Enteral feeding can be administered through the following routes of access:
- Nasogastric tubes: A nasogastric or orogastric tube with radiologic confirmation of positioning is the first line of enteral access. Gastric feeding is preferred because it is well tolerated in the majority of patients, is more physiological, requires a lower level of expertise, and minimizes any delay in initiation of feeding.
- Postpyloric tubes: Postpyloric feeding tubes are indicated if gastric feeding is poorly tolerated or if the patient is at high risk for aspiration because jejunal feedings decrease the incidence of reflux, regurgitation, and aspiration.
- Percutaneous access: When long-term enteral access is required – that is, for greater than 4 weeks – a percutaneous enteral access device should be placed. Prolonged use of a nasoenteric tube may be associated with erosion of the nares and an increase in the incidence of aspiration pneumonia, sinusitis, and esophageal ulceration or stricture. Patients who have had a stroke are the most likely to benefit from percutaneous endoscopic gastrostomy placement, as 40% of patients can have continued dysphagia as long as 1 year after.4,10 Absolute contraindications for PEG placement include serious coagulation disorders (international normalized ratio greater than 1.5; fewer than 50,000 platelets/mcL), sepsis, abdominal wall infections, marked peritoneal carcinomatosis, peritonitis, severe gastroparesis, gastric outlet obstruction, or a history of total gastrectomy. Risks often outweigh benefits in patients who have cirrhosis with ascites, patients undergoing peritoneal dialysis, and patients who have portal hypertension with gastric varices, but PEG can be considered on a case-by-case basis.11
Parenteral nutrition is reserved for patients in whom enteral feeding is contraindicated or who fail to meet their nutritional needs with enteral feedings. If EN is not feasible, then parenteral nutrition should be initiated as soon as possible in patients who had high nutritional risk on admission. Otherwise, PN should not be initiated during the first week of hospitalization because there is evidence to suggest net harm when initiated early. Supplemental PN may be considered for patients already on EN who are unable to meet more than 60% of their energy and protein requirements by the enteral route alone, but again, this should only be considered after 7-10 days on EN. PN is generally stopped when the patients achieve more than 60% of their energy and protein goals from EN.4