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Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. Reply
... Further, it is commonly accepted that patient head of bed (HOB) is typically elevated to a lesser degree. For example, Heyland et al. (2002) reported an average HOB elevation of 29 o (in critically-ill, bowel-fed subjects) [24], similar to the HOB values reported by Llaurado-Serraa et al. (2015) for mechanically-ventilated patients [25]. These HOB values are perhaps routine, but are less than the 30° minimum HOB angle recommended by a recent caregiver consortium for mechanically-ventilated patients [1]. ...
... Further, it is commonly accepted that patient head of bed (HOB) is typically elevated to a lesser degree. For example, Heyland et al. (2002) reported an average HOB elevation of 29 o (in critically-ill, bowel-fed subjects) [24], similar to the HOB values reported by Llaurado-Serraa et al. (2015) for mechanically-ventilated patients [25]. These HOB values are perhaps routine, but are less than the 30° minimum HOB angle recommended by a recent caregiver consortium for mechanically-ventilated patients [1]. ...
Study Aim: Patient position during care has significant implications for patient pulmonary performance, such that standard guidelines exhibit for consideration of bedded patient torso angle in order to ensure sufficient pulmonary function. It is known that both torso flexion and head rotation independently impair exhalation performance, but their combined effects have not been examined, despite the fact that bedridden subjects routinely experience both simultaneously. Methods: To assess the magnitude and form of interaction that torso angle and head rotation exert on patient pulmonary performance, we used spirometry to measure exhalation function in healthy young adults in combinations of torso and head positions designed to mimic the positioning of bedridden patients. Subject maximal values for both Forced Vital Capacity (FVC) and Forced Expiratory Volume (FEV1) at each position were scored relative to individual predicted values, and compared using ANOVA for both main and interactive positioning effects. Results: As expected, head rotation alone caused decrements in both subject FVC and FEV1, while changes in torso angle exhibited a small influence on subject FEV1 alone. No significant interaction between torso angle and head rotation was revealed, suggesting that the effects of head rotation were uniform across all torso angles examined. The combined effects of both torso flexion and head rotation closely matched those predicted by additive combination of their independent effects, suggesting that their interaction is linear, and non-synergistic. Conclusion: While torso flexion and head rotation exhibit only modest effects on pulmonary function in healthy subjects, their combined effects are additive, and mutually consistent. As such, attention must be paid to both torso flexion and head rotation during patient care for subjects whose ventilatory performance is most crucial.
... It is not known if small bowel feeding is associated with a lower risk of pneumonia in critically ill patients. Multiple systematic reviews reached conflicting results[6][7][8][9]. Recently, an RCT by Davies et al. that included 180 patients suggested that there is no difference in the risk of ventilator-associated pneumonia (VAP) between patients receiving gastric versus jejunal feeds[10]. ...
... Over the past decade four systematic reviews were published on this topic, and seemingly reached conflicting results. Two suggested that small bowel feeding reduces the risk of pneumonia[6,9]whereas the other two did not[7,8]. This discrepancy in conclusion could be related to differences in search strategies, inclusion criteria, or outcome definition. ...
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.
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.
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.
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.
... EN is associated with diarrhea and intolerance, and large residual volumes can potentially contribute to bacterial colonization of the stomach and aspiration pneumonia. 4,[20][21][22] In a prospective observational study in mixed surgical and medical ICU patients receiving nasogastric tube feeding, high gastric aspirate volume was associated with sedation (OR 1.78; 95% CI 1.17-2.71; P ¼ .007) ...
... Three meta-analyses have been published demonstrating no difference in mortality but with differing conclusions on the rate of pneumonia, largely based on one study. 21,22,29 Taylor and colleagues prospectively compared a standard enteral feeding protocol with gradual increase to goal rate to an early aggressive feeding protocol, where feedings were started at goal rate in 84 mechanically ventilated patients with severe head injuries. 30 The rate of pneumonia decreased from 63% to 44% in the aggressive feeding protocol, but only 34% had a post-pyloric feeding tube placed. ...
Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. Although recently high-grade evidence on nutrition support in the critically ill population has been published, many controversies still exist. In obese patients, use of hypocaloric feedings with increased protein has been demonstrated to promote weight loss and improved glucose management. In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.
... The results of these studies have been conflicting as to feeding intolerance and pneumonia rates. [20][21][22][23][24][25][26][27][28][29] Meta-analysis of a group of these randomized studies demonstrated a statistically significant decrease in pneumonia rates in the postpylorus group. However, positioning of the tube beyond the Ligament of Treitz (distal small bowel) is believed to be the most effective way to achieve this decrease in pneumonia rates. ...
... However, positioning of the tube beyond the Ligament of Treitz (distal small bowel) is believed to be the most effective way to achieve this decrease in pneumonia rates. 3,23,29 Further studies using the control groups of jejunal feeding versus gastric feeding are needed to see if this hypothesis is borne out in practice. ...
Aspiration pneumonia is a serious complication of mechanical ventilation and enteral tube feedings. It results in increased patient mortality, increased length of hospital stay, and increased healthcare costs. This article describes an evidence-based practice approach to the creation of an enteral feeding protocol and an aspiration risk reduction algorithm. These tools were piloted in a Medical Intensive Care Unit at a Midwest tertiary care center. Chart audits show an increase in the percentage of patients who reach their goal rate for enteral feedings from 78% to 85%. Reported aspiration pneumonias decreased from an average count of 4.8 patients per month to 4.3 per month and ventilator-associated pneumonia rates decreased from 6.8 to 3.2 per 1000 patient days.
... Artificial nutrition support in the form of enteral nutrition (EN) or parenteral nutrition (PN) is therefore considered an integral part of the standard care received by the critically ill. Recent studies have generated evidence to support its use by demonstrating that various nutrition support practices influence clinically important outcomes such as length of stay, morbidity, and mortality34567. Despite these benefits, enteral or parenteral feeding should be adopted with caution because nutrition practices themselves are not without adverse effects or risks [8,9]. Consequently, making decisions regarding the most effective and safe means of feeding patients in the ICU can be challenging. ...
The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs).
We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN / energy prescribed by the dietitian x 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy.
The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs.
Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.
... Although the authors' center favors distal jejunal feeding, there are pros and cons to both distal jejunal and NG feeding, as summarized. As suggested in Heyland's metanalysis [79], the ultimate balance can only be determined by the conduct of a sufficiently powered multicenter clinical randomized comparative trial incorporating patients at risk of developing the complications associated with high mortality rates, and whose illness is likely to be protracted, making nutritional support essential for survival. ...
Nutritional support can improve the outcome from severe acute pancreatitis in two ways: first by providing the building blocks for tissue repair and recovery, and second, by modulating the inflammatory response and preventing organ failure, both of which are responsible for most of the morbidity and mortality associated with the disease. This review discusses the evidence on which these statements are based.
Purpose of Review
Despite the large body of evidence supporting adequate early enteral nutrition (EN) in surgical patients, iatrogenic underfeeding is common. Myths and misconceptions persist and patients may receive suboptimal nutritional therapy as a result of outdated or uninformed practices. EN is safe and potentially beneficial in patients requiring vasopressor support. Early feeding proximal to a “fresh” anastomosis is safe.
Recent Findings
Routine monitoring of gastric residual volume (GRV) for tube feeding intolerance is no longer recommended, and routine post-pyloric feeding in patients without evidence of impaired gastric emptying does not lower the risk of aspiration. Awaiting the return of flatus before initiating post-operative feeding is not required. Albumin is not an accurate marker of nutritional adequacy in the hospital setting. Permissive underfeeding may not be beneficial for malnourished surgical patients.
Summary
This article addresses myths and misconceptions of enteral nutrition in surgical patients.
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. © 2014, Sociedade Brasileira de Pneumologia e Tisiologia. All rights reserved.
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.
