Title: Reducing The Risks Of Enteral Nutrition In ICU Patients
1Reducing The RisksOf Enteral NutritionIn ICU
Patients
Andrew Davies Senior Intensivist The
Alfred Melbourne
2Nutritional support is important
- ICU patients are sick
- So they dont eat
- So if they are not already malnourished,
malnutrition is likely - Malnutrition worsens outcomes
3Nutritional support is important
- ICU patients are sick
- So they dont eat
- So if they are not already malnourished,
malnutrition is likely - Malnutrition worsens outcomes
-
- Associated with - poor wound healing
- - higher infection rates
- - longer hospital stays
4Nutritional support is important
- ICU patients are sick
- So they dont eat
- So if they are not already malnourished,
malnutrition is likely - Malnutrition worsens outcomes
- THIS IS NOW AN OUTDATED ARGUMENT
5Nutritional support is important
- ICU patients are sick
- So they dont eat
- So we should provide nutritional support to all
of them - Because NS improves clinical outcomes
- THE NEW ARGUMENT
6Nutritional support in ICU
- ACCEPT trial
- Recent multi-centre cluster-randomized trial in
Canada - Evidence-based algorithms for nutritional support
- 14 sites, 462 patients
Martin CM, Doig GS, et al. CMAJ 2004 170197-204
7(No Transcript)
8Nutritional support in ICU
- ACCEPT trial
- Recent multi-centre cluster-randomized trial in
Canada - Evidence-based algorithms for nutritional support
- 14 sites, 462 patients
p 0.02
p 0.04
Martin CM, Doig GS, et al. CMAJ 2004 170197-204
9Nutritional support in ICU
p 0.06
p 0.003
- ACCEPT trial
- Major outcomes
Martin CM, Doig GS, et al. CMAJ 2004 170197-204
10So feed the prisoners
- For our ICU patients (as a group)
- measures used to maximise amounts of NS received
- lead to improved clinical outcomes
11Basic rules of nutrition in ICU
- Nutritional support improves clinical outcomes
- So start nutritional support as early as you feel
you can - Start with enteral nutrition if possible
- If so, start with NG feeding
12How do we feed in Australia and NZ
- One day observational study
- 91 Australian and New Zealand hospitals
- 1013 patients on nutritional support
- 49 with ICU beds
- 286 ICU patients enrolled
- 37 patients were commencing NS
- Type of nutritional support used
AuSPEN Clinical Research Group 2003
13How do we feed in Australia and NZ
- One day observational study
- 286 ICU patients enrolled
- 37 patients were commencing NS
- Route of enteral feeding
AuSPEN Clinical Research Group 2003
14How do we feed in Australia and NZ
- One day observational study
- 286 ICU patients enrolled
- Success of feeding in patients on EN
- of target nutritional support received
AuSPEN Clinical Research Group 2003
15So whats the big deal
- Nutritional support improves clinical outcomes
- Australian and New Zealand ICUs do what we
should - - start early
- - use EN
- - use NG feeding
- - seem deliver reasonable amounts of energy
16Is NG feeding as good as we think?
- Up to 70 will achieve target feeding in a
reasonable timeframe (depending on aggressiveness
of protocol) - Overall ICU patients receive about 50-60 of
energy requirements - Summary Most are fine, however more than a few
are not
17GIT motility is impaired in ICU patients
- Paracetamol absorption
- Worsened by
- age (older)
- sex (male)
- use of opiates
Heyland D, et al. Intensive Care Med 1996 221339
18Which leads to upper GIT intolerance
- 153 patient observational study
- Upper GIT intolerance defined as 1 of
- - GRV gt 150 mls twice
- - GRV gt 500 mls once
- - vomiting
- Occurred in 70 patients (46)
- More likely if
- - sedation
- - catecholamines
- This increased the
- - pneumonia rate
- - hospital length of stay
- - mortality
Mentec H, et al. Crit Care Med 2001 291955
19NG feeding may be more harmfulthan delayed
feeding
- 150 patient pseudo-RCT
- Early group increased to target
- vs
- Delayed group 20 target for 4 days
- Early group had
- - more nutrition (4 times)
- - increased VAP rate
- - increased ICU and hosp LOS
- - same mortality
Ibrahim E, et al. JPEN 2002 26174
20We have a dilemma
- Feeding (especially EN) generally improves
outcomes - however
- NG feeding may have associated risks
- - pneumonia
- - mortality
21So what should we do?
- Should we use promotility drugs?
- Should we use small bowel feeding?
- Should we switch over to TPN?
- Should we combine EN TPN (add TPN and turn down
the EN)?
22So what should we do?
- Should we use promotility drugs?
- Should we use small bowel feeding?
- Should we switch over to TPN?
- Should we combine EN TPN (add TPN and turn down
the EN)?
23Cisapride
- Cisapride
- Improves gastric emptying
- Reduces GRV
- However
- No clinical outcome advantages
- Off the market in most countries due to risk of
dysrhythmias
Spapen H. Crit Care Med 1995 23481
24 Erythromycin
- Erythromycin
- Improves gastric emptying
- Improves patterns of motility
- Reduces GRV
- Improves tolerance in short term when large GRVs
are present - 20 patient study
Chapman M. Crit Care Med 2000 282334
25 Erythromycin
- RCT of 5 days of erythromycin vs placebo
- Reduces GRV
- Improves tolerance of EN
- However
- No clinical outcome advantages
- Concerns regarding
- - antibiotic resistance
- - risk of dysrhythmias
Reignier J. Crit Care Med 2002 301237
26Metoclopramide
- Metoclopramide
- Also improves gastric emptying (10 patient study)
- 305 patient clinical outcome study
- - No difference in pneumonia rate
- - Pneumonia slightly earlier in control group
Yavagal D. Crit Care Med 2000 281408
27Promotility agents
- Metoclopramide and erythromycin improve gastric
emptying - (surrogate outcomes)
- Not been shown to influence clinical outcomes
- Some risks (risk-benefit ratio ??)
