Immediate enteral nutrition following multisystem trauma: a decade perspective

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

Feeding the Open Abdomen

BACKGROUND

The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA).

METHODS

Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation.

RESULTS

Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than $50,000.

CONCLUSIONS

EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Enteral nutrition versus parenteral nutrition after major abdominal surgery in patients with gastrointestinal cancer: a systematic review and meta-analysis

To clarify the benefits of enteral nutrition (EN) versus total parenteral nutrition (TPN) in patients with gastrointestinal cancer who underwent major abdominal surgery. Medline, Cochrane, EMBASE, and Google Scholar were searched for studies published until July 10, 2015, reporting outcomes between the two types of postoperative nutritional support. Only randomized controlled trials (RCTs) were included. A χ2-based test of homogeneity was performed using Cochran's Q statistic and I2. A total of 2540 patients (1268 who received EN and 1272 who received TPN; average age range: 58.3–67.7 years) from 18 RCTs were included for assessment. Patients who received EN had shorter lengths of hospital stay (pooled difference in mean=−1.74, 95% CI −2.41 to −1.07, p<0.001, shorter time to flatus (pooled difference in mean=−1.27, 95% CI −1.69 to −0.85, p<0.001), and significantly greater increases in albumin levels (pooled difference in mean=−1.33, 95% CI −2.18 to −0.47, p=0.002) compared with those who received TPN after major abdominal surgery, based on a random-effects model of analysis. EN after major abdominal surgery provided better outcomes compared with TPN in patients with gastrointestinal cancer.

Nutritional management in critically ill trauma patients is challenging

Background

The physiological stress following major trauma in critical illness leads to rapid malnutrition and provision of optimal nutritional support in these circumstances can be challenging.

Case report

We present a complex trauma case where relatively aggressive nutritional support failed to minimise weight loss.

Conclusion

Nutritional support plays an integral role in the care of critically ill major trauma patients and needs to be continuously monitored in the subacute and rehabilitation phase.

A pilot study to explore the safety of perioperative postpyloric enteral nutrition

BACKGROUND

The practice of holding enteral nutrition (EN) 8 hours prior to surgery is common. We hypothesized that it was safe to continue postpyloric EN, and we developed an institutional practice pattern to investigate our hypothesis.

METHODS

Our pilot study included intubated patients in the surgical intensive care unit at Froedtert Memorial Lutheran Hospital who received EN via a nasojejunal (NJ) feeding tube and underwent 1 or more surgical procedures. Demographic, illness, and injury information were collected as well as length of time to NJ placement, time to initiation of EN, EN interruptions, and complications. Additional hours of EN were calculated by totaling the number of hours a patient received EN past midnight on the day of surgery.

RESULTS

A total of 14 patients with mean (SD) age 44.3 (19.9) were included. Patients had a mean (SD) Injury Severity Score (ISS) of 26.1 (9.2) on admission and underwent a total of 38 operations following placement of a feeding tube. The most frequent operation performed was an orthopedic procedure (n = 17; 46.1%). The mean (SD) length of EN interruptions for a single procedure was 222.4 (206.9) minutes. Patients received an additional 11.9 (4.7) hours of EN over the course of their hospitalization and an additional 1064.9 (490) kcal/d per operation. There were no adverse events.

CONCLUSION

Perioperative continuation of postpyloric EN is feasible in some critically ill surgical patients and can result in additional calories provided. A multidisciplinary approach and an institutional policy can increase the likelihood of meeting nutrition goals in these patients.

Nutrition and the open abdomen

Adequate nutrition support is critical in the management of patients with an open abdomen. Despite the literature supporting its use in trauma patients, provider concerns and clinical controversies remain regarding the early administration and long-term sequelae of enteral nutrition (EN) therapy in these patients. The purpose of this article is to review the clinical concepts behind the use of the open abdomen, as well as examine the altered nutrition requirements associated with the maintenance of a temporary laparostomy. The rationale for early EN is described, as well as the pros and cons surrounding the use of supplemental parenteral nutrition in those patients unable to meet nutrition goals enterally in a reasonable time frame. Finally, an open abdomen nutrition support algorithm is provided as part of the critical care plan in these patients who represent the sickest of surgical patients.

Nutritional management of critically ill trauma patients in the deployed military setting

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.

Impact of enteral nutrition on nitrogen balance in patients of trauma

BACKGROUND

A prospective study of 50 patients of trauma was carried out at a tertiary level trauma center in Mumbai. The aim was to study the hypermetabolic response to trauma and the effect of early enteral feeding and nutritional supplementation in blunting this response in these patients.

METHODS

Early enteral feeding was started within 72 h in most patients. The caloric requirement was calculated as per the body weight and a 150: 1 ratio of nonprotein calories to protein was maintained. A 24-h urinary nitrogen loss was estimated and nitrogen balance was calculated on days 1, 3 and 7.

