore feeding tubes.9

Consider using a fiber-contain-ing enteral nutrition formula (eg,Jevity, Pediasure with fiber, or Pro-mote with fiber) in patients whorequire additional dietary fiber forlaxative effects.28

CONSIDERATIONS WITH LIQUIDMEDICATIONS

Liquid dosage forms arepreferable if medication must begiven via the enteral feeding tube.The medication dosage or frequen-cy may need adjustment whenswitching from solid to liquidpreparations.9 For example, pheny-toin capsules are extended-releaseproducts and may be given oncedaily; phenytoin suspension is animmediate-release product andmust be dosed 2 to 4 times daily.Extended-release diltiazem tabletsmay be given once daily, but imme-diate-release diltiazem tablets mustbe given 4 times daily.29 In somecases, the feeding rate or schedulemust be adjusted to maintain ade-quate nutrition, especially if enter-al feedings are interrupted severaltimes daily for medication admin-istration.5,9

Many commercial liquids haveosmolalities well over 1000mOsm/kg (see Table 3).5,30 Theosmolality of GI secretions rangesfrom 100 to 400 mOsm/kg. Diar-rhea, cramping, abdominal disten-tion, and vomiting may occur afteradministration of hyperosmolarproducts through the feedingtube.3,5 These effects may bereduced by diluting medicationwith 10 to 30 mL of sterile waterbefore administration.5,11,12 Theosmolality of the resulting mixturemay be calculated using the formu-la: Osmolality of diluted mixture =(Osmolality of drug x Volume ofdrug)/Total volume of mixture.31

Sterile water contains no soluteand does not contribute to the


Table 3. Osmolality (mOsm/kg) of Some Liquid Medications30,31*

Commercially Available Product Average Osmolality

Acetaminophen elixir, 65 mg/mL 5400

Acetaminophen/codeine elixir 4700

Amantadine HCl solution, 10 mg/mL 3900

Aminophylline liquid, 21 mg/mL 450

Amoxicillin suspension, 25 mg/mL 1541

Amoxicillin suspension, 50 mg/mL 2250

Ampicillin suspension, 50 mg/mL 2250

Belladonna alkaloids elixir 1050

Cephalexin suspension, 50 mg/mL 1950

Cimetidine solution, 60 mg/mL 5550

Co-trimoxazole suspension 2200

Dexamethasone intensol solution, 1 mg/mL 3100

Digoxin elixir, 50 mcg/mL 1350

Diphenhydramine HCl elixir, 2.5 mg/mL 850

Diphenoxylate/atropine suspension 8800

Docusate sodium syrup, 3.3 mg/mL 3900

Erythromycin ethyl succinate suspension, 40 mg/mL 1750

Ferrous sulfate liquid, 60 mg/mL 4700

Furosemide solution, 10 mg/mL 2050

Haloperidol concentrate, 2 mg/mL 500

Hydroxyzine HCl syrup, 2 mg/mL 4450

Kaolin-pectin suspension 900

Lactulose syrup, 0.67 g/mL 3600

Lithium citrate syrup, 1.6 mEq/mL 6850

Magnesium citrate solution 1000

Milk of magnesia suspension 1250

Multivitamin liquid 5700

Nystatin suspension, 100,000 units/mL 3300

Phenytoin sodium suspension, 25 mg/mL 1500

Promethazine HCl syrup, 1.25 mg/mL 3500

Pyrantel pamoate suspension, 50 mg/mL 4350

Pyridostigmine bromide syrup, 12 mg/mL 3800

Sodium citrate liquid 2050

Sodium phosphate liquid, 0.5 g/mL 7250

Theophylline solution, 5.33 mg/mL 700

Thiabendazole suspension, 100 mg/mL 2150

Note: These preparations require dilution with 10 to 30 mL sterile water prior to admin-istration via the feeding tube.

