Optimizing Benefits and Minimizing Risks of EN

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Optimizing Benefits and Minimizing Risks of EN
Jan Greenwood, RD. ICU Clinical Dietitian
Specialist Vancouver General Hospital
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Use of EN vs PN

• Does EN compared to PN result in better outcomes
  in the critically ill adult patient?

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The Evidence
12 LEVEL 2 STUDIES 1 LEVEL 1 STUDY
Outcomes Mortality (12) Infections (6) LOS
(4)Ventilator days (4) Other complications
Nutritional intake (11) Hyperglycemia
(5) Cost (4)
EN vs PN
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EN VS PN CONCLUSIONS

• The use of EN compared to PN is not associated
  with a reduction in mortality.
• The use of EN compared to PN is associated with a
  significant reduction in the number of infectious
  complications.

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EN VS PN CONCLUSIONS

• No difference in ventilator days or LOS between
  grps receiving EN vs PN.
• Insufficient data to comment on other
  complications.
• Hyperglycemia or higher calories not found to
  result in higher motality or infections.
• EN is associated with a cost savings when
  compared to PN.

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Use of EN vs PN

• RecommendationBased on 1 level 1 and 12 level
  2 studies, when considering nutrition support for
  critically ill pts , we strongly recommend the
  use of EN over PN.

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Early vs Delayed Nutrient Intake

• Does early EN compared to delayed nutrient intake
  (EN, Oral, PN) result in better outcomes in the
  critically ill patient?

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The Evidence
8 LEVEL 2 STUDIES
Mortality (8) Infections (3) LOS (7) Ventilator
days (4) Other complications Nutritional
endpoints (7)
Early vs delayed
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EARLY VS DELAYED CONCLUSIONS

• In critically ill pts early EN when compared to
  delayed nutrient intake is associated with
• trend towards reduction in mortality.
• trend towards reduction in infectious
  complications.
• improved nutritional intake.

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EARLY VS DELAYED CONCLUSIONS

• Early EN compared to delayed nutrient intake has
  no effect on ICU or hospital LOS.

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Early vs Delayed Nutrient Intake

• RecommendationBased on 8 level 2 studies, we
  recommend early EN (within 24-48 hrs of
  resuscitation).

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Nutritional Prescription of EN Achieving Target
Dose of EN

• Does achieving target dose of EN result in better
  outcomes in the critically ill adult patient?

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The Evidence
1 LEVEL 2 STUDYHI pts. Grp 1start goal rate day
1 (34 required ND) vs Grp 2 start 15 mL/hr and
slow ?.
Mortality (1) Infections (NR) LOS (1)Ventilator
days (NR) Other complications
Target dose
Taylor SJ, et al. Crit Care Med 1999
27(11)2525-31.
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TARGET DOSE CONCLUSIONS

• No effect of early EN on mortality, LOS,
  ventilator days.
• Early aggressive EN compared to slower EN rate
  advancement associated with trend1) reduction
  in infections (p 0.02)andcomplications in HI
  pts.2) better neurological outcomes at 3 mths
  (p0.08) 3) more adequate kcal (p 0.0008) and
  pro (plt 0.001) intake.

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Achieving Target Dose of EN

• RecommendationBased on 1 level 2 study, when
  initiating EN in HI pts, strategies to optimize
  nutrient delivery (start at target rate, higher
  threshold GRV, SB feedings) should be considered.
  Other pts - insufficient data.

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Immune Enhancing Diets supplemented with
arginine and select other nutrients

• Compared to standard enteral feeds, do diets
  supplemented with arginine and other nutrients
  result in improved clinical outcomes in
  critically ill pts?

histidine, beta- carotene, cysteine, omega 3 FA,
Vit E, etc
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The Evidence
2 LEVEL 1 STUDIES 12 LEVEL 2 STUDIES
Mortality (14) Infections (10) LOS (H - 8/ICU
9)Ventilator days (9) Other complications
Arginine
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ARGININE CONCLUSIONS

• No effect on rate of infectious complications.
• Overall no effect on mortality (higher quality
  studies show no effect on mortality lower
  quality show a trend).
• May possibly reduce hospital length day, ICU
  length of stay, mechanical ventilation.

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Diets supplemented with arginine and select
other nutrients

• RecommendationBased on 2 level 1 studies and
  12 level 2 studies, we recommend that diets
  supplemented with arginine and other select
  nutrients not be used for critically ill pts.