RESULTS

The correlation between the injury severity and the severity of catabolism was also analysed. Urinary nitrogen loss and nitrogen balance were used as parameters to evaluate the hypermetabolic response.

CONCLUSIONS

Early (within 72 h) enteral nutritional support blunts this hypermetabolic response to some extent in these trauma patients.

A guide to enteral access procedures and enteral nutrition

The advent of total parenteral nutrition in the late 1960s meant that no situation remained in which a patient could not be fed. Unfortunately, total parenteral nutrition was complicated by serious infective and metabolic side effects that undermined the beneficial effects of nutrient repletion. Consequently, creative ways of restoring upper gut function were designed, based on semielemental diets and novel feeding tube systems. The employment of specific protocols and acceptance of increased gastric residual volumes has allowed most patients in intensive care to be fed safely and early by nasogastric tube. However, nasogastric feeding is unsuitable for patients with severely compromised gastric emptying owing to partial obstruction or ileus. Such patients require postpyloric tube placement with simultaneous gastric decompression via double-lumen nasogastric decompression and jejunal feeding tubes. These tubes can be placed endoscopically 40-60 cm past the ligament of Treitz to enable feeding without pancreatic stimulation. In patients whose disorders last more than 4 weeks, tubes should be repositioned percutaneously, by endoscopic, open or laparoscopic surgery. Together, the advances in enteral access have improved patients' outcomes and led to a 70-90% reduction in the demand for total parenteral nutrition.

Total parenteral nutrition causes circumferential intestinal atrophy, remodeling of the intestinal wall, and redistribution of eosinophils in the rat gastrointestinal tract

Total parenteral nutrition (TPN) is held to cause intestinal atrophy and weaken mechanical and immunological barriers. To monitor the degree of atrophy caused by TPN, female Sprague-Dawley rats were, for 8 days, maintained on TPN (n = 6) and compared to identically housed controls given food and water ad libitum (n = 6). Specimens from jejunum, ileum, and colon were taken for histology and morphometric analysis. Topographic distribution and presence of eosinophils, by eosinophil peroxidase (EPO) staining, were examined in the gastric fundus, jejunum, ileum, and colon. Atrophy in terms of a markedly reduced circumference was noted throughout the intestinal tract in all rats subjected to TPN. The width of jejunal and ileal villi was narrowed and the length of jejunal villi was decreased. Furthermore, submucosal thickness in the jejunum and ileum increased. The height of ileal enterocytes remained unaltered. The number of goblet cells decreased in jejunal but not in ileal villi. The Paneth cells, suggested to play important roles in innate defense, increased in size. In the gastric fundus a marked increase in eosinophils was revealed predominantly in the mucosa and submucosa. The number and distribution of jejunal and ileal eosinophils were identical to those of controls. In colon from TPN rats, a redistribution of eosinophils was noted, causing a "band-like" accumulation of eosinophils in the basal portion of the mucosa. In conclusion, TPN causes gut atrophy and an increase in Paneth cell size. Eosinophils increase in number in the gastric fundus and a topographic redistribution occurs in the colon.

Advances in Surgical Nutrition

Dr. Stanley Dudrick invented total parenteral nutrition in 1968, providing a desperately needed therapy to those patients who could not eat. It has since saved thousands of patients worldwide. Nutrition interventions (NI) in surgical/trauma and critically ill patients have evolved dramatically during the last 20 years from a supportive therapy to a clear therapeutic role. Like any other form of therapy, NI will benefit patients when adequately indicated and prescribed. NI, however, may cause significant side effects and harm when poorly ordered. This article reviews the indications for the prescription of the different forms of NI available to the clinician caring for the surgical patient.

Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications

BACKGROUND

The role of early postoperative enteral nutrition after gastrointestinal surgery is controversial. Traditional management consist of 'nil by mouth', where patients receive fluids followed by solids when tolerated. Although several trials have implicated lower incidence of septic complications and faster wound healing upon early enteral feeding, other trials have shown opposite results. The immediate advantage of caloric intake could be a faster recovery with fewer complications, to be evaluated systematically.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition compared to traditional management (no nutritional supply) is associated with fewer complications in patients undergoing gastrointestinal surgery

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, and LILACS from 1979 (first RCT published) to March 2006. We manually scanned the references from the relevant articles, and consulted primary authors for additional information.

SELECTION CRITERIA

We looked for randomised controlled trials (RCT's) comparing early commencement of feeding (within 24 hours) with no feeding in patients undergoing gastrointestinal surgery. Early enteral nutrition is defined as all oral intakes (i.e. registered oral intake, supplemented oral feeding) and any kind of tube feeding (gastric, duodenal or jejunal) containing caloric content. No feeding is traditional management, defined as none caloric oral intake or any kind of tube feeding before bowel function. The definition 'no nutrition' includes non caloric placebo and water.