*Adapted with permission from Dickerson RN, Melnick G30


mixture’s osmolality.32

Inactive ingredients or excipi-ents in liquid products may alsocause side effects when given enter-ally. Ingredient-related diarrheamay occur in up to 50% ofpatients.33 Many sweeteners,including mannitol, lactose, sac-charin, and sucrose, may cause orworsen diarrhea. However, theexcipient most likely to cause GIproblems is sorbitol.5,11,34

A poorly absorbed polyalcoholsugar, sorbitol is used therapeuti-cally as a laxative in doses of 7.5 to30 g.15 It is added to many liquidproducts to sweeten solutions,improve solution stability, and toprovide a vehicle for medication.5,34

Sorbitol frequently causes gas andbloating at total daily doses of 10g, while cramping and diarrheaoccur with 20 g/day.34

Table 4 lists the sorbitol con-tent of various medications. Thelist is not comprehensive, becausesorbitol content varies by manu-facturer and by drug concentra-tion. While many preparationscontain only small amounts, sor-bitol’s effects are cumulative, basedon the total daily dose. Patientsreceiving multiple drugs containingsorbitol are more likely to experi-ence adverse reactions. Minimizerisk by avoiding sorbitol-contain-ing agents whenever possible.11,12,34

Sudden-onset diarrhea due tosorbitol or hyperosmolar medica-tions is not a reason to discontinuetube feeding, but may suggest theneed for changes in medications oradministration routes.11,12,34

DRUG INTERACTIONS AND INCOMPATIBILITY

Some medications may not beadministered with enteral formulasbecause they form precipitates thatmay clog the feeding tube andreduce drug absorption (see Table5). Syrups and other acidic medica-

tions (pH less than 4) may clumpwhen mixed with enteral feedingformulas. In most cases, theseinteractions may be avoided bystopping the enteral feeding for 1to 2 hours before and 2 hours afterdrug administration.9,10,35,36

To avoid compromising nutri-tional status, minimize the amountof time that feeding is interruptedby using once daily or twice dailydosage regimens.9,10 Nutrientintake is reduced 12.5% to 17%with once daily dosing and 25% to33% with twice daily dosing,unless the feeding rate is increased.

PhenytoinPhenytoin absorption decreas-

es dramatically when given withenteral nutrition, reducing serumlevels by 50% to 75%.5,37 The clin-ical effect of this interaction maybe decreased by interrupting tubefeeding for 2 hours before andafter each dose, in addition toflushing the tube before and aftereach phenytoin dose.5,9 Maintainadequate nutrition by placing thepatient on a twice daily phenytoinregimen and gradually increasingthe feeding rate to account for thelost time. Monitor serum levelsclosely, especially once the patientbegins oral intake.

WarfarinWarfarin’s effects may decrease

in patients receiving enteral feed-ing, due to reduced absorption andvitamin K antagonism. Warfarinabsorption may be decreased bydrug binding to components of theenteral feeding solution. Vitamin Kis found in most enteral formulasand directly blocks warfarin’seffects when given in doses of 140to 500 mcg/day, a level that may bereached in patients receiving largevolumes of tube feeds.5,38–41

Monitor prothrombin timecarefully in patients requiring anti-

coagulation. Consider increasingthe warfarin dose or using alter-nate anticoagulants (heparin, low-molecular weight heparin). Whenthe patient is switched from enter-al feeding to oral or parenteralfeeding, it may be necessary toreduce the warfarin dosage.

FluoroquinolonesThe pharmacokinetics of some

fluoroquinolone antibiotics [ie,ciprofloxacin (Cipro), levofloxacin(Levaquin), ofloxacin (Floxin)]may change erratically when givenvia NG tubes or J tubes in patientsreceiving enteral feeds.42–47 Peakconcentrations decrease and thetime to peak increases, changesthat may alter antimicrobial effica-cy and adversely affect patient out-comes.42–46 The bioavailability ofciprofloxacin varies from 31% to82% when given via the NG tubein patients receiving continuousenteral feeding. Although there iswide variability among patients,peak concentrations and overalldrug exposure tend to be lowerwith administration via NGtubes.47

The mechanism for thesechanges is not well-understood,although it may be caused by fluo-roquinolone binding of divalentcations in the enteral feeding for-mula.42-45,48 To reduce the interac-tion, fluoroquinolones should notbe given within 2 hours before or 4hours after enteral formulas.Although studies have only evalu-ated three agents (ciprofloxacin,levofloxacin, ofloxacin), the inter-action is likely a class effect of allfluoroquinolones, including gati-floxacin (Tequin), due to their sim-ilar chemical structures and druginteraction profiles.15,49

To ensure efficacy, avoid givingfluoroquinolones via enteral feed-ing tubes or concomitantly withenteral formulas. Instead, adminis-




Table 4. Sorbitol Content of Selected Oral Liquid Medications34,49*

Generic Name Strength Sorbitol Average Adult Sorbitol Dose(Trade Name, (per mL) (% w/v) Dose (per day) (g/day)Manufacturer(s))

