Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy

Role of registered dietitians in nasoenteric feeding tube placement

Provision of enteral nutrition (EN) in hospitalized patients is an integral part of clinical care. For various reasons, including but not limited to delayed enteral access placement and EN initiation, it is becoming more prevalent for registered dietitians (RDs) to place feeding tubes in various clinical settings. Although numerous RDs have expanded their practice by learning this skill, many remain hesitant about adding feeding tube placement to their scope of responsibilities. Feeding tube placement is within RDs' scope of practice. The recently updated Accreditation Council for Education in Nutrition and Dietetics (ACEND) standards is requiring dietetic interns to learn the process and assist in placing feeding tubes. This will help promote the inclusion of this practice and open doors for future advancement in the scope of practice for RDs. This review will provide an overview of feeding tube placement methods, evidence-based techniques, training, competencies, and barriers to accepting this practice in dietetics.

Postpyloric vs gastric enteral nutrition in critically ill children: A single-center retrospective cohort study

BACKGROUND

We aimed to describe enteral nutrition (EN) delivery in patients receiving postpyloric EN (PPEN) vs gastric EN (GEN).

METHODS

Single-center retrospective study including patients aged <21 years admitted to an intensive care unit in a pediatric quaternary care hospital for ≧48 h who received PPEN or GEN as a first approach, as guided by a nutrition algorithm. PPEN patients were 1:1 propensity score matched to GEN patients on demographics, clinical characteristics, and disease severity. Days to EN initiation from admission, percentage of EN adequacy (delivered EN volume/prescribed EN volume) on days 1-3 and 7 after EN initiation, and time to achieving 60% of prescribed EN volume were compared between the two groups using Wilcoxon Mann-Whitney tests and a Cox proportional hazards model. Data are presented as median (IQR1, IQR3).

RESULTS

Forty-six PPEN and 46 GEN patients were matched. Median time to EN initiation was 3.25 (2, 6.8) days for PPEN and 4.15 (1.5, 7.1) days for GEN (P = 0.6). Percentage of EN adequacy was greater for PPEN than GEN patients (day 1 PPEN 59.4% [18.8, 87.5] vs GEN 21.1% [7.8, 62.8], day 2 PPEN 54.3% [16.7, 95.8] vs GEN 24% [5.4, 56.7], day 3 PPEN 65.4% [14.7, 100] vs GEN 16% [0, 64.6], day 7 PPEN 77.8% [11.1, 100] vs GEN 13.8% [0, 74.5]; P < 0.05). PPEN patients had greater likelihood of achieving 60% of their prescribed EN volume than GEN patients (hazard ratio 1.84, 95% CI 1.07-3.15; P = 0.028).

CONCLUSION

PPEN was associated with greater EN delivery compared with GEN.

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

Gastric-tube feeding and post-pyloric feeding are the two most common forms of enteral nutrition, each with advantages and disadvantages. To explore the effects and safety of gastric-tube versus post-pyloric feeding in critical patients by comparing pulmonary aspiration- and nutrition-related outcomes, a meta-analysis was conducted. It was performed by systematically searching the following databases: PubMed, EMBASE, Cochrane library, BMJ best practice, ProQuest dissertations and theses, CINAHL, web of science, SinoMed, WANFANG, CNKI, and the platform of clinical trial registration. The databases were searched through December 31, 2019, and studies were evaluated by two independent researchers. Review Manager software was used for data analysis. We included 41 studies conducted in ten countries and involving 3248 participants. Meta-analysis showed that post-pyloric feeding had a lower incidence rate of pulmonary aspiration, gastric reflux, and pneumonia (P < 0.001, all), less incidence of gastrointestinal complications including vomiting, nausea, diarrhea, abdominal distension, high gastric residual volume, and constipation (P < 0.05, all), more optimal gastrointestinal nutrition including the percentage of total nutrition provided to the patient, the time to tolerate enteral nutrition, the time required to start feeding and the time required to reach nutritional targets (P < 0.05, all), shorter length of mechanical ventilation, stay in ICU and stay in hospital (P < 0.001, all), compared with gastric-tube feeding. No significant differences were shown in the time of gastrointestinal function recovery, mortality, or hospitalization expenses between the two feeding routes. This review provides evidence that post-pyloric feeding appears to be the safer and more effective choice, as compared to gastric-tube feeding among critical patients.

