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Elmahdi A, Eisa M, Omer E. Aspiration pneumonia in enteral feeding: A review on risks and prevention. Nutr Clin Pract 2023; 38:1247-1252. [PMID: 37227191 DOI: 10.1002/ncp.11020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/02/2023] [Accepted: 04/30/2023] [Indexed: 05/26/2023] Open
Abstract
Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.
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Affiliation(s)
- Alsiddig Elmahdi
- Internal Medicine, Virginia Commonwealth University Health Systems, Richmond, Virginia, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
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De Lucia SS, Candelli M, Polito G, Maresca R, Mezza T, Schepis T, Pellegrino A, Zileri Dal Verme L, Nicoletti A, Franceschi F, Gasbarrini A, Nista EC. Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence. Nutrients 2023; 15:1939. [PMID: 37111158 PMCID: PMC10144915 DOI: 10.3390/nu15081939] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.
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Affiliation(s)
- Sara Sofia De Lucia
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Giorgia Polito
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Rossella Maresca
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Teresa Mezza
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Tommaso Schepis
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Pellegrino
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Lorenzo Zileri Dal Verme
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Alberto Nicoletti
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Enrico Celestino Nista
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
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Du G, Liu F, Ma X, Chen S, Dai M, Wei L, Liu Z. Comparison Between Percutaneous Endoscopic Gastrostomy and Nasogastric Feeding in 160 Patients with Swallowing Disturbances: A Two-Year Follow-Up Study. Clin Interv Aging 2022; 17:1803-1810. [PMID: 36506851 PMCID: PMC9733445 DOI: 10.2147/cia.s389891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose We retrospectively compared the complications, blood biochemical indexes and outcomes in patients with swallowing disturbances receiving nasogastric tube (NGT) feeding and percutaneous endoscopy gastrostomy (PEG). Methods Among 160 patients, 72 cases received PEG and 88 cases received NGT. All patients were followed up for two years. We collected their clinical data from the medical records. Indicators, such as body mass index (BMI), white blood cell (WBC), hemoglobin (HGB), complications, including recurrent aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and outcomes (survival or death) were compared between the two groups semi-annually. Results SAt both six months and one year after receiving treatment, there was no statistical difference between the two groups in indicators, complications and outcomes, with all P >0.05. It can be seen that, when the patients were followed up for one and a half years18 months, ALB was lower in the NGT group (33.81±0.46) compared with the PEG group (36.14±0.50) (P <0.05). After two years of follow-up, differences between the NGT and PEG group could be seen in a variety of indicators, including BMI (20.08±0.27 vs 21.03±0.25), WBC (9.12±0.56 vs 7.08±0.29), ALB (33.11±0.43 vs 35.75±0.49), creatinine (55.07±1.83 vs 63.21±2.94), and the complications, such as aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and electrolyte disorder, in the PEG group were significantly reduced compared to the NGT groupthan that in its counterpart, P <0.05. In the two-year follow-up period, there were 13 and 22 patients died in the PEG group and NGT group, respectively. Conclusion Both techniques are safe and effective in the short term. However, on a longer-term basis, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications for patients with swallowing disturbances.
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Affiliation(s)
- Ge Du
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
| | - Fangfang Liu
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
| | - Xiaomin Ma
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
| | - Shanshan Chen
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
| | - Min Dai
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
| | - Li Wei
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China,Correspondence: Li Wei; Zishuang Liu, Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, 100144, People’s Republic of China, Tel/Fax + 86-010-56981582, Email ;
| | - Zishuang Liu
- Department of Rehabilitation Center for Elderly, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, People’s Republic of China
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Pérez G, González E, Zamora L, Fernández SN, Sánchez A, Bellón JM, Santiago MJ, Solana MJ. Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation. J Pediatr Gastroenterol Nutr 2022; 74:110-115. [PMID: 34636794 PMCID: PMC8673839 DOI: 10.1097/mpg.0000000000003317] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/06/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population. METHODS A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded. RESULTS One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN). CONCLUSIONS Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.
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Affiliation(s)
- Gema Pérez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Gregorio Marañón Health Research Institute (IISGM)
| | - Elena González
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Laura Zamora
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Sarah N. Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Amelia Sánchez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | | | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
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Moran JL. Multivariate meta-analysis of critical care meta-analyses: a meta-epidemiological study. BMC Med Res Methodol 2021; 21:148. [PMID: 34275460 PMCID: PMC8286437 DOI: 10.1186/s12874-021-01336-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022] Open
Abstract
Background Meta-analyses typically consider multiple outcomes and report univariate effect sizes considered as independent. Multivariate meta-analysis (MVMA) incorporates outcome correlation and synthesises direct evidence and related outcome estimates within a single analysis. In a series of meta-analyses from the critically ill literature, the current study contrasts multiple univariate effect estimates and their precision with those derived from MVMA. Methods A previous meta-epidemiological study was used to identify meta-analyses with either one or two secondary outcomes providing sufficient detail to structure bivariate or tri-variate MVMA, with mortality as primary outcome. Analysis was performed using a random effects model for both odds ratio (OR) and risk ratio (RR); borrowing of strength (BoS) between multivariate outcome estimates was reported. Estimate comparisons, β coefficients, standard errors (SE) and confidence interval (CI) width, univariate versus multivariate, were performed using Lin’s concordance correlation coefficient (CCC). Results In bivariate meta-analyses, for OR (n = 49) and RR (n = 48), there was substantial concordance (≥ 0.69) between estimates; but this was less so for tri-variate meta-analyses for both OR (n = 25; ≥ 0.38) and RR (≥ -0.10; n = 22). A variable change in the multivariate precision of primary mortality outcome estimates compared with univariate was present for both bivariate and tri-variate meta-analyses and for metrics. For second outcomes, precision tended to decrease and CI width increase for bivariate meta-analyses, but was variable in the tri-variate. For third outcomes, precision increased and CI width decreased. In bivariate meta-analyses, OR coefficient significance reversal, univariate versus MVMA, occurred once for mortality and 6 cases for second outcomes. RR coefficient significance reversal occurred in 4 cases; 2 were discordant with OR. For tri-variate OR meta-analyses reversal of coefficient estimate significance occurred in two cases for mortality, nine cases for second and 7 cases for third outcomes. In RR meta-analyses significance reversals occurred for mortality in 2 cases, 6 cases for second and 3 cases for third; there were 7 discordances with OR. BoS was greater in trivariate MVMAs compared with bivariate and for OR versus RR. Conclusions MVMA would appear to be the preferred solution to multiple univariate analyses; parameter significance changes may occur. Analytic metric appears to be a determinant.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
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Juan-Díaz M, Mateu-Campos ML, Sánchez-Miralles A, Martínez Quintana ME, Mesejo-Arizmendi A. Recommendations for specialized nutritional-metabolic management of the critical patient: Monitoring and safety. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:44-51. [PMID: 32532410 DOI: 10.1016/j.medin.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/21/2019] [Accepted: 12/15/2019] [Indexed: 12/20/2022]
Affiliation(s)
- M Juan-Díaz
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, Valencia, España.
