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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Jing W, Wu S, Gao S, Shi X, Liu W, Ren Y, Ouyang L, Zheng K, Guo S, Wu C, Jin G. Early oral feeding versus nasojejunal early enteral nutrition in patients following pancreaticoduodenectomy: a propensity score-weighted analysis of 428 consecutive patients. Int J Surg 2024; 110:229-237. [PMID: 37755371 PMCID: PMC10793729 DOI: 10.1097/js9.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/10/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Notwithstanding that significant medical progress has been achieved in recent years, the optimal nutritional support method following pancreaticoduodenectomy (PD) remains uncertain. This study compared the safety and feasibility of early oral feeding (EOF) with nasojejunal early enteral nutrition (NJEEN) after PD. METHODS A retrospective cohort study was conducted on 428 consecutive patients who underwent PD between August 2018 and December 2020. During the first study phase, the routine postoperative feeding strategy was NJEEN, later replaced by EOF during the second study phase. The primary outcome was the incidence of delayed gastric emptying (DGE) following PD. Propensity score weighting was used to control for confounding factors. RESULTS Four hundred forty patients underwent PD during the overall study period, with 438 patients aged 18 years and older. Ten patients experienced accidental tube dislodgement or migration and were excluded from the study based on the exclusion criteria. Finally, 211 patients and 217 patients underwent EOF and NJEEN, respectively. After propensity score weighting, it was observed that patients who underwent postoperative EOF experienced a significantly lower DGE (B/C) rate compared to those who underwent postoperative NJEEN [7.38% (31/424) vs. 14.97% (62/413), P =0.0005]. Subgroup analyses according to the presence of soft pancreatic texture yielded consistent results. The EOF group exhibited lower DGE grade, DGE (B/C) rate [5.90% (11/194) vs. 22.07% (43/193), P <0.0001], postoperative gastrointestinal endoscopic intervention rate, and Clavien-Dindo Grade III or higher rate. CONCLUSIONS EOF is superior to NJEEN in reducing the incidence of grade B/C DGE after PD. The EOF procedure is safe and feasible and should be recommended as the optimal postoperative feeding method following PD.
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Affiliation(s)
- Wei Jing
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Shengyong Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Wuchao Liu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Yiwei Ren
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Liu Ouyang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Kailian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Cheng Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
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Amenu E, Karim S, Da Silva RC. Tube Feeding-Related Bowel Ischemia Presenting As Extensive Intestinal Pneumatosis Complicated With Hepatic Portal Venous Gas. Cureus 2022; 14:e24313. [PMID: 35602779 PMCID: PMC9122104 DOI: 10.7759/cureus.24313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Hepatic portal venous gas (HPVG) is a condition where air embolization from disrupted intestinal mucosa reaches the portal system. It is an uncommon finding and denotes severity. This report describes HPVG as a rare and lethal complication of enteral nutrition. The patient had a history of pancreatic adenocarcinoma (PADC) managed with Whipple's surgery, complicated with poor oral intake, requiring percutaneous jejunostomy. Subsequently, the patient presented with severe abdominal pain and distension. On imaging, he was found to have diffuse pneumatosis intestinalis (PI) and HPVG. The patient underwent exploratory laparotomy with intraoperative findings of bowel ischemia starting at the distal point of the enteral tube feeding. Despite aggressive intensive support, the patient died. The aim of this case description is to highlight a rare complication of enteral feeding with impressive imaging findings. Intensive care providers should consider this complication in patients with acute abdominal symptoms, who are under enteral feeding.
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Affiliation(s)
- Eunice Amenu
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Sahar Karim
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Rafael C Da Silva
- School of Medicine, Universidade Para o Desenvolvimento do Alto Vale do Itajaí, Rio do Sul, BRA
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
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Fujii K, Seki T, Nakata Y, Atagi K, Matsuyama T. Non-occlusive mesenteric ischemia during acute stroke management: three case reports. Surg Case Rep 2022; 8:36. [PMID: 35226203 PMCID: PMC8885953 DOI: 10.1186/s40792-022-01392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background There are many reports of non-occlusive mesenteric ischemia in patients on maintenance hemodialysis and following cardiac surgery. However, there are few reports of non-occlusive mesenteric ischemia in patients with acute stroke. Case presentation We report three cases of non-occlusive mesenteric ischemia with onset during treatment for acute stroke. All of the patients were undergoing strict blood-pressure control, and two patients developed NOMI soon after tracheostomy when enteral nutrition had been resumed. Conclusion Many stroke patients are older adults with risk factors such as arteriosclerosis. Thus, during acute stroke management, there is a possibility that patients may develop non-occlusive mesenteric ischemia due to decreased intestinal blood flow secondary to strict blood-pressure control. This case report implicates early enteral nutrition as a potential etiopathogenic factor of non-occlusive mesenteric ischemia in patients with acute stroke.
