Enteral nutrition in critically ill patients

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Enteral Nutrition might save life
Where Should We Feed critically ill patients?
Done by Dr KHALED AL SEWIFY
MD, MRCP, EDIC
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Artificial Nutritional Support
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Enteral nutrirition

• Preserves the intestinal mucosal integrity
• Maintains mucosal immunity.
• Prevents of increased mucosal permeability.
• Decreases bacterial translocation.
• Marik, Zaloga CCM 2005

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The Gut is the Motor of Sepsis
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Theory of BT

• SB and colon contain 1010 anaerobes and 107 Gram
  ve and Gram -ve aerobes and Enough Endotoxins to
  kill us 1000 X.
• 
  
• 
  
• Magnotti
  Deitch 2005 JOABA

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Saving lives in severe sepsis with the help of
enteral nutrition

• EN enriched with eicosapentaeonic acid,
  ?-linolenic acid antioxidants in ARDS patients
  with severe sepsis mortality with
• ARR of 19.4.
• Pontes-Arruda-Crit Care Med,Sept.2006
  34. 2325-2333.
• Pontes-Arruda-Crit Care Med  2006
  34. 2325-2333.

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Effect of EN enriched with EPA/GLA ON MORTALITY
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Ventilator Free days////ICU Free days
P lt 0.001
7.6 more ventilator-free days
6.2 more ICU-free days
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PaO2/FIO2
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Advantages of gastric feeding 

• It is more physiological, is easier to begin and
  more convenient.
• Spare both gastropancreatic reflexes and gastrin
  release.
• Buffers gastric acid well.

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Intragastric feeding buffer gastric acid better
than post-pyloric feeding
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What are The Problems Associated with Gastric
Feeding in Critical Illiness ?
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Gastric Ilieus
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• Syndrome of Upper (GIT) Intolerance of EN

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Incidence of UGIT Intolerance to Gastric
Feeding
Mentec H (2001) Crit Care Med 29
1955-1961
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What are the sequelae of upper GIT intolerance
to enteral nutrition?
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1-Inadequate Caloric Supply
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Prospective survey in Australian ICUs
De Beaux (2001)EN in the critically ill
Anaesth. Intensive Care 29619-622
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Hazards of UGIT Intolerance
Incidence of Nosocomial Pneumonia
2-Patients with Upper GIT Intolerance Had
Increased Incidence Of Nosocomoial Pneumonia

Feeding intolerance
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Hazards of UGIT Intolerance
Mortality Rate
2-Patients With Upper GIT Intolerance Had
Increased Mortality

Feeding intolerance
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Hazards of UGIT Intolerance
ICU Length Of Stay
4-Patients With Upper GIT Intolerance Had
Longer Duration of ICU Stay

Feeding intolerance
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• So probably the gastric feeding may not always be
  as safe as it is sometimes considered.
• The net result is Aspiration Syndrome.
• Heyland DK 199-AM J Respir Crit Care Med
  1591249-1256.

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Aspiration Is A Real Threat
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Aspiration Syndrome

• 1. 70 with altered LOC.
• 2. gt 70 of trauma patients at injury.
• 3. gt 40 of patients with EN.
• Bowman, et al CCNQ 2005

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So ICU clinicians are facing a dilemma
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they have to balance between
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Prokinetic therapy for feed intolerance in
critical illnes one drug or two ?

• Erythromyicin is superior to Metoclopramide.
• Combination therapy had greater feeding success,
  received more daily calories, and had a lower
  requirement for postpyloric feeding less
  incidence of tachyphylaxis.
• Should be considered as first line therapy in
  treatment of feed intolerance in criticall
  illness.
• Reignier J - Crit Care Med.2002,
  301237-1241.
• Nguyen NQ - Crit Care Med. 2007
  Nov35(11)2561-7.

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But Pro-kinetic drugs are not free from side
effects
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What is new ?

• Motilin derivatives
• Long term efficacy is unknown.
• Very rapid tachyphylaxis.
• Cholecystokinin antagonist Loxiglumide
• Very recent.
• Accelerate gastric emptying in healthy
  humans.
• No trials in critically ill patients.
• Castllo E, et al .Am J Physiol
  2004287G363-G369
• Cremonini F,et al.Am J Gastroenterol
  2005100625-663

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? ? ? ?

• Where Best To Deliver Enteral Nutrition In
  Critically Ill Patients ?
• Is Small Bowel Feed The Answer ?
• What Are The Advantages Of Small Bowel Feed?

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Advantages of Small Bowel Feed

• Improved absorptive capacity.
• Less impairment of motility.
• Better respiratory function as it prevents
  gastric distension.
• Greater distance between the delivery site and
  the pharynx respiratory tree.

