1. ENS Weaning and De-Escalation Protocols

As gastrointestinal and swallow function recover, a structured, evidence-based de-escalation protocol minimizes complications and supports nutritional goals.

A. Criteria for Transition to Oral Intake

• Swallow evaluation by a speech-language pathologist demonstrating intact cough/gag reflexes and safe swallow trials.
• Gastric residual volumes consistently <200–250 mL without nausea or vomiting.
• Hemodynamic stability: off or on minimal vasopressors for ≥24 hours.
• Ability to tolerate clear liquids, advancing to a pureed/soft diet with multidisciplinary dietitian oversight.

B. Stepwise Volume Reduction and Monitoring

• Decrease continuous feed rate by 25% every 24 hours once oral intake exceeds 30% of the caloric goal.
• Switch to intermittent bolus feeding (4–6 times/day) when oral intake is >50% of needs.
• Discontinue ENS when enteral feeds contribute <25% of total intake and the oral diet meets requirements.
• Monitor weight daily, serum prealbumin weekly, and nitrogen balance as indicated.
• Pause the protocol if two consecutive gastric residuals are >250 mL or new GI dysfunction arises; reassess tolerance and motility.

C. Tolerance Assessment and Adjustment

• Clinical exam: abdominal distension, bowel sounds, stool output (>3 loose stools/day).
• Glycemic checks: q6h during feed advances; aim for 140–180 mg/dL.
• Electrolytes: check phosphate, magnesium, and potassium q24–48 h to detect refeeding syndrome.
• If diarrhea persists: reduce rate by 10–20% and consider a semi-elemental formula.
• For hyperglycemia >180 mg/dL: initiate basal insulin or lower the dextrose concentration in the formula.
• A temporary hold (2 hours) followed by reinitiation at a 50% rate can often restore tolerance without full cessation.

2. Conversion of Intravenous to Enteral Medications

Safe conversion hinges on appropriate formulation selection, pharmacokinetic/pharmacodynamic adjustments, and strict tube management to preserve efficacy and prevent occlusion.

A. Formulation Suitability and Compatibility

• Immediate vs. Extended-Release: Crush only immediate-release tablets. Avoid altering extended-release (ER) or enteric-coated forms to prevent dose dumping and loss of efficacy.
• Excipients Risk: Fillers like microcrystalline cellulose and talc may clog tubes. Select liquid or compounding alternatives when possible.

B. Enteral Dosing Adjustments (PK/PD)

• Phenytoin: Levels can drop by approximately 25–30% with continuous enteral nutrition. Hold feeds for 1 hour before and after administration.
• Fluoroquinolones: Separate from calcium/magnesium-containing formulas by at least 2 hours to prevent chelation and reduced absorption.
• Lipophilic drugs: May have enhanced absorption with fat-containing feeds; monitor levels and clinical effect accordingly.

C. Administration Techniques and Tube Flushing

• Flush with 15–30 mL of water before and after each medication dose. Add a 5–10 mL flush between multiple drugs.
• Use syringe pressure (not gravity) for viscous suspensions. Label all syringes and document administration times meticulously.
• Verify tube placement radiographically or by pH check prior to dosing.

3. Post-ICU Syndrome Prevention

Implementing the ABCDEF Bundle and targeted risk stratification mitigates the physical, cognitive, and psychological sequelae that can occur after critical illness.

A. Risk Stratification

• High-risk features: mechanical ventilation >7 days, deep sedation, sepsis-associated encephalopathy, and pre-existing frailty.
• Early screening for ICU-acquired weakness (ICU-AW) and cognitive impairment is crucial to guide rehabilitation referrals.

B. ABCDEF Bundle Components

1. Assess, prevent, and manage Pain.
2. Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs).
3. Choice of analgesia and sedation to minimize deliriogenic agents.
4. Delirium: Assess, prevent, and manage using validated tools like CAM-ICU or ICDSC.
5. Early Mobility and Exercise: progressing from passive range of motion to active exercises and ambulation.
6. Family Engagement and Empowerment in care planning and mobility sessions.

4. Medication Reconciliation and Discharge Counseling

A pharmacist-led handoff that combines thorough medication review, patient education, and interdisciplinary communication is essential for ensuring continuity of care and patient safety.

A. Comprehensive Medication Review

• Compare pre-hospital, ICU, and current ward medication regimens to identify and resolve duplications, omissions, and discrepancies from IV-to-enteral conversions.
• Critically review the ongoing need for therapies initiated in the ICU, such as stress ulcer prophylaxis, VTE prophylaxis, and insulins.

B. Patient and Caregiver Education

• Demonstrate enteral pump operation, tubing care, and formula preparation.
• Provide a clear medication-feed schedule and a troubleshooting guide for common tube issues.
• Highlight warning signs that require immediate attention: tube displacement, clogging, signs of feed intolerance, and when to seek professional help.

C. Interdisciplinary Communication

• A structured handoff template must include the current ENS regimen, the weaning plan, tube type and care instructions, pending lab results, and all scheduled follow-up appointments (e.g., dietitian, home health, pharmacy).

5. Pharmacotherapy Section: Enteral Medication Conversion

Detailed drug-by-drug guidance ensures effective enteral therapy, covering mechanism, dosing, monitoring, and common pitfalls.

A. Mechanism & Absorption Variations

• Levothyroxine: Requires an acidic environment for optimal absorption. Co-administration with proton pump inhibitors (PPIs) may reduce absorption by 15–20%.
• Phenytoin: Binding to enteral formula components can significantly alter absorption. Consider monitoring free phenytoin levels, especially in patients with low albumin.

B. Indications & Agent Selection

• Opioids: Switch to immediate-release liquid forms (e.g., morphine solution 2–4 mg q4h PRN) once the enteral route is patent and reliable.
• Antibiotics: Use enteral levofloxacin 500 mg daily for susceptible infections; ensure separation from divalent cations in formula by at least 2 hours.

C. Dosing, Titration & Monitoring

• Phenytoin: Start at 5 mg/kg/day in divided doses. Check total and free levels after 72 hours and adjust based on levels and clinical response.
• Levofloxacin: Standard dosing is usually appropriate. Monitor for GI tolerance and clinical signs of efficacy.
• Morphine: Titrate dose to achieve adequate pain relief. Monitor for sedation, respiratory depression, and bowel function.

D. Contraindications, Warnings & Pitfalls

• Never crush extended-release (ER) or enteric-coated tablets.
• Avoid sorbitol-based liquid suspensions in patients experiencing diarrhea, as sorbitol is an osmotic laxative.
• Use caution with drugs that affect the QT interval or have significant hemodynamic effects in unstable patients.

E. Comparative Analysis: IV vs. Enteral Route

F. Clinical Pearls & Decision Points

• Always verify tube placement immediately before administering any dose.
• If the enteral route becomes contraindicated (e.g., due to ileus, high-output fistula, or shock), promptly revert to IV therapy until GI function is restored.