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Affiliation(s)
- Kazuki Fujii
- Nara Prefecture General Medical Center, 2-897-5, Schichijo Nishimachi, Nara, Nara, 630-8581, Japan.
| | - Tadahiko Seki
- Nara Prefecture General Medical Center, 2-897-5, Schichijo Nishimachi, Nara, Nara, 630-8581, Japan
| | - Yasuyuki Nakata
- Nara Prefecture General Medical Center, 2-897-5, Schichijo Nishimachi, Nara, Nara, 630-8581, Japan
| | - Kazuaki Atagi
- Nara Prefecture General Medical Center, 2-897-5, Schichijo Nishimachi, Nara, Nara, 630-8581, Japan
| | - Takeshi Matsuyama
- Nara Prefecture General Medical Center, 2-897-5, Schichijo Nishimachi, Nara, Nara, 630-8581, Japan
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Preiser JC, Arabi YM, Berger MM, Casaer M, McClave S, Montejo-González JC, Peake S, Reintam Blaser A, Van den Berghe G, van Zanten A, Wernerman J, Wischmeyer P. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Crit Care 2021; 25:424. [PMID: 34906215 PMCID: PMC8669237 DOI: 10.1186/s13054-021-03847-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/27/2021] [Indexed: 12/15/2022] Open
Abstract
The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.
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Affiliation(s)
- Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium.
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mette M Berger
- Adult Intensive Care, Lausanne University Hospital, CHUV, 1011, Lausanne, Switzerland
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stephen McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Juan C Montejo-González
- Intensive Care Medicine, Hospital Universitario, 12 de Octubre, Instituto de Investigación imas12, Madrid, Spain
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, Australia.,Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arthur van Zanten
- Ede and Division of Human Nutrition and Health, Gelderse Vallei Hospital, Wageningen University and Research, Wageningen, The Netherlands
| | - Jan Wernerman
- Division of Anaesthesiology and Intensive Care Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
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Dorken Gallastegi A, Gebran A, Gaitanidis A, Naar L, Hwabejire JO, Parks J, Lee J, Kaafarani HMA, Velmahos GC, Mendoza AE. Early versus late enteral nutrition in critically ill patients receiving vasopressor support. JPEN J Parenter Enteral Nutr 2021; 46:130-140. [PMID: 34599785 DOI: 10.1002/jpen.2266] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/14/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Outcomes of early enteral nutrition (EEN) in critically ill patients on vasoactive medications remain unclear. We aimed to compare in-hospital outcomes for EEN vs late EN (LEN) in mechanically ventilated patients receiving vasopressor support. METHODS This was a retrospective study using the national eICU Collaborative Research Database. Adult patients requiring vasopressor support and mechanical ventilation within 24 h of admission and for ≥2 days were included. Patients with an admission diagnosis that could constitute a contraindication for EEN (eg, gastrointestinal [GI] perforation, GI surgery) and patients with an intensive care unit (ICU) length of stay (LOS) <72 h were excluded. EEN and LEN were defined as tube feeding within 48 h and between 48 h and 1 week (nothing by mouth during the first 48 h) of admission, respectively. Propensity score matching was performed to derive two cohorts receiving EEN and LEN that were comparable for baseline patient characteristics. RESULTS Among 1701 patients who met the inclusion criteria (EEN: 1001, LEN: 700), 1148 were included in propensity score-matched cohorts (EEN: 574, LEN: 574). Median time to EN was 29 vs 79 h from admission in the EEN and LEN groups, respectively. There was no significant difference in mortality or hospital LOS between the two nutrition strategies. EEN was associated with shorter ICU LOS, lower need for renal replacement therapy, and lower incidence of electrolyte abnormalities. CONCLUSION This study showed no difference in 28-day mortality between EEN and LEN in critically ill patients receiving vasopressor support.
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Affiliation(s)
- Ander Dorken Gallastegi
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Gebran
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Apostolos Gaitanidis
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leon Naar
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Parks
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April E Mendoza
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ruiz NC, Kamel AY, Shoulders BR, Rosenthal MD, Murray-Casanova IM, Brakenridge SC, Moore FA. Nonocclusive mesenteric ischemia: A rare but lethal complication of enteral nutrition in critically ill patients. Nutr Clin Pract 2021; 37:715-726. [PMID: 34462980 DOI: 10.1002/ncp.10761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism guidelines recognize that critically ill patients receiving stable, low doses of vasopressors have experienced the advantages of early initiation of enteral nutrition (EN). However, clinical questions remained unanswered including vasopressor combinations associated with complications, the advent of other therapies during hypotensive states, as well as the volume and content of EN that might contribute to the development of a nonocclusive mesenteric ischemia (NOMI). PRESENTATION A 68-year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease with two-vessel bypass grafting, and peripheral vascular disease underwent subtotal excision of an infected right axillofemoral-femoral bypass graft. Postoperatively, EN was held because of hemodynamic instability and postsurgical complications. A fiber-free, high-protein, and low-residue formula was started at 10 ml/h while the patient was receiving stable doses of midodrine, norepinephrine, and vasopressin. Despite advancement of tube-feed rates to goal, nasogastric output never exceeded 300 ml. Computerized tomography of the abdomen showed diffuse bowel distention with pneumatosis, concerning for bowel ischemia. No surgical interventions were pursued, and the patient died. CONCLUSIONS Our patient developed NOMI postoperatively while receiving EN. Further studies addressing EN route, trophic vs full EN, recommended formula, the safety of vasoactive agents, the addition of fiber to EN, and continuous venovenous hemodiafiltration in relation to NOMI are needed, as there continues to be clinical controversy regarding these topics.
