Hypocaloric Tolerance and Enteral Feeding in ICU

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Hypocaloric Tolerance and Enteral Feeding in ICU

• ICU 4A2 Ri ??? / VS ???

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Hypocaloric Feeding Consequence-from Current
Opinion in Critical Care, April 2007
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Pros the advantages of hypocaloric feeding

• Overfeeding is deleterious and causes a series of
  side effects such as hyperglycemia, fatty liver,
  higher rates of infectious complications, and
  finally, more deaths.
• Providing some energy to the gut that is,
  delivering about 500 kcal/day as enteral
  nutrition may contribute to maintain the gut
  mucosa.

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Cons the disadvantages of hypocaloric feeding

• Malnutrition
• Increases insulin resistance and causes negative
  nitrogen balances with deleterious effects on
  muscle function

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Energy debt

• Delaying initiation of nutritional support
  exposes patients to energy deficits that cannot
  be compensated later on.
• A negative energy balance may cause ARDS, sepsis,
  renal failure, pressure sores, and total
  complication rates increase.

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How long can fasting be tolerated by critically
ill patients?

• There is no real comparative study assessing this
  question, although there are a few studies
  showing that standard care (no feeding) is
  associated with poor outcome compared with
  feeding
• Clearly, the tolerable length of limited intake
  will depend on the severity of disease.
• Although the evidence is strongly against
  prolonged hypocaloric feeding that is, more
  than 96 h the demonstration that limiting
  underfeeding improves outcomes in the critically
  ill still awaits a prospective trial.

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Hypocaloric Feeding of the Critically Ill

• Studies have shown hypocaloric nutrition support
  to be safe and to achieve nitrogen balance
  comparable with traditional regimens.
• Benefits shown include improved glycemic control,
  decreased intensive care unit (ICU) length of
  stay (LOS), and decreased ventilator days and
  infection rate
• However, not all studies have produced identical
  results.

from Nutrition in Clinical Practice, Vol. 21, No.
6, 617-622 (2006)
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Tolerance factors

• Providing adequate dietary protein has emerged as
  an important factor in efficacy of the
  hypocaloric regimen.
• Although it is inconclusive, currently available
  research suggests that a nutrition support goal
  of 1020 kcal/kg of ideal or adjusted weight and
  1.52 g/kg ideal weight of protein may be
  beneficial during the acute stress response.
• Well-designed, randomized, controlled studies
  with adequate sample size that evaluate relevant
  clinical outcomes such as mortality, ICU LOS, and
  infection while controlling for factors such as
  glycemic control, severity of illness,
  incorporation of calories from all sources, in
  addition to feeding regimens, are needed to
  definitively determine the effects of hypocaloric
  nutrition support.

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• Enteral feeding protocol
• From ENTERAL FEEDING GUIDELINES
• Harborview Medical Center,
• Seattle, Washington State

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Adults

• A. Gastric Feeding
• a. Standard formulas should be started at a rate
  of 50cc/hr unless there is significant concern
  regarding gastric motility
• b. If tolerated the rate of feeding can be
  advanced by 25cc/hr every 4-8 hours
• c. Elemental formulas should start at full
  strength at 25cc/hr for the first 12 hours then
  advance by 25cc/hr every 6-12 hours

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Adults-2

• B. Jejunal or duodenal feeding
• a. Standard or elemental feedings at full
  strength at 25 cc/hr for the first 12 hours then
  advance by 25cc/hr every 6-12 hrs
• b. Do not use bolus feeding

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Pediatrics-1

• A. Gastric Feeds (NG, continuous) (5)
• 1. Initiation of feeding 1-2 ml/kg/hr
• If the patient has been NPO for several days
  initiate the feeding more slowly.
• 2. If tolerated increase q 6-8 hrs to goal rate
• 3. Gastric Residual evaluation
• If residuals are greater than the previous hour's
  feeding volume this is considered a significant
  volume. Hold tubefeeds for one hour.
• If patient continues to have a high residual, use
  of a prokinetic agent should be considered.
• Consider post-pyloric feeding tube placement if
  necessary.

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Pediatrics-2

• B. Gastric Feeds ( PEG - Percutaneous
  Gastrostomy Tubes)
• 1. Initiation
• Infant lt1 30 ml q 3hrs x 2
• Toddler 1-5 50 ml q 3hrs x 2
• Child gt 5 75 ml q 3hrs x 2
• Adol 12-14 100 ml q 3hrs x 2
• 2. If bolus feeds tolerated then begin
  continuous feed and then advance as tolerated
• Infant lt1 10 ml/hr x 24 hrs
• Toddler 1-5 20ml/hr x 24 hrs
• Children gt5 30ml/hr x 24 hrs

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• 3. Gastric Residual evaluation (6) Check
  residual q 4 hrs.
• a. Bolus Feedings If residual is gt than half
  the volume of the last bolus, hold feeds and
  evaluate the patient
• b. Continuous Feedings If residual volume is gt
  2x the hourly rate then hold feeds and evaluate
  the patient
• C. Jejunostomy feedings
• Rarely used in children.
• Do not use bolus feedings.

