Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer

Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature

PURPOSE OF REVIEW

This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention.

RECENT FINDINGS

Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.

Safety of probiotics in patients receiving nutritional support: a systematic review of case reports, randomized controlled trials, and nonrandomized trials

BACKGROUND

Probiotics are increasingly used in patients receiving nutritional support; however, some case reports and trials have questioned their safety in such patients.

OBJECTIVE

The objective was to investigate the safety of probiotics in patients receiving nutritional support through a systematic review of case reports, randomized controlled trials (RCTs), and nonrandomized trials.

DESIGN

The systematic review followed Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. Six electronic databases were searched, a hand search of conference proceedings and reference lists was performed, and experts were contacted. Case reports, RCTs, and nonrandomized trials of probiotic use in patients also receiving enteral or parenteral nutrition were included in the review. Two reviewers independently screened the relevant articles and extracted the data.

RESULTS

In total, 1966 articles were identified, of which 72 fulfilled the inclusion criteria. There were 20 case reports of adverse events in 32 patients, all of which were infections due to Lactobacillus rhamnosus GG or Saccharomyces boulardii; the risk factors included central venous catheters and disorders associated with increased bacterial translocation. There were 52 articles reporting 53 trials in which 4131 patients received probiotics. Most trials showed either no effect or a positive effect on outcomes related to safety (eg, mortality and infections). Only 3 trials showed increased complications, which were largely noninfectious in nature and in specific patient groups (eg, transplant and pancreatitis). In 2 of these trials, the probiotic was administered through a postpyloric tube.

CONCLUSION

Many probiotics have been used safely in patients receiving nutritional support, although some probiotic products (strains or combinations) have been shown to increase the risk of complications in specific patient groups.

Enteral-tube-feeding diarrhoea: manipulating the colonic microbiota with probiotics and prebiotics

Diarrhoea is a common and serious complication of enteral tube feeding. Its pathogenesis involves antibiotic prescription, enteropathogenic colonization and abnormal colonic responses, all of which involve an interaction with the colonic microbiota. Alterations in the colonic microbiota have been identified in patients receiving enteral tube feeding and these changes may be associated with the incidence of diarrhoea. Preventing negative alterations in the colonic microbiota has therefore been investigated as a method of reducing the incidence of diarrhoea. Probiotics and prebiotics may be effective because of their suppression of enteropathogenic colonization, stimulation of immune function and modulation of colonic metabolism. Randomized controlled trials of probiotics have produced contrasting results, although Saccharomyces boulardii has been shown to reduce the incidence of diarrhoea in patients in the intensive care unit receiving enteral tube feeding. Prebiotic fructo-oligosaccharides have been shown to increase the concentration of faecal bifidobacteria in healthy subjects consuming enteral formula, although this finding has not yet been confirmed in patients receiving enteral tube feeding. Furthermore, there are no clinical trials investigating the effect of a prebiotic alone on the incidence of diarrhoea. Further trials of the efficacy of probiotics and prebiotics, alone and in combination, in preventing diarrhoea in this patient group are warranted.

Practicalities of nutrition support in the intensive care unit

PURPOSE OF REVIEW

Nutrition support improves clinical outcomes in the critically ill and our understanding of its effects has advanced significantly over the last few years. Three recently published evidence-based guidelines have made generally consistent and thorough recommendations to assist clinicians in providing nutrition support. This review will focus on various aspects of these recommendations, concentrating on the practicalities of nutrition support in the intensive care unit, such as its optimal mode and composition.

RECENT FINDINGS

Enteral nutrition is preferred to parenteral nutrition unless there is a major gut condition which will delay commencement of enteral nutrition. Nasogastric feeding should begin within 24 h, but if intolerance develops, small bowel feeding or pro-motility drugs (erythromycin or metoclopramide) should be attempted before resorting to supplementary parenteral nutrition. Enteral nutrition should not routinely be supplemented with arginine or glutamine, but it should contain a package of eicosapentaenoic acid, gamma-linolenic acid and antioxidants if the patient has acute lung injury or sepsis. Parenteral nutrition should be glutamine supplemented and the prescription should be limited in energy to avoid hyperglycemia. Whether using enteral nutrition or parenteral nutrition, most patients should receive intravenous selenium, and may also need zinc and copper supplementation.

SUMMARY

Intensive care unit patients should have nutrition support based on recent evidence-based guidelines with a preference for nasogastric feeding. If intolerance occurs, pro-motility drugs and small bowel feeding should be attempted. Clinicians should also consider carefully the composition of the nutrition support regimen with regard to lipid content (especially eicosapentaenoic acid and gamma-linolenic acid), antioxidants, glutamine and other micronutrients.