DATA COLLECTION AND ANALYSIS

The three authors independently assessed the identified trials, and extracted the relevant data using a specifically developed data extraction sheet. Primary end points of interest were: Wound infections and intraabdominal abscesses, postoperative complications such as acute myocardial infarction, postoperative thrombosis or pneumonia, anastomotic leakages, mortality, length of hospital stay, and significant adverse effects. We combined data to estimate the common relative risk of postoperative complications, and calculated the associated 95% confidence intervals. For analysis, we used fixed effects model (risk ratios to summarise the treatment effect) whenever feasible. The treatment effect on length of stay was estimated using effect size (presented as mean +/- SD). Some outcomes were not analysed but presented in a descriptive way. We used a random effects model to estimate overall risk ratio and effect size.

MAIN RESULTS

We identified thirteen randomised controlled trials, with a total of 1173 patients, all undergoing gastrointestinal surgery. Individual clinical complications failed to reach statistical significance, but the direction of effect indicates that earlier feeding may reduce the risk of post surgical complications. Mortality was the only outcome showing a significant benefit, but not necessarily associated with early commencement of feeding, as the reported cause of death was anastomotic leakage, reoperation, and acute myocardial infarction.

AUTHORS' CONCLUSIONS

Although non-significant results, there is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery, and this review support the notion on early commencement of enteral feeding.

Efficacy of enteral nutrition for the treatment of pancreatitis using standard enteral formula

BACKGROUND AND AIMS

Elemental formula delivered distal to the ligament of Treitz has demonstrated efficacy in patients with pancreatitis, presumably by decreasing pancreatic stimulation. Few data exist on the use of standard enteral formula in such patients. This study describes the outcomes of pancreatitis patients managed with long-term standard enteral nutrition (EN).

METHODS

One hundred twenty-six patients managed at the University of Virginia Health System with pancreatitis requiring nutritional support between August 2000 and June 2004 received a standard formula delivered distal to the ligament of Treitz and were followed prospectively to resolution of their disease process. Predictors of improvement in CT Severity Index, duration of EN, and length of hospital stay were identified. Changes in body weight and serum albumin were determined.

RESULTS

Mean age was 50.8 +/- 15.2 yr (male, 83). Etiology included alcohol (46), gallstones (49), idiopathic (15), post-ERCP (7), drug (5), hyperlipidemia (3), and pancreas divisum (1). EN lasted a median of 18.9 (2.4 to 111.7) wk. Median CT Severity Index decreased from 4 to 2 (p < 0.001). Underweight patients gained 9.8 lbs; overweight and obese patients lost 7.2 and 28.8 lbs, respectively. Albumin concentration increased from 3 to 3.8 g/dL (p < 0.001).

CONCLUSIONS

Standard enteral formula is effective in the management of patients with complicated pancreatitis.

Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis

Malnutrition is well recognized as a potential cause of increased morbidity and mortality in surgical patients. Early postoperative enteral nutrition through a feeding jejunostomy has been shown to improve results in patients undergoing major resections for gastrointestinal malignancies, trauma, and perforation peritonitis. We conducted a prospective study to assess the feasibility and short-term efficacy of early enteral feeding through a nasoenteric tube placed intraoperatively in patients with nontraumatic perforation peritonitis with malnutrition. One hundred patients with nontraumatic perforation peritonitis with malnutrition undergoing exploratory laparotomy were randomly divided into a test group (TG) and a control group (CG) of 50 patients each. TG patients had a nasoenteric tube placed at the time of surgery and were started on an enteral feeding regime 24 hours postoperatively. Patients in CG were allowed to eat orally once they passed flatus. The differences between the two groups with respect to nutritional intake in terms of energy and protein, changes in nutritional status as assessed by anthropometric, biochemical, and hematological values, amount of nasogastric aspirate, return of bowel motility, and complication rates were analyzed. The nasoenteric feeding was well tolerated. Total calorie and protein intake in TG was significantly higher than in CG: 981 vs. 505 kcal (p < 0.01), protein 24 vs. 0 g on day 3 and 1498 vs. 846 kcal (p < 0.01), protein 44 vs. 23 g (p < 0.01) on day 7, respectively. There was reduction in the amount of nasogastric aspirate in TG compared with that in CG: 431 vs. 545 ml/24 h on day 2 and 301 vs. 440 ml/24 h on day 3, respectively. There was much faster recovery of bowel motility in TG than in CG at 3.34 vs. 4.4 days (p < 0.01). Complications developed in 39 of 50 patients in TG and in 47 of 50 in CG. The major complications occurred in 6 patients in TG and 12 patients in CG (p < 0.05). Patients with perforation peritonitis with malnutrition are likely to develop large energy deficits postoperatively, resulting in higher incidence of infective complications. Early enteral feeding through a nasoenteric tube is well tolerated by these patients and helps to improve energy and protein intake, reduces the amount of nasogastric aspirate, reduces the duration of postoperative ileus, and reduces the risk of serious complications.