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Affiliation(s)
- Nicole C Ruiz
- Department of Internal Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amir Y Kamel
- Department of Pharmacy, Nutrition Support/Critical Care Clinical Pharmacy Specialist, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Bethany R Shoulders
- Clinical Pharmacy Specialist, Surgical/Trauma ICU, College of Pharmacy, University of Florida and UF Health Shands Hospital, Gainesville, Florida, USA
| | - Martin D Rosenthal
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Irina M Murray-Casanova
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Scott C Brakenridge
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Frederick A Moore
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
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Affiliation(s)
- Jan Powers
- Jan Powers is Director for Nursing Research and Professional Practice at Parkview Health, Fort Wayne, Indiana
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss recent findings related to providing adequate and well tolerated nutrition to the critically ill surgical patient. RECENT FINDINGS The majority of nutritional studies in the critically ill have been performed on well nourished patients, but validated scoring systems can now identify high nutrition risk patients. Although it remains well accepted that early enteral nutrition with protein supplementation is key, mechanistic data suggest that hypocaloric feeding in septic patients may be beneficial. For critically ill patients unable to tolerate enteral nutrition, randomized pilot data demonstrate improved functional outcomes with early supplemental parenteral nutrition. Current guidelines also recommend early total parenteral nutrition in high nutrition risk patients with contraindications to enteral nutrition. When critically ill patients require low or moderate-dose vasopressors, enteral feeding appears well tolerated based on a large database study, while randomized prospective data showed worse outcomes in patients receiving high-dose vasopressors. SUMMARY Current evidence suggests early enteral nutrition with protein supplementation in critically ill surgical patients with consideration of early parenteral nutrition in high nutrition risk patients unable to achieve nutrition goals enterally. Despite established guidelines for nutritional therapy, the paucity of data to support these recommendations illustrates the critical need for additional studies.
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Al-Dorzi HM, Arabi YM. Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers. Nutr Clin Pract 2020; 36:88-97. [PMID: 33373481 DOI: 10.1002/ncp.10621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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11
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Mesenteric ischemia with pneumatosis intestinalis and portal vein gas associated with enteral nutrition: a series of three patients. Clin J Gastroenterol 2020; 13:1160-1164. [PMID: 32794155 DOI: 10.1007/s12328-020-01206-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/05/2020] [Indexed: 01/16/2023]
Abstract
Enteral nutrition is usually associated with a low risk of intestinal complications. We report three non-critically ill patients who received enteral nutrition and developed mesenteric ischemia with pneumatosis intestinalis and hepatic portal vein gas. These findings are often considered to be indications for emergency surgery. In these three patients, prompt cessation of enteral nutrition avoided progression to intestinal necrosis obviating the need for intestinal resection, although one patient underwent surgical exploration. Follow-up computed tomography scan showed resolution of the radiologic findings, and all patients started enteral nutrition again without complications. All patients had comorbidities associated with atherosclerosis, which may have led to a mismatch between oxygen delivery and demand in the bowel, resulting in ischemia. To the best of our knowledge, this is the first report of successful management of mesenteric ischemia related to enteral nutrition in non-critically ill patients without resection. If the cause of mesenteric ischemia such as enteral nutrition, can be eliminated quickly, non-resectional and possibly nonoperative management can be a reasonable management option, with close follow-up and readiness for resection.
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Sabino KM, Fuller J, May S, Wakefield D. Safety and Tolerance of Enteral Nutrition in the Medical and Surgical Intensive Care Unit Patient Receiving Vasopressors. Nutr Clin Pract 2020; 36:192-200. [PMID: 32643840 DOI: 10.1002/ncp.10548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/05/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Multiple societal guidelines recommend enteral nutrition (EN) be initiated within 24 to 48 hours of admission to the intensive care unit (ICU) once a patient is hemodynamically stable. Gastrointestinal intolerance and occurrence of bowel ischemia have been a concern for patients receiving vasopressors while concurrently receiving luminal nutrients. The study objective was to determine whether patients receiving vasopressors while concomitantly receiving enteral nutrients had more incidences of bowel ischemia and intolerance than those receiving EN without vasopressor agents. METHODS This retrospective study included 319 medical and surgical ICU patients from a level 1 trauma center. The patients were either receiving vasopressors simultaneously with EN (n = 178) or EN alone (n = 141). Data regarding gastric residual volume (GRV), new abdominal pain, emesis, and bowel ischemia were collected. RESULTS There were more patients who had elevated GRV in the group that received vasopressors than patients who did not (20% vs 7%; P-value < .01). There were no differences between rates of bowel ischemia, emesis, or new abdominal pain between the 2 groups. CONCLUSION Based on our findings, EN is generally well tolerated and safe for those patients simultaneously receiving vasopressors.
