Experience with enteral nutrition in a hospital population of acutely ill patients

Development of clinical application for a nutritional prescription support system for total parenteral/enteral nutrition

One of the important roles of pharmacists as members of a nutrition support team is nutritional prescription support. We developed a nutritional prescription support system (NPSS) that facilitates prescription support and analysis and evaluated its usefulness in nutritional therapy. An NPSS for prescription support and the management of patient information was created. With this NPSS, the nutritional status was assessed, and, on the basis of the results, such variables as the total energy expenditure were calculated. This system allows prescription support for parenteral nutrition (PN) therapy, enteral nutrition (EN) therapy, and the transition period between them. This system was used for 2 representative patients and evaluated. In a malnourished patient receiving oral warfarin, EN solutions were compared by means of the NPSS, and an appropriate EN solution was selected. In addition, the prothrombin time-international normalized ratio was monitored, and favorable results were obtained regarding the adjustment of the warfarin dose and nutritional management. In a patient with aspiration pneumonia, continuous nutritional management to EN from PN therapy was straightforwardly performed with the NPSS. This NPSS allows rapid, comprehensive nutritional management during the transition period to EN from PN therapy, despite these therapies being considered separately in conventional nutritional management. The NPSS is useful for simplifying prescription support and facilitating information sharing among members of a nutrition support team.

Intermittent oro-esophageal tube feeding in acute stroke patients -- a pilot study

OBJECTIVE

Acute stroke patients with dysphagia are usually fed by nasogastric tube. However, this method sometimes causes pneumonia or diarrhea. We investigated the use of a new feeding procedure called intermittent oro-esophageal (IOE) tube feeding in acute stroke patients with severe dysphagia.

MATERIALS AND METHODS

The IOE method was used in 13 acute stroke patients (68 +/- 14 years old; 12 had a brainstem infarction), who were alert, but had severe dysphagia and a weak pharyngeal reflex. IOE tube feeding was carried out as follows. A feeding tube was passed orally into the lower portion of the esophagus, food supplements were administered through the tube at a rate of approximately 50 ml/min, and the tube was removed after finishing the supplement infusion.

RESULTS

We found that the IOE method had the following advantages: (i) IOE feeding took approximately 15 min; (ii) potentially reduced a risk of complications such as pneumonia and diarrhea; and (iii) oral tube insertion stimulated the oral cavity and pharynx, which may improve the swallowing function. However, the IOE feeding method should not be used in patients who: (i) could not understand the IOE procedure; (ii) had an esophageal hiatal hernia or incomplete peristalsis of the esophagus, as such patients are at risk of having the supplement reflux into the oral cavity.

CONCLUSION

The IOE feeding method may be one of the alternatives to continuous nasogastric tube feeding in acute stroke patients with severe dysphagia, who are alert.

Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding?

INTRODUCTION

Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area.

METHOD

A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications.

RESULTS

The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported.

CONCLUSION

The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

Nutritional intake in the critically ill: Improving practice through research

Enteral feeding is the preferred method of nutritional support in the critically ill; however, evidence suggests that many critically ill patients do not meet their nutritional goals. The implementation of enteral feeding protocols has improved nutritional delivery, although protocols can be widely variable. Similarly, enteral feeding related nursing practice is also inconsistent within and between intensive care units (ICUs). These variations in enteral feeding practice can be linked to the shortage of reliable and valid research into the many issues associated with the effective delivery of enteral nutrition. In the absence of a strong research tradition and practice, rituals are embraced and rarely challenged, further contributing to the wide variations in enteral feeding practice. Of particular importance are practice issues related to the commencement of enteral feeding and the assessment of feeding tolerance. This article seeks to review the literature related to commencing enteral feeding, with particular reference to the suitability of enteral nutrition, methods of enteral feeding and adjustment of enteral feeding rates. Issues relating to feeding intolerance, including the assessment of gastric residual volume and the development of diarrhoea, will also be explored.

Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites

OBJECTIVE

We describe our protocol for performing decompression radiologic gastrostomy and gastrojejunostomy in patients with ascites and small-bowel obstruction. We also assess the technical success rate, the complications, and the morbidity and mortality in 45 patients who underwent radiologic gastrostomy.

MATERIALS AND METHODS

Forty-five consecutive patients with ascites associated with metastatic ovarian cancer underwent a radiologic gastrostomy or gastrojejunostomy with gastropexy. Six patients underwent gastrostomy, and 39 patients underwent gastrojejunostomy. Locking catheters were placed using the Seldinger technique after gastropexy in all patients. Paracentesis was performed before gastrostomy or gastrojejunostomy. Additional serial paracenteses were performed after the procedure when reaccumulation of ascites close to the site of gastropexy was detected on follow-up sonography.

RESULTS

Forty-five procedures were attempted. The technical success rate was 97.8%. The complication rate was 15.6%. Three major complications (6.7%) and four minor complications (8.9%) occurred. One procedure-related death (2.2%) occurred 16 days after gastrojejunostomy.

CONCLUSION

Radiologic gastrostomy and gastrojejunostomy can be performed safely in patients with ascites if the patients undergo paracentesis first and if the reaccumulation of ascites is prevented after tube placement. In patients with ascites, gastropexy plays an important role in preventing pericatheter leakage. Ascites and peritoneal carcinomatosis should not be considered contraindications for radiologic gastrostomy or gastrojejunostomy.

Nasogastric tube feeding and medication administration: a survey of nursing practices

Using a 62-item, investigator-developed mailed questionnaire, this descriptive study of 350 randomly selected staff nurses sought to identify variations in practices in the care of patients with nasogastric tubes (NGT). Reported here are the results from the 35 questionnaire items related to NGT feedings and medication administration. Wide variations were found in the amount of gastric residual considered "excessive," as well as in whether the entire residual was returned to the stomach. A large percentage of the nurses relied on physicians' orders for gavage feeding rate, giving additional water, and using the liquid form of a medication. Data indicate that published nursing research is not consistently used in practice, which represents a theory-practice gap. In addition, a theory-practice deficit in several areas related to NGT feedings points to the need for further research.

Gastric decompression in adult patients. Survey of nursing practice

Using a 62-item investigator-developed mailed questionnaire, this descriptive study of 350 randomly selected staff nurses sought to identify variations in practices in the care of patients with nasogastric tubes. Reported here are the results on the 15 questionnaire items related to the use of nasogastric tubes for gastric decompression. Results show that practice is not always consistent with published research; additionally, there are areas of practice for which no research was found. Subjects' responses by age, education, and amount of experience showed marked frequency variations on several items, as did employment in teaching versus community hospitals. Results have implications for nursing educators in clinical agencies and nursing schools.

Application of A.S.P.E.N. clinical guidelines: parenteral nutrition use at a university hospital and development of a practice guideline algorithm

Few studies have attempted to implement the 1993 A.S.P.E.N. Guidelines into clinical practice. We retrospectively studied parenteral nutrition (PN) use over a 3-month period in 148 patients. Forty-three percent of PN starts lasted < or = 5 days. This short-term use of PN was more likely to occur when peripheral access for PN was used. Overall, short-term use of PN was found over a wide variety of diagnoses for a large number of reasons given in the medical record. Next, an algorithm was developed for the decision to initiate PN based on the 1993 A.S.P.E.N. Guidelines and was used to evaluate the use of PN. Several potential means for reducing overuse of PN were identified: using established criteria for malnutrition, restricting PN to known conditions in which the gastrointestinal (GI) tract cannot be used, and recognizing the transitory nature of many GI disorders.