Acetaminophen (Tylenol) 32 mg < 20 1.3 – 3.9 g < 8 – 24

Aluminum hydroxide gel (Roxane) 135 mg 10.5 15 – 180 mL 1.6 – 18.9

Aluminum hydroxide/magnesium 6.3 mg A/23.9 mg M 7.3 15 – 180 mL 1.1 – 13.1carbonate (Gaviscon)

Aluminum hydroxide/magnesium 45 mg A/40 mg M 4.5 15 – 180 mL 0.7 – 8.1hydroxide (Maalox)

Aluminum hydroxide/magnesium 120 mg A/60 mg M 15 15 – 180 mL 2.2 – 27hydroxide (Maalox TC)

Amantadine HCl (Symmetrel) 10 mg 72 200 mg 14.4

Aminocaproic acid (Amicar) 0.25 g 18.2 13 – 15 g 9.5 – 10.9

Carbamazepine (Tegretol) 20 mg 17 400 – 1200 mg 3.4 – 10.2

Charcoal, activated (Actidose w/Sorbitol) 0.208 g 40 110 – 260 g 211.0 – 499.2

Chlorpromazine HCl (Roxane) 100 mg 3.5 40 – 300 mg 0.01 – 0.1

Cimetidine (Tagamet) 60 mg 46.1 800 mg 6.1

Diphenoxylate HCL/atropine sulfate 0.5 mg D/0.005 mg A 21 5 – 20 mg D 2.1 – 8.4(G.D. Searle)

Ferrous sulfate (FerInSol) 125 mg 30.9 975 mg 2.4

Furosemide (Roxane) 8 mg 28 20 – 80 mg 1.2 – 4.0

Furosemide (Roxane) 10 mg 30 20 – 80 mg 1 – 3

Ibuprofen (Whitehall) 20 mg 10 1.2 – 3.2 g 6.0 – 16.0

Indomethacin (Indocin) 5 mg < 1 75 – 150 mg 0.2 – 0.5

Lithium citrate (Roxane) 1.6 mEq† 54 900 – 1800 mg 8.1 – 16.2

Morphine sulfate (Roxane) 2 mg 14 40 – 120 mg 1.7 – 5

Oxybutynin (Ditropan) 1 mg 26 10 – 15 mg 2.6 – 3.9

Perphenazine 3.2 mg 20 12 – 24 mg 0.8 – 1.5

Phenobarbital (Rugby) 4 mg 12.8 30 – 120 mg 1 – 3.8

Potassium chloride (UDL) 1.33 mEq 17.5 16 – 100 mEq 2.1 – 13.1

Pseudoephedrine (Rugby) 6 mg 5 240 – 360 mg 14 – 21

Pseudoephedrine/triprolidine 6 mg P/0.25 mg T 49 240 – 360 mg P 19.6 – 29.4

Pyridostigmine HBr (Mestinon) 12 mg 14 600 mg 7

Ranitidine (Zantac) 15 mg 10 150 – 300 mg 1 – 2

Sodium polystyrene sulfonate (Roxane) 250 mg 23.5 15 – 60 g 14.1 – 56.4

Sulfamethoxazole/trimethoprim (Biocraft) 40 mg S/8 mg T 10 1600 mg S 4

Tetracycline HCl (Sumycin) 25 mg 23 1 – 2 g 9.2 – 18.4

Theophylline (Roxane) 5.33 mg 45.5 150 – 600 mg 12.8 – 51.2

Thioridazine (Pharm Assoc) 30 mg 21 200 – 800 mg 1.4 – 5.6

Valproate sodium (Depakene) 50 mg 15 1 – 4 g 3 – 12

Vitamin E (Aquasol) 50 IU 20 200 – 400 IU 0.8 – 1.6

*Adapted with permission from Lutomski DM et al34

†Lithium citrate 8 mEq is equivalent to lithium carbonate 300 mg


ter the drugs parenterally inpatients who cannot take oralmedications. If a fluoroquinolonemust be given via the feeding tube,crush the tablets and mix in 20 to60 mL sterile water immediatelybefore giving.42–47,50 Adjust the feed-ing rate to compensate for the losttime.5,9,10

Ciprofloxacin suspensionshould never be given via the feed-ing tube, since its thick consistencymay clog the tube. In addition, theoil-based suspension does not mixwith aqueous solutions and cannotbe easily flushed with water.51,52

