Effect of early enteral nutrition on outcomes of trauma patients requiring intensive care

Clinical effects and safety of semi-solid feeds in tube-fed patients: a meta-analysis and systematic review

Background

Enteral nutrition is a very important form of treatment for critically ill patients. This meta-analysis aimed to evaluate the clinical effects and safety of semi-solid feeds in tube-fed patients.

Methods

Two researchers searched PubMed, clinical trials, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data, and Weipu databases for randomized controlled trials (RCTs) on the clinical effects and safety of semi-solid feeds in tube-fed patients until 10 October 2023. The quality evaluation tool recommended by the Cochrane Library was used to evaluate the quality of included RCTs. RevMan 5.4 software was used for data analysis.

Results

A total of eight RCTs involving 823 tube-fed patients were included in this meta-analysis. A synthesized outcome indicated that semi-solid feeds reduced the incidence of diarrhea (RR = 0.32, 95%CI:0.20-0.50, P < 0.001), vomiting (RR = 0.31, 95%CI:0.15-0.64, P = 0.002), abdominal distension (RR = 0.41, 95%CI:0.22-0.76, P = 0.005), length of intensive care unit (ICU) stay (MD = -3.61, 95%CI: -6.74 to -0.48, P = 0.02), and length of hospital stay (MD = -7.14, 95%CI: -10.31 to -3.97, P < 0.01) in tube-fed patients. Enteric feeding had no effect on the 30-day mortality (RR = 0.55, 95%CI: 0.19-1.56, P = 0.26). No publication bias was detected by the Egger's test results (all P > 0.05).

Conclusion

Semi-solid feeds are beneficial in reducing the incidence of diarrhea, abdominal distension, vomiting, and hospital stay. More high-quality studies are needed in the future to verify the effects of semi-solid feeds on mortality.

Impact of a multidisciplinary collaborative nutritional treatment model in patients who are critically ill with neurological disorders: A randomized controlled trial

BACKGROUND

Malnutrition is a widespread problem in critically ill patients with neurological disorders.

OBJECTIVE

The purpose of this study is to investigate the effect of a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support on the outcome metrics in patients with neurological disorders who are critically ill.

METHODS

We enrolled 84 participants who were hospitalized in the intensive care unit (ICU) of Yancheng No. 1 People's Hospital for neurological disorders between June 2018 and December 2021. The participants were randomly assigned to the control group and the test group. The control group received traditional nutritional support, while the test group was treated with a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support. We collected the general information, feeding tolerance (FT), nutritional risk score, and laboratory indicators before intervention, after intervention for one week, and after intervention for 2 weeks, and other data of the participants.

RESULTS

After the intervention, the test group scored significantly lower than the control group in the incidence of gastroparesis and diarrhea, as well as the NUTRIC score, with statistically significant differences (P< 0.001). The prealbumin levels in the test group increased progressively prior to intervention, after intervention for one week, and after intervention for two weeks. Compared to the control group, the test group had higher prealbumin levels prior to intervention, after intervention for one week, and after intervention for two weeks, with statistically significant differences (P< 0.001).

CONCLUSION

We developed a multidisciplinary collaborative nutritional treatment model based on a standard unit for nutritional support. This model can improve neural function, FT, and pertinent outcome indicators and is generally applicable.

Influence of early enteral nutrition plus probiotics on intestinal function of senile patients with sepsis

PURPOSE

This research project aimed to discuss the effect of early enteral nutrition (EEN) plus probiotics on intestinal function of senile patients with sepsis.

METHODS

108 senile sepsis patients admitted to our hospital from January 2019 to January 2022 were selected in this retrospective study. These patients including 50 cases in a control group (CG) and 58 cases in a research group (RG). Both groups received EEN, but the research group was given EEN plus probiotics. The two cohorts of patients were compared with respect to treatment efficacy, intestinal mucosal barrier, nutritional status and 28-day mortality. Cox regression was performed to analyze the prognostic factors of elderly patients with sepsis.

RESULTS

Compared to the CG, the RG had evidently higher overall response rate and post-treatment albumin (Alb) and prealbumin (PA) levels, as well as statistically lower intestinal fatty acid binding protein, diamine oxidase, D-lactate and 28-day mortality. Furthermore, Alb and PA were identified as independent predictors of prognosis in elderly patients with sepsis.

CONCLUSIONS

EEN supplemented with probiotics is superior to EEN alone in the treatment of senile patients with sepsis. This combined regimen can significantly improve intestinal function, nutritional status and prognosis of patients. Moreover, Alb and PA are independently related to the prognosis of elderly patients with sepsis.

The efficacy of modified HuangLian JieDu decoction for early enteral nutrition in patients with sepsis: A randomized controlled study

OBJECTIVE

This study aimed to evaluate the efficacy of modified HuangLian JieDu decoction (MHLJDD) as a supplementary medication for early enteral nutrition in septic patients.

