Midwinter Meeting February 29, 2020 Untangling Medication - - PowerPoint PPT Presentation

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Midwinter Meeting February 29, 2020 Untangling Medication - - PowerPoint PPT Presentation

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Midwinter Meeting February 29, 2020 Untangling Medication Administration in Patients with Feeding Tubes Lilian F. Ooi, PharmD, BCPS, BCCCP Advanced Clinical Pharmacist Intermountain McKay-Dee Hospital Disclosure I have no conflicts of

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Midwinter Meeting February 29, 2020

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Untangling Medication Administration in Patients with Feeding Tubes

Lilian F. Ooi, PharmD, BCPS, BCCCP Advanced Clinical Pharmacist Intermountain McKay-Dee Hospital

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Disclosure

I have no conflicts of interest to disclose. Off-label uses of drugs will be discussed.

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Learning Objectives

At the conclusion of this activity, pharmacists should be able to successfully:

  • 1. Recognize the methods of enteral feeding
  • 2. Describe considerations for medication administration through a feeding tube
  • 3. Evaluate factors to safely prepare and administer medications through a feeding tube
  • 4. Formulate an approach to dosage form selection and drug administration methods in

patients with enteral feeding tubes

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Learning Objectives

At the conclusion of this activity, pharmacy technicians should be able to successfully:

  • 1. Recognize the methods of enteral feeding
  • 2. Recall issues with medication administration through a feeding tube
  • 3. Evaluate factors to safely prepare, deliver, and store medication to be given through

an enteral access device

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Enteral Access Sites

1Williams NT. AJHP 2008. 2White R. Pharmaceutical Press 2015.

Classified by

  • Site of insertion
  • Location of distal tip of the

feeding tube Selection based on

  • Short-term usage
  • Long-term usage
  • Disease state
  • Patient-specific factors
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  • Most common in hospital setting
  • Slow, continuous rate over 24‐hour period

Continuous

  • Continuous feeding over a specific period
  • Generally overnight

Cyclic

  • Mimic usual eating patterns
  • 4‐6 times per day

Bolus

Enteral Feeding Delivery Methods

1Williams NT. AJHP 2008. 3Boullata JI. ASPEN 2019.

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  • Outer lumen tube diameter measured in French (Fr) units
  • 1 Fr = 0.33 mm
  • Small-bore tubes
  • 5-12 Fr
  • Gastrostomy, NG, NJ
  • Large-bore tubes
  • ≥14 Fr
  • PEG

Feeding Tube Size

1Williams NT. AJHP 2008. 4Image from https://www.compactcath.com/blog/catheter‐types‐and‐sizes.

NG = Nasogastric; NJ = Nasojejunal; PEG = Percutaneous Endoscopic Gastrostomy .

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  • Occlusions
  • Particle obstruction
  • Inadequately crushed tablets
  • Coating
  • Precipitate formation
  • Drug-feed interaction
  • Drug-drug interaction
  • Adverse events
  • Decreased efficacy
  • Increased systemic effects
  • Death

Complications

1Williams NT. AJHP 2008. 5McIntyre CM, Monk HM. AJHP 2014. 6 Schallom M. Am Nurse Today 2016. 7Logrippo S et al. Clin Interv Aging 2017.

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Determine route suitability Establish drug and dosage form suitability Utilize proper administration techniques Report issues

Safe Practice Recommendations

1Williams NT. AJHP 2008. 8Boulllata JI. JPEN 2017.

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  • Determine location of distal end of feeding tube
  • Most medications absorbed in small intestine
  • Feeding tube may bypass site of absorption
  • Antacids, sucralfate, bismuth
  • Require gastric acid for absorption
  • Ferrous sulfate, aspirin
  • Bypass first-pass hepatic metabolism
  • Opioids, tricyclic antidepressants, ß-blockers

Drug Route Suitability

1Williams NT. AJHP 2008. 5McIntyre CM. AJHP 2014.