CLOGGED FEEDING TUBESMedications cause occlusion in

approximately 15% of patientswith enteral feeding tubes.2,9 Sever-

al mechanisms for managingclogged feeding tubes are outlinedin Appendix B. Before removingthe tube, attempt to clear theobstruction with warm water andgentle pressure.11,53–55

If the feeding tube remainsclogged, flush the tube with car-bonated water, Clog Zapper, oralkalinized enzyme solution.11,55,56

Clog Zapper is a commercial prod-uct containing papain, amylase,and cellulase that may be used forocclusions caused by enteral for-mulas. Because Clog Zapper hasnot been evaluated for drug-relatedocclusions,56 alkalinized enzymesolution should be used in thesecases.

To prepare the solution, crushone sodium bicarbonate 324 mg

tablet and the contents of oneViokase or Cotazym capsule. Bothproducts contain lipase 8000 units,amylase 30,000 units, and protease30,000 units.31,49,55

Cranberry juice and carbonat-ed colas have been used in the pastto restore the patency of occludedtubes.2,9,53,54 However, these liquidsare acidic and may actually con-tribute to tube occlusion by denat-urating proteins in the enteral for-mulas.9,57

SUMMARYDrug therapy need not be com-

promised in patients receivingenteral nutrition. Careful selectionand preparation of dosage formsreduces the complications of drugadministration. Properly flushingthe feeding tube and screening forincompatibilities lowers the risk oftube clogging and the need forreplacement.

REFERENCES

1. Rollins CJ. Adult enteral nutrition. In:Koda-Kimble MA et al, eds. AppliedTherapeutics: The Clinical Use of Drugs.6th ed. Vancouver: Applied Therapeu-tics; 1995, 34.1–28.

2. Belknap DC, et al. Administration ofmedications through enteral feedingcatheters. Am J Crit Care.1997;6(5):382–92.

3. Silberman H. Parenteral and EnteralNutrition. 2nd ed. Norwalk, CT: Apple-ton & Lange; 1989, 117–58.

4. Rombeau JL, Caldwell MD, eds. In:Clinical Nutrition: Enteral and TubeFeeding. 2nd ed. Philadelphia, PA: WBSaunders; 1990.

5. Estoup M. Approaches and limita-tions of medication delivery in patientswith enteral feeding tubes. Crit CareNurse. 1994;14:68–72,79.

6. Gora ML, et al. Considerations ofdrug therapy in patients receiving enteralnutrition. Nutr Clin Pract. 1989;4:105–10.

7. Klein S, Fleming CR. Enteral and par-enteral nutrition. In: Sleisenger MG, et


Table 5. Drug/Formula Incompatibilities.9-11,35,36,45,47,62

Aluminum hydroxide

Aluminum hydroxide – magnesium hydroxide

Brompheniramine/phenylephrine elixir

Calcium glubionate 1.8 g/5 mL (Calcionate)

Chlorpromazine 100 mg/mL

Ferrous sulfate 220 mg/5 mL

Fluoroquinolones: ciprofloxacin (Cipro), gatifloxacin (Tequin), levofloxacin(Levaquin) ofloxacin (Floxin)

Guaifenesin 20 mg/mL (Robitussin)

Lithium citrate 8 mEq/5 mL*

Medium chain triglyceride oil (MCT Oil)

Metoclopramide 1 mg/mL (Roxane)

Opium tincture, camphorated, 0.04% elixir (Paregoric)

Potassium chloride 10% liquid

Potassium chloride 20% liquid

Pseudoephedrine 6 mg/mL (Rugby)

Sodium biphosphate 480 mg/mL (Fleets Phospho-soda)

Sucralfate (Carafate)

Thioridazine 30 mg/mL; 100 mg/mL

Zinc sulfate capsules

*Lithium citrate 8 mEq is equivalent to lithium carbonate 300 mg


al, eds. Gastrointestinal Disease: Patho-physiology Diagnosis Management. 5thed. Philadelphia, PA: WB Saunders;1993, 2062–96.

8. Schuffler MD, Sinanan MN. Intestinalobstruction and pseudo-obstruction. In:Sleisenger MH, et al, eds. Gastrointesti-nal Disease: Pathophysiology DiagnosisManagement. 5th ed. Philadelphia: WBSaunders; 1993, 898–916.