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When to Hold Enteral feeding

• a. 1/2 hour prior to procedures requiring the
  Trendelenberg position
• b. 6 hours prior to general anesthesia for
  non-intubated patients
• c. Intubated patients having either airway
  surgery (includes tracheostomy) or planned
  reintubation (such as thoracotomy/thoracoscopy)
  NPO a minimum of 6 hours.
• d. Intubated patients having planned surgery on
  the GI tract, NPO from midnight.
• e. All other intubated patients, enteral
  feeds can be continued until the time of
  departure to the operating room. This includes
  any patient who will be proned during surgery or
  extubated post-operatively

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Monitoring Tolerance and complications of enteral
feeding

• 1. Monitoring tolerance
• a. Gastric feeds
• - Check gastric residual volumes every 4 hours.
  Hold tube feedings for residuals greater than
  200cc. Reinfuse the residual and recheck in 2
  hours. Notify MD if residuals remain so high that
  the patient cannot be fed for more than 2 hours.
• - Feeds should also be held for increasing
  abdominal distension and/or emesis.
• b. Jejunal feeds
• - Residual volumes are not helpful. Monitor
  abdomen for distension and bowel sounds q4 hrs.
  Hold feeds for emesis, abdominal pain or
  distension.

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Protocol of ICU Nutritional Support from
Protocol of ICU Nutritional Support in NTUH

• step1 Can GI use?
• ? NO (??????,TPN )
• ? YES (step2)
• Step2 GI can intake gt80 of requirement?
• ? NO(Partial Parenteral Nutrition)
• ? YES(step3)
• Step3 Need nutrient modulation?
• ? NO??general formula(powder) ?SEF(can)?
• ? YES
• Step4 Stomach use?
• ? NO(elemental diet and step7 structure change)
• ? YES(general formula or SEF???)
• Step5 SIRS
• ? YES(elemental diet and step7 Immune modulation)
• Step6 Feeding route?
• ? bolus feeding 240-400cc/time, 3-5min,
  5-8times/day
• ? Intermittent feeding 240-400cc/time, 30-60min,
  5-8times/day(??feeding bag)
• ? Continuous feeding, rate start 20-50cc/hr, add
  10-25cc/hr (??feeding pump,????????10cc/hr)

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• Step7 Elemental dietlow-fat and hi-protein
• ? Structure change(short bowl?pancreatitis)
• Vital (20 proteiolysis)
• Alitraq (50 amino-acid, arginine and glutamine)
• Vivonex(100 amino-acid, arginine and glutamine)
• Nu-PEP(100 peptides)
• ? Immune modulation
• IMPACT(immune-enhance)
• IMPACT-glutamine(immune-enhance)
• Nu-immune(immune-enhance)
• Oxepa(immune-modulation for ARDS)

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No GI feeding, when

• 1.use pressors (bosmin, levophed)
• 2.metabolic acidosis
• 3.need volume resuscitation
• 4.serum lactate gt 3 mmole/L
• 5.NG aspiration gt 200 mL

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• Routine, head of the bed elevated 30 when bolus
  intragastric feeding
• Bolus feeding, max. 400 mL in total
• Stop GI feeding for 6 hours at night (000
  500)
• When NG feeding cannot work, consider jejunal
  feeding soon
• GI feeding intolerance signs bloating, cramp,
  nausea, abdominal distension, (In jejunal
  feeding, it depends on S/S to decide feeding
  amount or stop feeding)

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Reference

• 1. Hypocaloric Feeding Pros and Cons
• Berger, Mette M Chioléro, René L
• Current Opinion in Critical Care April 2007 -
  Volume 13 - Issue 2 - p 180-186
• 2. Hypocaloric Feeding of the Critically Ill
• Megan Boitano, MS, RD, CNSD
• Nutrition in Clinical Practice, Vol. 21, No. 6,
  617-622 (2006)
• 3. Harborview Medical Center ENTERAL FEEDING
  GUIDELINES
• Adapted from ASPEN Guidelines for the Use of
  Parenteral and Enteral Nutrition in Adult and
  Pediatric Patients
• Adapted from The Science and Practice of
  Nutrition Support, A Case-Based Core Curriculum,
  "Enteral Nutrition Indications, Options, and
  Formulations", by Pamela Charney, pg. 148, 2001,
  Kendall/Hunt Publishing Co.
• 4. Protocol of ICU Nutritional Support in NTUH
• ?????, ???

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• Thank you for your attention !!