Optimising enteral nutrition in critically ill patients by reducing fasting times

Effect of Fasting Prior to Extubation on Prevalence of Empty Stomach in Enterally Fed and Mechanically Ventilated Patients

BACKGROUND

Practice on fasting prior to extubation in critically ill patients is variable. Efficacy of fasting in reducing gastric volume has not been well established. The primary objective of this study was to assess the effect of 4 h of fasting on prevalence of empty stomach using gastric ultrasonography in critically ill subjects who are fasted for extubation. The secondary objectives were to evaluate the change in gastric volumes during 4 h of fasting and to determine factors associated with empty stomach after fasting.

METHODS

This was a single-center, prospective, observational study on adult ICU subjects who were enterally fed for at least 6 h continuously and mechanically ventilated. Gastric ultrasound was performed immediately prior to commencement of fasting, after 4 h of fasting, and after nasogastric (NG) aspiration after 4 h of fasting. An empty stomach was defined as a gastric volume ≤ 1.5 mL/kg.

RESULTS

Forty subjects were recruited, and 38 (95%) had images suitable for analysis. The prevalence of empty stomach increased after 4 h of fasting (25 [65.8%] vs 31 [81.6%], P = .041) and after 4 h of fasting with NG aspiration (25 [65.8%] vs 34 [89.5%], P = .008). There was a significant difference in median (interquartile range) gastric volume per body weight between before fasting and 4 h after fasting (1.0 [0.5-1.8] mL/kg vs 0.4 [0.2-1.0] mL/kg, P < .001). No patient factors were associated with higher prevalence of empty stomach after 4 h of fasting.

CONCLUSIONS

Most mechanically ventilated subjects had empty stomachs prior to fasting for extubation. Fasting for 4 h further increased the prevalence of empty stomach at extubation to > 80%.

Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery

INTRODUCTION

Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention.

METHODS

We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery.

RESULTS

Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05.

CONCLUSIONS

For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

(Mal)nutrition in critical illness and beyond: a narrative review

Close liaison with ICU-trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients- this should be done while monitoring closely for refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient-centred outcomes including complications and mortality. Obesity is part of that story, and isocaloric and high-protein provision of nutrition is important in this group of patients who comprise a growing proportion of people treated. Assessing protein stores and appropriate dosing is, however, challenging in all groups of patients. It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post-pyloric feeding and a multidisciplinary framework to support the importance of nutritional education.

Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: A scoping review

BACKGROUND

There is limited understanding of fasting practices and reported safety concerns for airway procedures in critically ill adults.

OBJECTIVE

To describe fasting practices including safety concerns for airway procedures in critically ill adult patients in the reported literature.

INCLUSION CRITERIA

Studies conducted in adult critically ill patients receiving enteral nutrition (EN) and undergoing an airway procedure (endotracheal intubation, endotracheal extubation, and tracheostomy) were included if EN fasting practices and/or prespecified nutrition and clinical outcomes were reported.

METHODS

A scoping review using the Joanna Briggs Institute methodology was conducted. MEDLINE, Embase, and CINAHL were searched from 2000 to January 19, 2022. Results are presented via narrative synthesis.

RESULTS

Fourteen studies were included, with only one randomised control trial (RCT). Twelve studies reported on fasting practices with varied EN fasting durations (0-34 h) and two reported data on nutrition adequacy. Three studies investigated continued EN in one study arm and four studies minimised fasting duration by including gastric suctioning prior to the airway procedure. Safety concerns primarily related to aspiration events (61%) were reported in nine studies.

CONCLUSION

In the reported literature, there is wide variation in EN fasting practices for airway procedures in critically ill patients with limited evidence to inform practice.

Preoperative fasting: exploring guidelines and evidence to ensure consistent, high-quality care

Many nurses will still be familiar with the instruction 'nil by mouth from midnight' traditionally given to patients preparing to undergo surgery. National and international guidelines now promote much shorter preoperative fasting times, encapsulated in the '2-4-6 rule' - two hours for clear fluids, four hours for breast milk and six hours for solids. The latest evidence appears to show that these fasting times are in need of revision. Furthermore, there are inconsistencies in how guidelines are implemented. This article explores the guidelines and literature on preoperative fasting in adults and children to determine what the evidence is and what changes could be made to ensure consistent, high-quality patient care.