9. Thomson FC, et al. Managing drugtherapy in patients receiving enteral andparenteral nutrition. Hosp Pharmacist.2000;7:155–64.

10. Gilbar PJ. A guide to enteral drugadministration in palliative care. J PainSymptom Manage. 1999;17:197–207.

11. Rombeau JL, Caldwell MD, eds.Clinical Nutrition: Enteral and TubeFeeding. 3rd ed. Philadelphia, PA: WBSaunders; 1997.

12. Janson DD, Chessman KH. Enteralnutrition. In: DiPiro JT et al, eds. Phar-macotherapy: A PathophysiologicApproach. 5th ed. New York, NY:McGraw-Hill; 2002, 2495–517.

13. Mitchell JF. Oral dosage forms thatshould not be crushed or chewed. HospPharm. 2002; 37:213–14.

14. Personal communication. White-house Station, NJ: Merck; 1994.

15. AHFS Drug Information 2002.Bethesda, MD: American Society ofHealth-System Pharmacists; 2002.

16. Personal communication. Lake For-est, IL: TAP Pharmaceuticals; 1996.

17. Nexium (esomeprazole) [packageinsert]. Wilmington, DE: AstraZeneca;2001.

18. Aciphex (rabeprazole sodium)delayed-release tablets package insert.Teaneck, NJ: Eisai Pharmaceuticals;2000.

19. Protonix (pantoprazole sodium)delayed-release tablets [package insert].Philadelphia, PA: Wyeth; 2001.

20. Sharma VK, et al. Oral pharmacoki-netics of omeprazole and lansoprazoleafter single and repeated doses as intactcapsules or as suspensions in sodiumbicarbonate. Aliment Pharmacol Ther.2000;14:887–92.

21. Song JC, et al. A prospective study of

simplified omeprazole suspension for theprophylaxis of stress-related mucosaldamage. Am J Health Syst Pharm.2001;58:689–94.

22. Sharma VK, et al. Simplified lanso-prazole suspension—a liquid formula-tion of lansoprazole—effectively sup-presses intragastric acidity when admin-istered through a gastrostomy. Am JGastroenterol. 1999;94:1813–7.

23. Zimmermann A, et al. Alternativemethods of proton-pump inhibitoradministration. Consult Pharm.1997;12:990–8.

24. Phillips JO, et al. A prospective studyof simplified omeprazole suspension forthe prophylaxis of stress-related mucosaldamage. Crit Care Med.1996;24:1793–800.

25. Omeprazole nasogastric administra-tion (Drug Consult). In: Hutchison TA,Shahan DR, eds. Drugdex System.Greenwood Village, CO: Micromedex.(Edition expires September 30, 2002).

26. Prevacid (lansoprazole) delayed-release capsules and Prevacid (lansopra-zole) for delayed-release oral suspension[package insert]. Lake Forest, IL: TAPPharmaceuticals; 2002.

27. Safety briefs. ISMP Medication Safe-ty Alert! 2002;7(12):1–2.

28. Product reference guide. Deerfield,IL: Nestle Clinical Nutrition; 2001.

29. Hutchison TA, Shahan DR, eds.Drugdex System. Greenwood Village,CO: Micromedex (Edition expires Sep-tember 30, 2002).

30. Dickerson RN, Melnik G. Osmolali-ty of oral drug solutions & suspensions.Am J Hosp Pharm. 1988;45:832–34.

31. Jew RK, et al. Osmolality of com-monly used medications and formulas inthe neonatal intensive care unit. NutrClin Pract. 1997;12:158–63.

32. Sterile water for injection. In:USP24/NF 19 The United States Phar-macopeia/The National Formulary.Rockville, MD: United States Pharma-copeial Convention; 1999, 1753.

33. Klang MG. Medicating tube-fedpatients. Nursing. 1996;26:18.

34. Lutomski DM, et al. Sorbitol contentof selected oral liquids. Ann Pharma-cother. 1993;27:269–74.

35. Burns PE, et al. Physical compatibili-ty of enteral formulas with various com-mon medications. J Am Diet Assoc.1988;88:1094–6.

36. Cutie AJ, et al. Compatibility ofenteral products with commonlyemployed drug additives. JPEN J Par-enter Enter Nutr. 1983;7:186–91.