| | - M L Mateu-Campos
- Servicio de Medicina Intensiva, Hospital General Universitario de Castellón, Castellón, España
| | - A Sánchez-Miralles
- Servicio de Medicina Intensiva, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, España
| | - M E Martínez Quintana
- Servicio de Medicina Intensiva, Hospital General Universitario Los Arcos del Mar Menor, Pozo Aledo, Murcia, España
| | - A Mesejo-Arizmendi
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, Valencia, España
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Kuwajima V, Bechtold ML. Should I Start With A Postpyloric Enteral Nutrition Modality? Nutr Clin Pract 2020; 36:76-79. [PMID: 33326156 DOI: 10.1002/ncp.10607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Nutrition therapy is a key element in the management of malnourished and critically ill patients. Although many aspects of enteral nutrition (EN) have been well defined by research, with clear recommendations by 3 major society guidelines, EN delivery method remains a topic for debate. The goal of this manuscript is to concisely review gastric vs postpyloric enteral feeding in critically ill adult patients and provide a set of recommendations to individualize EN delivery method based on patient characteristics and specific needs.
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Affiliation(s)
- Vanessa Kuwajima
- Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Matthew L Bechtold
- Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri, USA
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8
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Shahi N, Skillman HE, Phillips R, Cooper EH, Shirek GP, Goldsmith A, Meier MR, Kaizer AM, Recicar JF, Banks A, Moulton SL. Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes. J Burn Care Res 2020; 42:171-176. [PMID: 32810219 DOI: 10.1093/jbcr/iraa129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Massachusetts, Worcester.,Department of Surgery, University of Colorado School of Medicine, Aurora
| | | | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Colorado School of Medicine, Aurora
| | - Emily H Cooper
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | | | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Maxene R Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | - Alexander M Kaizer
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora
| | - John F Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Ashley Banks
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora.,Department of Surgery, University of Colorado School of Medicine, Aurora
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A comparative study of risk of pneumonia and mortalities between nasogastric and jejunostomy feeding routes in surgical critically ill patients with perforated peptic ulcer. PLoS One 2019; 14:e0219258. [PMID: 31269088 PMCID: PMC6608947 DOI: 10.1371/journal.pone.0219258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Enteral nutrition (EN) is important in the management of critically illness. Yet, the best route (e.g. pre-pyloric or post-pyloric) for EN in critically ill patients remains to be investigated, especially in specific surgical patients group. In addition, EN could be associated with a higher risk of aspiration pneumonia. Therefore, we evaluate the effect of various EN routes in surgical critically ill perforated peptic ulcer (PPU) patients who underwent surgery and required mechanical ventilation. METHOD We collected data of surgical critically ill PPU patients admitted to intensive care unit. The patients were managed with appropriate care bundle and program. To reduce the impact of surgery types, we excluded those who had received other surgical procedures and included patients that only received simple closure. Patients were classified into nasogastric and jejunostomy feeding groups. The demographics, severity scores (e.g.: APACHE II, SOFA, and POSSUM), body mass index (BMI), comorbidities, ventilator days, use of proton pump inhibitors (PPIs), pneumonia occurrence, mortality and complications were collected for analysis. RESULTS A total of 136 critically ill PPU patients that received surgery and mechanical ventilation were enrolled. There were 53 patients in NG group and 83 patients in FJ group. There were no differences in demographics, severity scores, BMI, comorbidities, ventilator days, use of PPIs, pneumonia occurrence, mortalities and complications between groups. CONCLUSION Our study indicates that there are no differences in mortalities and pneumonia occurrence using nasogastric or feeding jejunostomy in surgical critically ill PPU patients underwent surgery. However, further studies are required.
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Abstract
Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. In critically ill patients, EN must be discontinued or interrupted, if gastrointestinal complications, particularly vomiting and bowel movement disorders, do not resolve with appropriate management. To avoid such gastrointestinal complications, EN should be started as soon as possible with a small amount of EN first and gradually increased. EN itself may also promote intestinal peristalsis. The measures to decrease the risk of reflux and aspiration include elevation the head of the bed (30° to 45°), switch to continuous administration, administration of prokinetic drugs or narcotic antagonists to promote gastrointestinal motility, and switch to jejunal access (postpyloric route). Moreover, the control of bowel movement is also important for intensive care and management. In particular, prolonged diarrhea can cause deficiency in nutrient absorption, malnutrition, and increase in mortality. In addition, diarrhea may cause a decrease the circulating blood volume, metabolic acidosis, electrolyte abnormalities, and contamination of surgical wounds and pressure ulcers. If diarrhea occurs in critically ill patients on EN management, it is important to determine whether diarrhea is EN-related or not. After ruling out the other causes of diarrhea, the measures to prevent EN-related diarrhea include switch to continuous infusion, switch to gastric feeding, adjustment of agents that improve gastrointestinal peristalsis or laxative, administration of antidiarrheal drugs, changing the type of EN formula, and semisolidification of EN formula. One of the best ways to success for EN management is to continue as long as possible without interruption and discontinuation of EN easily by appropriate measures, even if gastrointestinal complications occur.