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Affiliation(s)
- Kim M Sabino
- Trinity Health Of New England, Saint Francis Hospital and Medical Center, Hartford, Connecticut, 06105, USA
| | - Julie Fuller
- Trinity Health Of New England, Saint Francis Hospital and Medical Center, Hartford, Connecticut, 06105, USA
| | - Scott May
- Trinity Health Of New England, Saint Francis Hospital and Medical Center, Hartford, Connecticut, 06105, USA
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ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
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Patel JJ, Rice T, Heyland DK. Safety and Outcomes of Early Enteral Nutrition in Circulatory Shock. JPEN J Parenter Enteral Nutr 2020; 44:779-784. [PMID: 32052460 DOI: 10.1002/jpen.1793] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/17/2019] [Accepted: 01/06/2020] [Indexed: 12/28/2022]
Abstract
Circulatory shock is one of the most common reasons for an intensive care unit admission, has been shown to impair gut barrier and immune functions, and promotes dysbiosis. The exact timing and dose of enteral nutrition (EN) in circulatory shock remains unclear. In fact, because of fear of complications such as nonocclusive mesenteric ischemia and bowel necrosis and splanchnic steal phenomenon, clinicians may hesitate to start EN in critically ill patients with circulatory shock. In this narrative review, we identify and appraise contemporary evidence evaluating the safety and outcomes of EN in circulatory shock.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Todd Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Daren K Heyland
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Hu B, Sun R, Wu A, Ni Y, Liu J, Guo F, Ying L, Ge G, Ding A, Shi Y, Liu C, Xu L, Jiang R, Lu J, Lin R, Zhu Y, Wu W, Xie B. Prognostic Value of Prolonged Feeding Intolerance in Predicting All-Cause Mortality in Critically Ill Patients: A Multicenter, Prospective, Observational Study. JPEN J Parenter Enteral Nutr 2019; 44:855-865. [PMID: 31429970 DOI: 10.1002/jpen.1693] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/27/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The 2012 European Society of Intensive Care Medicine (ESICM) guidelines provided a clear definition of feeding intolerance (FI). The study aimed to investigate the association between FI based on the current ESICM definition and clinical outcome and to further explore the effect of the duration of FI on mortality. METHODS Adult patients from 14 general intensive care units (ICUs) with an expected ICU stay ≥24 hours were prospectively studied. Based on FI duration in the first week of admission to the ICU, FI was categorized as 7-day persistent feeding tolerance (FT), delayed FT, delayed FI, and 7-day persistent FI. The primary outcomes were 28-day and 60-day all-cause mortality. RESULTS Of 499 patients, the prevalence of 3-day and 7-day persistent FI was 39.2% (n = 196) and 25.4% (n = 106), respectively. The patients with 3-day FT had lower risk of 28-day and 60-day mortality rates and higher prevalence in ventilator weaning and vasoactive medication on the seventh day of ICU admission than those with 3-day FI. Three-day FI remained an independent predictor for 60-day mortality. In a subgroup analysis including 418 patients with 7-day survival, compared with those with 7-day persistent FT, the odds ratios of 60-day mortality were 1.67, 1.97, and 2.62 in the patients with delayed FT, delayed FI, and 7-day persistent FI, respectively. CONCLUSION FI was associated with increased mortality and longer duration of mechanical ventilation and vasoactive support. Prolonged or relapsing FI represented an incremental risk of adverse outcomes in critically ill patients.
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Affiliation(s)
- Bangchuan Hu
- ICU, Zhejiang Provincial People's Hospital, Hangzhou, P. R. China
| | - Renhua Sun
- ICU, Zhejiang Provincial People's Hospital, Hangzhou, P. R. China
| | - Aiping Wu
- ICU, Zhejiang Provincial People's Hospital, Hangzhou, P. R. China
| | - Yin Ni
- ICU, Zhejiang Provincial People's Hospital, Hangzhou, P. R. China
| | - Jingquan Liu
- ICU, Zhejiang Provincial People's Hospital, Hangzhou, P. R. China
| | - Feng Guo
- ICU, Sir Run Shaw Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, P. R. China
| | - Lijun Ying
- ICU, Shaoxing People's Hospital, Shaoxing, P. R. China
| | - Guoping Ge
- ICU, Jinhua People's Hospital, Jinhua, P. R. China
| | - Aijun Ding
- ICU, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, P. R. China
| | - Yunchao Shi
- ICU, The First Hospital of Jiaxing, Jiaxing, P. R. China
| | - Changwen Liu
- ICU, Hangzhou First People's Hospital, Hangzhou, P. R. China
| | - Lei Xu
- ICU, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo, P. R. China
| | - Ronglin Jiang
- ICU, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, P. R. China
| | - Jun Lu
- ICU, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, P. R. China
| | - Ronghai Lin
- ICU, Taizhou Hospital of Zhejiang Province, Linhai, P. R. China
| | - Yannan Zhu
- ICU, Zhuji People's Hospital of Zhejiang Province, Shaoxing, P. R. China
| | - Weidong Wu
- ICU, The Central Hospital of Lishui City, Lishui, P. R. China
| | - Bo Xie
- ICU, Huzhou Central Hospital, Huzhou, P. R. China
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Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kurita D, Fujita T, Horikiri Y, Sato T, Fujiwara H, Daiko H. Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature. Surg Case Rep 2019; 5:36. [PMID: 30788678 PMCID: PMC6382915 DOI: 10.1186/s40792-019-0580-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 02/04/2019] [Indexed: 12/27/2022] Open
Abstract
Background Non-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy. Case presentation In case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48. In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28. Conclusions The causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.