A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis

BACKGROUND

After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed.

METHODS

A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays.

RESULTS

A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group.

CONCLUSIONS

The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.

Effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis

A randomized, controlled clinical trial investigated the effect of early enteral nutrition (EN) on intestinal permeability, intestinal protein loss, and outcome in parvoviral enteritis. Dogs were randomized into 2 groups: 15 dogs received no food until vomiting had ceased for 12 hours (mean 50 hours after admission; NPO group), and 15 dogs received early EN by nasoesophageal tube from 12 hours after admission (EEN group). All other treatments were identical. Intestinal permeability was assessed by 6‐hour urinary lactulose (L) and rhamnose (R) recoveries (%L, %R) and L/R recovery ratios. Intestinal protein loss was quantified by fecal α₁‐proteinase inhibitor concentrations (α₁‐PI). Median time to normalization of demeanor, appetite, vomiting, and diarrhea was 1 day shorter for the EEN group for each variable. Body weight increased insignificantly from admission in the NPO group (day 3: 2.5±2.8% day 6: 4.3±2.3% mean ± SE), whereas the EEN group exhibited significant weight gain (day 3: 8.1±2.7% day 6: 9.7 ± 2.1%). Mean urinary %L was increased, %R reduced, and L/R recovery ratios increased compared to reference values throughout the study for both groups. Percent lactulose recovery decreased in the EEN group (admission: 22.6±8.0% day 6: 17.9 ± 2.3%) and increased in the NPO group (admission: 11.0±2.6% day 6: 22.5 ± 4.6%, P= .035). Fecal α₁‐PI was above reference values in both groups and declined progressively. No significant differences occurred for %R, L/R ratios, or α₁‐PI between groups. Thirteen NPO dogs and all EEN dogs survived (P= .48). The EEN group showed earlier clinical improvement and significant weight gain. The significantly decreased %L in the EEN versus NPO group might reflect improved gut barrier function, which could limit bacterial or endotoxin translocation.

A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients

BACKGROUND

Early jejunal feeding after surgery or trauma reduces infectious complications. Although not ideal gastric and postpyloric feedings are often used, however, because of difficulty in placing feeding tubes distal to the ligament of Treitz (LOT). Our hypothesis was that feeding tube placement distal to the LOT can be accomplished using a bedside transendoscopic technique.

METHODS

Transendoscopic jejunal (TEJ) tube placement and TEJ tubes inserted simultaneously through percutaneous gastrostomy (PEG) tubes (PEG/TEJ) were attempted to be placed distal to the LOT.

RESULTS

In all, 226 feeding tubes (185 TEJ, 41 PEG/TEJ) were placed in 179 trauma and 47 nontrauma patients over 3 years (August 20, 1998 to July 15, 2001). Tube location was jejunal in 93.8% of trauma patients, 76.6% of nontrauma patients, and 90.3% of all patients. (Confidence intervals were 89.3% to 96.5%, 62.8% to 86.4%, and 85.7% to 93.5%). Days of total parenteral nutrition were reduced 71.3% in trauma patients, 22.8% in nontrauma patients, and 45% overall at one institution.

CONCLUSIONS

Bedside TEJ and PEG/TEJ placement is safe and successful in placing feeding tubes distal to the LOT in more than 90% of critically ill surgical patients.

Provision of phosphorylatable substrate during hypoxia decreases jejunal barrier function

OBJECTIVES

There is an emerging consensus that early enteral nutrition benefits the high-risk surgical patient. However, in patients with inadequate gastrointestinal perfusion, food in the intestine may increase the oxygen demand beyond that which can be satisfied by the available delivery, potentially leading to intestinal malfunction. The effect of metabolic substrate on gastrointestinal function during various oxygenation states was investigated.

METHODS

Jejunal samples obtained from 32 male Sprague-Dawley rats (263 +/- Q15 g) were stripped of the muscularis, mounted in modified Ussing chambers, and randomized to be incubated in media equilibrated with one of four gas mixtures (95%, 75%, 50%, and 25% oxygen). After equilibration, fluorescent probes (4400 and 17 200 molecular weight [MW]) were added to the incubation media on the mucosal side. The rate of probe accumulation on the serosal side was determined before and after the addition of one of four substrates to the mucosal medium: mannitol (an osmotic control), glucose (which is transported, phosphorylated, and metabolized), 2-deoxyglucose (a glucose analog that is transported and phosphorylated but not metabolized), or 3-O-methylglucose (a glucose analog that is transported but not phosphorylated or metabolized).