Nasogastric/nasoenteric tube-related adverse events: an integrative review

Objective:

to analyze in the scientific literature the evidence on nasogastric/nasoenteric tube related adverse events in adult patients.

Method:

integrative literature review through the search of publications in journals indexed in PubMed/MEDLINE, CINAHL, LILACS, EMBASE and Scopus, and hand searching, was undertaken up to April 2017.

Results:

the sample consisted of 69 primary studies, mainly in English and published in the USA and UK. They were divided in two main categories and subcategories: the first category refers to Mechanical Adverse Events (respiratory complications; esophageal or pharyngeal complications; tube obstruction; intestinal perforation; intracranial perforation and unplanned tube removal) and the second alludes to Others (pressure injury related to fixation and misconnections). Death was reported in 16 articles.

Conclusion:

nasogastric/nasoenteric tube related adverse events are relatively common and the majority involved respiratory harm that resulted in increased hospitalization and/or death. The results may contribute to healthcare professionals, especially nurses, to develop an evidence-based guideline for insertion and correct positioning of bedside enteral tubes in adult patients.

ESPEN guideline on clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

Current perspective for tube feeding in the elderly: from identifying malnutrition to providing of enteral nutrition

With the number of individuals older than 65 years expected to rise significantly over the next few decades, dramatic changes to our society and health care system will need to take place to meet their needs. Age-related changes in muscle mass and body composition along with medical comorbidities including stroke, dementia, and depression place elderly adults at high risk for developing malnutrition and frailty. This loss of function and decline in muscle mass (ie, sarcopenia) can be associated with reduced mobility and ability to perform the task of daily living, placing the elderly at an increased risk for falls, fractures, and subsequent institutionalization, leading to a decline in the quality of life and increased mortality. There are a number of modifiable factors that can mitigate some of the muscle loss elderly experience especially when hospitalized. Due to this, it is paramount for providers to understand the pathophysiology behind malnutrition and sarcopenia, be able to assess risk factors for malnutrition, and provide appropriate nutrition support. The present review describes the pathophysiology of malnutrition, identifies contributing factors to this condition, discusses tools to assess nutritional status, and proposes key strategies for optimizing enteral nutrition therapy for the elderly.

Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A consensus statement

BACKGROUND & AIMS

Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia-Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia-Pacific and the Middle East.

METHODS

The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia-Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions.

RESULTS

Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU.

CONCLUSIONS

The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes.

Determining Feeding Tube Location by Gastric and Intestinal pH Values

BACKGROUND

The purpose of this study was to evaluate a series of pH values of aspirates from feeding tubes to differentiate between gastric and intestinal tube placement.

METHODS

One hundred ventilator-supported subjects, with an order for nasoduodenal feeding tube placement were randomly selected. The feeding tube was placed into the stomach, verified by auscultation, and 2 pH measurements were obtained. After the pH measurements were taken, tube location was then verified by fluoroscopy. When the tube was advanced into the small intestine, location was verified by fluoroscopy, and 2 additional pH measurements were obtained.

RESULTS

From the selected subjects, both a gastric and intestinal aspirate were obtained from 82 subjects. For the 82 subjects, the mean gastric and intestinal pH values were 4.8 +/- 2.3 and 7.1 +/- 1.0, respectively. For patients receiving acid-suppressing agents, these values were 5.0 +/- 2.3 and 7.2 +/- 1.0, respectively. For subjects not receiving acid-suppressing agents, these pH values were 4.0 +/- 2.5 and 6.7 +/- 1.1, respectively. For all patients, using a pH value of 6.5 as a predictor of feeding tube location, the sensitivity and specificity were 0.66 and 0.90. In addition, when an increase in pH > or = 1.0 was used as a predictor of location change for all patients, the sensitivity was 0.58.

CONCLUSIONS

The pH value was a reliable predictor of nasoduodenal tube placement. However, radiographic confirmation of location could not be excluded because of the low sensitivity using pH measurements alone. An increase of > or = 1.0 in gastric vs intestinal pH specimens could be useful to determine use of radiography confirmation of tube placement.

Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis

BACKGROUND

There is conflicting evidence about the relationship between the dose of enteral caloric intake and survival in critically ill patients. The objective of this systematic review and meta-analysis is to compare the effect of lower versus higher dose of enteral caloric intake in adult critically ill patients on outcome.