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Affiliation(s)
- Daisuke Kurita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yasumasa Horikiri
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takuji Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hisashi Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr 2019; 39:460-467. [PMID: 30808573 DOI: 10.1016/j.clnu.2019.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/18/2019] [Accepted: 02/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Despite extensive research on early enteral nutrition (EEN), it remains unclear whether EEN is effective for patients with shock requiring vasopressors. This study aimed to compare outcomes between EEN and late enteral nutrition (LEN) in ventilated patients with shock requiring low-, medium-, or high-dose noradrenaline. METHODS Using a national inpatient database in Japan, we identified ventilated patients admitted to intensive care units who had shock requiring catecholamines (noradrenaline or dobutamine) from July 2010 to March 2016. We defined patients who started enteral nutrition within 2 days after starting mechanical ventilation as EEN group and the others as LEN group. Propensity score matching was performed between patients undergoing EEN and LEN in each of the low- (<0.1 μg/kg/min), medium- (0.1-0.3 μg/kg/min), and high-dose (≥0.3 μg/kg/min) noradrenaline groups. RESULTS We identified 52,563 eligible patients during the 69-month study period, including 38,488, 11,042, and 3033 patients in the low-, medium-, and high-dose noradrenaline groups, respectively. One-to-two propensity score matching created 5,969, 2,162, and 477 one-to-two matched pairs in the low-, medium-, and high-dose noradrenaline groups, respectively. The 28-day mortality rate was significantly lower in the EEN than LEN group in the low-dose noradrenaline group (risk difference, -2.9%; 95% confidence interval [CI], -4.5% to -1.3%) and in the medium-dose noradrenaline group (risk difference, -6.8%; 95% CI, -9.6% to -4.0%). In the high-dose noradrenaline group, 28-day mortality did not differ significantly between the EEN and LEN groups (absolute risk difference, -1.4%; 95% CI, -7.4%-4.7%). CONCLUSIONS Although the size of the subgroup requiring high-dose noradrenaline may have been too small to demonstrate a significant difference, the results suggest that EEN was associated with a reduction in mortality in ventilated adults treated with low- or medium-dose noradrenaline but not in those requiring high-dose noradrenaline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Lewis SR, Schofield‐Robinson OJ, Alderson P, Smith AF. Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit. Cochrane Database Syst Rev 2018; 6:CD012276. [PMID: 29883514 PMCID: PMC6353207 DOI: 10.1002/14651858.cd012276.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition. OBJECTIVES To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting. AUTHORS' CONCLUSIONS We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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McCall ME, Adamo A, Latko K, Rieder AK, Durand N, Nathanson T. Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU. J Intensive Care Med 2017; 33:209-217. [PMID: 29284322 DOI: 10.1177/0885066617749175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery. DESIGN This was a prospective observation trial of up to 14 days duration. SETTING A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada. PATIENTS We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours. MEASUREMENTS We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines. MAIN RESULTS Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption. CONCLUSIONS Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.
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Affiliation(s)
- Michele E McCall
- 1 Medical/Surgical Intensive Care Unit, Specialized Complex Care Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Alice Adamo
- 2 Trauma/Neurosurgery Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ashley K Rieder
- 4 West Toronto Diabetes Education Program, Toronto, Ontario, Canada
| | - Nicole Durand
- 5 Georgian Bay Family Health Team, Collingwood, Ontario, Canada
| | - Tova Nathanson
- 1 Medical/Surgical Intensive Care Unit, Specialized Complex Care Program, St. Michael's Hospital, Toronto, Ontario, Canada
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Sethuraman SA, Dhar VK, Habib DA, Sussman JE, Ahmad SA, Shah SA, Tsuei BJ, Sussman JJ, Abbott DE. Tube Feed Necrosis after Major Gastrointestinal Oncologic Surgery: Institutional Lessons and a Review of the Literature. J Gastrointest Surg 2017; 21:2075-2082. [PMID: 28956273 DOI: 10.1007/s11605-017-3593-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/15/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Small bowel necrosis after enteral feeding through a jejunostomy tube (tube feed necrosis, TFN) is a rare, serious complication of major abdominal surgery. However, strategies to reduce the incidence and morbidity of TFN are not well established. Here, in the largest series of TFN presented to date, we report our institutional experience and a comprehensive review of the literature. METHODS Eight patients who experienced TFN from 2000 to 2014 after major abdominal surgery for oncologic indications at the University of Cincinnati were reviewed. Characteristics of post-operative courses and outcomes were reviewed prior to and after a change in tube-feeding protocol. The existing literature addressing TFN over the last three decades was also reviewed. RESULTS Patients with TFN ranged from 50 to 74 years old and presented with upper gastrointestinal tract malignancies amenable to surgical resection. Six and two cases of TFN occurred following pancreatectomy and esophagectomy, respectively. Prior to TF protocol changes, which included initiation at a low rate, titrating up more slowly and starting at one-half strength TF, three of six cases of TFN (50%) resulted in mortality. With the new TF protocol, there were no deaths, goal TF rate was achieved 3 days later, symptoms of TFN were recognized 3 days earlier, and re-operation was conducted 1 day earlier. CONCLUSION This case series describes a change in clinical practice that is associated with decreased morbidity and mortality of TFN. Wider implementation and further refinement of this tube-feeding protocol may reduce TFN incidence at other institutions and in patients with other conditions requiring enteral nutrition.