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Immune Enhancing Fish oils, borage oils and
antioxidants

• Does the use of an enteral formula with fish
  oils, borage oils and antioxidants result in
  improved clinical outcomes in the critically ill
  pt?

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The Evidence
1 LEVEL 1 STUDY (Gadek JE, et al. Crit
Care Med 1999271409-20) ARDS pts. Compared
Oxepa to high fat formula.
Mortality (1) Infections (1) LOS (1) Ventilator
days (1) Other complications New organ
failures (1)
Oxepa fish oil, borage oil, antioxidants (Vit E,
Vit C, beta-carotene, taurine, L-carnitine)
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Immune Enhancing Fish oils, borage oils and
antioxidants

• Associated with reduction in days receiving
  supplemental oxygen (13.6 vs 17.1, p0.078).
• Fewer days ventilatory support (9.6 vs 13.2,
  p0.027).
• Fewer days in ICU (11.0 vs 14.8, p0.016).
• Fewer new organ failures (10 vs 25, p0.018).
• Trend towards reduction in mortality (16 vs 25,
  p0.17).

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FISH OILS, BORAGE OILS and ANTIOXIDANTS
CONCLUSION

• When compared to a high fat formula, the use of a
  formula that contains fish oils/borage
  oil/antioxidants may be associated with a trend
  towards lower mortality and a significant
  reduction in ICU LOS, ventilated days and organ
  failure in critically ill pts.

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Immune Enhancing Fish oils, borage oils and
antioxidants

• RecommendationBased on one level 1 study the
  use of a formula containing fish oils/borage oil/
  antioxidants should be considered in pts with
  ARDS.

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Immune Enhancing Diets Glutamine

• Compared to standard care, does glutamine
  -supplemented EN result in improved clinical
  outcomes in critically ill pts?

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The Evidence
1 LEVEL 1 STUDY 4 LEVEL 2 STUDIES
Mortality (5) Infections (2) LOS (2)Ventilator
days (NR) Other complications
Glutamine
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GLUTAMINE CONCLUSIONS

• Glutamine supplemented EN may be associated
  with A reduction in mortality in burn pts. A
  reduction in infectious complications
  in trauma pts.

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Immune Enhancing Diets Glutamine

• RecommendationBased on 4 level 2 studies and1
  level 1 study, enteral glutamine should be
  considered in burn and trauma pts. Insufficient
  data to support routine use of enteral
  glutaminein other critically ill pts.

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Composition of EN Low fat/high CHO

• Does a low fat/high CHO enteral formula affect
  outcomes in critically ill pts?

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The Evidence
1 LEVEL 2 STUDY (gt20 BSAB pts)
Mortality (1) Infections (1) LOS (1) Ventilator
days (NR) Other complications
Low fat/ high CHO
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LOW FAT/HIGH CHOCONCLUSIONS

• Low fat enteral feeding formula may be associated
  with lower incidence of pneumonia and a trend
  towards a reduction in LOS in burn pts.

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Composition of EN Low fat/high CHO

• RecommendationBased on 1 level 2 study, a low
  fat formula could be considered in pts with gt20
  TBSA burn injury. Insufficient data in other
  pts.

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Composition of EN Protein/peptides

• Does the use of a peptide based enteral formula
  compared to intact protein formula, result in
  better outcomes in critically ill pts?

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The Evidence
4 LEVEL 2 STUDIES
Mortality(2) Infections (2) LOS (1) Ventilator
days (NR) Other complications Diarrhea
Protein/peptides
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PROTEIN/PEPTIDES CONCLUSIONS

• No difference in mortality or infections between
  pts receiving a peptide based vs standard
  formula.
• No difference in diarrhea between pts receiving a
  peptide based vs standard formula.
• Peptide based formula vs standard formula may be
  associated with a trend towards fewer hospital
  days.

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Composition of EN Protein/Peptides

• RecommendationBased on 4 level 2 studies,
  when initiating enteral feeds, we recommend the
  use of whole protein formulas (polymeric).

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Strategies to optimize delivery and minimize
risks of EN Feeding protocols

• Does the use of a feeding protocol result in
  better outcomes in the critically ill adult pt?

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The Evidence
No RCT looking at clinically important
endpoints. One RCT - surrogate outcome only.
Compared protocol with high GRV (250 ml)
mandatory prokinetics vs low GVR (150 ml)
protocol.
Mortality (NR) Infections (1) LOS (NR) Ventilator
days (NR) Other complications Elevated GR
aspirations Time to reach goal rate
needs met
Feeding protocols
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FEEDING PROTOCOLS CONCLUSIONS

• Feeding protocols with prokinetics and higher GRV
  threshold (250 mL) are associated with tend
  towards reduction in gastric residual aspirations
  (plt0.005) and a trend less time to reach goal
  feeding rate (plt0.09).

