Parenteral versus enteral nutrition in the critically ill patient: additional sensitivity analysis supports benefit of early parenteral compared to delayed enteral nutrition

Blind versus endoscopy-guided postpyloric feeding tube placement in adults with ischemic stroke: A retrospective cohort study

BACKGROUND

This study compared the one-time success rate of blind and endoscopy-guided postpyloric feeding tube placement after implementing a comprehensive nursing scheme of intestinal blind placement for patients with ischemic stroke.

METHODS

This retrospective cohort study included 179 patients with blind bedside placement and 118 with endoscopy-guided placement. The primary outcome was the one-time success rate of radiologically confirmed postpyloric placement. The secondary endpoints included the position of the tube tip, length of insertion, time of placement, and expenses. The safety endpoints were the incidence of complications caused by placement.

RESULTS

The results showed that the method of tube placement did not significantly affect the outcome of the first tube placement (odds ratio [OR] = 0.41; 95% CI = 0.137-1.207; P = 0.105). Compared with endoscopy-guided placement, blind placement was half the cost. We also found that a history of abdominal surgery (OR = 0.003; 95% CI  = 0.000-0.059; P < 0.001) and longer intensive care unit (ICU) days (OR = 0.94; 95% CI = 0.903-0.981; P = 0.004) were inversely associated with the one-time success rate.

CONCLUSION

Our study suggested that blind intestinal feeding tube placement has an equivalent one-time success rate compared with endoscopy-guided placement in hospitalized patients with ischemic stroke if operators can be trained well. However, the expenses of endoscopy-guided placement were twice those of blind bedside methods. We also found that patients with abdominal surgery history and longer ICU stay were more likely to fail at the first placement. Further research is needed to replicate our single-center observations in a larger population of patients.

Early versus delayed enteral nutrition in ICU patients with sepsis: a propensity score-matched analysis based on the MIMIC-IV database

Background

Early enteral nutrition (EN) is recommended for sepsis management, but its optimal timing and clinical benefits remain uncertain. This study evaluates whether early EN improves outcomes compared to delayed EN in patients with sepsis.

Methods

We analyzed data of septic patients from the MIMIC-IV 2.2 database, focusing on those in the Medical Intensive Care Unit (MICU) and Surgical Intensive Care Unit (SICU). Patients who initiated EN within 3 days were classified into the early EN group, while those who started EN between 3 and 7 days were classified into the delayed EN group. Propensity score matching was used to compare outcomes between the groups.

Results

Among 1,111 patients, 786 (70.7%) were in the early EN group and 325 (29.3%) were in the delayed EN group. Before propensity score matching, the early EN group demonstrated lower mortality (crude OR = 0.694; 95% CI: 0.514-0.936; p = 0.018) and shorter ICU stays (8.3 [5.2, 12.3] vs. 10.0 [7.5, 14.2] days; p < 0.001). After matching, no significant difference in mortality was observed. However, the early EN group had shorter ICU stays (8.3 [5.2, 12.4] vs. 10.1 [7.5, 14.2] days; p < 0.001) and a lower incidence of AKI stage 3 (49.3% vs. 55.5%; p = 0.030). Subgroup analysis revealed that early EN significantly reduced the 28-day mortality rate in sepsis patients with lactate levels ≤4 mmol/L, with an adjusted odds ratio (aOR) of 0.579 (95% CI: 0.361, 0.930; p = 0.024).

Conclusion

Early enteral nutrition may not significantly reduce overall mortality in sepsis patients but may shorten ICU stays and decrease the incidence of AKI stage 3. Further research is needed to identify specific patient characteristics that benefit most from early EN.

The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study

BACKGROUND

Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN.

METHODS

In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeeding during three-month study period. Decisions regarding EN were made and substantiated by the doctors. No feeding protocol was in use. The EN rate was assessed daily and considered insufficient if less than 50 kcal/h was administered and the rate had not increase in the previous 12 hour period.

RESULTS

Eighty-seven patients were screened for 707 patient-days. Nurses documented 141 instances of insufficient EN in 49 patients (56.7% of all study subjects). EN was not initiated in 61% of these cases, EN was stopped in 14%, EN decreased in 2% and insufficient EN was not increased in 23%. EN was not initiated primarily due to surgical reasons. EN was not increased due to clinical instability. EN was decreased or stopped primarily due to high gastric residual volumes (GRV). The study served as step one in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol.

CONCLUSION

The main reasons for insufficient EN in intensive care patients include recent GI surgery, shock and large GRV. EN is commonly withheld for several days after GI surgery, whereas in shock there was a prohibition on increasing EN towards the target. Insufficient EN is highly prevalent; the incidence of EN should be reduced by training and the acceptance of more liberal EN policies.

Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study

PURPOSE

Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.

METHODS

In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.

RESULTS

We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.

CONCLUSION

In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.

Recent advances in multidisciplinary critical care

The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.

Development and current use of parenteral nutrition in critical care - an opinion paper

Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

Experience with an enteral-based nutritional support regimen in critically ill trauma patients

BACKGROUND

Assuring adequate enteral nutritional support in critically ill patients is challenging. By describing our experience, we sought to characterize the challenges, benefits, and complications of an approach that stresses enteral nutrition.

STUDY DESIGN

We examined nutritional support received by victims of blunt trauma from 8 trauma centers. We grouped patients according to mean daily enteral caloric intake during the first 7 days. Group 1 received the fewest (0 kcal/kg/d) and group 5 the greatest (16 to 30 kcal/kg/d) number of calories in the first week. We focused our analyses on the patients remaining in the ICU for 8 days or longer and compared clinical outcomes among the groups.

RESULTS

There were 1,100 patients in the ICU for 8 days or longer. Patients receiving the greatest number of enteral calories during the first week (group 5) had the highest incidence of ventilator-associated pneumonia (49%) and the lowest incidence of bacteremia (14%). Use of parenteral nutrition was associated with bacteremia (adjusted odds ratio = 2.5; 95% CI, 1.8-3.5), ventilator-associated pneumonia (adjusted odds ratio = 2.4; 95% CI, 1.7-3.3), and death (adjusted odds ratio = 1.9; 95% CI, 1.1-3.1).

CONCLUSIONS

Enteral caloric intake during the first week was related to the pattern and severity of injury and was associated with important infectious outcomes. Our observations support moderating enteral intake during the first week after injury and avoiding parenteral nutrition.