Decisions to be made when initiating enteral nutrition

Gastric Versus Small Bowel Feeding in Critically Ill Adults

Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.

Feeding tube placement: errors and complications

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

Enteral feeding in the critically ill: the role of the gastroenterologist

Expertise in enteral nutrition (EN) is an important aspect of the skill set of the clinical gastroenterologist. Delivery of adequate EN in critically ill patients is an active therapy that attenuates the metabolic response to stress and favorably modulates the immune system. EN is less expensive than parenteral nutrition and is favored in most cases because of improvement in patient outcomes, including infections and length of stay. Newer endoscopic techniques for placing nasoenteric feeding tubes have been developed, which improve placement success and efficiency. It appears that there is an ideal window period of 24-48 h when enteral feeding should be started in critically ill patients. Most patients can be fed into the stomach, but certain groups may benefit from small bowel feeding. Protocols on how to start and monitor enteral feeding have been developed. Immune-modulating feeding formulations also appear to be beneficial in specific patient populations. The gastroenterologist is a crucial member of the multidisciplinary team for nutritional support in the intensive care unit patient, with his knowledge of gastrointestinal pathophysiology, nutrition, and endoscopic feeding-tube placement.