Gastric-tube versus post-pyloric feeding in critical patients: a systematic review and meta-analysis of pulmonary aspiration- and nutrition-related outcomes

The enteroendocrine axis and its effect on gastrointestinal function, nutrition, and inflammation

PURPOSE OF REVIEW

Gastrointestinal (GI) dysfunction limits enteral nutrition (EN) delivery in critical illness and contributes to systemic inflammation. The enteroendocrine (EE) axis plays an integral role in this interface between nutrition, inflammation, and GI function in critical illness. In this review, we present an overview of the EE system with a focus on its role in GI inflammation and function.

RECENT FINDINGS

Enteroendocrine cells have been primarily described in their role in macronutrient digestion and absorption. Recent research has expanded on the diverse functions of EE cells including their ability to sense microbial peptides and metabolites and regulate immune function and inflammation. Therefore, EE cells may be both affected by and contribute to many pathophysiologic states and interventions of critical illness such as dysbiosis , inflammation, and alternative EN strategies. In this review, we present an overview of EE cells including their growing role in nonnutrient functions and integrate this understanding into relevant aspects of critical illness with a focus on EN.

SUMMARY

The EE system is key in maintaining GI homeostasis in critical illness, and how it is impacted and contributes to outcomes in the setting of dysbiosis , inflammation and different feeding strategies in critical illness should be considered.

Nutritional support for the trauma and emergency general surgery patient: What you need to know

ABSTRACT

Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Nutrition practices in critically ill adults receiving noninvasive ventilation: A quantitative survey of Australian and New Zealand intensive care clinicians

BACKGROUND

Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap.

OBJECTIVE

The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults.

METHODS

A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with ≥12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%).

RESULTS

A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n = 108, 79%) reported that nutrition during NIV was 'important or very important'. Oral intake was perceived to be the most common route (n = 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n = 106, 78%) reported that ≤50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n = 55, 40%). Reported nutrition barriers were aspiration risk (n = 87, 64%), fasting for intubation (n = 84, 62%), and nutrition perceived as a lower priority (n = 73, 54%). Reported facilitators were evidence-based guidelines (n = 77, 57%) and an NIV interface compatible with enteral nutrition tube (n = 77, 57%).

CONCLUSION

ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored.

Aspiration pneumonia in enteral feeding: A review on risks and prevention

Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.

Effectiveness and safety of early postpyloric feeding during therapeutic hypothermia in patients with large hemispheric infarction: A retrospective cohort study

BACKGROUND

What kind of feeding should be provided during therapeutic hypothermia (TH) in patients with large hemispheric infarction (LHI) is not clear. Therefore, we conducted a retrospective observational study to determine whether providing early postpyloric feeding (PPF) (<24 h after admission) is beneficial or harmful for patients with this condition.

METHODS

This study retrospectively screened 78 patients with LHI who were treated with TH from one neurological intensive care unit (ICU). The patients were receiving either early PPF (n = 52) or early parenteral nutrition (PN) (n = 26). Data regarding 30-day mortality, neurological outcome, nutrition-related laboratory indicators, ICU hospitalization time, mechanical ventilation (MV) duration, and complications were collected.

RESULTS

A greater number of patients who received early PPF had favorable neurologic outcome than those who received early PN (57.7% vs 30.7%, P = 0.025). The early PPF group had a lower severity of pulmonary infection than the early PN group, as measured by the Clinical Pulmonary Infection Score (7.33 ± 0.96 vs 9.42 ± 2.11, P = 0.006). The total protein and hemoglobin levels in the early PPF group were higher than those in the early PN group (59.56 ± 5.09 vs 56.52 ± 7.94 g/L, P = 0.046; 131.06 ± 19.58 vs 122.07 ± 17.72 g/L, P = 0.045). The MV duration and ICU hospitalization time were shorter in the early PPF group (13 [9;21] vs 21 [14;30] days, P = 0.006; 28 [22;36] vs 34 [33;51] days, P = 0.014). There were no significant differences in the incidence of catheter-related bloodstream infections, 30-day mortality, or nutrition intolerance between the two groups.

CONCLUSION

Early PPF is an effective and safe enteral nutrition method for patients with LHI receiving TH.

Preprocedural fasting policies for patients receiving tube feeding: A national survey

BACKGROUND

Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures.

METHODS

The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated.

RESULTS

The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed.

CONCLUSIONS

Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

Nasogastric tube insertion length measurement and tip verification in adults: a narrative review

Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.

Stomach position evaluated using computed tomography is related to successful post-pyloric enteral feeding tube placement in critically ill patients: a retrospective observational study

BACKGROUND

Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement.

METHODS

Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion.

RESULTS

Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91).

CONCLUSIONS

Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.

Current insights in ICU nutrition: tailored nutrition

PURPOSE OF REVIEW

To summarize recent research on critical care nutrition focusing on the optimal composition, timing, and monitoring of enteral feeding strategies for (post)-ICU patients. We provide new insights on energy and protein recommendations, feeding intolerance, and describe nutritional practices for coronavirus disease 2019 ICU patients.

RECENT FINDINGS

The use of indirect calorimetry to establish individual energy requirements for ICU patients is considered the gold standard. The limited research on optimal feeding targets in the early phase of critical illness suggests avoiding overfeeding. Protein provision based upon the absolute lean body mass is rational. Therefore, body composition measurements should be considered. Body impedance analysis and muscle ultrasound seem reliable, affordable, and accessible methods to assess body composition at the bedside. There is inadequate evidence to change our practice of continuous enteral feeding into intermittent feeding. Finally, severe acute respiratory syndrome coronavirus 2 patients are prone to underfeeding due to hypermetabolism and should be closely monitored.

