Safe practices for enteral nutrition in critically ill patients

Effect of abdominal massage on feeding intolerance in patients receiving enteral nutrition: A systematic review and meta‐analysis

AIM

This study aimed to evaluate the effect of abdominal massage (AM) on feeding intolerance (FI) in patients receiving enteral nutrition (EN).

DESIGN

A systematic review and meta-analysis.

METHODS

We searched seven electronic databases to September 2021. STATA and RevMan were used to analyse the data.

RESULTS

Eleven studies were included. The results revealed that AM could significantly reduce gastric residual volume and abdominal circumference difference, and reduce the incidence of gastric retention, vomiting, abdominal distention (all p < 0.001), diarrhoea (p = 0.02) and constipation (p = 0.002) in the experimental group. One study reported the incidence of aspiration in the control group was higher, but this was not statistically significant (p = 0.07). The meta-regression analysis showed there was a statistically significant correlation between intervention personnel and gastric residual volume (p = 0.035).

CONCLUSION

AM could reduce the amount and incidence of gastric retention and the changes in abdominal circumference, and significantly reduce the incidence of gastrointestinal symptoms, without increasing the incidence of aspiration for EN patients. No Patient or Public Contribution.

Safety of Using Enteral Nutrition Formulations Containing Dietary Fiber in Hospitalized Critical Care Patients: A Systematic Review and Meta-Analysis

Enteral nutrition (EN) is the preferred route of nutrition support for patients with critical illness undergoing intensive care. Experts in the field caution against using fiber during EN because of perceived adverse patient outcomes; however, a comprehensive assessment of this topic is not evident to date. In this systematic review and meta-analysis, we searched four databases from inception to April 20, 2020, for studies on adverse events or health outcomes associated with using EN formulations containing fiber in hospitalized adults with critical illness. Nineteen articles were included. Random-effects meta-analysis models showed significantly lower diarrhea scores for fiber groups compared with nonfiber groups (pooled mean difference: -2.78; 95% CI, -4.10 to -1.47) but mixed results for risk of diarrhea between groups, depending on measures used for diarrhea (Hart and Dobb scale, pooled risk ratio [RR]: 0.68; 95% CI, 0.45-1.02; other diarrhea scales, pooled RR: 0.42; 95% CI, 0.20-0.89). Models showed 39% lower risk of gastrointestinal (GI) complications overall for fiber compared with nonfiber groups (pooled RR: 0.61; 95% CI, 0.47-0.79) but no group differences for individual GI complications, mortality, and intensive care unit or hospital length of stay. Analyses stratified by soluble- or mixed-fiber interventions reduced heterogeneity in models but showed identical conclusions. EN formulas with fiber may help reduce incidence and severity of diarrhea and GI complications overall in critically ill patients, without increased risk of other adverse events. Bias among specific GI measures indicates more high-quality studies are needed to verify these conclusions.

Effect of abdominal massage on prevention of aspiration in intubated and enterally fed patients: A randomized controlled trial

Background Aspiration is a serious side effect of delayed gastric emptying and increased residual volume in intensive care patients. Aspiration can increase the risk of pneumonia and death. Currently, pharmaceutical methods are the most commonly used techniques for decreasing aspiration, but non-pharmaceutical methods may also be effective in reducing aspiration. One of these methods is an abdominal massage. The present study aimed to examine the effect of abdominal massage on aspiration incidence in intensive care patients with an endotracheal tube. Methods This study was a randomized controlled clinical trial. Seventy intensive care patients with an endotracheal tube were chosen by convenience sampling and allocated to an intervention or a control group by the minimization method. The intervention group was provided with a 15-min abdominal massage twice a day for 3 days, while the control group received only routine cares. The patients' respiratory secretion was suctioned before and after the intervention, and immediately after suctioning, the incidence of the aspiration was assessed using special strips which are sensitive to respiratory secretion pH and glucose. SPSS 18 was used to analyze data. Descriptive statistics were used. T independent, Mann-Whitney U, χ2, and Fisher exact tests were used to compare two groups. Results The incidence rates of the aspiration were 5.7% (confidence interval: 0.0-14.3%) and 20% (confidence interval: 8.6-34.3%) in the abdominal massage and the control groups, respectively. The incidence of aspiration differed between two groups, but it was not statistically significant (p=0.07). Conclusion Although the low rate of aspiration in the abdominal massage group did not differ significantly with that of the control group, it can be clinically important. It is suggested that further studies be conducted to confirm the effect of abdominal massage on the prevention of aspiration in intensive care patients with an endotracheal tube.