Nutritional support protocol for patients with COVID-19

BACKGROUND & AIMS

COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19.

METHODS

A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients.

RESULTS

The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge.

CONCLUSION

Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

Intragastric prepyloric enteral nutrition, bolus vs continuous in the adult patient: A systematic review and meta-analysis

Bolus and continuous nutrition are commonly used enteral nutrition (EN) administration methodologies. Currently, there is insufficient evidence to establish which is the most effective method for reducing gastrointestinal complications in adult patients. The aim of this review is to evaluate the impact of bolus/intermittent EN compared with continuous EN for the following outcomes: diarrhea, constipation, emesis/vomiting, gastric residual volume, aspiration, and glycemic control in adult patients receiving intragastric prepyloric EN in the hospital setting. Bibliographical research was performed on the following databases: PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. The review included all randomized and nonrandomized controlled trials of patients aged ≥18 years with preserved gastrointestinal function. Meta-analysis was performed by Review Manager V.5.3. Seven studies including 551 patients were included in the meta-analysis. Five of these studies reported that the diarrhea rate was higher in the bolus feeding group (risk ratio [RR] = 2.50; 95% CI, 1.17-5.34; P = 0.02), and another five of these studies indicated that the aspiration rate was higher in the continuous feeding group (RR = 0.55; 95% CI, 0.35-0.87; P = 0.01). There were no significant differences for the other outcomes. In conclusion, intermittent EN appears to reduce the incidence of aspiration in the hospital setting; however, it may increase the risk of diarrhea. For future research, we hypothesize the joint use of continuous nutrition until the patient reaches tolerance and then passing to bolus nutrition, thus reducing the incidence of aspiration and enabling a physiological nutrition intake.

Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study

BACKGROUND

Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG.

METHODS

150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups.

RESULTS

Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7).

CONCLUSION

Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.

Observational study evaluating the nutritional impact of changing from 1% to 2% propofol in a cardiothoracic adult critical care unit

BACKGROUND

Nutritional support in the critically ill aims to avoid under and overfeeding, adjusting to changes in energy expenditure during critical illness. The sedation propofol provides significant fat and energy load. We investigated whether changing from 1% to a 2% propofol, would decrease non-nutritional energy, avoid energy overfeeding and increase the amount of protein delivered.

METHODS

A retrospective observational study was performed. The primary outcome was protein delivery. Secondary outcomes were energy from propofol fat and the total energy delivered from nutrition and propofol.

RESULTS

In total, 100 patients were investigated, with 50 patients in each group. The propofol dose was comparable for each group. The nutrition energy prescribed was significantly less for the 1% compared to 2% group, taking the energy from propofol into consideration. Both groups had similar protein targets, although the amount delivered was significantly higher in the 2% group. Thirty-six percent of individuals receiving 1% exceeded 45% of total energy from fat. The poor delivery of nutrition resulted in inadequate energy and protein, irrespective of propofol dose.

CONCLUSIONS

We investigated the impact of propofol on energy overfeeding and under delivery of protein, and highlighted suboptimal nutritional provision. Work is needed to investigate the harm that high-fat delivery may pose in light of poor nutrition delivery.

Ward-based nutrition care practices and a snapshot of patient care: Results from nutritionDay in the ICU

BACKGROUND

Poor adherence to intensive care unit (ICU) guidelines is common, leading to suboptimal nutritional care. This study determined current ward-based nutrition care practices in the Indian ICU setting, comparing them to international best-practice guidelines and provided patient demographic, clinical and nutritional information to serve as baseline data for future benchmarking.

METHODS

This multi-site cross-sectional retrospective study analysed data collected from nutritionDay worldwide audits (2012-2016) across ICUs from a chain of urban private hospitals in India. Additional guideline-specific data were collected through questionnaires and phone interviews with the Head of Dietetics Departments in the participating hospitals.