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Affiliation(s)
- Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, Hokkaido 060-8543 Japan
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Bedside electromagnetic-guided placement of nasoenteral feeding tubes among critically Ill patients: A single-centre randomized controlled trial. J Crit Care 2018; 48:216-221. [PMID: 30243201 DOI: 10.1016/j.jcrc.2018.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/02/2018] [Accepted: 09/03/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement among critically ill patients. MATERIALS AND METHODS We performed a single-center, randomized controlled trial among 161 adult patients admitted to intensive care units (ICUs) requiring nasoenteral feeding. Patients were randomly assigned to EM-guided or endoscopic nasoenteral feeding tube placement (1:1). The primary end point was the total success rate of correct jejunal placement. RESULTS This was achieved in 74/81 and 76/80 patients who underwent EM-guided and endoscopic jejunal tube placements, respectively (91.4% vs. 95%; relative risk, 0.556; [CI], 0.156-1.980; P = 0.360). The EM-guided group had more placement attempts, longer placement time, and shorter inserted nasal intestinal tube length. However, they had shorter total placement procedure duration and physician's order-tube placement and order-start of feeding intervals. The EM-guided group had higher discomfort level and recommendation scores and lesser patient costs. This trial is registered at Chinese Clinical Trials Registry (ChiCTR-IOR-17011737). CONCLUSION Bedside EM-guided placement is as fast, safe, and successful as endoscopic placement and may be considered the preferred technique in critically ill patients.
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Ortiz LA, Dante Yeh D. Nutrition in the Post-surgical Patient: Myths and Misconceptions. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Cao HX, Zhang W, Zhang J, Hua XH, Qin JJ, Li Y. Application of bronchoscope for the placement of nasoenteric feeding tube in patients with esophagectomy: a novel technique. J Thorac Dis 2017; 9:577-581. [PMID: 28449465 DOI: 10.21037/jtd.2017.02.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Currently the available techniques for the placement of nasoenteric feeding tube (NET), utilizing transnasal gastroscope are fast and tolerable, which is known as the most popular method. However, lots of hospitals don't have this endoscopic system. Bronchoscope, which is the basic respiratory endoscope, not only has the advantages of transnasal endoscopy, but also is popular in common hospitals. We used oxygen instillation as air supply plant of the bronchoscope, which broke its application limitation in digestive tract. The aim of this study is to evaluate the feasibility and availability of the method of placing NET with the bronchoscope in patients with esophagectomy. METHODS From January 2013 to January 2016, a total of 48 patients with esophagectomy who underwent NET placement with the bronchoscope were included in our study. Information concerning age, gender, as well as background disease of the patients was collected. The success rate, procedure duration, and complications were recorded for each patient. RESULTS The technique success rate reached 100%, procedure time ranged from 150 to 750 s, with an average time of 257 s. All patients tolerated well under local anesthesia, no complication of epistaxis or perforation occurred. CONCLUSIONS The new technique of placing NET with the bronchoscope is fast, safe, effective, and well tolerated for patients with esophagectomy.
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Affiliation(s)
- Hai-Xia Cao
- Division of Endoscopy, Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
| | - Wei Zhang
- Division of Endoscopy, Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
| | - Jun Zhang
- Division of Endoscopy, Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
| | - Xiong-Huai Hua
- Division of Endoscopy, Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
| | - Jian-Jun Qin
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer hospital, Zhengzhou 450008, China
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Park J, Krzeminski S, Tan J, Bandlamuri M, Carlson RW. Electromagnetic Tube-Placement Device: The Replacement for the Radiographic Gold Standard? Am J Crit Care 2017; 26:162-163. [PMID: 28249870 DOI: 10.4037/ajcc2017680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Julia Park
- Julia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the University of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Sylvia Krzeminski
- Julia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the University of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Joshua Tan
- Julia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the University of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Meghana Bandlamuri
- Julia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the University of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Richard W Carlson
- Julia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the University of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona.
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Lodewijkx PJ, Besselink MG, Witteman BJ, Schepers NJ, Gooszen HG, van Santvoort HC, Bakker OJ. Nutrition in acute pancreatitis: a critical review. Expert Rev Gastroenterol Hepatol 2017; 10:571-80. [PMID: 26823272 DOI: 10.1586/17474124.2016.1141048] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.
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Affiliation(s)
- Piet J Lodewijkx
- a Department of Surgery , Jeroen Bosch hospital , s-Hertogenbosch , The Netherlands
| | - Marc G Besselink
- b Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
| | - Ben J Witteman
- c Department of Gastroenterology and Hepatology , Hospital Gelderse Vallei Ede , Ede , The Netherlands
| | - Nicolien J Schepers
- d Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands.,e Department of Gastroenterology and Hepatology , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Hein G Gooszen
- f Department of Operating Theatres and Evidence Based Surgery , Radboud University Medical Center , Nijmegen , The Netherlands
| | | | - Olaf J Bakker
- g Department of Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
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Whitehead K, Cortes Y, Eirmann L. Gastrointestinal dysmotility disorders in critically ill dogs and cats. J Vet Emerg Crit Care (San Antonio) 2016; 26:234-53. [PMID: 26822390 DOI: 10.1111/vec.12449] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 07/21/2015] [Accepted: 08/30/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the human and veterinary literature regarding gastrointestinal (GI) dysmotility disorders in respect to pathogenesis, patient risk factors, and treatment options in critically ill dogs and cats. ETIOLOGY GI dysmotility is a common sequela of critical illness in people and small animals. The most common GI motility disorders in critically ill people and small animals include esophageal dysmotility, delayed gastric emptying, functional intestinal obstruction (ie, ileus), and colonic motility abnormalities. Medical conditions associated with the highest risk of GI dysmotility include mechanical ventilation, sepsis, shock, trauma, systemic inflammatory response syndrome, and multiple organ failure. The incidence and pathophysiology of GI dysmotility in critically ill small animals is incompletely understood. DIAGNOSIS A presumptive diagnosis of GI dysmotility is often made in high-risk patient populations following detection of persistent regurgitation, vomiting, lack of tolerance of enteral nutrition, abdominal pain, and constipation. Definitive diagnosis is established via radioscintigraphy; however, this diagnostic tool is not readily available and is difficult to perform on small animals. Other diagnostic modalities that have been evaluated include abdominal ultrasonography, radiographic contrast, and tracer studies. THERAPY Therapy is centered at optimizing GI perfusion, enhancement of GI motility, and early enteral nutrition. Pharmacological interventions are instituted to promote gastric emptying and effective intestinal motility and prevention of complications. Promotility agents, including ranitidine/nizatidine, metoclopramide, erythromycin, and cisapride are the mainstays of therapy in small animals. PROGNOSIS The development of complications related to GI dysmotility (eg, gastroesophageal reflux and aspiration) have been associated with increased mortality risk. Institution of prophylaxic therapy is recommended in high-risk patients, however, no consensus exists regarding optimal timing of initiating prophylaxic measures, preference of treatment, or duration of therapy. The prognosis for affected small animal patients remains unknown.