Medical Nutrition Terminology and Regulations in the United States and Europe-A Scoping Review: Report of the ISPOR Nutrition Economics Special Interest Group

BACKGROUND

The term medical nutrition (MN) refers to nutritional products used under medical supervision to manage disease- or condition-related dietary needs. Standardized MN definitions, aligned with regulatory definitions, are needed to facilitate outcomes research and economic evaluation of interventions with MN.

OBJECTIVES

Ascertain how MN terms are defined, relevant regulations are applied, and to what extent MN is valued.

METHODS

ISPOR's Nutrition Economics Special Interest Group conducted a scoping review of scientific literature on European and US MN terminology and regulations, published between January 2000 and August 2015, and pertinent professional and regulatory Web sites. Data were extracted, reviewed, and reconciled using two-person teams in a two-step process. The literature search was updated before manuscript completion.

RESULTS

Of the initial 1687 literature abstracts and 222 Web sites identified, 459 records were included in the analysis, of which 308 used MN terms and 100 provided definitions. More than 13 primary disease groups as per International Classification of Disease, Revision 10 categories were included. The most frequently mentioned and defined terms were enteral nutrition and malnutrition. Less than 5% of the records referenced any MN regulation. The health economic impact of MN was rarely and insufficiently (n = 19 [4.1%]) assessed, although an increase in economic analyses was observed.

CONCLUSIONS

MN terminology is not consistently defined, relevant European and US regulations are rarely cited, and economic evaluations are infrequently conducted. We recommend adopting consensus MN terms and definitions, for example, the European Society for Clinical Nutrition and Metabolism consensus guideline 2017, as a foundation for developing reliable and standardized medical nutrition economic methodologies.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

A breath of fresh air: a quality-improvement study comparing an air-circulating technique versus conventional technique to prevent nasogastric tube dysfunction

Background

Nasogastric tubes are an important component of care in patients with gastrointestinal obstructions. However, they are prone to malfunction despite conventional flushing techniques, with potentially severe consequences. There is no widely accepted, gold-standard way to ensure that a nasogastric tube succeeds in maintaining an empty stomach following flushing.

Methods

We have developed a flushing technique to better ensure successful tube function. We compared this technique to conventional flushing both in vitro (using a plastic stomach model) and in vivo (in a pig model), and we provide a didactic video.

Results

The mean gastric residual volume following our novel flushing technique is nearly 25-fold lower than following conventional flushing (13 mL vs. 330 mL).

Conclusions

Our simple technique is more effective than conventional techniques in maintaining nasogastric tube function and therefore should prevent dangerous vomiting and aspiration pneumonia better than conventional techniques.

Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis

AIM: To investigate fiber and prebiotic supplementation of enteral nutrition (EN) for diarrhea, fecal microbiota and short-chain fatty acids (SCFAs).

METHODS: MEDLINE, EMBASE, Cochrane Library, CINAHL, Academic Search Premier, and Web of Science databases were searched for human experimental and observational cohort studies conducted between January 1990 and June 2014. The keywords used for the literature search were fiber, prebiotics and enteral nutrition. English language studies with adult patient populations on exclusive EN were selected. Abstracts and/or full texts of selected studies were reviewed and agreed upon by two independent researchers for inclusion in the meta-analysis. Tools used for the quality assessment were Jadad Scale and the Scottish Intercollegiate Guidelines Network Critical Appraisal of the Medical Literature.

RESULTS: A total of 456 possible articles were retrieved, and 430 were excluded due to lack of appropriate data. Of the 26 remaining studies, only eight investigated the effects of prebiotics. Results of the meta-analysis indicated that overall, fiber reduces diarrhea in patients receiving EN (OR = 0.47; 95%CI: 0.29-0.77; P = 0.02). Subgroup analysis revealed a positive effect of fiber supplementation in EN towards diarrhea in stable patients (OR = 0.31; 95%CI: 0.19-0.51; P < 0.01), but not in critically ill patients (OR = 0.89; 95%CI: 0.41-1.92; P = 0.77). Prebiotic supplementation in EN does not improve the incidence of diarrhea despite its manipulative effect on bifidobacteria concentrations and SCFA in healthy humans. In addition, the effect of fiber and/or prebiotic supplementation towards fecal microbiota and SCFA remain disputable.