RESULTS

Overall, 10 ICUs and 457 participants were included. It was common practice to use modified versions of the Mini Nutritional Assessment-Short Form (MNA-SF) and Subjective Global Assessment (SGA) for nutrition screening and assessment. Nearly half the participants (n = 222, 49%) received nutrition orally. A majority of the remaining participants received enteral nutrition (n = 163, 36%) or no nutrition (n = 60, 13%) at the time of data collection. The calories prescribed for most participants were between 1500 and 1999 kilocalories per day (n = 207, 45%), with no nutrition planned for 115 (25%) participants. Three-quarters (n = 129, 74%) of participants on EN received the planned calories, while 24% (n = 42) were given less than planned.

CONCLUSION

Overall, most participants received the calories planned for enteral nutrition. The use of modified screening and assessment tools and suboptimal delivery of EN remains a global problem for critical care, possibly requiring a more pragmatic approach to nutritional therapy.

Impact of enteral nutrition interruptions on underfeeding in intensive care unit

BACKGROUND & AIMS

Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care.

METHODS

This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available.

RESULTS

In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001).

CONCLUSIONS

The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.

How long are mechanically ventilated patients fasted prior to surgery? An exploratory study examining preoperative fasting practices across trauma centres

For mechanically ventilated patients undergoing surgery, interrupting enteral feeding to prevent pulmonary aspiration is common; however, there are no published preoperative fasting guidelines for these patients, resulting in fasting practices that often vary greatly between hospitals. This retrospective study described fasting practices and surgical outcomes of mechanically ventilated patients across five trauma centres. The primary exposure was hours nil per os before surgery and was stratified into short (<6h) and moderate (≥6h) fasting duration. Shared frailty models assessed the relationship between time to perioperative complication and nil per os category. Three of the five hospitals had preoperative fasting guidelines, and those most compliant required patients to be fed up until surgery. Most patients were fasted ≥6h prior to surgery and no increased risk of complication was found for patients who were fasted <6h. Future studies are needed to establish appropriate preoperative fasting thresholds for mechanically ventilated patients.

Continuous or intermittent feeding: pros and cons

PURPOSE OF REVIEW

There has been a recent shift in the focus of providing nutrition support to critically ill adults towards enhancing recovery and promoting survivorship. With this has come an evaluation of our current approaches to nutrition support, which includes whether continuous feeding is optimal, particularly for reducing muscle wasting, but also for managing blood glucose levels and feeding intolerance and at the organizational level. This review will discuss the pros and cons of using intermittent and continuous feeding relating to several aspects of the management of critically ill adults.

RECENT FINDINGS

Few studies have investigated the effect of intermittent feeding over continuous feeding. Overall, intermittent feeding has not been shown to increase glucose variability or gastrointestinal intolerance, two of the reasons continuous feeding is the preferred method. A current study investigating the effect of intermittent vs. continuous feeding is awaited to provide insight into the effect of muscle wasting.

SUMMARY

Although there are limited studies investigating the safety and efficacy of an intermittent rather than continuous feeding regimen in critically ill adults, there are several theoretical advantages. Further studies should investigate these and in the meantime, feeding regimens should be devised based on individual patient factors.

Exploring fasting practices for critical care patients - A web-based survey of UK intensive care units

Background

Enteral nutrition delivery in the critically ill is frequently interrupted for surgical and airway procedures to avoid aspiration of stomach contents. Recurrent fasting leads to under delivery of enteral nutrition and this underfeeding is associated with worse outcomes. International fasting recommendations do not provide guidance for intubated patients receiving enteral nutrition. This study aimed to gain a detailed perspective of UK critical care fasting practices.

Methods

A web-based survey was sent to 232 UK intensive care units consisting of questions relating to fasting practices, presence of guidelines, average fasting times for common procedures and dietitian time per intensive care unit bed.

Results

A total of 176 intensive care units responded. Only 20% of units had guidelines and respondents stated that they were not consistently adhered to (mean compliance 66%). Units with greater dietetic involvement were more likely to have guidelines (p = 0.04). Fasting times were shorter for abdominal surgery (p = 0.002), non-abdominal surgery (p = 0.016) and radiology (p = 0.015) if a guideline was present. Fasting for extubation and tracheostomy was similar irrespective of the presence of a guideline. Considerable variation in fasting times was reported, usually due to inconsistencies in clinical decision-making.

Conclusions

This survey of national practice demonstrates that fasting times are varied and inconsistent, which may lead to under-delivery of enteral nutrition. More dietetic input was associated with increased likelihood of a fasting guideline.