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Affiliation(s)
- S A Sethuraman
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - V K Dhar
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D A Habib
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - J E Sussman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Shah
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - B J Tsuei
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - J J Sussman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, K4/742, Madison, WI, 53792, USA.
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Abstract
BACKGROUND Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. METHODS Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. RESULTS The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. CONCLUSIONS Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.
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Ortiz LA, Dante Yeh D. Nutrition in the Post-surgical Patient: Myths and Misconceptions. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, Fruhwald S, Hiesmayr M, Ichai C, Jakob SM, Loudet CI, Malbrain MLNG, Montejo González JC, Paugam-Burtz C, Poeze M, Preiser JC, Singer P, van Zanten ARH, De Waele J, Wendon J, Wernerman J, Whitehouse T, Wilmer A, Oudemans-van Straaten HM. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 2017; 43:380-398. [PMID: 28168570 PMCID: PMC5323492 DOI: 10.1007/s00134-016-4665-0] [Citation(s) in RCA: 410] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022]
Abstract
Purpose To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. Methods We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. Results We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. Conclusions We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.
- Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Mette M Berger
- Services of Adult Intensive Care Medicine and Burns, Lausanne University Hospital, Lausanne, Switzerland
| | - Michael P Casaer
- Department of Intensive Care Medicine, University Hospital Leuven, Louvain, Belgium
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Hiesmayr
- Klinische Abteilung für Herz-Thorax-Gefäßchirurgische Anästhesie & Intensivmedizin, Medizinische Universität Wien, Vienna, Austria
| | - Carole Ichai
- Intensive Care Unit, Hôpital Pasteur 2, University of Nice, Nice, France
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland
| | - Cecilia I Loudet
- Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín de La Plata, Buenos Aires, Argentina
| | - Manu L N G Malbrain
- Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium
| | | | - Catherine Paugam-Burtz
- Anesthesiology and Perioperative Care Medicine Department, Hôpital Beaujon APHP, Clichy, France
| | - Martijn Poeze
- Department of Surgery/IntensiveCare Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Singer
- Intensive Care Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
- Anesthesia and Intensive Care Division, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Julia Wendon
- Department of Intensive Care Medicine, Division of Immunobiology and Transplantation, King's College London, King's College Hospital, London, UK
| | - Jan Wernerman
- Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK
| | - Alexander Wilmer
- Medical Intensive Care Unit, University Hospital Leuven, Leuven, Belgium
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Marr AB, McQuiggan MM, Kozar R, Moore FA. Gastric Feeding as an Extension of an Established Enteral Nutrition Protocol. Nutr Clin Pract 2017; 19:504-10. [PMID: 16215146 DOI: 10.1177/0115426504019005504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Indiscriminate gastric feeding in ICU patients imposes unacceptable risks of aspiration. Believing that a subset of ICU patients can be fed safely via the stomach, we have developed a protocol to identify appropriate patients and guide the bedside clinician in how to safely and effectively feed via the stomach. METHODS A literature search was done to identify appropriate medical literature. High grade evidence along with local expert opinions were used to develop a protocol. This protocol has been refined and implemented. RESULTS Based on perceived risk of aspiration, patients are assigned enteral access (ie, stomach vs. distal post-pyloric). Enteral formula is selected based on patient characteristics. It is then advanced by a standard protocol with specific precautions while monitoring for symptoms of intolerance. Management of intolerance is dictated by the type and severity of intolerance. CONCLUSION We have implemented a gastric feeding into a subset of our ICU patients. Gastric feeding requires certain precautions but appears to be safe. With more experience and better understanding of the pathogenesis gastroparesis, we believe that most ICU patients should be able to safely feed into the stomach. This is logistically easier than post-pyloric feeding and offers physiologic advantages.
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Affiliation(s)
- Alan B Marr
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, USA
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Abstract
Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. The purpose of this paper is to critically review the literature studying the use of enteral vs parenteral nutrition (PN) and to provide the rationale for early enteral nutrition. Additional controversies confronting clinicians are reviewed, including the use of immune-enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence-based recommendations for clinical practice are presented when available.
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Affiliation(s)
- S Rob Todd
- Acute Care Surgery, The Methodist Hospital-Houston/Weill Medical College of Cornell University, 6550 Fannin Street, Smith Tower 1661, TX 77030, USA.
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de Brito-Ashurst I, Preiser JC. Diarrhea in Critically Ill Patients: The Role of Enteral Feeding. JPEN J Parenter Enteral Nutr 2016; 40:913-23. [PMID: 27271709 DOI: 10.1177/0148607116651758] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
Abstract
This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bruns BR, Kozar RA. Feeding the Postoperative Patient on Vasopressor Support: Feeding and Pressor Support. Nutr Clin Pract 2015; 31:14-7. [PMID: 26703957 DOI: 10.1177/0884533615619932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Initiating enteral nutrition in the postoperative patient can be challenging. Postoperative ileus and bowel edema, bowel anastomosis, and intra-abdominal pathology contribute to the reluctance and inability to achieve adequate nutrition in this patient population. The addition of vasopressors confounds the difficulties. Clinical data are sparse but suggest that most postoperative patients requiring vasopressor therapy can be safely initiated and advanced on enteral nutrition. Consideration of the vasopressor agent being utilized and its dose is imperative, as are individual patient characteristics. Temporal changes in the dosage should be closely monitored, as increasing doses may reflect worsening clinical status that can be due to intestinal ischemia. Well-designed prospective trials are clearly necessary to address this controversial topic.