CONCLUSION: Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive.

Optimizing nutrition therapy to enhance mobility in critically ill patients

Critically ill patients are at high risk of malnutrition and lean body mass loss. Screening for malnutrition and performing detailed assessment of energy needs should be routine for patients admitted to intensive care units. Providing adequate calorie and protein provisions can attenuate muscle loss in many at-risk patients. Enteral nutrition is associated with decreased risks of morbidity and infections and is therefore preferred to parenteral nutrition in hemodynamically stable patients with favorable anatomy. Judicious use of steroids and paralytics in combination with adequate glucose control may decrease the risk of developing critical illness polyneuromyopathy. There is growing evidence for the potential immune-enhancing benefits of many micronutrients and vitamins in the critically ill, but more research is needed to determine which nutrients are most effective in which disease processes and what dosing regimens are safe and effective. Elderly, obese, and very young patients pose unique challenges for nutrition therapy and early mobility programs. Pairing early mobility programs with optimal nutrition therapy can help reduce morbidity, limit muscle loss, and speed recovery in intensive care unit patients.

Jordanian nurses' knowledge and responsibility for enteral nutrition in the critically ill

BACKGROUND

Poor nursing adherence to evidence-based guidelines has negative consequences leading to higher mortality rates, delayed recovery and longer length of stay. Evidence-based practice has the potential to minimize complications and discrepancies between nurses.

AIM

This study aimed to assess nurses' practice and perception of their knowledge and responsibility in relation to enteral nutrition (EN) in the critically ill.

DESIGN AND METHODS

This descriptive correlational design was applied to nurses working in intensive care units (ICUs) from three health care sectors in Jordan (Governmental, Military and Private sectors). Nurses were recruited using a stratified sampling technique. A pre-prepared questionnaire focusing on nurses' practice and perception towards EN was used.

RESULTS

A total of 253 ICU nurses completed the questionnaire. Nurses revealed a tendency to undertake nutritional care despite the recognition clinical nutrition is a secondary role. In terms of nursing processes, nurses showed greater levels of knowledge and responsibility for 'preventing complications' and 'evaluation' more than 'assessment' and 'identifying goals'. Nurses inadequately assess both gastric residuals and tube placement before feeding. Diarrhoea was the most frequent complication followed by abdominal pain, vomiting, tube dislodgment and weight loss. However, nurses realized that the incidences of complications is less likely when applying evidence-based protocol.

CONCLUSION

It is necessary to establish a preliminary assessment for patients' nutritional needs prior to using EN. Aspiration reduction measures are still deficient and need further attention. An evidence-based protocol for EN should be adopted in the critically ill.

RELEVANCE TO CLINICAL PRACTICE

This article provides insight into the current practice of Jordanian intensive care nurses in different health care sectors. The study can contribute to redirect the perception of nurses towards nutrition in the critically ill in addition to enhance positive adherence to evidence base.

Monitoring for intolerance to gastric tube feedings: a national survey

BACKGROUND

Confusion about how to assess for intolerance to feedings often results in unnecessary feeding interruptions.

OBJECTIVES

To report findings from a national survey of methods used by critical care nurses to assess tolerance to gastric tube feedings and to discuss the findings in light of current enteral nutrition guidelines.

METHODS

A paper-and-pencil survey was mailed to 1909 members of the American Association of Critical-Care Nurses. In addition, the same survey was posted online in a newsletter circulated to association members. Results from both surveys were pooled for data analysis.

RESULTS

A total of 2298 responses were obtained; most respondents reported using a combination of methods to assess tolerance to gastric tube feedings (listening for bowel sounds, measuring gastric residual volumes, observing for abdominal distention/discomfort and for nausea and vomiting). More than 97% of the nurses reported measuring gastric residual volumes; the most frequently cited threshold levels for interrupting feedings were 200 mL and 250 mL. About 25% of the nurses reported interrupting feedings for gastric residual volumes of 150 mL or less; only 12.6% of the respondents reported allowing gastric residual volumes of up to 500 mL before interrupting feedings.

CONCLUSIONS

Practice among the 2298 critical care nurses varied widely. Many of the survey respondents are practicing in ways that can unnecessarily diminish the delivery of calories to patients. Protocols based on current enteral nutrition guidelines must be developed and implemented in practice settings.