INTRODUÇÃO A desnutrição, o aumento da taxa metabó-lica e a maior propensão às complicações do tratamento são fatores que dificultam a tera-pia nutricional nessa situação. A maior pro-pensão às complicações metabólicas decorre das limitações na capacidade de manipular volume hídrico e substrato, que são próprias do estresse metabólico. Como as ofertas ex-cessivas de líquidos e de nutrientes também podem comprometer a função pulmonar, as alterações no balanço hídrico próprias da doença obrigam a prescrição de menores volumes hídricos e, conseqüentemente, meno-res ofertas nutricionais, o que pode aumentar o risco de desnutrição. Serão abordadas neste capítulo as interações entre desnutrição e função pulmonar, os efeitos da oferta de substrato sobre o sistema respira-tório, as peculiaridades da terapia nutricional em algumas doenças específicas e os fundamen-tos práticos da nutrição enteral na insuficiência respiratória. EFEITOS DA DESNUTRIÇÃO SOBRE A FUNÇÃO PULMONAR • Perda de massa muscular diafragmática e comprometimento da função da muscu-latura respiratória, com conseqüente re-dução da ventilação pulmonar. • A desnutrição e o jejum prolongado, por reduzirem a taxa metabólica, podem di-minuir o drive ventilatório. • Diminuição da produção de surfactante. • Produção diminuída de proteínas e colá-geno, necessários ao processo de repara-ção do parênquima pulmonar. • Predisposição à infecção, por atelecta-sia e redução da função imunológica. A resposta imunológica é prejudicada, particularmente em relação à imunida-de celular, mas há também a redução da eficiência do processo de fagocito-se e o aumento da aderência das bacté-rias ao epitélio respiratório, favorecen-do a colonização bacteriana. A respos-ta humoral geralmente é adequada, mas tem sido relatada a redução de IgA secretória.
JUSTIFICATIVA E OBJETIVOS: Esta revisão tem como objetivo levantar os principais aspectos necessários para a realização de terapia nutricional segura e eficaz ao paciente crítico. CONTEÚDO: Foi feito um levantamento bibliográfico com livros didáticos e artigos científicos em Português, Inglês e Espanhol com resultados dos últimos 20 anos.A terapia nutricional é parte integrante dos cuidados do paciente em unidades de terapia intensiva. O seu sucesso envolve as etapas de avaliação nutricional, determinação das necessidades de calorias e nutrientes, decisão da via de infusão e o tipo de dieta empregada. CONCLUSÕES: O uso de nutrientes com a finalidade de melhorar a função imunológica (imunonutrientes), é cada vez mais freqüente, porém seu uso não está bem estabelecido para pacientes críticos. Mais estudos clínicos são necessários para estabelecer a melhor forma de nutrir o paciente crítico.BACKGROUND AND OBJECTIVES: The purpose of this review is to approach the main necessary aspects for the accomplishment of safety and efficient nutritional therapy to the critically ill patient. CONTENTS: Bibliographical survey with didactic books and scientific articles was made in Portuguese, English and Spanish with results of the last 20 years. Nutritional support is an integrant part in the care of patients in intensive care units. The success of the nutritional therapy involves the stages of nutritional assessment, determines the route of diet infusion and the calories and nutrients needs. CONCLUSIONS: The use of nutrients with immune function (immunonutrients) is each more frequents, however, its use is not well established for critical illness. More clinical studies are necessary to establish the best form to nourish the critical ill patient.
Background:
Enteral feeding tube placement has been performed by nurses, gastroenterologists using endoscopy, and interventional radiologists. We hypothesized that midlevel providers placed feeding tubes at bedside using fluoroscopy safely, rapidly, and cost-effectively.
Methods:
We retrospectively analyzed bedside feeding tube placement under fluoroscopy by trained nurse practitioners. We compared charges for this method with charges for placement by other practitioners.
Results:
Nurse practitioners placed 632 feeding tubes in 462 patients. Three hundred seventy-nine placements took place in mechanically ventilated placements. Ninety-seven percent of tubes were positioned past the pylorus. The mean fluoroscopy time was 0.7 ± 1.2 minutes. The mean procedure time was 7.0 ± 5.1 minutes. All tubes were placed within 24 hours of the request. There were no complications. Institutional charges for tube placement were $149 for nurse practitioners, $226 for gastroenterologists, and $328 for interventional radiologists.
