Practical Aspects of Nutrition Support in the ICU

1
Practical Aspects of Nutrition Support in the ICU

• John W. Drover, MD, FRCSC, FACS
• Associate Professor
• Queens University
• Kingston, ON
• Canada

www.criticalcarenutrition.com
2
Disclosure Information

• None

www.criticalcarenutrition.com
3
(No Transcript)
4
Objectives

• At the end of the session the participant will be
  able to
• List 3 strategies to maximize the benefits of
  enteral nutrition.
• List 2 advantages of post-pyloric enteral
  feeding.
• Identify 1 method of gaining post-pyloric access
  at the bedside in the ICU.

5
Outline

• Review the rationale for enteral feeding.
• Focus on the data regarding post-pyloric feeding.
• Specifically RCTs
• Clinically important outcomes
• Review the risks of and obstacles to post-pyloric
  feeding.
• Develop a recommendation

www.criticalcarenutrition.com
6
Case 1

• Day 1
• 50 yo female COPD with CAP
• Intubated, resuscitated
• Who would start EN within 24 hours of admission?
• Who would attempt to place a post-pyloric feeding
  tube?

7
Case 2

• Day 5
• 50 yo female COPD with CAP
• Intubated, resuscitated
• feeding tube in stomach
• Receiving metoclopromide
• Achieving lt30 of goal GRV gt400ml
• Who would recommend placement of a post-pyloric
  feeding tube?

8
Nutrition in the Critically ill

• Enteral nutrition strongly recommended
• Early enteral nutrition recommended
• Optimize the benefits and minimize risks
• Use of feeding protocols
• Motility agents for gastric feeding
• Small bowel feeding

9
Intra-gastric feeding

• The good
• Easy access
• Early initiation
• Often tolerated well
• The bad
• Gastric residual volumes (GRVs)
• Gastro-pharyngeal reflux
• Respiratory aspiration
• Unrealized nutritional goals

10
Post-pyloric feeding

• 2 RCTs that have evaluated aspiration
• 33 patients, 1st 3 days
• GE regurg 24.9 vs. 39.8 (p0.04)
• Further into small bowel less aspiration
• 54 patients, twice weekly
• Low rate of aspiration
• 7 vs 13 aspiration

Heyland et al, CCM, 2001
Esparaza et al, Int Care Med, 2001
11
Post-pyloric feeding

• 11 RCTs of SB vs Gastric feeding
• Med/Surg (4), Med (3), Trauma (2), Neuro (2)
• N664
• One study used arginine containing diets
• Variable design for selection
• Different methods of enteral access
• Outcomes
• No difference in mortality, LOS, vent days

Heyland et al, JPEN 2002
12
Post-pyloric feeding

• Taylor et al. CCM, 1999
• Neurotrauma, n82
• Standard gastric feeding
• 15ml/h increase Q8h
• Aggressive SB feeding (when feasible)
• SB access only 34
• Start at target rate and adjust
• Outcomes
• Pneumonia 44 vs 63(NS)

13
Post-pyloric feeding

• Nutritional outcomes
• Small bowel feeding associated with
• Reaching nutritional goals sooner
• Better success at meeting goals
• Meta-analysis not possible
• Variable gastric feeding strategies
• Goals and success reported in different ways

14
Post-pyloric feeding

• Infections pneumonia (9 studies)
• 8 clinical criteria 1 bronchoscopy
• SB feeding associated with reduced pneumonia
• RR0.77(0.60-1.0), p0.05
• 23 risk reduction
• With Taylor study removed
• RR0.83(0.6-1.15), p0.3

15
Post-pyloric feeding
16
Post-pyloric feeding
17
Controversy

• A comparison of early gastric feeding in
  critically ill patients a meta-analysis
• No difference in outcomes
• Same RCTs
• Exclude Taylor
• Use studies of reflux
• Didnt count all pneumonia in Montecalvo study

Ho et al, ICM 2006
18
Post-pyloric feeding

• Problems associated with
• Difficult to achieve
• Once achieved may move
• Doesnt overcome all issues
• (eg. ACS, short bowel, enteric fistula)
• Bowel necrosis rare event not clearly
  associated with enteral nutrition

Canadian survey says 10
Safe
Zaloga Nutrition Week 2005
19
The ENTERIC Study

• The Early Nasojejunal Tube To Meet Energy
  Requirements In Intensive Care Study

Study Investigators Andrew R Davies Rinaldo
Bellomo D Jamie Cooper Gordon S
Doig Simon R Finfer Daren K Heyland For the
ANZICS Clinical Trials Group
20
Conclusions

• SB feeding improves
• time to reach target goals
• success at achieving target goals
• SB feeding may be associated with less pneumonia

21
Discussion

• Routine use
• Difficulties of SB access
• Blind
• Endoscopic
• Flouroscopic
• Patients with gastric intolerance
• Patients with other risk factors
• GERD
• unable to nurse semi-recumbent
• (eg. C-spine injury)

22
Discussion

• If your unit has feasible access
• Go for it
• If your unit has ability with effort
• Use it for patients at risk
• i.e. inotropes, sedatives, paralytics, high GRVs
• If your unit has great difficulty
• Use in patients who do not tolerate gastric
  feeding

23
Bedside placement into SB

• Feeding tube in stomach
• Wire with 30o bend, 3cm from end
• Zaloga, Chest 1991
• Insufflate stomach with 500ml
• Salasidis, CCM 1998
• Rotate while advancing
• Samis and Drover, ICM 2004

24
(No Transcript)
25
Thank You!