RESULTS

Lumenal glucose, 2-deoxyglucose, and 3-O-methylglucose increased permeation of the 4400-MW probe at all oxygen levels, whereas mannitol did not alter permeation in the 95% and 75% oxygen groups. Lumenal glucose increased (P < 0.05) the permeation rate of the 17 200-MW probe at all oxygen levels, whereas 2-deoxyglucose and 3-O-methylglucose did not increase the permeation rate of the 17 200-MW probe until oxygen was lowered to 75% and 50%, respectively. Regardless of substrate treatment, jejunal permeation of the 4400-MW (P < 0.001) and 17 200-MW (P < 0.05) probes increased in the 25% and 50% oxygen groups compared with the 75% and 95% oxygen groups.

CONCLUSIONS

These initial results suggest that the provision of lumenal nutrients exacerbates the loss of gastrointestinal barrier function during hypoxia. Although the early provision of nutrients is an important intervention in acutely injured patients, care must be taken to ensure that gastrointestinal perfusion is adequate to allow substrate metabolism and prevent further compromise in gastrointestinal function.

Enteral nutrition by nasojejunal tube in hyperemesis gravidarum

We describe two cases in which self-propelling, blind placed nasojejunal tubes were placed in severe hyperemesis gravidarum. This method provides an alternative to parenteral nutrition and to percutaneous endoscopic tubes, is well tolerated, cost effective and with a low rate of complication. Both mothers were given nutritional support at home, had normal subsequent pregnancies and normal babies.

Luminal nutrients exacerbate intestinal hypoxia in the hypoperfused jejunum

BACKGROUND

Provision of enteral nutrients shortly after traumatic injury has become the preferred method of nutrition support provided to patients. However, traumatic shock results in splanchnic hypoperfusion, which may cause persistent intestinal hypoxia. This study tested the hypothesis that delivery of enteral nutrients to the hypoperfused jejunum increases oxidative demand beyond that available, thereby exacerbating intestinal hypoxia.

METHODS

Wistar-Furth rats (186+/-4 g; n = 24) were randomized to receive intestinal hypoxia (superior mesenteric artery occlusion) or serve as normoxic controls (sham laparotomy). Within the jejunum of each rat, 4 6-cm loops were randomized to receive luminal perfusions with 1 of 4 substrates: mannitol (an osmotic control); glucose (undergoes active transport via the sodium-glucose co-transporter [SGLT-1] and is metabolized); 3-o-methylglucose (3-o-mg; uses SGLT-1 but is not metabolized); or fructose (does not use SGLT-1 but is metabolized). After in situ perfusions, jejunal tissue was removed for analysis of nutrient transport and barrier function in modified Ussing chambers. Tissue homogenate was used to determine concentration of ATP, lactate, pyruvate, and protein. Also, jejunal tissue was stained with hematoxylin and eosin for qualitative analysis of ischemia and necrosis.

RESULTS

Transmural resistance was lower (p < .001) in the hypoxia groups, irrespective of substrate, indicating increased mucosal permeability. When compared with the normoxic controls, glucose transport was impaired (p < .001) in the hypoxic groups; however, glutamine transport was unaffected. The degree of intestinal hypoxia, assessed by jejunal lactate concentration, was higher (p < .001) in the glucose and fructose groups, than the control mannitol and 3-o-mg groups.

CONCLUSIONS

The observation that 3-o-mg did not differ from the mannitol control indicates that SGLT-1 activation alone does not exacerbate hypoxia. Rather, these results indicate that provision of metabolizable nutrients to the hypoperfused intestine exacerbate hypoxia and potentially lead to intestinal ischemia. Although early enteral nutrition is an important intervention after trauma, care must be taken to ensure intestinal perfusion is adequate to allow for nutrient metabolism and prevent further compromise.

Nasogastric feeding in severe acute pancreatitis may be practical and safe

BACKGROUND

Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis.

PATIENTS AND METHODS

Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit.

RESULTS

Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding.

CONCLUSION

It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.

Early and sufficient feeding reduces length of stay and charges in surgical patients

BACKGROUND

The role of perioperative nutrition in surgical patients remains controversial. We performed a Clinical Practice Improvement (CPI) study that, while controlling for severity of illness, explored the relationship between the timing and amount of parenteral or enteral nutrition, with two outcomes: length of stay (LOS) and total charges in patients undergoing open intestinal operations.

MATERIALS AND METHODS

A CPI study was conducted at eight hospitals to determine which process steps were associated with shorter LOS and lower charges. Hospital charts were abstracted for over 800 components of detailed patient, process, and outcome measures. Severity of illness was measured multiple times during the stay using the Comprehensive Severity Index, a disease-specific physiologic severity measurement instrument. Data on 1007 patients undergoing intestinal operations, 183 of whom received nutritional support, were then analyzed using multiple regression procedures. Early (within 48 h of surgery) and sufficient (60% of protein and calorie goals) nutrition, patient variables, and a severity of illness measure were included as independent variables and LOS and hospital charges were used as dependent variables.