METHODS

We reviewed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through November 2015. We included randomized and quasi-randomized studies in which there was a significant difference in the caloric intake in adult critically ill patients, including trials in which caloric restriction was the primary intervention (caloric restriction trials) and those with other interventions (non-caloric restriction trials). Two reviewers independently extracted data on study characteristics, caloric intake, and outcomes with hospital mortality being the primary outcome.

RESULTS

Twenty-one trials mostly with moderate bias risk were included (2365 patients in the lower caloric intake group and 2352 patients in the higher caloric group). Lower compared with higher caloric intake was not associated with difference in hospital mortality (risk ratio (RR) 0.953; 95 % confidence interval (CI) 0.838-1.083), ICU mortality (RR 0.885; 95 % CI 0.751-1.042), total nosocomial infections (RR 0.982; 95 % CI 0.878-1.077), mechanical ventilation duration, or length of ICU or hospital stay. Blood stream infections (11 trials; RR 0.718; 95 % CI 0.519-0.994) and incident renal replacement therapy (five trials; RR 0.711; 95 % CI 0.545-0.928) were lower with lower caloric intake. The associations between lower compared with higher caloric intake and primary and secondary outcomes, including pneumonia, were not different between caloric restriction and non-caloric restriction trials, except for the hospital stay which was longer with lower caloric intake in the caloric restriction trials.

CONCLUSIONS

We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality. Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy (five trials only). The heterogeneity in the design, feeding route and timing and caloric dose among the included trials could limit our interpretation. Further studies are needed to clarify our findings.

Endoscopy versus fluoroscopy for the placement of postpyloric nasoenteric tubes in critically ill patients: A meta-analysis of randomized controlled trials

INTRODUCTION

Early postpyloric nasoenteric nutrition is considered an accepted method of nutritional support in critically ill patients. Both endoscopy and fluoroscopy placement of postpyloric nasoenteric tubes (PNTs) have the highest percentages of placement success rate. We aimed to evaluate the differences in efficacy and safety between endoscopy and fluoroscopy methods for the placement of PNTs in critically ill patients.

METHOD

We searched MEDLINE, Embase, and electronic databases of Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing endoscopy and fluoroscopy placement of PNTs in critically ill patients. Two reviewers assessed the quality of each study and collected data independently. We performed the meta-analysis with Cochrane Collaboration RevMan 5.3.

RESULTS

Three randomized controlled trials involving 243 patients were included. There were no significant differences in the placement success rate (RR, 0.99; 95% CI, 0.93, 1.06; z = 0.20, P = .84,) or procedure time (standardized mean difference, -0.08; 95% CI, -6.93, 6.77; z = 0.02, P = .98) between the 2 groups. No severe complications (digestive tract hemorrhage, perforation, respiratory problems, hemodynamic instability, or death) were noted in the three studies. There was a slight difference in the incidence of minor complications (RR, 8.12; 95% CI, 1.07, 61.53; z = 2.03, P = .04) between the 2 groups.

CONCLUSIONS

Endoscopy and fluoroscopy placement of PNTs can be accurately and safely performed in critically ill patients. Endoscopy may be at least equally as safe as fluoroscopy for the placement of PNTs.

A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: We should revisit nasointestinal feeding versus dual prokinetic treatment: Achieving goal nutrition in critical illness and delayed gastric emptying: Trial of nasointestinal feeding versus nasogastric feeding plus prokinetics

BACKGROUND & AIMS

Delayed gastric emptying (DGE) commonly limits the use of enteral nutrition (EN) and may increase ventilator-associated pneumonia. Nasointestinal feeding has not been tested against dual prokinetic treatment (Metoclopramide and Erythromycin) in DGE refractory to metoclopramide. This trial tests the feasibility of recruiting this 'treatment-failed' population and the proof of concept that nasointestinal (NI) feeding can increase the amount of feed tolerated (% goal) when compared to nasogastric (NG) feeding plus metoclopramide and erythromycin treatment.

METHODS

Eligible patients were those who were mechanically ventilated and over 20 years old, with delayed gastric emptying (DGE), defined as a gastric residual volume ≥250 ml or vomiting, and who failed to respond to first-line prokinetic treatment of 3 doses of 10 mg IV metoclopramide over 24 h. When assent was obtained, patients were randomised to receive immediate nasointestinal tube placement and feeding or nasogastric feeding plus metoclopramide and erythromycin (prokinetic) treatment.