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Affiliation(s)
- KimMi Whitehead
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Yonaira Cortes
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Laura Eirmann
- the Nutrition Department (Eirmann), Oradell Animal Hospital, Paramus, NJ, 07452
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Toh Yoon E, Nishihara K, Murata H. Maintaining Enteral Nutrition in the Severely Ill using a Newly Developed Nasojejunal Feeding Tube with Gastric Decompression Function. Intern Med 2016; 55:2945-2950. [PMID: 27746430 PMCID: PMC5109560 DOI: 10.2169/internalmedicine.55.6915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
For nutritional support of critically ill patients, the enteral route is preferred over the parenteral route. Although nasojejunal feeding can be superior to gastric feeding when gastrointestinal symptoms occur, it does not necessarily solve the problem of large gastric residual volumes. We report the successful use of a newly developed nasojejunal feeding tube with gastric decompression function in an 84-year-old man with severe pneumonia. After gastric feeding was considered not well tolerated, the use of this tube improved the delivery of nutrition until the patient was stable enough to undergo percutaneous endoscopic gastrostomy.
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Affiliation(s)
- Ezekiel Toh Yoon
- Department of Internal Medicine, Hiroshima Kyoritsu Hospital, Japan
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Saran D, Brody RA, Stankorb SM, Parrott SJ, Heyland DK. Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients: Results of a Multicenter Observational Study. JPEN J Parenter Enteral Nutr 2015; 39:910-6. [PMID: 24947058 DOI: 10.1177/0148607114540003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 05/20/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients. MATERIALS AND METHODS International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60-day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses. RESULTS Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66-1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72-1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87-1.55; P = .307) after adjusting for confounders. CONCLUSIONS Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.
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Affiliation(s)
- Delara Saran
- Department of Nutritional Sciences, School of Health Related Professions, Rutgers, The State University of New Jersey, Newark, New Jersey Food & Nutrition Services, Fraser Health Authority, British Columbia, Canada
| | - Rebecca A Brody
- Department of Nutritional Sciences, School of Health Related Professions, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Susan M Stankorb
- Department of Nutritional Sciences, School of Health Related Professions, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Scott J Parrott
- Department of Nutritional Sciences, School of Health Related Professions, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Ontario, Canada Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Hallal C, Chaves VS, Borges GC, Werlang IC, Fontella FU, Matte U, Goldani MZ, Carvalho PR, Trotta EA, Piva JP, Barros SGS, Goldani HAS. Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children. Chest 2015; 148:333-339. [PMID: 25654241 DOI: 10.1378/chest.14-1967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.
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Affiliation(s)
- Cristiane Hallal
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil.
| | - Veridiana S Chaves
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Gilberto C Borges
- Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Isabel C Werlang
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Fernanda U Fontella
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Ursula Matte
- Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Marcelo Z Goldani
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Paulo R Carvalho
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Eliana A Trotta
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Jefferson P Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Sergio G S Barros
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse 2015; 34:14-21; quiz 22. [PMID: 25086090 DOI: 10.4037/ccn2014243] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.
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Affiliation(s)
- Melissa L Stewart
- Melissa Stewart is a staff nurse in the medical intensive care unit at the University of Kentucky Chandler Medical Center in Lexington.
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Li Z, Qi J, Zhao X, Lin Y, Zhao S, Zhang Z, Li X, Kissoon N. Risk-Benefit Profile of Gastric vs Transpyloric Feeding in Mechanically Ventilated Patients. Nutr Clin Pract 2015; 31:91-8. [PMID: 26260278 DOI: 10.1177/0884533615595593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Zhuo Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Jirong Qi
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaoke Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Yiqun Lin
- University of Calgary, Calgary, Alberta, Canada
| | - Shaodong Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Zendi Zhang
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaonan Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Niranjan Kissoon
- The University of British Columbia and BC Children’s Hospital, Vancouver, British Columbia, Canada
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Alkhawaja S, Martin C, Butler RJ, Gwadry‐Sridhar F, Cochrane Emergency and Critical Care Group. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD008875. [PMID: 26241698 PMCID: PMC6516803 DOI: 10.1002/14651858.cd008875.pub2] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed. OBJECTIVES To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data. MAIN RESULTS We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials. AUTHORS' CONCLUSIONS We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.
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Affiliation(s)
- Sana Alkhawaja
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Claudio Martin
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Ronald J Butler
- University of Western Ontario, London Health Sciences Centre, University HospitalDepartment of Anesthesia and Critical Care339 Windermere RdLondon, OntarioCanadaN6A 5A5
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Gomes Jr CAR, Andriolo RB, Bennett C, Lustosa SAS, Matos D, Waisberg DR, Waisberg J, Cochrane Upper GI and Pancreatic Diseases Group. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev 2015; 2015:CD008096. [PMID: 25997528 PMCID: PMC6464742 DOI: 10.1002/14651858.cd008096.pub4] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT. OBJECTIVES To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances. SEARCH METHODS We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search. SELECTION CRITERIA We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%. MAIN RESULTS We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants). AUTHORS' CONCLUSIONS PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.