RESULTS

Mean patient age was 58 years. After controlling for severity of illness, patients who received early and sufficient nutrition had significantly shorter LOS (11.9 days) and lower charges ($34,602) than patients who received early (13.3; $36,452), sufficient (14.6, $39,883), or neither early nor sufficient (14.8, $38,578) (P < or = 0.0001 for early and sufficient versus all other groups).

CONCLUSIONS

CPI methodology provides a detailed view of the actual relationship between the timing and the amount of nutrition with LOS and hospital charge outcomes.

Nasogastric feeding in severe acute pancreatitis may be practical and safe

BACKGROUND

Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis.

PATIENTS AND METHODS

Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit.

RESULTS

Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding.

CONCLUSION

It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.

Which therapeutic interventions in critical care medicine have been shown to reduce mortality in prospective, randomized, clinical trials? A survey of candidates for the Belgian Board Examination in Intensive Care Medicine

OBJECTIVE

To highlight the lack of randomized controlled trial (RCT) evidence in support of accepted therapeutic interventions in the intensive care unit by assessing the ability of Intensive Care Board Examination candidates to cite relevant studies.

DESIGN

As part of the Board Examination for Intensive Care Medicine in Belgium, candidates were asked to name accepted therapeutic interventions that have been shown to reduce mortality in RCTs.

SETTING

Survey of doctors.

SUBJECTS

Candidates for the 1998 Board Examination for Intensive Care Medicine in Belgium.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Of the 46 candidates, 25 (54%) gave no response and 3 (7%) stated that no such study exists; 16 responses from 13 doctors were considered acceptable answers.

CONCLUSIONS

Candidates for the Board Examination of Intensive Care in Belgium were unable to list many accepted interventions in critical care medicine that are supported by RCT evidence. The RCT may not be the most appropriate tool for assessing the value of an intervention in the intensive care environment.

Complications of surgical feeding jejunostomy in trauma patients

OBJECTIVE

To determine the complication rate of feeding jejunostomy (FJ) performed as an adjunct to trauma celiotomy.

METHODS

Retrospective analysis of 222 patients from January of 1988 to May of 1998.

RESULTS

Thirty-seven total FJ-related complications occurred in 22 patients (10%). Major FJ-related complications occurred in nine patients (4%): two small bowel perforations, two small bowel volvuli with infarction, two intraperitoneal leaks, and three small bowel necroses. Patients suffering major FJ-related complications were similar to those without complications, except for the FJ type. Patients with major FJ-related complications were more likely to have had a Witzel tube jejunostomy than a needle catheter jejunostomy (p = 0.03). Three deaths were related to major FJ complications, for a FJ-related mortality rate of 1.4%.

CONCLUSIONS

FJ has a major complication rate of 4% in severely injured patients. Major complications occur more frequently with larger, Witzel-type tubes. Needle catheter jejunostomy appears to be a safer method of surgical jejunal access in trauma patients.

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery

OBJECTIVE

To evaluate those factors that impact on the delivery of enteral tube feeding.

DESIGN

Prospective study.

SETTING

Medical intensive care units (ICU) and coronary care units at two university-based hospitals.

PATIENTS

Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding.

INTERVENTIONS

Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented.

MEASUREMENTS AND MAIN RESULTS

Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes.

CONCLUSIONS

The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

Are patients fed appropriately according to their caloric requirements?

BACKGROUND

Specific morbidity related to underfeeding and overfeeding necessitates the design of nutrition support regimens that provide calories equal to those required on the basis of energy expenditure. This prospective multicenter trial was designed to determine what percent of patients in long-term acute care facilities receive feeding appropriate to their needs and whether accuracy of feeding has an impact on patient clinical status.

METHODS

Patients on mechanical ventilation who were hospitalized at 32 Vencor Hospitals over a 9-week period and who were receiving only enteral nutrition by continuous infusion at a presumed goal rate were evaluated once by indirect calorimetry (IC) while on feeding. Caloric intake over the preceding 24 hours was determined by physician orders and by patient intake/output (I/O) record. Caloric requirements were defined by measured resting energy expenditure (REE) + 10% for activity. Degree of metabolism was defined by the ratio: (measured REE/Harris-Benedict predicted REE) x 100, and the degree of feeding by the ratio: (calories provided/calories required) x 100.

