Tube Feeding And Hemodialysis

[Chisca, RN]

Trying to determine what ICU nurses are doing with tube feeds when dialysis occurs. Hold feeds or keep them running?

[Chisca, RN]

Postprandial hypotension is a drop in blood pressure after eating a meal. Stomach distension is the trigger as the body shunts blood to digest the food based on this signal. No distension and there isn't a signal. Bolus feeding would trigger the response but trickle feeding does not. If you do hold the feeds during dialysis the risk is a dramatic drop in blood sugar as you are depriving the patient of glucose as the dialysis machine is removing glucose. The glucose molecule is slightly bigger than a water molecule and during a 3-4 hour treatment I have seen sugars fall up to 200 points. If your patient has any liver issues and can't convert fat to glucose the fall in serum glucose levels will be more rapid. European and asian countries routinely feed patients while on dialysis while the US and Canada do not.

[Kallie3006, ADN]

What does the nephrologist have down in the orders?

[MunoRN, RN]

Maybe I've been out of the loop, but I've never come across the practice of habitually putting tube feedings on hold during dialysis, we even let them eat meals PO during dialysis.

[Chisca, RN]

Not specified in the standard orderset.

[guest769224]

Same thoughts here as Muno. I've had HD patients continue tube feeds or eat their meal on the tray while HD is running. Never heard any mention of contraindication for doing so.

[Chisca, RN]

Thank you to KeepinitrealCCRN and MunoRN for voting, for the rest of the 311 slugs who viewed this question and didn't respond, why not?

[emmjayy, BSN, RN]

This is an issue I've never really had to deal with, because a.) none of my HD patients have been on bolus tube feeds, it's always been continuous and b.) they're all so unstable that they're on levophed during HD anyway.

[Shanimal]

I've never heard of any blanket protocol that recommends holding tube feedings during dialysis in ICU settings (and I'm here in the US), nor can I identify generalized recommendations for such in the literature. An exception for this would be if the patient has a femoral dialysis catheter access that requires patient positioning to be more supine, but the rationale for this is related to aspiration and not postprandial hypotension. Postprandial hypotension is a more patient-specific concern, and I see no reason for universal application to all patients. If we did this for every potential thing that could go wrong in patient care, we wouldn't be performing any healthcare interventions at all. This underscores the importance of bedside nurses that are competent and vigilant with strong assessment skills.

You mention routine feeding of patients during dialysis is common Europe and Asia, but not in Canada and the US. Where are you finding this information?

[Chisca, RN]

Quote

On the other hand, meals are routinely given to dialysis outpatients in most European and Southeast Asian countries. German dialysis patients invariably eat during their hemodialysis treatments and have higher serum albumin and greater survival than their U.S. counterparts.

https://www.jrnjournal.org/article/S1051-2276(12)00226-9/pdf

[AGRN152]

As both a current critical care nurse and dialysis nurses I may have some insight. I have done hemodialysis in the inpatient setting for years and I have worked as an ICU nurse for years as well. I have never in either role had to have tube feeds turned off during HD. Nutrition is a major issue in the ICU and 9-12 hours a week of no nutrition has been shown to correlate with increased hospital stays and prolonged healing times. Additionally, in the setting of CRRT/CVVH the treatments would be running for days making it impossible to starve patients this long. The blood flow rate on a CVVH machine and on a dialysis machine is nearly the same and the hemodynamic shift would not be much different. In the US many patients in the outpatient setting are advised not to eat but in a hospital setting they eat whenever they want and truthfully I have seen not consistent trend that I would even say remotely links hypotension to eating.