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Strategies to optimize delivery and minimize
risks of EN Feeding protocols

• RecommendationInsufficient data to rec feeding
  protocol.If a feeding protocol is to be used,
  based on 1 level 1 study, a protocol that
  incorporates prokinetics (metoclopramide) at
  initiation and a higher GRV (250 ml) could be
  considered as a strategy to optimize delivery of
  EN in critically ill pts.

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Strategies to optimize delivery and minimize
risks of EN Motility agents

• Compared to standard practice (placebo) does the
  routine use of motility agents improve outcomes
  in critically ill pts?

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The Evidence
One systematic review of literature
synthesized RCT of cisapride, metoclopramide,
erythromycin. Only 1 RCT looked at clinically
important endpoints - no significant tx effect.
Motility agents
Booth CM, Heyland DK, Paterson WG. Crit Care
Med 2002 30(7)1429-35
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MOTILITY AGENTS CONCLUSIONS

• Motility agents may be associated with an
  increase in gastric emptying and a reduction in
  feed intolerance in critically ill patients.

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Strategies to optimize delivery and minimize
risks of EN Motility agents

• RecommendationBased on a systematic review of
  the literature, in critically ill patents who
  experience feed intolerance (high GRV, emesis)
  the use of metoclopramide as a motility agent
  should be considered.

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Strategies to optimize delivery and minimize
risks of EN Small bowel feedings

• Does enteral feeding via the small bowel compared
  to gastric feeding result in better outcomes in
  critically ill pts?

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The Evidence
11 LEVEL 2 STUDIES
Mortality (9) Infections (9) LOS (5) Ventilator
days (1) Other complications GI - V, D, abd
bloating Meeting goal rate Neurological
outcome
SB feeding
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SMALL BOWEL FEEDINGS CONCLUSIONS

• SB feeding compared to gastric feeding may be
  associated with a reduction in pneumonia in
  critically ill pts.
• No difference in mortality, or vent days in
  critically ill pts receiving SB vs gastric
  feeds.
• SB feeding improves kcal and protein intake and
  is associated with less time to reach target rate
  of EN when compared to gastric feeds.

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Strategies to optimize delivery and minimize
risks of EN Small bowel feedings

• RecommendationBased on 11 level 2 studies, SB
  feeding compare to gastric feeding maybe
  associated with a reduction in pneumonia in
  critically ill pts. In units were SB access is
  feasible, we recommend the routine use of SB
  feedings.

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Strategies to optimize delivery and minimize
risks of EN Small bowel feedings

• In units where obtaining SB access involves more
  logistical difficulties, SB feeding should be
  considered for pts at high risk of intolerance
  (on inotropes, continuous infusion of sedatives,
  or paralytic agents, or pts with high NG
  drainage) or at high risk for regurgitation and
  aspiration (nursed in supine position).

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Strategies to optimize delivery and minimize
risks of EN Small bowel feedings
In units where obtaining SB access is not
feasible (no access to fluoroscopy or endoscopy
and blind techniques not reliable) SB feedings
should be considered for those select pts who
repeatedly demonstrate high GRV and are not
tolerating adequate amounts of EN delivered into
the stomach.

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Strategies to optimize delivery and minimize
risks of EN Body position

• Do alterations in body position result in better
  outcomes in the critically ill adult pt?

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The Evidence
1 LEVEL 2 STUDY
Mortality (1) Infections (1) LOS (1) Ventilator
days (1) Other complications
Body position
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BODY POSITION CONCLUSIONS

• Semi recumbent position has no effect on
  mortality in critically ill pts.
• Semi recumbent position is associated with a
  significant reduction in nosocomial pneumonia
  (p0.018) in critically ill pts.

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Strategies to optimize delivery and minimize
risks of EN Body position

• RecommendationBased on 1 level 1 study, we
  recommend that critically ill pts receiving EN
  have the HOB elevated to 45 degrees. Where this
  is not possible attempts to raise the HOB as much
  as possible should be considered.

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INSUFFICIENT DATA

• Continuous vs other administration methods.
• Indirect Calorimetry vs Predictive Equation.
• Composition of EN high fat/low CHO pH fibre.
• Closed vs open delivery system.
• Probiotics.