Conclusions:
The placement of feeding tubes under fluoroscopy by nurse practitioners is safe, timely, and cost-effective.
Anosocomial infection (NI) is defined as an infection that is not present or incubating when the patient is admitted to a hospital or other health
care facility.1 Generally, an infection that is discovered 48–72 h after admission is indicative of nosocomial, rather than community-acquired,
infection. Although usually associated with hospital admission (hence the term hospital-acquired infection), Ms can arise
after admission to any health care facility, and the term health care-associated infection is now preferred. Nosocomial infections are increasingly considered as a measure of quality of care and are the focus of
safety and quality improvements efforts in many hospitals today.2–8 To date, the extent these NIs are avoidable under real-life hospital conditions and what represents the irreducible minimum
remain unclear.9–11 A number of observational studies implementing multimodality strategies and standardized policies and practices have demonst
rated a 10% to 70% reduction in infection rates depending on the setting, study design, type of infection, and baseline infection
rates.9–15
Malnourished patients and those at risk of malnutrition are candidates for nutrition intervention. This includes previously well-nourished patients who have been or will be without oral intake for 3 to 5 d (pediatric populations) or 5 to 10 d (adults). Enteral nutrition (EN), which is synonymous with tube feeding, should be considered when a patient cannot, will not, or should not consume appropriate quantities of nutrients by mouth to prevent malnutrition. There are few absolute contraindications to tube feeding other than a bowel obstruction that cannot be bypassed. However, conditions such as diffuse peritonitis, intractable vomiting, intractable diarrhea, and ischemia of the small bowel may be contraindications to EN therapy (1). Most other conditions allow at least some nutrients to be delivered enterally.
Nutritional support of the critically ill patient is an important aspect of medical care and universally applicable to all
hospitalized patients. Malnutrition is prevalent in the surgical intensive care unit (SICU) and can impair vital organ function,
depress immune status, prolong ventilator dependence, and increase infection and mortality rates.1–4 In surgical patients,
a preoperative weight loss of greater than 10% of usual body weight has been associated with increased postoperative complications
such as pneumonia, wound infection, longer length of stay, and increased mortality5–7 The goal of nutritional support in the
critically ill patient is to support wound healing and immune function, and prevent malnutrition and its comorbid consequences.
Meeting the elevated nutritional requirements of critically ill patients while avoiding the metabolic complications can be
difficult. This chapter addresses the many challenges of feeding the SICU patient and provides guidelines for safe and effective
nutritional support.
Nutrition support is an important part of care management in critically ill patients, not only to prevent and treat malnutrition but also it has a significant impact on recovery from illness and overall outcome. There is little information available about present nutritional support practice for patients in intensive care units (ICU) in the UK. This survey was designed to evaluate the present nutrition support practice in ICU and high dependency units (HDU) in England. Data were gathered by a 72 h phone survey from 245 ICU and HDU in 196 hospitals in England. A questionnaire was completed over the telephone, including general information, nutrition support and teams involved in the nutrition management in the ICU. Of 1286 total patients in the ICU, 703 (54·6 %) were receiving nasogastric feeding, two (1·5 %) were receiving feeding via a percutaneous endoscopically placed gastrostomy tube and two (1·5 %) were receiving nasojejunal feeding. One hundred and forty-seven (11·4 %) patients were on parenteral feeding during the study period. A nutrition support team was not available in 158 (83·1 %) ICU and there was no dietitian or specialist nutrition nurse to cover ICU in nine (4·7 %) hospitals. In conclusion, the present survey reported an increased trend in usage of enteral feeding in ICU in England, and a reduction in the use of parenteral nutrition compared with previous surveys. However, we are still far from integrating nutrition into care management in the ICU.
There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.