- Low cost intervention, so probably should have
low threshold to use metoclopramide or
erythromycin
28So what should we do?
- Should we use promotility drugs?
- Should we use small bowel feeding?
- Should we switch over to TPN?
- Should we combine EN TPN (add TPN and turn down
the EN)?
29Small bowel EN
- The biological rationale for using the small
bowel - - has greater absorptive capacity
- - less impairment of intestinal motility
- - greater distance between site of delivery and
respiratory tree
30Small bowel versus gastric
- Small bowel patients have improved energy
delivery - - some studies clearly demonstrate this
- - others have not
- Meta-analysis small bowel patients
- receive additional 169 calories
- (95 CI -34 to 320) p0.09
Montecalvo M, et al. Crit Care Med 1992 201377
Marik P, Zaloga G. Crit Care 2003 7R46
31Small bowel versus gastric
- Australian study
- (73 patients)
- Trend towards improved tolerance of EN
p 0.09
Davies AR, French CJ, Bellomo R. Crit Care Med
2002 30586
32Small bowel versus gastric
Small bowel patients have lower gastric residual
volumes
975
p 0.02
mls
517
491
p 0.01
197
Davies AR, French CJ, Bellomo R. Crit Care Med
2002 30586
33Small bowel feeding versus gastric
- Small bowel patients had
- - gastro-oesoph reflux
- - microaspiration (ns)
- 33 ICU patients
- Radio-labelled EN
Heyland D, et al. Crit Care Med 2001 291495
34Does small bowel feeding lower VAP rate?
- Spanish multi-centre RCT
- 101 patients
- Pneumonia rate not reduced
- Mortality rate not reduced
Montejo JC, et al. Crit Care Med 2002 30796
35Meta-analysis 1 (small bowel vs gastric)
Outcome Pneumonia rate
Heyland DK, et al. JPEN 2003 27355
36Meta-analysis 2 (small bowel vs gastric)
Outcome Pneumonia rate
Marik P, Zaloga G. Crit Care 2003 7 R46
37Summary of small bowel feeding
- Possibly increases energy delivery (not
conclusive) - Does decrease GRV (although surrogate outcome)
- May lower pneumonia rate (not conclusive)
- Jejunum may be better than duodenum (reasonable
to try for this)
38But small bowel tubes are a problem
- Logistics are difficult and success rates are
poor - Many techniques means none is perfect
- Blind
- Blind with mechanical techniques
- Blind with expert
- Blind with promotility drugs
- Fluoroscopy
- Endoscopy
- For clinical practice, we need a tube that any
bedside clinician can insert successfully - Ideally it should be easy to get into the jejunum
39The Tiger Tube
- 14 French 155 cm long nasojejunal tube
- Frictional tube
- Features innovative flaps or barbs which allow
allowing peristalsis to gently drag the catheter
into the jejunum
40Tiger tube results
- Case series of 24 patients with Tiger tube
- All patients who had failed to tolerate NG
feeding with promotility agents - Mean APACHE II score 19 ( 8)
- 22 of 24 in jejunum (92)
- No complications
Orford N, Davies A, et al. ANZICS abstract 2004
41Tiger tube results
- Non-randomised, prospective comparison of 3
techniques - Tiger tube more successful
- - post-pyloric placement
- - jejunal placement
- Less physician time with Tiger tube
- Only complication minor nasal bleeding
Samis A, Heyland D, Drover J. CSCN abstract 2004
42Small bowel feeding
- In ICU patients (all-comers)
- - likely to increase energy delivered - may
lower pneumonia rate - - definitely decreases GRV - jejunum better
than duodenum - Placement of NJ tubes is difficult (although
Tiger tube may make it easier) - Difficult to recommend jejunal feeding for all
ICU patients - However, place a NJ tube -if high risk of
pneumonia - -if large GRVs and small nutritional intake
43JPEN Sept/Oct 2003 27(5)355-373www.criticalcar
enutrition.com
44Compared with standard practice (placebo), does
the routine use of motility agents result in
better clinical outcomes in critically ill
patients?
- Recommendation
- According to a systematic review of the
literature, in critically ill patients who
experience feed intolerance (high gastric
residuals, emesis), the use of metoclopramide as
a motility agent should be considered.
45Does enteral feeding via the small bowel compared
with gastric feeding result in better outcomes in
the critically ill adult patient?
- Recommendation
- According to 11 level 2 studies, small bowel
feeding compared with gastric feeding may be
associated with a reduction in pneumonia in
critically ill patients. - In units where obtaining small bowel access is
feasible, we recommend the routine use of small
bowel feedings. - In units where obtaining access involves more
logistical difficulties, small bowel feedings
should be considered for patients at high risk
for intolerance to EN or at high risk for
regurgitation and aspiration. - In units where obtaining small bowel access is
not feasible, small bowel feedings should be
considered for those select patients who
repeatedly demonstrate high gastric residual
volumes and are not tolerating adequate amounts
of EN delivered into the stomach.
46Conclusions about NS in ICU
- Nutritional support improves clinical outcomes
- Measures to optimise NS in individual patients
are probably more vital than we give them credit
for - In general, start EN early and use a NG tube
- Consider metoclopramide or erythromycin because
they are easy and cheap (although positive
clinical outcome studies awaited) - Jejunal feeding may lower pneumonia rate, so if
patients have a high risk of pneumonia, have a
low threshold to place a NJ tube from the start - If you start with NG and have large GRVs,
consider NJ feeding then