37. Bauer LA. Interference of oral pheny-toin absorption by continuous nasogas-tric feedings. Neurol. 1982:32:570–2.

38. Kutsop JJ. Update on vitamin K1content of enteral products [letter]. Am JHosp Pharm. 1984;41:1762.

39. Landau J, Moulds RFW. Warfarinresistance caused by vitamin K in intesti-nal feeds [letter]. Med J Aust.1982;263–4.

40. Watson AJM, et al. Enteral feedsmay antagonise warfarin. BMJ.1984;288: 557.

41. Parr MD, et al. Effect of enteralnutrition on warfarin therapy [letter].Clin Pharm. 1982;1:274–6.

42. Healy DP, et al. Ciprofloxacinabsorption is impaired in patients givenenteral feedings orally and via gastrosto-my and jejunostomy tubes. AntimicrobAgents Chemother. 1996;40:6–10.

43. de Marie S, et al. Bioavailability ofciprofloxacin after multiple enteral andintravenous doses in ICU patients withsevere gram-negative intra-abdominalinfections. Intensive Care Med.1998;24:343–6.

44. Wright DH, et al. Decreased in vitrofluoroquinolone concentrations afteradmixture with an enteral feeding for-mulation. JPEN J Parenter Enter Nutr.2000;24:42–8.

45. Cohn SM, et al. Enteric absorptionof ciprofloxacin during tube feeding inthe critically ill. J Antimicrob Chemoth-er. 1996;38:871–6.

46. Mueller BA, et al. Effect of enteralfeeding with Ensure on oral bioavailabil-ities of ofloxacin and ciprofloxacin.Antimicrob Agents Chemother.1994;38:2101–5.

47. Mimoz O, et al. Pharmacokineticsand absolute bioavailability ofciprofloxacin administered through anasogastric tube with continuous enteralfeeding to critically ill patients. Intensive



Care Med. 1998;24:1047–51.

48. Cipro (ciprofloxacin) and enteralnutrition [written communication]. WestHaven, CT: Bayer; 2001.

49. Drug Facts and Comparisons. St.Louis, MO: Facts & Comparisons;2002.

50. Crushing tables/enteral feeds – Lev-aquin (levofloxacin) [written communi-

cation]. Raritan, NJ: Ortho-McNeil;2001.

51. Cipro (ciprofloxacin) [packageinsert]. West Haven, CT: Bayer; 2000.

52. Cipro (ciprofloxacin) oral suspen-sion [written communication]. WestHaven, CT: Bayer; 2002.

53. Marcuard SP, et al. Clearingobstructed feeding tubes. JPEN J Par-

enter Enter Nutr. 1989;13:81–3.

54. Bommarito AA, et al. A newapproach to the management ofobstructed enteral feeding tubes. NutrClin Pract. 1989;4:111–4.

55. Bailey K. Management of phytobe-zoars and clogged feeding tubes. Phar-macy Newsletter. (Thomas Jefferson Uni-versity Hospital) 1994;12:13.


Appendix A: Approach to Medication Administration in Patients with Feeding Tubes.3,5-7,9,11,12,14,15,17,22-24,42-46,49

Evaluate necessity of each medication; temporarily discontinue if possible. Consider giving medication by an alternate route:Buccal Intramuscular Intravenous TransdermalNebulized Rectal Subcutaneous Sublingual

Administration through feeding tube:Assess drug absorption site, site of action, duration of action, incompatibilities, and effects of food on drug absorption.Select medication dosage form (listed in order of preference*). Only liquid dosage forms should be given via small-boreenteral feeding tubes.• Oral liquid. Dilute with 10 to 30 mL sterile water or enteral formula if hyperosmolar.• Oral immediate-release tablet. Crush to fine powder and mix with 15 to 30 mL water to form slurry.• Oral immediate-release capsule. Crush capsule contents to fine powder and mix with 10 to 30 mL water to form a slurry.• Oral soft gelatin capsule. Aspirate liquid contents and mix with 10 to 30 mL water.• IV liquid preparation.If drug requires administration on an empty stomach and the tube empties into the stomach, stop enteral feeds for

30 minutes before and after administration. Adjust enteral feeding rate to maintain adequate nutrition.Flush feeding tube with 30 mL sterile water prior to administration.Give each medication separately via the feeding tube and flush with 30 mL sterile water between medications.Flush feeding tube with 30 mL sterile water to clear residual medication.

Special situations

Cardizem CD, Cardizem SR, Fergon, Respbid oral capsules: Open capsule and pour intact pellets down large bore enter-al feeding tube. Flush feeding tube with 30 mL water before and after administration.