SUMMARY

Nutritional therapy should be adapted to the patient's characteristics, diagnosis, and state of metabolism during ICU stay and convalescence. A personalized nutrition plan may prevent harmful over- or underfeeding and attenuate muscle loss. Despite novel insights, more research is warranted into tailored nutrition strategies during critical illness and convalescence.

Challenges of Gastric Versus Post-pyloric Feeding in COVID-19 Disease

Purpose of the Review

The COVID-19 pandemic has had an unprecedented challenge to the critical care providers caring for those patients, including the delivery of nutrition. This review will address the challenges of gastric versus post gastric feeding in patients in COVID-19 disease.

Recent Recommendations

Many societies, including American, British, and Australian recommend initiating of enteral feeding in COVID-19 patients as soon as 24 h of ICU admission or within 12 h after intubation. Consideration for post-pyloric feeding if there is evidence of intolerance to gastric feeding.

Summary

The same principle for non-COVID-19 critically ill patients applies to COVID-19 patients when it comes to the route of nutritional delivery. Gastric feeding should be initiated as soon as 24 h of admission to the ICU, and post gastric feeding should be reserved to patients who demonstrate gastric feeding intolerance.

Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation

Background

Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported.

Objective

We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients.

Methods

A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates.

Results

The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05).

Conclusion

Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.

Risk factors for pneumonia in hospitalized older people with femoral fractures: Results from a Brazilian prospective cohort

BACKGROUND

Pneumonia is a common complication in older people who are hospitalized to treat different fractures, which increases morbimortality in this population.

OBJECTIVES

Estimating the pneumonia incidence density in older people hospitalized to treat femoral fractures and identifying risk factors for this infection.

METHODS

Prospective cohort study whose data were collected from a population of older people who were being treated for femoral fractures at a hospital in the central region of Brazil between September 2016 and February 2017. The pneumonia diagnosis was based on radiography and clinical tests. Incidence density was estimated according to gender, age, Charlson comorbidity index, polypharmacy, chronic pulmonary disease, admission to the intensive care unit, surgical treatment, and nasoenteral tube feeding. Magnitude of the associations was estimated by multiple Poisson regression.

RESULTS

Among the 200 patients, the pneumonia incidence density was 13.04/1,000 person-days. For men and older people 80 years old or older, the pneumonia incidence density was 15.6/1,000 person-days and 18.3/1,000 person-days, respectively. After adjusting for age, gender, chronic pulmonary disease, and admission to the intensive care unit, use of nasoenteral tubes remained associated with occurrence of pneumonia in older people, and the risk of developing the infection was eight times higher in the population who received nasoenteral feeding than that calculated for the population that did not use the devices (p ≤ 0.001).

CONCLUSION

Using nasoenteral tubes during hospital stays increased the risk of developing pneumonia in hospitalized older people, which reinforces the need for continuous care monitoring regarding use of tubes to prevent complications.

Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial

BACKGROUND

Ventilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding.

METHODS/DESIGN

In this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely.

DISCUSSION

The VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia.

TRIAL REGISTRATION

Chictr.org.cn ChiCTR2100051593 . Registered on 28 September 2021.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

A Two-Stage Bedside Intubation Method to Improve Success Rate of Post-pyloric Placement of Spiral Nasoenteric Tubes in Critically Ill Patients: A Multi-Center, Prospective Study

Backgrounds

Prokinetic agents could improve the success rate of post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs), and bedside blind technique might apply as a rescue therapy subsequent to spontaneous transpyloric migration failure. The objective of this study was to investigated the validity and safety of these two bedside intubation methods as a sequential procedure for post-pyloric placement of spiral NETs in critically ill patients.

Methods

The multicenter, prospective study was conducted in intensive care units of four tertiary hospitals (June 2020 to January 2021). Eligible patients received self-propelled spiral NET placements, promoted by prokinetic agents (Stage 1). An abdominal X-ray performed 24 h post-intubation confirmed the position of the tube tip. Patients with a failed transpyloric migration entered Stage 2, where beside blind intubation was conducted (reconfirmed by X-ray). The primary end point was the overall success rate of post-pyloric placement.

Results

The overall success rate of post-pyloric placement of the spiral NET was 91.1% (73.4% in the third portion of the duodenum [D3] or beyond). The total adverse event rate was 21.0%, without any serious adverse events. In Stage 1, 55.6% of participants achieved transpyloric migration, of these, 44.4% migrated to D3 or beyond. The median time from decision to intubate to the initiation of enteral nutrition (EN) was 25 h. In Stage 2, 83.0% of patients had successful post-pyloric intubation (67.9% in D3 or beyond). The median time from decision to EN initiation after the two-stage process was 36 h.

Conclusions

Prokinetic agents-assisted self-propelled intubation and remedial bedside blind technique as a sequential procedure for post-pyloric placement of spiral NETs were effective and safe, and this two-stage process did not affect the implementation of early EN in critically ill patients.

Trial Registration

Chinese Clinical Trial Registry, ChiCTR1900026381. Registered on 6 October 2019.

Placement of Nasogastric Feeding Tube and Postinsertion Care Review

Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.