RESULTS

Of 208 patients with DGE, 77 were eligible, 2 refused assent, 25 had contraindications to intervention, almost exclusively prokinetic treatment, and it was feasible to recruit 50. Compared to patients receiving prokinetics (n = 25) those randomised to nasointestinal feeding (n = 25) tolerated more of their feed goal over 5 days (87-95% vs 50-89%) and had a greater area under the curve (median [IQR] 432 [253-464]% vs 350 [213-381]%, p = 0.026) demonstrating proof of concept. However, nasointestinally fed patients also had a larger gastric loss (not feed) associated with the NI route but not with the fluid volume or energy delivered.

CONCLUSIONS

This is first study showing that in DGE refractory to metoclopramide NI feeding can increase the feed goal tolerated when compared to dual prokinetic treatment. Future studies should investigate the effect on clinical outcomes.

EU CLINICAL TRIALS REGISTER

EudraCT number: 2012-001374-29.

Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults

BACKGROUND

Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed.

OBJECTIVES

To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data.

MAIN RESULTS

We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.

Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis

Clinicians and researchers frequently use the phrase 'feeding intolerance' (FI) as a descriptive term in enterally fed critically ill patients. We aimed to: (1) determine what is the most accepted definition of FI; (2) estimate the prevalence of FI; and (3) evaluate whether FI is associated with important outcomes. Systematic searches of peer-reviewed publications using PubMed, MEDLINE, and Web of Science were performed with studies reporting FI extracted. We identified 72 studies defining FI. In 33 studies, the definition was based on large gastric residual volumes (GRVs) together with other gastrointestinal symptoms, while 30 studies relied solely on large GRVs, six studies used inadequate delivery of enteral nutrition (EN) as a threshold, and three studies gastrointestinal symptoms without reference to GRV. The median volume used to define a 'large' GRV was 250 ml (ranges from 75 to 500 ml). The pooled proportion (n = 31 studies) of FI was 38.3% (95% CI 30.7-46.2). Five studies reported outcomes, all of them observed adverse outcome in FI patients. In three studies, respectively, FI was associated with increased mortality and ICU length-of-stay. In summary, FI is inconsistently defined but appears to occur frequently. There are preliminary data indicating that FI is associated with adverse outcomes. A standard definition of FI is required to determine the accuracy of these preliminary data.

A practice change initiative to improve the provision of enteral nutrition to intensive care patients

AIM

To describe a practice change initiative that improved the provision of enteral nutrition (EN) to patients in a New Zealand tertiary intensive care unit (ICU).

METHODS

The project reviewed and summarized EN literature, amended local policy, and an evidence-based EN delivery algorithm was developed. The EN practice change initiative was implemented and evaluated. Data was collected and analyzed in a pre-audit (2009) and a post-audit (2013).

RESULTS

Comparison of the pre-audit (N = 25) and the post-audit (N = 40) data demonstrated improvements in three areas of EN delivery. The commencement of early EN within 24 h of admission was evident for a large proportion of patients in both 2009 and 2013 audits. There was a large reduction in time between the two audits for both ICU admission to achievement of EN goal rate (M = 57·71 h versus M = 33·79 h, p = 0·006) and also for EN commencement to achievement of EN goal rate (M = 31·65 h versus M = 10·15 h, p = 0·000). The volume of prescribed EN delivered on days 2, 4 and 6 was greater in the 2013 audit in comparison to the 2009 audit. Staff compliance with adhering to the EN policy and algorithm improved from 46% in 2009, to 95% in 2013.

CONCLUSIONS

The practice change has significantly improved the practice delivery of EN for patients in the local ICU resulting in optimal care.

RELEVANCE TO CLINICAL PRACTICE

Malnutrition is highly prevalent among intensive care patients. Strategies and initiatives that improve the delivery of enteral nutrition to the critical care population is therefore vitally important. This article describing such an initiative is thus highly relevant to all health care professionals delivering enteral nutrition in intensive and critical care units.

Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients: Results of a Multicenter Observational Study

BACKGROUND

To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients.

MATERIALS AND METHODS

International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60-day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses.

RESULTS

Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66-1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72-1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87-1.55; P = .307) after adjusting for confounders.

CONCLUSIONS

Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.