RESULTS

IC was performed on 335 patients (mean, 11.2 patients per center; range, 1 to 32), of which 72 were excluded for nonphysiological results or failure to achieve steady state, 21 for receiving parenteral nutrition, and 29 for not being on mechanical ventilation at time of testing. The 213 study patients were 58.7% male with mean age 70.1 years (range, 20 to 90 years). Measured REE was <25 kcal/kg in 66.2% of patients and 25 to 35 kcal/kg in 28.6%. Barely half (48.4%) of this patient population was hypermetabolic. Based on physician orders, the majority of patients (58.2%) were overfed, receiving >110% of required calories, and 12.2% were underfed, receiving <90% of requirements. Discrepancies based on I/O records, however, suggested that 36.1% of patients received <90% of those calories ordered. By either basis, only about 25% of patients received feeding within 10% of required calories. The percent of patients being overfed varied between centers, ranging from 32.2% to 92.8%, and was not affected by years of facility IC experience or volume of IC studies per month. The pattern of caloric provision as measured by degree of feeding correlated inversely to degree of metabolism (p < .0001, R2 = .24). Accuracy of feeding had an impact on ventilatory status, as degree of feeding correlated inversely with minute ventilation (p = .001, R2 = .05). Degree of overfeeding also led to significant increases in azotemia (p = .033, R2 = .02). Extrapolating study data over 1 year, reduction in excess volume of enteral formula would have resulted in a cost savings of up to $1.3 million for the Vencor system.

CONCLUSIONS

Because energy expenditure is difficult to predict on the basis of conventional equations, patients in long-term acute care facilities routinely are overfed and underfed, with only 25% receiving calories within 10% of required needs. Measuring a patient's energy requirement at least once by IC is important, because the degree of metabolism predicts how easily a patient will be underfed or overfed. The amount of infused calories should be compared with caloric requirements measured by IC, because the accuracy or degree of underfeeding or overfeeding has an impact on ventilatory status and the likelihood for developing azotemia. Although physician practice or bias may reduce the optimal clinical effect, the use of IC to determine caloric requirements may result in significant cost savings.

Influence of twinline, an elemental diet, on the generation of nitric oxide and reactive-oxygen intermediates from mouse peritoneal macrophages and polymorphonuclear leukocytes

The influence of Twinline (SNN-6010), an elemental diet containing medium-chain triglycerides, on the generation of nitric oxide (NO) and superoxide (O2.-) has been examined in mouse peritoneal macrophages and polymorphonuclear leukocytes (PMN). When PMN and peritoneal macrophages obtained from untreated mice were cultured in medium containing 0.1% and 1% (v/v) Twinline for 48h and stimulated with phorbol myristate acetate or N-formyl-methionyl-leucyl-phenylalanine, their chemiluminescence and O2.- generation were strongly suppressed, as was NO generation from peritoneal macrophages. PMN and peritoneal macrophages obtained from mice fed Twinline for 30 days generated much smaller amounts of 02.- and NO compared with PMN and peritoneal macrophages from control mice. In conjunction with this suppressed NO generation, inducible NO synthase and its mRNA expression in peritoneal macrophages were suppressed by Twinline both in-vivo and ex-vivo. Although phagocytosis of PMN and peritoneal macrophages was not suppressed by Twinline; their candida-killing activity was markedly suppressed. These results indicate that Twinline suppresses the host-defence function of PMN and peritoneal macrophages by down-regulating their generation of reactive-oxygen intermediates and NO.

Early postoperative enteral feeding in patients with nontraumatic intestinal perforation and peritonitis

BACKGROUND

In our clinical setting, patients with perforative peritonitis are frequently malnourished. Immediate postoperative enteral feeding has been shown effective in reducing septic morbidity in patients with abdominal trauma. This study was designed to investigate the feasibility and efficacy of immediate postoperative enteral feeding in patients with nontraumatic intestinal perforation and peritonitis.

STUDY DESIGN

A prospective study spanning 1 year was conducted on patients with nontraumatic intestinal perforation and peritonitis. After laparotomy, patients were assigned randomly to a control or study group. The study group underwent a feeding jejunostomy and received enteral feeding from 12 hours postoperatively. A low-residue, milk-based diet was used. All patients underwent assessment for severity of sepsis and nutritional status at admission. Studies of nutritional status and nitrogen balance were repeated on days 4 and 7.

RESULTS

Forty-three patients (21 in the study group; 22 in the control group) were included. The two groups were comparable except for a higher sepsis score in the study group (p < 0.05). Patients in the study group achieved a positive nitrogen balance by the third postoperative day; patients in the control group remained in negative nitrogen balance throughout the study. Abdominal distention (four patients) required temporary withdrawal of feeding. Diarrhea occurred in four patients but was controlled easily. The mortality rate was similar in the control and study groups (18.2% versus 19.1%). The control group had a total of 22 septic complications, versus eight in the study group (p < 0.05).

CONCLUSIONS

Immediate postoperative feeding is feasible in patients with perforative peritonitis and reduces septic morbidity.

Nutritional management in acute and chronic pancreatitis

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.

Elective bedside surgery in critically injured patients is safe and cost-effective

OBJECTIVE

The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients.

SUMMARY BACKGROUND DATA

This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study.

METHODS

All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside.

RESULTS

Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was $611,994. When examined independently, the cost was $324,224 for BDT, $164,088 for PEG, and $123,682 for IVC filter. OR use was reduced by 506 hours.