Gastrocrom oral capsules: Open capsule, dissolve contents in water, pour down feeding tube. Flush feeding tube with 30mL water before and after administration.

Fluoroquinolones (ciprofloxacin, gatifloxacin, levofloxacin): Give IV whenever possible. However, if absolutely necessaryto give enterally via large bore feeding tube, crush tablets and mix with 20 to 30 mL water immediately prior to admin-istration. Stop enteral feeding for at least 2 hours before and 4 hours after administration.

Phenytoin: Switch patient to twice daily administration of phenytoin suspension. Stop enteral feeding for at least 2 hoursbefore and 2 hours after administration.

Proton-pump inhibitors, delayed-release capsules (lansoprazole, omeprazole):• Gastric or nasogastric feeding tube, large bore (18 French or larger): Immediately before administration, open capsule

and gently mix intact granules with acidic fruit juice. Discontinue enteral feeding temporarily and pour mixture downfeeding tube. After administration, flush feeding tube with additional acidic fruit juice and clamp the feeding tube forat least 1 hour. May use apple, cranberry, grape, orange, pineapple, prune, tomato, or V-8 juice.

• Intestinal feeding tube or small bore gastric feeding tube (smaller than 18 French): Give simplified oral suspension (lan-soprazole 3 mg/mL or omeprazole 2 mg/mL). Prior to administration, shake suspension well and temporarily discon-tinue enteral feeding formula. Pour suspension down feeding tube. After administration, flush the feeding tube with 5to 10 mL water and clamp the feeding tube for at least 1 hour.

*According to cost, ease of use, and risk of adverse effects


56. Clog Zapper information. Wheeling,IL: Corpak Medsystems; 2002.

57. Guenter P. Administering medica-tions via feeding tubes: What consultantpharmacists need to know. ConsultPharm. 1999;14:41–4, 47–8.

58. Mosby’s GenRx. 11th ed. St. Louis,MO: Mosby Incorporated; 2001.

59. Medication administration. In:DeLaune SC et al, eds. Fundamentals ofNursing: Standards and Practice. 2nd ed.Clifton Park, NJ: Delmar/ThomsonLearning; 2002, 673–740.

60. Administering medications. In: Pot-ter PA, et al, eds. Basic Nursing: A Criti-cal Thinking Approach. 4th ed. St. Louis,MO: Mosby; 1999:596–670.

61. Beckwith MC, Tyler LS, eds. CancerChemotherapy Manual. St. Louis, MO:Facts and Comparisons; 2001.

62. Engle KK, Hannawa TE. Techniquesfor administering oral medications tocritical care patients receiving continu-ous enteral nutrition. Am J Health SystPharm. 1999;56:1441–4. ■


Appendix B: Approach to Clogged Feeding Tubes11,53–56

1. Withdraw any enteral solution remaining in tube.

2. Attempt to remove obstruction, using the following methods in the order given.• Warm water: Inject 5 mL warm water into tube and clamp for 5 minutes. Unclamp tube, apply gentle pressure, and

attempt suction. If tube is unclogged, flush with water until clear. If still obstructed, try carbonated water or alkalinizedenzyme.

• Carbonated water: Inject carbonated water into tube and clamp for 1 hour. Then, unclamp tube, apply gentle pressure,and attempt suction. If tube is unclogged, flush with water until clear. If still obstructed, try alkalinized enzyme method.

• Clog Zapper enzyme solution (for formula-related occlusions): Fill enclosed syringe to 10 mL mark with 7.1 mL water,cap syringe, and shake until powder dissolves completely. Inject 2 to 5 mL of mixture into tube and clamp for 30 to 60minutes. Flush with water until clear. Refrigerate remaining solution and use within 24 hours.

• Alkalinized enzyme solution (for medication-related occlusions): Crush one sodium bicarbonate 324 mg tablet. Mixpowder with contents of one Cotazym or Viokase capsule and 5 mL sterile water. Inject mixture into tube and clampfor 5 minutes. Flush with water until clear.

3. Replace feeding tube, only if there is an inadequate response to steps 1 and 2.

fact and comparison ngt

Documents

aluminum hydroxide magnesium hydroxide

increased bleeding tendency

receive enteral nutrition

liquid dosage forms

acidic fruit juice

lower esophageal sphincter

dosage form selection

reduced intestinal motility