The advent of total parenteral nutrition in the late 1960s meant that no situation remained in which a patient could not be fed. Unfortunately, total parenteral nutrition was complicated by serious infective and metabolic side effects that undermined the beneficial effects of nutrient repletion. Consequently, creative ways of restoring upper gut function were designed, based on semielemental diets and novel feeding tube systems. The employment of specific protocols and acceptance of increased gastric residual volumes has allowed most patients in intensive care to be fed safely and early by nasogastric tube. However, nasogastric feeding is unsuitable for patients with severely compromised gastric emptying owing to partial obstruction or ileus. Such patients require postpyloric tube placement with simultaneous gastric decompression via double-lumen nasogastric decompression and jejunal feeding tubes. These tubes can be placed endoscopically 40-60 cm past the ligament of Treitz to enable feeding without pancreatic stimulation. In patients whose disorders last more than 4 weeks, tubes should be repositioned percutaneously, by endoscopic, open or laparoscopic surgery. Together, the advances in enteral access have improved patients' outcomes and led to a 70-90% reduction in the demand for total parenteral nutrition.
Displacement of jejunal feeding tubes is a major problem in enteral feeding. Although endoscopic clips have been used to prevent migration of the tube during placement, the long-term effect of the clips on tube displacement is unknown.
The purpose of this study was to examine the long-term effect of endoscopic clips on preventing displacement of the jejunal feeding tube.
A retrospective study.
A single tertiary medical center.
The success rate of the procedure and the functional duration of the feeding tube.
About 93% of patients had a percutaneous endoscopic gastrostomy jejunal (PEGJ) tube successfully placed with use of endoscopic clips. About 7% had tube migration and repeat procedures were successful. The mean functional duration of the tube was 55 days. Limitations Retrospective, single-center.
Use of endoscopic clips can prevent migration during placement of the feeding tube and can also reduce tube displacement in the long term.
Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use.
Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study. Patients were fed Probalance (Nestle USA) to provide 25 kcal/kg per day (to which 10 yellow microscopic beads and 4.5 mL of blue food coloring per 1,500 mL was added). Patients were randomized to one of two groups based on management of RV: cessation of enteral tube feeding for RV >400 mL in study patients or for RV >200 mL in controls. Acute Physiology and Chronic Health Evaluation (APACHE) III, bowel function score, and aspiration risk score were determined. Bedside evaluations were done every 4 hrs for 3 days to measure RV, to detect blue food coloring, to check patient position, and to collect secretions from the trachea and oropharynx. Aspiration/regurgitation events were defined by the detection of yellow color in tracheal/oropharyngeal samples by fluorometry. Analysis was done by analysis of variance, Spearman's correlation, Student's t-test, Tukey's method, and Cochran-Armitage test.
Forty patients (mean age, 44.6 yrs; range, 18-88 yrs; 70% male; mean APACHE III score, 40.9 [range, 12-85]) were evaluated (21 on nasogastric, 19 on percutaneous endoscopic gastrostomy feeds) and entered into the study. Based on 1,118 samples (531 oral, 587 tracheal), the mean frequency of regurgitation per patient was 31.3% (range, 0% to 94%), with a mean RV for all regurgitation events of 35.1 mL (range, 0-700 mL). The mean frequency of aspiration per patient was 22.1% (range, 0% to 94%), with a mean RV for all aspiration events of 30.6 mL (range, 0-700 mL). The median RV for both regurgitation and aspiration events was 5 mL. Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably. Aspiration risk and bowel function scores did not correlate with the incidence of aspiration or regurgitation. Blue food coloring was detected on only three of the 1,118 (0.27%) samples. RV was < or =50 mL on 84.1% and >400 mL on 1.4% of bedside evaluations. Sensitivities for detecting aspiration per designated RV were as follows: 400 mL = 1.5%; 300 mL = 2.3%; 200 mL = 3.0%; and 150 mL = 4.5%. Low RV did not assure the absence of events, because the frequency of aspiration was 23.0% when RV was <150 mL. Raising the designated RV for cessation of enteral tube feeding from 200 mL to 400 mL did not increase the risk, because the frequency of aspiration was no different between controls (21.6%) and study patients (22.6%). The frequency of regurgitation was significantly less for patients with percutaneous endoscopic gastrostomy tubes compared with those with nasogastric tubes (20.3% vs. 40.7%, respectively; p = .046). There was no correlation between the incidence of pneumonia and the frequency of regurgitation or aspiration.
