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Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, Fruhwald S, Hiesmayr M, Ichai C, Jakob SM, Loudet CI, Malbrain MLNG, Montejo González JC, Paugam-Burtz C, Poeze M, Preiser JC, Singer P, van Zanten ARH, De Waele J, Wendon J, Wernerman J, Whitehouse T, Wilmer A, Oudemans-van Straaten HM. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 2017; 43:380-398. [PMID: 28168570 PMCID: PMC5323492 DOI: 10.1007/s00134-016-4665-0] [Citation(s) in RCA: 414] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022]
Abstract
Purpose To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. Methods We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. Results We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. Conclusions We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.
- Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Mette M Berger
- Services of Adult Intensive Care Medicine and Burns, Lausanne University Hospital, Lausanne, Switzerland
| | - Michael P Casaer
- Department of Intensive Care Medicine, University Hospital Leuven, Louvain, Belgium
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Hiesmayr
- Klinische Abteilung für Herz-Thorax-Gefäßchirurgische Anästhesie & Intensivmedizin, Medizinische Universität Wien, Vienna, Austria
| | - Carole Ichai
- Intensive Care Unit, Hôpital Pasteur 2, University of Nice, Nice, France
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland
| | - Cecilia I Loudet
- Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín de La Plata, Buenos Aires, Argentina
| | - Manu L N G Malbrain
- Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium
| | | | - Catherine Paugam-Burtz
- Anesthesiology and Perioperative Care Medicine Department, Hôpital Beaujon APHP, Clichy, France
| | - Martijn Poeze
- Department of Surgery/IntensiveCare Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Singer
- Intensive Care Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
- Anesthesia and Intensive Care Division, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Julia Wendon
- Department of Intensive Care Medicine, Division of Immunobiology and Transplantation, King's College London, King's College Hospital, London, UK
| | - Jan Wernerman
- Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK
| | - Alexander Wilmer
- Medical Intensive Care Unit, University Hospital Leuven, Leuven, Belgium
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Padar M, Uusvel G, Starkopf L, Starkopf J, Reintam Blaser A. Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study. World J Crit Care Med 2017; 6:56-64. [PMID: 28224108 PMCID: PMC5295170 DOI: 10.5492/wjccm.v6.i1.56] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/08/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients.
METHODS An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital’s Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed.
RESULTS In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower cumulative amount of parenterally (P < 0.001) provided calories by day 7, with an overall reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition.
CONCLUSION The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension.
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Zhang Z, Li Q, Jiang L, Xie B, Ji X, Lu J, Jiang R, Lei S, Mao S, Ying L, Lu D, Si X, He J, Ji M, Zhu J, Chen G, Shao Y, Xu Y, Lin R, Zhang C, Zhang W, Luo J, Lou T, He X, Chen K, Sun R. Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: a study protocol for before-and-after design. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:308. [PMID: 27668228 PMCID: PMC5009025 DOI: 10.21037/atm.2016.07.15] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Enteral feed is an important component of nutritional therapy in critically ill patients and underfeeding has been associated with adverse outcomes. The article developed an enteral feeding protocol and planed a before-and-after comparative trial to explore whether implementation of enteral feeding protocol was able to improve clinical outcomes. METHODS AND ANALYSIS The study will be conducted in intensive care units (ICUs) of ten tertiary care academic centers. Critically ill patients expected to stay in ICU for over 3 days and require enteral nutrition (EN) were potentially eligible. This is a before-and-after study comprising three phases: The first phase is the period without enteral feeding protocol; the second phase involves four-week training program, and the last phase is to perform the protocol in participating centers. We plan to enroll a total of 350 patients to provide an 80% power and 0.05 error rate to detect a 15% reduction of mortality. The primary outcome is 28-day mortality. ETHICS AND DISSEMINATION Ethical approval to conduct the research has been obtained from all participating centers. Additionally, the results will be published in peer-reviewed journal. TRIAL REGISTRATION The study was registered at International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry (ISRCTN10583582).
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Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | - Qian Li
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
| | - Lingzhi Jiang
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
| | - Bo Xie
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Xiaowei Ji
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Jiahong Lu
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Ronglin Jiang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Shu Lei
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Shihao Mao
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Lijun Ying
- Department of Critical Care Medicine, Shaoxing People’s Hospital, Shaoxing 312000, China
| | - Di Lu
- Department of Critical Care Medicine, Shaoxing People’s Hospital, Shaoxing 312000, China
| | - Xiaoshui Si
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Jianxin He
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Mingxia Ji
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Jianhua Zhu
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Guodong Chen
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Yadi Shao
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Yinghe Xu
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Ronghai Lin
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Chao Zhang
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Weiwen Zhang
- Department of Critical Care Medicine, Quzhou People’s Hospital, Quzhou 324000, China
| | - Jian Luo
- Department of Critical Care Medicine, Quzhou People’s Hospital, Quzhou 324000, China
| | - Tianzheng Lou
- Department of Critical Care Medicine, Lishui People’s Hospital, Lishui 323000, China
| | - Xuwei He
- Department of Critical Care Medicine, Lishui People’s Hospital, Lishui 323000, China
| | - Kun Chen
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
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Arabi YM, Al-Dorzi HM, McIntyre L, Mehta S. Design of nutrition trials in critically ill patients: food for thought. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:186. [PMID: 27275499 DOI: 10.21037/atm.2016.05.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yaseen M Arabi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Hasan M Al-Dorzi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Lauralyn McIntyre
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Sangeeta Mehta
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
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