Gastroesophageal reflux in critically ill patients

Gastroesophageal reflux (GER) is a common occurrence in critically ill, mechanically ventilated patients. Reflux can lead to pulmonary aspiration of gastric contents and subsequent pneumonia. Several characteristics of patients, interventions provided in the intensive care unit setting, and factors associated with feeding increase a patient's risk for reflux. Critical care nurses and clinical nurse specialists can identify patients at highest risk for GER by utilizing the patient's history, reviewing the medications, and assessing the current status to provide interventions to reduce the risk of GER and its sequelae of aspiration pneumonia. This article reviews the physiology of GER, risk factors, and interventions to decrease GER in the critically ill patient.

Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials

INTRODUCTION

This systematic review and meta-analysis aimed to evaluate the effect of small bowel feeding compared with gastric feeding on the frequency of pneumonia and other patient-important outcomes in critically ill patients.

METHODS

We searched EMBASE, MEDLINE, clinicaltrials.gov and personal files from 1980 to Dec 2012, and conferences and proceedings from 1993 to Dec 2012 for randomized trials of adult critically ill patients in the intensive care unit (ICU) comparing small bowel feeding to gastric feeding, and evaluating risk of pneumonia, mortality, length of ICU stay, achievement of caloric requirements, duration of mechanical ventilation, vomiting, and aspiration. Independently, in duplicate, we abstracted trial characteristics, outcomes and risk of bias.

RESULTS

We included 19 trials with 1394 patients. Small bowel feeding compared to gastric feeding was associated with reduced risk of pneumonia (risk ratio [RR] 0.70; 95% CI, 0.55, 0.90; P = 0.004; I2 = 0%) and ventilator-associated pneumonia (RR 0.68; 95% CI 0.53, 0.89; P = 0.005; I2 = 0%), with no difference in mortality (RR 1.08; 95% CI 0.90, 1.29; P = 0.43; I2 = 0%), length of ICU stay (WMD -0.57; 95%CI -1.79, 0.66; P = 0.37; I2 = 0%), duration of mechanical ventilation (WMD -1.01; 95%CI -3.37, 1.35; P = 0.40; I2 = 17%), gastrointestinal bleeding (RR 0.89; 95% CI 0.56, 1.42; P = 0.64; I2 = 0%), aspiration (RR 0.92; 95% CI 0.52, 1.65; P = 0.79; I2 = 0%), and vomiting (RR 0.91; 95% CI 0.53, 1.54; P = 0.72; I2 = 57%). The overall quality of evidence was low for pneumonia outcome.

CONCLUSIONS

Small bowel feeding, in comparison with gastric feeding, reduces the risk of pneumonia in critically ill patients without affecting mortality, length of ICU stay or duration of mechanical ventilation. These observations are limited by variation in pneumonia definition, imprecision, risk of bias and small sample size of individual trials.

Comparison of postpyloric tube feeding and gastric tube feeding in intensive care unit patients: a meta-analysis

BACKGROUND AND OBJECTIVE

Enteral feeding is vital in the critical care setting; however, the optimal route of enteral feeding (postpyloric vs gastric feeding) remains debated. We aimed to systematically review the current evidence to see whether postpyloric feeding could provide additional benefits to intensive care unit (ICU) patients.

METHOD

Randomized controlled trials (RCTs) comparing the efficacy and safety of postpyloric feeding vs gastric feeding were included in our systematic review. Odds ratio (OR) was used for binary outcome data and weighted mean difference (WMD) was used for continuous outcome data. Summary effects were pooled using a fixed or random effects model as appropriate.

RESULTS

Seventeen RCTs were included in our meta-analysis. Postpyloric tube feeding could deliver higher proportions of estimated energy requirement (WMD, 12%; 95% confidence interval [CI], 5%-18%) and reduce the gastric residual volume (GRV) (WMD, -169.1 mL; 95% CI, -291.995 to -46.196 mL). However, the meta-analysis failed to demonstrate any benefits to critically ill patients with postpyloric tube feeding in terms of mortality (OR, 1.05; 95% CI, 0.77-1.44), new-onset pneumonia (OR, 0.77; 95% CI, 0.53-1.13), and aspiration (OR, 1.20; 95% CI, 0.64-2.25). There was no significant publication bias as represented by an Egger's bias coefficient of 0.21 (95% CI, -1.01 to 1.43; P = .7).

