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Practical Aspects of Nutrition Support in the ICU
John W. Drover, MD, FRCSC, FACSAssociate ProfessorQueen’s University
Kingston, ONCanada
www.criticalcarenutrition.com
Disclosure Information
• None
www.criticalcarenutrition.com
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.
Outline
• Review the rationale for enteral feeding.
• Focus on the data regarding post-pyloric feeding.– Specifically RCT’s– Clinically important outcomes
• Review the risks of and obstacles to post-pyloric feeding.
• Develop a recommendation
www.criticalcarenutrition.com
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?
Case #2
• Day #5• 50 yo female COPD with CAP• Intubated, resuscitated• feeding tube in stomach• Receiving metoclopromide• Achieving <30% of goal; GRV
>400ml• Who would recommend placement
of a post-pyloric feeding tube?
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
Intra-gastric feeding
The good:• Easy access• Early initiation• Often tolerated wellThe bad:• Gastric residual volumes (GRV’s)• Gastro-pharyngeal reflux• Respiratory aspiration• Unrealized nutritional goals
Post-pyloric feeding
2 RCT’s that have evaluated aspiration• 33 patients, 1st 3 days
– GE regurg 24.9% vs. 39.8% (p=0.04)– 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
Post-pyloric feeding
• 11 RCT’s of SB vs Gastric feeding– Med/Surg (4), Med (3), Trauma (2), Neuro
(2)– N=664– 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
Post-pyloric feeding
• Taylor et al. CCM, 1999– Neurotrauma, n=82
• 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)
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
Post-pyloric feeding
• Infections – pneumonia (9 studies)• 8 clinical criteria; 1 bronchoscopy• SB feeding associated with
reduced pneumonia– RR=0.77(0.60-1.0), p=0.05– 23% risk reduction
• With Taylor study removed– RR=0.83(0.6-1.15), p=0.3
Post-pyloric feeding
Post-pyloric feeding
Controversy
“A comparison of early gastric feeding in critically ill patients: a meta-analysis”
• No difference in outcomes• Same RCT’s• Exclude Taylor• Use studies of reflux• Didn’t count all pneumonia in
Montecalvo studyHo et al, ICM 2006
Post-pyloric feeding
• Problems associated with:– Difficult to achieve– Once achieved may move– Doesn’t overcome all issues
• (eg. ACS, short bowel, enteric fistula)
• Bowel necrosis – rare event not clearly associated with enteral nutrition Zaloga: Nutrition Week 2005
Canadian survey says10%
The ENTERIC Study
The Early Nasojejunal Tube To Meet Energy Requirements In Intensive Care Study
Study Investigators: Andrew R DaviesRinaldo BellomoD Jamie CooperGordon S DoigSimon R FinferDaren K Heyland
For the ANZICS Clinical Trials Group
Conclusions
• SB feeding improves– time to reach target goals– success at achieving target
goals
• SB feeding may be associated with less pneumonia
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)
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 GRV’s
• If your unit has great difficulty– Use in patients who do not tolerate
gastric feeding
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
Thank You!
• Choosing an approach to:
•MAXIMIZE BENEFIT
• Minimize risk