CONCLUSIONS

These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

Early feeding after elective open colorectal resections: a prospective randomized trial

BACKGROUND

A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported.

METHODS

Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24-48 h.

RESULTS

There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group.

CONCLUSION

Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

Percutaneous endoscopic gastrostomy for patients with severe cerebral injury

Early enteral nutrition improves the outcome of severely injured patients. To provide enteral nutrition, various methods are available. In a restrospective study we analysed the outcome of 24 severely traumatized patients (mean ISS = 44), in whom a percutaneous endoscopic gastrostomy (PEG) was used for enteral nutrition. All patients had been admitted to the intensive care unit with major cerebral injury. The mean duration of intensive care treatment and the in hospital stay were 28 and 71 days, respectively. PEG was introduced 14 days after hospital admittance. Enteral nutrition through the PEG was administered for 45 days. Four patients died, 8 patients were discharged from the hospital while being fed via the PEG and 12 patients resumed normal feeding and the PEG was removed. Three severe complications occurred; 1 patient aspirated massively and died; in 2 patients intra-abdominal leakage of the enteral nutrition occurred. Both patients recovered from this complication. We conclude that because of the advantages of early enteral nutrition on the one hand and the drawbacks of nasogastric feeding tubes on the other, in injured patients with severe cerebral damage, PEG placement is justified, despite the risk of complications.

Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis

BACKGROUND

This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis.

METHODS

Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission.

RESULTS

Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN ($3294 vs $761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth.

CONCLUSIONS

TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.

Clinical outcome and immunology of postoperative arginine, omega-3 fatty acids, and nucleotide-enriched enteral feeding: a randomized prospective comparison with standard enteral and low calorie/low fat i.v. solutions

In a prospective randomized trial in patients undergoing major abdominal surgery, the impact of a new enteral formula supplemented with arginine, omega-3 fatty acids, and nucleotides (A, n = 14) on immunological parameters was compared with a standard enteral formula (B, n = 14) and a low calorie/low fat intravenous solution (C, n = 13). Four days postoperatively, a statistically significant decrease in total leukocyte count (A, 9.0 +/- 2.9; B, 8.0 +/- 2.4; C, 11.1 +/- 3.5 x 10(6) cells/mL; A versus C, B versus C; p < 0.05), higher percentage of lymphocytes (A, 14.3 +/- 4.9; C, 8.2 +/- 6.1; p < 0.05), and decreased median CRP levels (A, 80.4 [69.9]; B, 70 [74]; C, 88.5 [142] in mg/L; A versus C, p < 0.05; B versus C; p < 0.05) were observed in the enteral nutrition groups. The expression of activated surface antigen HLA-DR was diminished on CD14+ cells over 4 d (A, 58.2 [39.2]; B, 52.2 [36.2]; C, 76.6 [25.2] in %; A versus C, p < 0.05; B versus C, p < 0.05) and 8-10 d (A, 37.9 [31.4]; C, 58.5 [37.6]; p < 0.05) postoperatively. Significantly enhanced median phagocytic activity of CD14+ monocytes and granulocytes was observed in group C 8-10 days postoperatively (A, 83.3 [11.8]; B, 71.6 [34.1]; C, 87.4 [10.8]; A versus B, B versus C, p < 0.05; and A, 75.7 [10.0]; B, 69.0 [37.8]; C, 80.0 [10.1] in %, B versus C, p < 0.05, respectively). Postoperative hospital and intensive care unit stay was similar among the three groups; however, infectious complications were less frequent in group A (A versus C, p = 0.15). Thus, a modified enteral nutritional support and supplementation may influence the immune competence toward a more efficient defense response.

Small bowel injuries: mechanisms, patterns, and outcome

OBJECTIVES

To determine the relationship between mechanism of injury (MI), operative management (OM), and outcome for traumatic jejunal and ileal wounds using an aggressive diagnostic, therapeutic, and support protocol.

METHODS

Medical records for patients discharged with small bowel injuries from the Trauma Service between 1988 and 1992 were reviewed. The MI, presence of shock, method of diagnosis, OM, morbidity, and mortality were analyzed.

RESULTS

Seventy patients had jejunal and/or ileal injuries. Blunt mechanisms caused injury in 33%, whereas the rest were penetrating wounds. Twenty-one diagnostic peritoneal lavages facilitated diagnosis (71% positive by tap). Ninety-six percent of the patients were explored within 3 hours of admission. Multiple perforations of jejunum were the most common injury of the small bowel. Using the Organ Injury Scale, grade III and IV wounds were statistically more common with penetrating injuries. Most of the injuries were managed with resection and stapled anastomosis, even in the presence of shock.

CONCLUSIONS

There is a significant difference in MI and OM for small bowel wounds. Resection and stapled anastomosis is safe even in the presence of shock. Mortality and morbidity are related to associated injuries.