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Affiliation(s)
- Brandon R Bruns
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Rosemary A Kozar
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Abstract
Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.
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Dickerson RN, Voss JR, Schroeppel TJ, Maish GO, Magnotti LJ, Minard G, Croce MA. Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries. Nutrition 2015; 32:309-14. [PMID: 26704967 DOI: 10.1016/j.nut.2015.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. METHODS Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. RESULTS Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13). CONCLUSION The majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN.
| | - Johnathan R Voss
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Thomas J Schroeppel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Casaer MP, Ziegler TR. Nutritional support in critical illness and recovery. Lancet Diabetes Endocrinol 2015; 3:734-45. [PMID: 26071886 DOI: 10.1016/s2213-8587(15)00222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.
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Affiliation(s)
- Michael P Casaer
- Intensive Care Department and Laboratory of Intensive Care Medicine, Leuven University Hospitals, Leuven, Belgium.
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA, USA
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Capriati T, Cardile S, Chiusolo F, Torroni F, Schingo P, Elia D, Diamanti A. Clinical management of post-pyloric enteral feeding in children. Expert Rev Gastroenterol Hepatol 2015; 9:929-41. [PMID: 25926033 DOI: 10.1586/17474124.2015.1041506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Post-pyloric feeding (PF) allows the administration of enteral nutrition beyond the pylorus, either into the duodenum or, ideally, into the jejunum. The main indications of PF are: upper gastrointestinal tract obstructions, pancreatic rest (e.g., acute pancreatitis), gastric dysmotility (e.g., critically ill patients and chronic intestinal pseudo-obstruction) or severe gastroesophageal reflux with risk of aspiration (e.g., neurological disability). Physiological and clinical evidence derives from adults, but can also be pertinent to children. This review will discuss the practical management and potential clinical applications of PF in pediatric patients. Some key studies pertaining to the physiological changes during PF will also be considered because they support the strategy of PF management.
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Affiliation(s)
- Teresa Capriati
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy
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Rosenthal MD, Vanzant EL, Martindale RG, Moore FA. Evolving paradigms in the nutritional support of critically ill surgical patients. Curr Probl Surg 2015; 52:147-82. [PMID: 25946621 DOI: 10.1067/j.cpsurg.2015.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/29/2015] [Accepted: 02/11/2015] [Indexed: 12/12/2022]
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Aaben C, Hammarqvist F, Mabesa T, Hardcastle T. Complications relating to enteral and parenteral nutrition in trauma patients: a retrospective study at a level one trauma centre in South Africa. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2015. [DOI: 10.1080/16070658.2015.11734533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yang S, Wu X, Yu W, Li J. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutr Clin Pract 2014; 29:90-6. [PMID: 24449685 DOI: 10.1177/0884533613516167] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Early enteral nutrition (EEN) in critically ill patients is associated with significant benefit as well as elevated risk of complications. Concomitant use of EEN with vasopressors has been associated with nonocclusive bowel necrosis in critically ill patients with hemodynamic instability. The decision when to initiate enteral nutrition in hemodynamically unstable patients that require vasoactive substances remains a clinical dilemma. This review summarizes the effect of EEN and vasoactive agents on gastrointestinal blood flow and perfusion in critically ill patients, based on current evidence. Animal and clinical data involving simultaneous administration of EEN and vasoactive agents for hemodynamic instability are reviewed, and the factors related to the safety and effectiveness of EEN support in this patient population are analyzed. Moreover, practical recommendations are provided. Additional randomized clinical trials are warranted to provide cutting-edge evidence-based guidance about this issue for practitioners of critical care.
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Affiliation(s)
- Shuofei Yang
- Wenkui Yu, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, People's Republic of China, Nanjing, 210002, China.
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Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol 2014; 20:8505-8524. [PMID: 25024606 PMCID: PMC4093701 DOI: 10.3748/wjg.v20.i26.8505] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 02/10/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.
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Flordelís Lasierra JL, Pérez-Vela JL, Montejo González JC. Enteral nutrition in the hemodynamically unstable critically ill patient. Med Intensiva 2014; 39:40-8. [PMID: 24907000 DOI: 10.1016/j.medin.2014.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/25/2014] [Accepted: 04/04/2014] [Indexed: 12/15/2022]
Abstract
The benefit of enteral nutrition in critically ill patients has been demonstrated by several studies, especially when it is started early, in the first 24-48h of stay in the Intensive Care Unit, and this practice is currently advised by the main clinical guidelines. The start of enteral nutrition is controversial in patients with hemodynamic failure, since it may trigger intestinal ischemia. However, there are data from experimental studies in animals, as well as from observational studies in humans that allow for hypotheses regarding its beneficial effect and safety. Interventional clinical trials are needed to confirm these findings.