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Affiliation(s)
- Claudio AR Gomes Jr
- Escola Paulista de Medicina, Universidade Federal de São PauloDepartment of Gastroenterological SurgerySão PauloSão PauloBrazil
| | - Regis B Andriolo
- Universidade do Estado do ParáDepartment of Public HealthTravessa Perebebuí, 2623BelémParáBrazil66087‐670
| | - Cathy Bennett
- Coventry UniversityCentre for Technology Enabled Health Research (CTEHR)Priory StreetCoventryUKCV1 5FB
| | - Suzana AS Lustosa
- Hospital Municipal Dr. Munir RaffulExtension, Research, Teaching Unit ‐ UEPEAvenida Jaraguá 1020Volta Redonda, RJSao PaoloBrazil2727130
| | - Delcio Matos
- Escola Paulista de Medicina, Universidade Federal de São PauloDepartment of Gastroenterological SurgerySão PauloSão PauloBrazil
| | - Daniel R Waisberg
- Universidade de São PauloFaculty of MedicineRua das Figueiras, no.550, apto 134Bairro Jardim, Santo AndreSao PauloSPBrazil09080‐300
| | - Jaques Waisberg
- Faculdade de Medicina do ABCAvenida Lauro Gomes 2000Santo AndreSao PauloBrazil09060‐870
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Friedman G, Flávia Couto CL, Becker M. Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying. Indian J Crit Care Med 2015; 19:71-5. [PMID: 25722547 PMCID: PMC4339907 DOI: 10.4103/0972-5229.151013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Studies comparing jejunal and gastric nutrition show inconsistent results regarding pneumonia. The aim of this study was to evaluate the incidence of pneumonia comparing gastric with jejunal nutrition. Secondarily, we evaluated 28(th) day Intensive Care Unit (ICU) mortality rate and other complications related to enteral feeding. SUBJECTS Age >18 years; need for enteral nutrition without contraindication for placement of an enteral tube, duration of ICU stay > than 48 h. METHODS Patients were randomly assigned to receive enteral feed via a gastric or jejunal tube. Jejunal tubes were inserted at bedside and placement was confirmed radiographically. RESULTS A total of 115 patients were enrolled, with 61 patients into the gastric tube group and 54 patients into the jejunal group tube. Baseline characteristics were similar. There was no difference in pneumonia or ICU mortality rates, ICU length of stay and ventilator days. Complications rates were similar. CONCLUSIONS We conclude that the enteral nutrition through a jejunal tube does not reduce the rate of pneumonia in comparison to a gastric tube. In addition, we did not observe differences in rates of gastrointestinal complications or ICU mortality. The routine placement of a jejunal tube in critically ill-patients cannot be recommended.
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Affiliation(s)
- Gilberto Friedman
- Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil ; Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Rosenthal MD, Vanzant EL, Martindale RG, Moore FA. Evolving paradigms in the nutritional support of critically ill surgical patients. Curr Probl Surg 2015; 52:147-82. [PMID: 25946621 DOI: 10.1067/j.cpsurg.2015.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/29/2015] [Accepted: 02/11/2015] [Indexed: 12/12/2022]
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Lheureux O, Preiser JC. Year in review 2013: Critical Care--metabolism. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:571. [PMID: 25672544 PMCID: PMC4330939 DOI: 10.1186/s13054-014-0571-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Novel insights into the metabolic alterations of critical illness, including new findings on association between blood glucose at admission and poor outcome, were published in Critical Care in 2013. The role of diabetic status in the relation of the three domains of glycemic control (hyperglycemia, hypoglycemia, and glycemic variability) was clarified: the association between mean glucose, high glucose variability, and ICU mortality was stronger in the non-diabetic than in diabetic patients. Improvements in the understanding of pathophysiological mechanisms of stress hyperglycemia were presented. Novel developments for the management of glucose control included automated closed-loop algorithms based on subcutaneous glucose measurements and microdialysis techniques. In the field of obesity, some new hypotheses that could explain the ‘obesity paradox’ were released, and a role of adipose tissue in the response to stress was suggested by the time course of adipocyte fatty-acid binding protein concentrations. In the field of nutrition, beneficial immunological effects have been associated with early enteral nutrition. Early enteral nutrition was significantly associated with potential beneficial effects on the phenotype of lymphocytes. Uncertainties regarding the potential benefits of small intestine feeding compared with gastric feeding were further investigated. No significant differences were observed between the nasogastric and nasojejunal feeding groups in the incidence of mortality, tracheal aspiration, or exacerbation of pain. The major risk factors to develop diarrhea in the ICU were described. Finally, the understanding of disorders associated with trauma and potential benefits of blood acidification was improved by new experimental findings.
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Nasogastric nutrition is efficacious in severe acute pancreatitis: a systematic review and meta-analysis. Br J Nutr 2014; 112:1769-78. [DOI: 10.1017/s0007114514002566] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In patients with severe acute pancreatitis (AP), enteral nutrition is delivered by nasojejunal (NJ) tube to minimise pancreatic stimulation. Nasogastric (NG) feeding represents an alternative route. The primary objective of this systematic review and meta-analysis was to evaluate the efficacy of NG feeding. Secondary objectives were to compare the NG and NJ routes and assess the side effects of the former. The primary endpoint was exclusive NG feeding with delivery of 75 % of nutritional targets. Additional outcomes included change to total parenteral nutrition (TPN), increased pain or disease severity, vomiting, diarrhoea, delivery rate reduction and tube displacement. Among the retrieved studies, six were found to be eligible for the qualitative review and four for the meta-analysis. NG nutrition was received by 147 patients; exclusive NG feeding was achieved in 90 % (133/147). Of the 147 patients, 129 (87 %) received 75 % of the target energy. In studies where all subjects received exclusive NG nutrition, 82 % (seventy-four of the ninety patients) received >75 % of the intended energy. Compared with NJ nutrition, there was no significant difference in the delivery of 75 % of nutritional targets (pooled risk ratio (RR) 1·02; 95 % CI 0·75, 1·38.) or no increased risk of change to TPN (pooled RR 1·05; 95 % CI 0·45, 2·48), diarrhoea (pooled RR 1·28; 95 % CI 0·62, 2·66), exacerbation of pain (pooled RR 1·10; 95 % CI 0·47, 2·61) or tube displacement (pooled RR 0·44; 95 % CI 0·11, 1·73). Vomiting and diarrhoea were the most common side effects of NG feeding (13·3 and 12·9 %, respectively). With respect to the delivery of nutrition, 11·2 % of the patients required delivery rate reduction and 3·4 % dislodged the tube. Other side effects included elevated levels of aspirates (9·1 %), abdominal distension (1·5 %), pain exacerbation (7·5 %) and increased disease severity (1·6 %). In conclusion, NG feeding is efficacious in 90 % of patients. Further research is required to optimise the delivery of NG nutrition and examine ‘gut-rousing’ approaches to nutrition in patients with severe AP.