Blue food coloring should not be used as a clinical monitor. Converting nasogastric tubes to percutaneous endoscopic gastrostomy tubes may be a successful strategy to reduce the risk of aspiration. No appropriate designated RV level to identify aspiration could be derived as a result of poor sensitivity over a wide range of RV. Study results do not support the conventional use of RV as a marker for the risk of aspiration.
Enteral nutrition has demonstrated to be a useful and safe method to nourish critically ill patients admitted to the Intensive Care Unit. Although the time a severely ill patient can stand without nutrition is unknown, accelerated catabolism and fasting may be deleterious in those patients, and the more common recommendation is to start on artificial nutrition when a fasting period longer than seven days is foreseen. At an experimental level, advantages of enteral nutrition over parenteral nutrition are evident since the use of nutritional substrates via the gastrointestinal tract improves the local and systemic immune response and maintains the barrier functions of the gut. Clinical studies have demonstrated that early enteral nutrition administered within the first 48 hours of admission decreases the incidence of nosocomial infections in these patients, but not the mortality, with the exception of special groups of patients, particularly surgical ones. The major inconvenience of enteral nutrition is its digestive intolerance and the transpyloric approach, necessary when there is gastroparesia. Its efficacy is also questioned when the patient has tissue ischemia. For early enteral nutrition to be effective, a treatment strategy must be implemented that includes from simple measures, such as uprising the bed headrest, to more sophisticated ones, such as the transpyloric approach or the use of nutrients with immunomodulatory capabilities. To date, the use of early enteral nutrition is the best method for nutritional support in this kind of patients provided that it is individualized according to each patient clinical status and that is done following an adequate therapeutic strategy.
To compare the effectiveness of active to passive dissemination of the Canadian clinical practice guidelines (CPGs) for nutrition support for the mechanically ventilated critically ill adult patient.
A cluster-randomized trial with a cross-sectional outcome assessment at baseline and 12 months later.
Intensive care units in Canada.
Consecutive samples of mechanically ventilated patients at each time period.
In the active group, we provided multifaceted educational interventions including Web-based tools to dietitians. In the passive group, we mailed the CPGs to dietitians.
The primary end point of this study was nutritional adequacy of enteral nutrition; secondary end points measured were compliance with the CPGs, glycemic control, duration of stay in intensive care unit and hospital, and 28-day mortality. Fifty-eight sites were randomized. At baseline and follow-up, 623 and 612 patients were evaluated. Both groups were well matched in site and patient characteristics. Changes in enteral nutrition adequacy between the active and passive arms were similar (8.0% vs. 6.2 %, p = .54). Median time spent in the target glucose range increased 10.1% in the active compared with 1.8% in the passive group (p = .001). In the subgroup of medical patients, enteral nutrition adequacy improved more in the active arm compared with the passive group (by 8.1%, p = .04), whereas no such differences were observed in surgical patients. When groups were combined, during the year of dissemination activities, there was an increase in enteral nutrition adequacy (from 43% to 50%, p < .001), an increase in the use of feeding protocols (from 64% to 76%, p = .03), and a decrease in patients on parenteral nutrition (from 26% to 21%, p = .04). There were no differences in clinical outcomes between groups or across time periods.
Although active dissemination of the CPGs did improve glycemic control, it did not change other nutrition practices or patient outcomes except in a subgroup of medical patients. Overall, dissemination of the CPGs improved other important nutrition support practices but was not associated with improvements in clinical outcomes.
The route, timing, and volume of enteral feeding delivered to a patient in the intensive care unit have a profound effect on clinical outcome. At the height of critical illness, problems with ileus, aspiration, and the systemic inflammatory response syndrome make the provision of enteral nutrients a difficult and somewhat risky endeavor. The gastrointestinal endoscopist has the technical skills to place feeding tubes deep within the jejunum and an underlying expertise in gut physiology to monitor patients effectively once feeds are initiated. Attention to detail in the techniques for attaining enteral access, early identification of potential problems, and quick institution of simple endoscopic strategies help improve delivery of nutrition support, minimize the likelihood for in-hospital complications, and optimize patient outcome.
These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention,
diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues,
equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials
in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis
are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon
the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated
pneumonia.