• Choosing an approach to
• MAXIMIZE BENEFIT
• Minimize risk

26
Questions

• 1) What strategies can be utilized to optimize
  the delivery of enteral nutrition?
• Feeding protocols
• Motility agents
• Post pyloric feeding
• All of the above

27
Questions

• 2) Post-pyloric feeding is associated with a
  reduced incidence of ventilator associated
  pneumonia.
• True or False
• 3) Small bowel necrosis associated with
  post-pyloric feeding is a rare event.
• True or False

28
Questions Answer Key

1. D (reference 1)
2. True (reference 1)
3. True (reference 2)

29
Reference List

• (1) Clinical Practice Guidelines Website
  http//www.criticalcarenutrition.com.
• (2) Drover JW, Dhaliwal R, Heyland DK. Post
  pyloric enteral feeding Not all it is cracked up
  to be! International Journal of Intensive Care
  20029139-45.
• (3) Heyland DK, Drover JW, Dhaliwal R, Greenwood
  J. Optimizing the Benefits and Minnimizing the
  Risks of Enteral Nutrition in the Critically Ill
  Role of Small Bowel Feeding. J Parenter Enteral
  Nutr 20022651-7.
• (4) Heyland DK, Drover JW, MacDonald S, Novak F,
  Lam M. Effect of postpyloric feeding on
  gastroesophageal regurgitation and pulmonary
  microaspiration results of a randomized
  controlled trial. Crit Care Med 2001
  Aug29(8)1495-501.
• (5) Kortbeek JB, Haigh PI, Doig C. Duodenal
  versus gastric feeding in ventilated blunt trauma
  patients a randomized controlled trial. Journal
  of Trauma-Injury Infection Critical Care 1999
  Jun46(6)992-6.
•  

30
Reference List

• (6) Montecalvo MA, Steger KA, Farber HW, Smith
  BF, Dennis RC, Fitzpatrick GF, et al. Nutritional
  outcome and pneumonia in critical care patients
  randomized to gastric versus jejunal tube
  feedings. The Critical Care Research Team. Crit
  Care Med 1992 Oct20(10)1377-87.
• (7) Davies AR, Froomes PR, French CJ, Bellomo R,
  Gutteridge GA, Nyulasi, et al. Randomized
  comparison of nasojejunal and nasogastric feeding
  in critically ill patients. Crit Care Med 2002
  Mar30(3)586-90.
• (8) Kearns PJ, Chin D, Mueller L, Wallace K,
  Jensen WA, Kirsch CM. The incidence of
  ventilator-associated pneumonia and success in
  nutrient delivery with gastric versus small
  intestinal feeding a randomized clinical trial.
  Crit Care Med 2000 Jun28(6)1742-6.
• (9) Minard G, Kudsk KA, Melton S, Patton JH,
  Tolley EA. Early versus delayed feeding with an
  immune-enhancing diet in patients with severe
  head injuries. Journal of Parenteral Enteral
  Nutrition 2000 May24(3)145-9.
• (10) Boivin MA, Levy H. Gastric feeding with
  erythromycin is equivalent to transpyloric
  feeding in the critically ill. Crit Care Med 2001
  Oct29(10)1916-9.

31
Reference List

• (11) Taylor SJ, Fettes SB, Jewkes C, Nelson RJ.
  Prospective, randomized, controlled trial to
  determine the effect of early enhanced enteral
  nutrition on clinical outcome in mechanically
  ventilated patients suffering head injury. Crit
  Care Med 1999 Nov27(11)2525-31.
• (12) Day L, Stotts NA, Frankfurt A,
  Stralovich-Romani A, Volz M, Muwaswes M, et al.
  Gastric versus duodenal feeding in patients with
  neurological disease a pilot study. J Neurosci
  Nurs 155 Sep 2033(3)148-9.
• (13) Esparza J, Boivin MA, Hartshorne MF, Levy
  H. Equal aspiration rates in gastrically and
  transpylorically fed critically ill patients.
  Intensive Care Med 2001 Apr27(4)660-4.
• (14) Neumann DA, DeLegge MH. Gastric versus
  small-bowel tube feeding in the intensive care
  unit a prospective comparison of efficacy. Crit
  Care Med 200230(7)1436-8.

32
Reference List

• (15) Montejo JC, Grau T, Acosta J, Ruiz-Santana
  S, Planas M, Garcia-De-Lorenzo A, et al.
  Multicenter, prospective, randomized,
  single-blind study comparing the efficacy and
  gastrointestinal complications of early jejunal
  feeding with early gastric feeding in critically
  ill patients. Crit Care Med 2002
  Apr30(4)796-800.
• (16) Spain DA, DeWeese RC, Reynolds MA,
  Richardson JD. Transpyloric passage of feeding
  tubes in patients with head injuries does not
  decrease complications. Journal of Trauma-Injury
  Infection Critical Care 1995 Dec39(6)1100-2.
• (17) Grahm TW, Zadrozny RN, Harrington T. The
  Benefits of Early Jejunal Hyperalimentation in
  the Head-Injured Patient. Neurosurgery
  198925(5)729-35.
• (18) Strong RM, Condon SC, Solinger MR, Namihas
  BN, Ito-Wong LA, Leuty JE. Equal aspiration rates
  from postpylorus and intragastric-placed
  small-bore nasoenteric feeding tubes a
  randomized, prospective study. Jpen Journal of
  Parenteral Enteral Nutrition 1992
  Jan16(1)59-63.