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Nguyen NQ. Pharmacological therapy of feed intolerance in the critically ills. World J Gastrointest Pharmacol Ther 2014; 5:148-55. [PMID: 25133043 PMCID: PMC4133440 DOI: 10.4292/wjgpt.v5.i3.148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/24/2014] [Accepted: 05/31/2014] [Indexed: 02/06/2023] Open
Abstract
Feed intolerance in the setting of critical illness is associated with higher morbidity and mortality, and thus requires promptly and effective treatment. Prokinetic agents are currently considered as the first-line therapy given issues relating to parenteral nutrition and post-pyloric placement. Currently, the agents of choice are erythromycin and metoclopramide, either alone or in combination, which are highly effective with relatively low incidence of cardiac, hemodynamic or neurological adverse effects. Diarrhea, however, can occur in up to 49% of patients who are treated with the dual prokinetic therapy, which is not associated with Clostridium difficile infection and settled soon after the cessation of the drugs. Hence, the use of prokinetic therapy over a long period or for prophylactic purpose must be avoided, and the indication for ongoing use of the drug(s) must be reviewed frequently. Second line therapy, such as total parenteral nutrition and post-pyloric feeding, must be considered once adverse effects relating the prokinetic therapy develop.
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30
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Nguyen NQ, Yi Mei SLC. Current issues on safety of prokinetics in critically ill patients with feed intolerance. Ther Adv Drug Saf 2014; 2:197-204. [PMID: 25083212 DOI: 10.1177/2042098611415567] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Feed intolerance in the setting of critical illness should be treated promptly given its adverse impact on morbidity and mortality. The technical difficulty of postpyloric feeding tube placement and the morbidities associated with parenteral nutrition prevent these approaches being considered as first-line nutrition. Prokinetic agents are currently the mainstay of therapy for feed intolerance in the critically ill. Current information is limited but suggests that erythromycin or metoclopramide (alone or in combination) are effective in the management of feed intolerance in the critically ill and not associated with significant cardiac, haemodynamic or neurological adverse effects. However, diarrhoea is a very common gastrointestinal side effect, and can occur in up to 49% of patients who receive both erythromycin and metoclopramide. Fortunately, the diarrhoea associated with prokinetic treatments has not been linked to Clostridium difficile infection and settles soon after the drugs are ceased. Therefore, prolonged or prophylactic use of prokinetics should be avoided. If diarrhoea occurs, the drugs should be stopped immediately. To minimize avoidable adverse effects the ongoing need for prokinetic drugs in these patient should be reviewed daily.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Swee Lin Chen Yi Mei
- Departments of Gastroenterology and Hepatology, Royal Adelaide Hospital; Adelaide, SA, Australia
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Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol 2014; 20:8505-8524. [PMID: 25024606 PMCID: PMC4093701 DOI: 10.3748/wjg.v20.i26.8505] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 02/23/2014] [Accepted: 04/15/2014] [Indexed: 02/06/2023] Open
Abstract
Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.
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32
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Endoscopic approaches to enteral feeding and nutrition core curriculum. Gastrointest Endosc 2014; 80:34-41. [PMID: 24773773 DOI: 10.1016/j.gie.2014.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 12/13/2022]
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Abstract
Advances in surgery, anesthesia and intensive care have led to a dramatic increase in the number of patients who spend time in our intensive care units (ICU). Gastrointestinal (GI) motility disorders are common complications in the intensive care setting and are predictors of increased mortality and length of the stay in the ICU. Several risk factors for developing GI motility problems in the ICU setting have been identified and include sepsis, being on mechanical ventilation and the use of vasopressors, opioids or anticholinergic medications. Our focus is on the most common clinical manifestations of GI motor dysfunction in the ICU patient: gastroesophageal reflux, gastroparesis, ileus and acute pseudo-obstruction of the colon.
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Affiliation(s)
- Abimbola Adike
- Department of Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas, USA
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Abstract
Providing artificial nutrition is an important part of caring for critically ill patients. However, because of a paucity of robust data, the practice has been highly variable and often based more on dogma than evidence. A number of studies have been published investigating many different aspects of critical care nutrition. Although the influx of data has better informed the practice, the results have often been conflicting or counter to prevailing thought, resulting in discordant opinions and different interpretations by experts in the field. In this article, we review and summarize the data from a number of the published studies, including studies investigating enteral vs parenteral nutrition, supplementing enteral with parenteral nutrition, and use of immunonutrition. In addition, published studies informing the practice of how best to provide enteral nutrition will be reviewed, including the use of trophic feedings, gastric residual volumes, and gastric vs postpyloric tube placement.
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Affiliation(s)
- Svetang V Desai
- Division of Gastroenterology, Duke University Medical Center, Durham, NC
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.
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35
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Lefrant JY, Hurel D, Cano N, Ichai C, Preiser JC, Tamion F. Nutrition artificielle en réanimation. NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Martinez EE, Bechard LJ, Mehta NM. Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study. Nutr Clin Pract 2014; 29:360-7. [PMID: 24740498 DOI: 10.1177/0884533614530762] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs). METHODS Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis. RESULTS Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding. CONCLUSIONS A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.