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Evidence-Based Medicine
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• www.criticalcarenutrition.com

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Conclusions OF THE META-ANALYSIS

• Small bowel feeding compared with gastric
  feeding
• Associated with a reduction in pneumonia .
• Improves calorie and protein intake and is
  associated with less time taken to reach target
  rate of EN.
• No difference in mortality or MV days.
• Drover JW - Gastrointest Endosc Clin N Am -
  01-OCT-2007 17(4) 765-75

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Comparison of early gastric and post-pyloric feed
in ccritically ill patients a meta-analysis

• By contrast to the previous meta-analysis there
  was no significant benefits on the risk of
  diarrhea, length of ICU stay, mortality or risk
  of aspiration pneumonia.
• Intensive Care Med 2006 32639

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Canadian Clinical Practice Guidelines
Recommendations

• Routine use of SB feedings in units where SB
  access is feasible.
• In units where obtaining access involves more
  logistic difficulties, SB feedings should be
  considered for patients at high risk for UGIT
  intolerance.
• When obtaining SB access is not feasible, SB
  feedings should be considered for selected
  patients with high gastric residuals repeatedly
  and are not tolerating gastric feed.
• Heyland DK - JPEN J Parenter Enteral Nutr
  200327355- Updated Jan 2007

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Benefits in head injury

• Grahm et al also found a decrease in infectious
  complications for patients with head injuries who
  received early enteral feeding into the jejunum.
• Grahm T, Zadrozny D, Harrington T. The
  benefits of early jejunal hyperalimentation in
  the head-injured patient.
• Neurosurgery. 198925729735

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Comparison Between Gastric Versus Jejunal Feeding
Incidence of Nosochomial Pneumonia
101 patients
Nosocomial Pneumonia
Gastric
Jejunal
P value 0.4
Jejunal feeding
with early gastric feeding in critically ill
patients Juan C.
Montejo - Crit.Care Med 2002 ,30769-800
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Benefits in acute pancreatitis 

• By bypassing the mouth, stomach and duodenum,
  jejunal feeding minimize the stimulation of
  pancreatic exocrine secretions .
• Accumulating evidence has suggested that
  post-pyloric feeding is safe and may also reduce
  complications.
• Ragins, H . Am J Surg 1973 126606.
• Wolfe, BM. Surg Gynecol Obstet 1975
  Feb140(2)241-5.

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The Disadvantages Of Small Bowel FeedING

• Difficulty in Placement and Ease of
• Displacement.
• Frequent occlusion of small bore tube
  especially with viscid feed and medications.
• Intestinal perforation.
• Feeding Intolerance with dumping syndrome.

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IS IT REALLY DIFFICULT TO PASS NAS-JEJUNAL TUBE ?
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Blind placement of SB tube

• Erythromycin appeared useful in 3 studies but
  metocopramide only in one trial.
• A recent systemic review concluded that
  erythromycin should be administered when blindly
  placing a small bowel tube.
• Booth CM. A systemic review of the
  evidence.Critc Care Med 2002,301429-1435.
• Griffith DP . A double blind, RCT . Crit Care
  Med 2003,3139- 44.

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Blind Placement of sb tube
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Non blind Placement of SB tube

• Flouroscopy ensures 90 post pyloric and more
  than 50 into the jejunum.
• Endoscopically-placed tubes appear to have the
  highest success rates 98 for tube placement into
  the jejunum.
• US guided, 67 duodenal.
• EMG guided.
• Davis AR . Critic Care Med 2002, 30
  586- 590
• G Gubler, et al.Endoscopy 2006.Dec.
  38 (12)1256-60

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Distal Duodenal Tube
Chest. 2004125587-591.)
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JejunaL Tube
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EMG Guided Post Pyloric Tube
Chest. 2004125587-591.)
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• Small bowel tubes

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TIGER TUBE

• Provides high insertion success rates (gt90).
• Cost effective.
• Self migrating.
• So it will be left in the stomach and it will
  migrate peristalsis to the jejunum.
• Samis AJ,. Evaluation of 3 different
  strategies for post pyloric placement of enteral
• feeding tubes. Intensive Care Med 2004, 30S
  149( abst)

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Tiger Tube
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Bengmark Tube

• Very effective
• 92.5 crossed the pylorus
• 89.14 reached the first jejunal loop
• 3.4 in the duodenum
• 7.5 stopped in the stomach
• Reached final position within 5.2 hours, 8
  instantly and all within 24 hours.
• Start feed immediately
• G Mangiant, et al.Chir Ital. 52 (5)573-8

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CORTRAK Monitor

• Displays track of the feeding tube during
  placement

www.criticalcarenutrition.com
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Key Benefits

• Safer
• 100 success rate in avoiding lung placement in
  clinical trial
• More Accurate
• Guides the clinician through the placement
  process by indicating the path of the tube as it
  is placed
• Less Expensive
• Fewer X-rays
• Reduced use of TPN
• No Fluoro
• Faster
• During clinical trials, placements averaged 10.5
  minutes

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Summary

• Feed Early Feed Enteral
• Elevate The Head Of The Bed
• Consider Small Bowel Feed if UGIT Intolerance/
  failed to respond to prokinetics
• Remember that patients with high doses
  Catecohlamines , Muscle Relaxants, Opiates
  Benzo. will never tolerate naso-gastric feed

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• The use of EN enriched with EPA, GLA
  Antioxidant in ARDS patients with severe sepsis
  and septic shock is associated with
• An improvement in oxygenation status.
• Reduced mechanical ventilation time.
• Fewer days in ICU less new organ
  dysfunction.
• A19.4 absolute risk reduction in mortality
  rate.

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THANK
YOU