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  • Use only immediate-release liquid or solid dosage forms
  • Be cognizant of osmolality and excipients
  • Avoid enteric-coated and film-coated products
  • Prepare hazardous drugs in central pharmacy
  • Recommend alternative routes of administration

Drug and Dosage Form Suitability

1Williams NT. AJHP 2008. 8Boullata J. JPEN 2017. 9Beckwith MC. Hosp Pharm 2004. 10Grissinger M. P&T 2013. 11Lippincott Procedures 2019.

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  • Tertiary references
  • Guidebooks, online drug databases
  • ISMP “Do Not Crush” list
  • NIOSH list of antineoplastic and other

hazardous drugs

  • Institutional policies and procedures
  • Primary literature

Resources

ISMP = Institute of Safe Medication Practices; NIOSH = National Institute for Occupational Safety and Health2019.

2White R. 2015. 8Boullata J. JPEN 2017. 12ISMP 2019. 13NIOSH 2016.

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Stop enteral feeding Prepare each medication separately

  • Open capsules
  • Crush solid

dosage forms to fine powder

  • Dilute medication

Administer each medication separately Flush well

  • 15‐30 mL purified

water

  • Flush in between

each administration

Restart feeding

Proper Administration Techniques

1Williams NT. AJHP 2008. 2White R. 2015. 3Boullata JI. ASPEN 2019. 8Boullata J. JPEN 2017. 9Beckwith MC. Hosp Pharm 2004. 11Lippincott Procedures 2019.

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NM is a 76-year-old male with acute cardioembolic stroke secondary to atrial fibrillation. He failed his swallow evaluation and consented to nasogastric (NG) tube placement. Medications: What recommendations would you discuss with the physician or communicate to the bedside nurse? Choose all the correct statements.

  • A. Apixaban and atorvastatin can be crushed and given via NG tube
  • B. Change metoprolol XL to immediate-release formulation given twice daily
  • C. Crush tamsulosin, dilute with purified water, and give via NG tube
  • D. Hold pantoprazole EC tab

Test Question-Pharmacists and Technicians

Apixaban 5 mg tab PO BID Docusate 100 mg cap PO BID Atorvastatin 80 mg tab PO QHS Pantoprazole enteric‐coated (EC) 40 mg tab PO daily Metoprolol extended‐release (XL) 50 mg tab PO Daily Tamsulosin 0.4 mg cap PO daily

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1. Williams NT. Medication administration through enteral feeding tubes. Am J Health-Syst Pharm. 2008; 65:2347-57. 2. White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3rd ed. London, UK: Pharmaceutical Press; 2015. 3. Boullata JI. Guidebook on Enteral Medication Administration. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2019. 4. French Cather Scale. CompactCath. https://www.compactcath.com/blog/catheter-types-and-sizes. Accessed January 20, 2020. 5. McIntyre CM, Monk HM. Medication absorption considerations in patients with postpyloric enteral feeding tubes. Am J Health-Syst Pharm 2014; 71:549-56. 6. Schallom M. How to recognize, prevent, and troubleshoot mechanical complications of enteral feeding tubes. Am Nurse Today 2016; 11(2):1-8. 7. Logrippo S, Ricci G, Sestili M et al. Oral drug therapy in elderly with dysphagia: between a rock and a hard place! Clin Interv Aging. 2017; 12:241-251. 8. Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41:15-103. 9. Beckwith MC, Feddema SS, Barton RG, Graves C. A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hosp Pharm 2004; 39:225-237.

  • 10. Grissinger M. Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes. P&T 2013; 28(10)575-576.
  • 11. Enteral tube drug instillation. (2019). In Lippincott procedures. Retrieved from http://procedures.lww.com.
  • 12. Oral Dosage Forms That Should Not Be Crushed. Institute for Safe Medication Practices. Updated November 1, 2018.

https://www.ismp.org/recommendations/do-not-crush. Accessed January 20, 2020.

  • 13. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings. Updated September 2016. https://www.cdc.gov/niosh/docs/2016-

161/pdfs/2016-161.pdf. Accessed January 20, 2020.

References