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Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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38
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39
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Lefrant JY, Hurel D, Cano NJ, Ichai C, Preiser JC, Tamion F. [Guidelines for nutrition support in critically ill patient]. ACTA ACUST UNITED AC 2014; 33:202-18. [PMID: 24565944 DOI: 10.1016/j.annfar.2014.01.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J-Y Lefrant
- Services des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hurel
- Service de réanimation médico-chirurgicale, centre hospitalier François-Quesnay, 2, boulevard Sully, 78201 Mantes-la-Jolie cedex, France
| | - N J Cano
- Service de nutrition, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand cedex, France; Unité de nutrition humaine, Clermont université, université d'Auvergne, BP 10448, 63000 Clermont-Ferrand, France; Inra, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - C Ichai
- Service de réanimation médico-chirurgicale, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06006 Nice cedex 1, France
| | - J-C Preiser
- Service des soins intensifs, hôpital universitaire Erasme, 808, route de Lennik, 1070 Bruxelles, Belgique
| | - F Tamion
- Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76081 Rouen cedex, France
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Prise en charge nutritionnelle au cours du syndrome de détresse respiratoire de l’adulte. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0847-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Alshadwi A, Nadershah M, Carlson ER, Young LS, Burke PA, Daley BJ. Nutritional Considerations for Head and Neck Cancer Patients: A Review of the Literature. J Oral Maxillofac Surg 2013; 71:1853-60. [DOI: 10.1016/j.joms.2013.04.028] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 04/22/2013] [Accepted: 04/25/2013] [Indexed: 12/11/2022]
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Alhazzani W, Almasoud A, Jaeschke R, Lo BWY, Sindi A, Altayyar S, Fox-Robichaud AE. Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R127. [PMID: 23820047 PMCID: PMC4056009 DOI: 10.1186/cc12806] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 07/02/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis aimed to evaluate the effect of small bowel feeding compared with gastric feeding on the frequency of pneumonia and other patient-important outcomes in critically ill patients. METHODS We searched EMBASE, MEDLINE, clinicaltrials.gov and personal files from 1980 to Dec 2012, and conferences and proceedings from 1993 to Dec 2012 for randomized trials of adult critically ill patients in the intensive care unit (ICU) comparing small bowel feeding to gastric feeding, and evaluating risk of pneumonia, mortality, length of ICU stay, achievement of caloric requirements, duration of mechanical ventilation, vomiting, and aspiration. Independently, in duplicate, we abstracted trial characteristics, outcomes and risk of bias. RESULTS We included 19 trials with 1394 patients. Small bowel feeding compared to gastric feeding was associated with reduced risk of pneumonia (risk ratio [RR] 0.70; 95% CI, 0.55, 0.90; P = 0.004; I2 = 0%) and ventilator-associated pneumonia (RR 0.68; 95% CI 0.53, 0.89; P = 0.005; I2 = 0%), with no difference in mortality (RR 1.08; 95% CI 0.90, 1.29; P = 0.43; I2 = 0%), length of ICU stay (WMD -0.57; 95%CI -1.79, 0.66; P = 0.37; I2 = 0%), duration of mechanical ventilation (WMD -1.01; 95%CI -3.37, 1.35; P = 0.40; I2 = 17%), gastrointestinal bleeding (RR 0.89; 95% CI 0.56, 1.42; P = 0.64; I2 = 0%), aspiration (RR 0.92; 95% CI 0.52, 1.65; P = 0.79; I2 = 0%), and vomiting (RR 0.91; 95% CI 0.53, 1.54; P = 0.72; I2 = 57%). The overall quality of evidence was low for pneumonia outcome. CONCLUSIONS Small bowel feeding, in comparison with gastric feeding, reduces the risk of pneumonia in critically ill patients without affecting mortality, length of ICU stay or duration of mechanical ventilation. These observations are limited by variation in pneumonia definition, imprecision, risk of bias and small sample size of individual trials.
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Deane AM, Adam MD, Dhaliwal R, Rupinder D, Day AG, Andrew GD, Ridley EJ, Emma JR, Davies AR, Andrew RD, Heyland DK, Daren KH. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R125. [PMID: 23799928 PMCID: PMC4056800 DOI: 10.1186/cc12800] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 06/21/2013] [Indexed: 12/26/2022]
Abstract
Introduction The largest cohort of critically ill patients evaluating intragastric and small intestinal delivery of nutrients was recently reported. This systematic review included recent data to compare the effects of small bowel and intragastric delivery of enteral nutrients in adult critically ill patients. Methods This is a systematic review of all randomised controlled studies published between 1990 and March 2013 that reported the effects of the route of enteral feeding in the critically ill on clinically important outcomes. Results Data from 15 level-2 studies were included. Small bowel feeding was associated with a reduced risk of pneumonia (Relative Risk, RR, small intestinal vs. intragastric: 0.75 (95% confidence interval 0.60 to 0.93); P = 0.01; I2 = 11%). The point estimate was similar when only studies using microbiological data were included. Duration of ventilation (weighted mean difference: -0.36 days (-2.02 to 1.30); P = 0.65; I2 = 42%), length of ICU stay (WMD: 0.49 days, (-1.36 to 2.33); P = 0.60; I2 = 81%) and mortality (RR 1.01 (0.83 to 1.24); P = 0.92; I2 = 0%) were unaffected by the route of feeding. While data were limited, and there was substantial statistical heterogeneity, there was significantly improved nutrient intake via the small intestinal route (% goal rate received: 11% (5 to 16%); P = 0.0004; I2 = 88%). Conclusions Use of small intestinal feeding may improve nutritional intake and reduce the incidence of ICU-acquired pneumonia. In unselected critically ill patients other clinically important outcomes were unaffected by the site of the feeding tube.
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[Nutrition and gastrointestinal intolerance]. Med Klin Intensivmed Notfmed 2013; 108:396-400. [PMID: 23740106 DOI: 10.1007/s00063-012-0203-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 12/26/2022]
Abstract
The functional integrity of the gastrointestinal tract is an essential prerequisite in intensive care patients for the sufficient administration of enteral nutrition. Up to 65% of patients in intensive care units develop symptoms of gastrointestinal dysfunction with high residual gastric volume, vomiting and abdominal distension. The pathophysiological alterations of gastrointestinal intolerance and the subsequent effect on the tolerance of enteral nutrition can affect the whole gastrointestinal tract. Gastroduodenal motility disorders in particular, with increased gastroesophageal reflux lead to intolerance. In more than 90% of intensive care patients with gastrointestinal motility disorders an adequate postpyloric enteral nutrition can be carried out using a jejunal tube. In addition to improved tolerance of enteral nutrition this leads to a reduction of gastroesophageal reflux and the incidence of ventilation-associated pneumonia. Apart from the possibility of endoscopic application of the jejunal tube, alternative techniques were developed which allow a faster positioning of the jejunal tube with less complications. Furthermore, there are therapeutic options for improvement of gastrointestinal motility disorders and apart from general measures, also medicinal options for treatment of gastrointestinal intolerance which allow a sufficient enteral nutrition for intensive care patients.