METHODS

This study was designed as a randomized controlled preliminary study. Septic patients were randomly divided into control (treated with the base treatment) and intervention (co-treated with MHLJDD and the base treatment) groups. The primary outcomes of this study were 60-day (d) mortality rate, length of mechanical ventilation (MV), and length of stay in the intensive care unit (ICU).

RESULTS

Of the 86 included patients, 44 and 42 were allocated to the intervention and control groups, respectively. Lengths of MV and ICU stay were significantly shorter in the intervention group than in the control group (10.31 ± 3.92 d vs 8.66 ± 2.84 d, P = .028; and 11.88 ± 5.25 d vs 10.41 ± 3.14 d, P = .029; respectively). However, the difference in 60-d mortality rate between the 2 groups was not statistically significant (20.45% vs 38.10%, P = .071). The enteral-nutrition tolerance score of the control group was higher than that of the intervention group (6.81 ± 4.28 vs 4.68 ± 4.04, P = .020). Incidence of hyperglycemia and gastric retention (gastric residual volume > 250 mL) was higher in the control group than in the intervention group (59.52% vs 29.55%, P = .005; and 28.57% vs 11.36%, P = .020, respectively).

CONCLUSIONS

MHLJDD can shorten the MV and ICU stay of septic patients.

A scoping review considering potential biomarkers or functional measures of gastrointestinal dysfunction and enteral feeding intolerance in critically ill adults

BACKGROUND & AIM

Enteral feeding intolerance (EFI) as a result of gastrointestinal (GI) dysfunction in critically ill adults can lead to suboptimal nutritional delivery, increasing the risk of hospital acquired malnutrition. There are no validated measures of EFI or consensus as to which measures could be used to define EFI. The aim of this scoping review is to explore the validity of biomarkers, physiological or functional measures of GI dysfunction and EFI in critically ill adults characterising their use in routine clinical practice to identify those with GI dysfunction to better guide nutritional support.

METHODS

Database searches were completed in Ovid MEDLINE, Embase, CINAHL and Web of Science using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The search was performed until June 2022. Articles were included if they reported original studies that identify potential biomarkers or functional measures of EFI in critically ill adults. A nine-stage process was completed to extract and complete data synthesis.

RESULTS

139 unique articles were identified. Following review of titles and abstracts, 114 of these articles were excluded, three further articles were excluded after full text review and 22 articles met the inclusion criteria. A thematic analysis of the articles included identified three overarching themes of GI dysfunction: (1) Serum biomarkers, (2) Physiological markers, and (3) Functional markers. Within the category of serum biomarkers, a further three sub-categories were identified: (i) enterohormones, (ii) markers of enterocyte function, and iii) cytokines and neurotransmitters. Some associations were seen between EFI and heparin binding protein, intra-abdominal pressure, cholecystokinin and acetylcholine levels but no markers are currently suitable for daily clinical use.

CONCLUSIONS

Further larger studies are required to characterise the relationships between serum biomarkers, physiological and functional makers of GI dysfunction in critically ill adults. A robust definition of GI dysfunction should be included in any future research.

Effect of Enteral Nutrition on the Intestinal Microbiome and Risk of Death in Ischemic Stroke Patients

BACKGROUND

Studies have shown that the intestinal microbiome of stroke patients is significantly altered and that the degree of microbiota disturbance correlates with prognosis. Enteral nutrition can reshape the intestinal microbiome and is important for stroke patients with dysphagia. We aimed to describe the intestinal microbiome in patients with ischemic cerebral infarction receiving standard enteral nutrition.

METHODS

First, 17 healthy controls (HC), 54 stroke patients with oral feeding (ON), and 50 stroke patients with enteral nutrition (EN) were matched to investigate the changes in the intestinal microbiota with enteral nutrition in the first week after admission and dynamic changes in the EN group in the second week. Second, we investigated the relationship between the intestinal microbiome and clinical characteristics in a larger sample of participants receiving enteral nutrition (n=147). Survival analysis was performed using Cox proportional hazards regression. The composition and structure of the intestinal microbiota were analyzed by 16S rRNA sequencing.

RESULTS

Compared with the HC and ON groups, patients with enteral nutrition exhibited significantly different compositions of the intestinal microbiota in the first week, including enrichment of the opportunistic pathogen Enterococcus and depletion of bacteria such as Lachnospiraceae, and Ruminococcus, which were further depleted in the second week. An increase in Parvimonas and Comamonas abundances was associated with an increased risk of 180-day mortality.

CONCLUSIONS

The intestinal microbiota in ischemic stroke patients receiving enteral nutrition is significantly altered, and specific strains of bacteria may be associated with prognosis and clinical indicators. This article is protected by copyright. All rights reserved.

Early metabolic support for critically ill trauma patients: A prospective randomized controlled trial

BACKGROUND

There is a lack of consensus regarding the optimal nutritional support for trauma patients. We hypothesize that early postinjury metabolic support focusing on adequate protein would modify the metabolic signature and alter the inflammatory environment for critically ill trauma patients.