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Affiliation(s)
- J L Flordelís Lasierra
- Servicio de Medicina Intensiva, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - J L Pérez-Vela
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - J C Montejo González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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Plantefeve G, Hellmann R, Pajot O, Thirion M, Bleichner G, Mentec H. Abdominal compartment syndrome and intraabdominal sepsis: two of the same kind? Acta Clin Belg 2014; 62 Suppl 1:162-7. [PMID: 24881714 DOI: 10.1179/acb.2007.62.s1.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Abdominal compartment syndrome and intra-abdominal hypertension are frequently associated with peritonitis. The aim of this study is to establish the relationship between intra-abdominal hypertension and intra-abdominal sepsis especially in critically ill patients. METHODS Relevant information was identified through a Medline search (1966-October 2006). The terms used were "intra-abdominal sepsis", "peritonitis", "abdominal compartment syndrome", "intra-abdominal hypertension" and "relaparotomy for sepsis". The search was limited to English- and French-language publications. RESULTS Only a few clinical trials exist on this specific topic. Further investigations are required to define the incidence of intra-abdominal hypertension in intra-abdominal sepsis, and the prognostic impact of this setting and finally the potential specific treatment. Abdominal compartment syndrome is more likely linked to the abdominal surgery than to peritonitis itself. CONCLUSION Intra-abdominal pressure monitoring can be valuable in critically ill patients with suspicion of persisting intra-abdominal sepsis after surgical peritonitis treatment.
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Abstract
OBJECTIVE Although enteral nutrition is the ideal mode of nutritional support following burn injury, it is often interrupted during episodes of severe sepsis and hemodynamic instability, leading to significant energy and protein deficits. Parenteral nutrition is not commonly used in burn centers due to concerns that it will lead to hyperglycemia, infection, and increased mortality. However, parenteral nutrition is often utilized in our burn unit when goal rate enteral nutrition is not feasible.To determine the safety and efficacy of a standardized protein-sparing parenteral nutrition protocol in which glucose infusion is limited to 5-7 mg/kg/hour. DESIGN Retrospective observational study. SETTING Pediatric burn hospital. PATIENTS A retrospective medical record review of all children admitted to our hospital with burns ≥ 30% total body surface area was conducted. Only patients admitted within one week of injury and who survived > 24 hours after admission were included in this study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 105 patients who met the inclusion criteria, 96 (91%) received parenteral nutrition or a combination of parenteral nutrition and enteral nutrition at some point during their care. Nine patients received only enteral nutrition. Demographic data were similar between groups. Protein intake was significantly higher in the parenteral nutrition group. Incidence of catheter-related blood infections did not differ between groups. Use of parenteral nutrition was not associated with blood or respiratory infections. Overall mortality rate was low (4%), as most patients (96%) achieved wound closure and were discharged home. CONCLUSIONS Judicious use of parenteral nutrition is a safe and effective means of nutritional support when goal enteral nutrition cannot be achieved. A hypocaloric, high-nitrogen parenteral nutrition solution can reduce energy and protein deficits while minimizing complications commonly associated with parenteral nutrition usage.
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Early minimal enteral supplementation in severely burned children receiving parenteral nutrition. Pediatr Crit Care Med 2013; 14:332-3. [PMID: 23462358 DOI: 10.1097/pcc.0b013e31827d0e58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Disease-specific nutrition therapy: one size does not fit all. Eur J Trauma Emerg Surg 2013; 39:215-33. [PMID: 26815228 DOI: 10.1007/s00068-013-0264-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states. METHODS A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients. RESULTS Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients. CONCLUSION There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.
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Provision of Enteral Nutrition During Vasopressor Therapy for Hemodynamic Instability. Nutr Clin Pract 2012; 27:521-6. [DOI: 10.1177/0884533612448480] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Allen JM. Vasoactive Substances and Their Effects on Nutrition in the Critically Ill Patient. Nutr Clin Pract 2012; 27:335-9. [DOI: 10.1177/0884533612443989] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- John M. Allen
- Auburn University, Harrison School of Pharmacy, Mobile, Alabama
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Metheny NA, Mills AC, Stewart BJ. Monitoring for intolerance to gastric tube feedings: a national survey. Am J Crit Care 2012; 21:e33-40. [PMID: 22381994 DOI: 10.4037/ajcc2012647] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Norma A. Metheny
- Norma A. Metheny is a professor and Andrew C. Mills is an associate professor at Saint Louis University School of Nursing, St Louis Missouri. Barbara J. Stewart is a professor emerita at Oregon Health & Science University in Portland, Oregon
| | - Andrew C. Mills
- Norma A. Metheny is a professor and Andrew C. Mills is an associate professor at Saint Louis University School of Nursing, St Louis Missouri. Barbara J. Stewart is a professor emerita at Oregon Health & Science University in Portland, Oregon
| | - Barbara J. Stewart
- Norma A. Metheny is a professor and Andrew C. Mills is an associate professor at Saint Louis University School of Nursing, St Louis Missouri. Barbara J. Stewart is a professor emerita at Oregon Health & Science University in Portland, Oregon
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Who Is Benefited by Enteral Nutrition via Abdominal Vagal Signaling? Ann Surg 2011; 254:661-2; author reply 662. [DOI: 10.1097/sla.0b013e3182306151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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