CONCLUSION

As compared with gastric feeding, postpyloric feeding is able to deliver higher proportions of the estimated energy requirement and can help reduce the GRV.

Evaluation of a new method for placing nasojejunal feeding tubes

AIM: To compare fluoroscopic, endoscopic and guide wire assistance with ultraslim gastroscopy for placement of nasojejunal feeding tubes.

METHODS: The information regarding nasojejunal tube placement procedures was retrieved using the gastrointestinal tract database at Tongji Hospital affiliated to Tongji Medical College. Records from 81 patients who underwent nasojejunal tubes placement by different techniques between 2004 and 2011 were reviewed for procedure success and tube-related outcomes.

RESULTS: Nasojejunal feeding tubes were successfully placed in 78 (96.3%) of 81 patients. The success rate by fluoroscopy was 92% (23 of 25), by endoscopic technique 96.3% (26 of 27), and by guide wire assistance (whether via transnasal or transoral insertion) 100% (23/23, 6/6). The average time for successful placement was 14.9 ± 2.9 min for fluoroscopic placement, 14.8 ± 4.9 min for endoscopic placement, 11.1 ± 2.2 min for guide wire assistance with transnasal gastroscopic placement, and 14.7 ± 1.2 min for transoral gastroscopic placement. Statistically, the duration for the third method was significantly different (P < 0.05) compared with the other three methods. Transnasal placement over a guidewire was significantly faster (P < 0.05) than any of the other approaches.

CONCLUSION: Guide wire assistance with transnasal insertion of nasojejunal feeding tubes represents a safe, quick and effective method for providing enteral nutrition.

A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness

OBJECTIVE

Current guidelines recommend enteral nutrition in critically ill adults; however, poor gastric motility often prevents nutritional targets being met. We hypothesized that early nasojejunal nutrition would improve the delivery of enteral nutrition.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Seventeen multidisciplinary, closed, medical/surgical, intensive care units in Australia.

PATIENTS

One hundred and eighty-one mechanically ventilated adults who had elevated gastric residual volumes within 72 hrs of intensive care unit admission.

INTERVENTIONS

Patients were randomly assigned to receive early nasojejunal nutrition delivered via a spontaneously migrating frictional nasojejunal tube, or to continued nasogastric nutrition.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the proportion of the standardized estimated energy requirement that was delivered as enteral nutrition. Secondary outcomes included incidence of ventilator-associated pneumonia, gastrointestinal hemorrhage, and in-hospital mortality rate. There were 92 patients assigned to early nasojejunal nutrition and 89 to continued nasogastric nutrition. Baseline characteristics were similar. Nasojejunal tube placement into the small bowel was confirmed in 79 (87%) early nasojejunal nutrition patients after a median of 15 (interquartile range 7-32) hrs. The proportion of targeted energy delivered from enteral nutrition was 72% for the early nasojejunal nutrition and 71% for the nasogastric nutrition group (mean difference 1%, 95% confidence interval -3% to 5%, p=.66). Rates of ventilator-associated pneumonia (20% vs. 21%, p=.94), vomiting, witnessed aspiration, diarrhea, and mortality were similar. Minor, but not major, gastrointestinal hemorrhage was more common in the early nasojejunal nutrition group (12 [13%] vs. 3 [3%], p=.02).

CONCLUSIONS

In mechanically ventilated patients with mildly elevated gastric residual volumes and already receiving nasogastric nutrition, early nasojejunal nutrition did not increase energy delivery and did not appear to reduce the frequency of pneumonia. The rate of minor gastrointestinal hemorrhage was increased. Routine placement of a nasojejunal tube in such patients is not recommended.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): neurocritical patient]

Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteral-parenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calore intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.

Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness

BACKGROUND

Few trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial.

OBJECTIVE

To test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness.

DESIGN

A 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes.

PARTICIPANTS/SETTING

One hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study.

INTERVENTION

Patients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as "less severe" and "more severe," with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20.

MAIN OUTCOME MEASURES

Daily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin.

STATISTICAL ANALYSES PERFORMED

Two-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes.

RESULTS

Among less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group.

CONCLUSIONS

To optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.

Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems

PURPOSE

Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options.

METHODS

The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology.

RESULTS

Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided.

CONCLUSIONS

State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes.

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.