METHODS

We conducted a prospective randomized controlled pilot trial for adult patients admitted to the surgical intensive care unit following traumatic injury. Patients were randomized to receive early metabolic support (EMS) (peripheral amino acid infusions) or standard of care (enteral nutrition as soon as feasible). Routine laboratory assessments, nitrogen balance, cytokines, and metabolomic analyses were assessed at baseline and day 5 after intervention.

RESULTS

A total of 42 trauma patients were randomized into well-balanced groups with similar age (32 years), Injury Severity Score (25), and body mass index (27.4 kg/m2). Early metabolic support provided significantly more protein (1.43 g/kg vs. 0.35 g/kg; p < 0.0001) and more calories (12.6 kcal/kg vs. 7.5 g/kg; p = 0.0012) over the first 5 days as compared with the standard of care. Early metabolic support modified protein catabolism and synthesis as demonstrated by a larger median negative nitrogen balance (-16.3 g vs. -5.3 g; p = 0.03) and a unique metabolomic profile at day 5. The biochemical profile of patients who received EMS was defined by greater declines in circulating levels of stress hormone precursors and increased levels of amino acids. The inflammatory response following EMS resulted in a greater decrease in interleukin-1B (p = 0.02) and increase in soluble interleukin-6 receptor (p = 0.01) between baseline and day 5 as compared with the standard of care. The EMS group had a decreased length of stay (15 vs. 22 days) and decreased surgical intensive care unit length of stay (8 vs. 9 days); however, this disappeared after adjustment for Injury Severity Score in this small population.

CONCLUSIONS

Early metabolic support with amino acid is safe, modifies metabolism, and may downregulate the inflammatory state associated with significant trauma, warranting a larger trial to assess for improved outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07-0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

The applied research on the intra-abdominal pressure monitoring in early enteral nutrition in patients with severe pneumonia

OBJECTIVE

To explore the applied value of intra-abdominal pressure (IAP) monitoring in early enteral nutrition (EEN) in patients with severe pneumonia.

METHODS

96 patients with severe pneumonia who underwent EEN treatment in our hospital from June 2017 to June 2019 were selected. According to the random number table method, they were divided into a control group (48 patients) and an observation group (48 patients). The control group was treated using the conventional EN method, and the observation group was treated using the intra-abdominal pressure monitoring besides the conventional EN method. The incidence of EN intolerance, the acute physiology and chronic health evaluation (APECHEll) scores, the positive end expiratory pressure (PEEP) value, mechanical ventilation time, EN implementation days, length of stay in ICU, the incidence of ventilator-associated pneumonia, mortality, and the incidence of multiple organ dysfunction syndrome were compared between the two groups.

RESULTS

Compared with the control group, the incidence of EEN intolerance in the observation group was significantly reduced. The results of univariate analysis showed that, in the EN intolerance group, the IAP, the PEEP value and APACHEII scores after 3 days of EEN implementation were higher than the EEN tolerance group, indicating a influencing factor of EEN intolerance (P<0.05). The results of multivariate analysis showed that IAP value was a risk factor for EEN intolerance (P<0.05). The ROC curve analysis result for IAP to predict EEN tolerance showed that the area under the curve for IAP value to predict EN tolerance was 0.856, the optimal cut-off value was 10.73 mmHg, the sensitivity was 95.10%, and the specificity was 89.60%.

CONCLUSION

The intra-abdominal pressure monitoring during the EEN in patients with severe pneumonia is a preferred method to guide the patients' EEN.

The Need for Nutritional Education Reform in US Medical Education System

BACKGROUND

To compare the setting, quality, and utility of nutritional education received by general surgery residents and faculty surgeons and their perceptions and challenges in managing patient nutritional needs.

METHODS

Cross-sectional analysis utilizing anonymous survey data distributed by the Association of Program Directors in Surgery (APDS) to its affiliated general surgery residency programs.

RESULTS

90.2% (n = 65) of residents and 85.7% (n = 24) of faculty surgeons reported having received nutritional education. The majority (78%) of respondents utilize patient nutrition on a regular basis (monthly or more often), with 54% reporting utilization daily or weekly. Overall, 65% of respondents reported experiencing challenges in managing patient nutritional needs, and 86% agreed that additional nutritional education during training would assist with patient care. Residents and faculty surgeons both significantly reported challenges in determining which specific nutritional formula to use (X² = 22.414, P = .049). Residents were associated with reporting challenges in successfully managing oral, enteral, and parenteral routes of nutrition (X² = 16.241, P = .023).

CONCLUSIONS

Despite receiving nutritional education, the majority of surgery residents and faculty surgeons report difficulty in managing their patients nutritional needs. Surgery residents report difficulties with all delivery modes of nutrition, including oral, parenteral, and enteral. Revising medical school nutritional education competencies to focus on more practical aspects of nutrition, reform of formal course format, greater interprofessional collaboration with dieticians starting at the student level, and enforcement of nutritional education requirements by medical school and residency program accrediting bodies can serve to advance physicians' nutritional knowledge and improve patient outcomes.