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Zhang Z, Xu X, Ding J, Ni H. Comparison of postpyloric tube feeding and gastric tube feeding in intensive care unit patients: a meta-analysis. Nutr Clin Pract 2013; 28:371-380. [PMID: 23614960 DOI: 10.1177/0884533613485987] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Enteral feeding is vital in the critical care setting; however, the optimal route of enteral feeding (postpyloric vs gastric feeding) remains debated. We aimed to systematically review the current evidence to see whether postpyloric feeding could provide additional benefits to intensive care unit (ICU) patients. METHOD Randomized controlled trials (RCTs) comparing the efficacy and safety of postpyloric feeding vs gastric feeding were included in our systematic review. Odds ratio (OR) was used for binary outcome data and weighted mean difference (WMD) was used for continuous outcome data. Summary effects were pooled using a fixed or random effects model as appropriate. RESULTS Seventeen RCTs were included in our meta-analysis. Postpyloric tube feeding could deliver higher proportions of estimated energy requirement (WMD, 12%; 95% confidence interval [CI], 5%-18%) and reduce the gastric residual volume (GRV) (WMD, -169.1 mL; 95% CI, -291.995 to -46.196 mL). However, the meta-analysis failed to demonstrate any benefits to critically ill patients with postpyloric tube feeding in terms of mortality (OR, 1.05; 95% CI, 0.77-1.44), new-onset pneumonia (OR, 0.77; 95% CI, 0.53-1.13), and aspiration (OR, 1.20; 95% CI, 0.64-2.25). There was no significant publication bias as represented by an Egger's bias coefficient of 0.21 (95% CI, -1.01 to 1.43; P = .7). CONCLUSION As compared with gastric feeding, postpyloric feeding is able to deliver higher proportions of the estimated energy requirement and can help reduce the GRV.
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Affiliation(s)
- Zhongheng Zhang
- Department of Gastroenterology , Jinhua Municipal Central Hospital, Jinhua, China.
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Khasawneh FA, Al-Janabi MG, Ali AH. Nasopharyngeal perforation by a new electromagnetically visualised enteral feeding tube. BMJ Case Rep 2013; 2013:bcr-2013-009807. [PMID: 23709151 DOI: 10.1136/bcr-2013-009807] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Enteral nutrition is the preferred route of feeding in critically ill patients. It has multiple advantages over parenteral nutrition and potentially improves patients' outcome. Enteral nutrition is delivered via gastric or postpyloric (small intestine) feeding tubes. The latter option used to be a more challenging choice to achieve unless the feeding tube is placed endoscopically or by interventional radiology. Multiple technical advances have facilitated postpyloric feeding, including a new electromagnetically visualised jejunal feeding tube system (CORTRAK Enteral Access System). We are presenting a case of a 50-year-old woman who suffered a nasopharyngeal perforation caused by this novel technology. The complication was recognised promptly and managed successfully with conservative measures. This case illustrates the importance of recognising patients at high risk for feeding tube placement complications, meticulous placement technique and appropriate follow-up once the tube has been inserted.
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Affiliation(s)
- Faisal A Khasawneh
- Section of Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, USA.
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Abstract
The management of pancreatic fistulas can be complex and mandates a multidisciplinary approach. Basic principles of fistula control/patient stabilization, delineation of ductal anatomy, and definitive therapy remain of paramount importance.
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Affiliation(s)
- Jeffrey A Blatnik
- Department of Surgery, Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications. Eur J Trauma Emerg Surg 2013; 39:235-42. [PMID: 26815229 DOI: 10.1007/s00068-013-0274-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 03/11/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients. OBJECTIVE To review the current techniques of gastrointestinal tract access for EN. METHODS For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: "enteral nutrition," "critically ill," and "gut access." We excluded outdated abstracts. RESULTS For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially. CONCLUSION In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.
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Abstract
PURPOSE OF REVIEW Gastrointestinal dysmotility and dysfunction underlie our difficulties in providing adequate nutrition by the enteral route to our critically ill patients. RECENT FINDINGS Recent studies have quantified gastric emptying and nutrient absorption. Slow gastric emptying is common and probably mediated by cholecystokinin and reduced active ghrelin concentrations. The cause of impaired nutrient absorption is not yet fully understood but may be related to small intestinal blood flow and/or mucosal factors. The absorption of the different macronutrients may be affected in different ways both by critical illness and by therapies. A better understanding of this may optimize the design of nutrient formulations in the future. New treatment modalities for gastrointestinal dysfunction are being investigated and include small intestinal feeding, nonpharmacological options such as acupuncture, and drugs including novel motilin receptor agonists, and opioid antagonists. SUMMARY We are gradually developing a better understanding of how the gut works during critical illness, which has implications for optimizing the delivery of nutrition and thereby improving nutritional and clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Abstract
It is a strong and commonly held belief among nutrition clinicians that enteral nutrition is preferable to parenteral nutrition. We provide a narrative review of more recent studies and technical reviews comparing enteral nutrition with parenteral nutrition. Despite significant weaknesses in the existing data, current literature continues to support the use of enteral nutrition in patients requiring nutrition support, over parenteral nutrition.
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Affiliation(s)
- David S. Seres
- Associate Professor of Clinical Medicine, Director, Medical Nutrition and Nutrition Support Service, Division of Preventive Medicine and Nutrition, Columbia University Medical Center P&S 9-501, 630 West 168th Street, New York, NY 10032, USA
| | - Monika Valcarcel
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Alexandra Guillaume
- Department of Medicine, Division of Preventive Medicine and Nutrition, Columbia University College of Physicians and Surgeons, and Institute of Human Nutrition, New York Presbyterian Hospital, New York, NY, USA
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