[Enteral feeding tubes for critically ill patients]

The use of enteral feeding tubes is an important part of early enteral feeding in intensive care medicine. In other faculties with non-critically ill patients, such as (oncologic) surgery, neurology, paediatrics or even in palliative care medicine feeding tubes are used under various circumstances as a temporary or definite solution. The advantage of enteral feeding tubes is the almost physiologic administration of nutrition, liquids and medication. Enteral nutrition is thought to be associated with a reduced infection rate, increased mucosal function, improved immunologic function, reduced length of hospital stay and reduced costs. However, the insertion and use of feeding tubes is potentially dangerous and may be associated with life-threatening complications (bleeding, perforation, peritonitis, etc.). Therefore, the following article will give a summary of the different types of enteral feeding tubes and their range of application. Additionally, a critical look on indication and contraindication is given as well as how to insert an enteral feeding tube.

Providing nutrition to critically ill obese adults: use of the nursing process

Caring for obese critically ill patients is not always the same as caring for critically ill patients who are not obese. Fortunately, nurses have many resources available to them to guide them in this process. However, research that specifically addresses the needs of obese critically ill patients is still lacking in many areas and should be considered as potential areas to develop evidence-based practices.

Disparate response to metoclopramide therapy for gastric feeding intolerance in trauma patients with and without traumatic brain injury

Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P < or = .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide-erythromycin were 55%, 62%, and 79%, respectively (P < or = .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P < or = .02), due to a greater prevalence of tachyphylaxis. Single-drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first-line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.

Jejunal feeding tubes can be efficiently and independently placed by intensive care unit teams

BACKGROUND

Nutrition support is an important therapeutic measure in critically ill patients. Several studies have shown that the enteral route is preferable to the parenteral route. Insertion of a feeding tube beyond the ligament of Treitz combined with continuous gastric drainage will reduce regurgitation and probably also the rate of nosocomial pneumonia. This study was conducted to assess the safety, success rate, and time required to establish jejunal nutrition by the fluoroscopy-guided technique in intensive care unit (ICU) patients.

METHODS

This was a prospective observational study in the ICUs of a 300-bed and a 600-bed community hospital. Indications were large gastric residuals during attempted gastric feeding, severe acute pancreatitis, or recurrent aspiration. Feeding tubes were introduced by the ICU staff at bedside under fluoroscopic guidance (a senior ICU physician and a resident or a registered ICU nurse). The correct jejunal position was documented by the application of a radiopaque contrast medium through the tube. After confirmation of the correct position, jejunal tube feeding was immediately started.

RESULTS

The insertion procedure in 38 patients lasted a median of 17 minutes. The median time from decision to place the tube until start of enteral feeding was 141 minutes. The success rate was 84.2%. No adverse events were observed.

CONCLUSIONS

Fluoroscopic placement of a jejunal feeding tube at the bedside is fast, is safe, and has a high success rate when performed by well-trained ICU staff. Using this method makes the ICU team more self-sufficient when critically ill patients require enteral nutrition and no gastroenterologist is available.

A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Introduction

To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).

Methods

Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.

Results

A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.

Conclusions

Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications

Trial Registration

Clinical Trial: anzctr.org.au:ACTRN12606000367549

Insertion of Post-Pyloric Feeding Tubes in the ICU is Not as Difficult as we Thought

Post-pyloric feeding has been shown to be beneficial compared to gastric feeding in terms of calories delivered, length of intensive care unit stay and possibly rates of ventilator-associated pneumonia and mortality. It has often been disregarded as taking too long or requiring expensive equipment, but we have established a rapid, safe, cheap and reliable technique for inserting post-pyloric feeding tubes.

[The Latin-American survey on nutrition in Pediatric Intensive Care (ELAN-CIP)]

INTRODUCTION

Artificial Nutrition Support (ANS) is an important therapeutic technique in the care of the critically ill child that is not always implemented appropriately and correctly. There are also different ways of applying it which varies between the different centres and, even among the different health professionals.

MATERIAL METHODS

A cross-sectional multicentre survey.

RESULTS

A total of 24 PICUs took part in 14 countries, the majority multidisciplinary and belonging to public and university hospitals. The preferred ANS was enteral, administrated by the gastric route and started within the first 72h after admission. The administration techniques and monitoring of the ANS, enteral and parenteral, were variable but generally consistent with the world-wide accept recommendations.

CONCLUSIONS

Latin-American PICUs prefer enteral ANS administered by gastric feed soon after admission.