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Reducing The Risks Of Enteral Nutrition In ICU Patients

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So if they are not already malnourished, malnutrition is likely ... (high gastric residuals, emesis), the use of metoclopramide as a motility agent ... – PowerPoint PPT presentation

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Title: Reducing The Risks Of Enteral Nutrition In ICU Patients


1
Reducing The RisksOf Enteral NutritionIn ICU
Patients
Andrew Davies Senior Intensivist The
Alfred Melbourne
2
Nutritional support is important
  • ICU patients are sick
  • So they dont eat
  • So if they are not already malnourished,
    malnutrition is likely
  • Malnutrition worsens outcomes

3
Nutritional 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

4
Nutritional 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  • THIS IS NOW AN OUTDATED ARGUMENT

5
Nutritional 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

6
Nutritional 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)
8
Nutritional 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
9
Nutritional support in ICU
p 0.06
p 0.003
  • ACCEPT trial
  • Major outcomes

Martin CM, Doig GS, et al. CMAJ 2004 170197-204
10
So feed the prisoners
  • For our ICU patients (as a group)
  • measures used to maximise amounts of NS received
  • lead to improved clinical outcomes

11
Basic 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

12
How 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
13
How 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
14
How 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
15
So 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

16
Is 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

17
GIT 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
18
Which 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
19
NG 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
20
We have a dilemma
  • Feeding (especially EN) generally improves
    outcomes
  • however
  • NG feeding may have associated risks
  • - pneumonia
  • - mortality

21
So 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)?

22
So 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)?

23
Cisapride
  • 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
26
Metoclopramide
  • 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
27
Promotility 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

28
So 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)?

29
Small 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

30
Small 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
31
Small 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
32
Small 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
33
Small 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
34
Does 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
35
Meta-analysis 1 (small bowel vs gastric)
Outcome Pneumonia rate
Heyland DK, et al. JPEN 2003 27355
36
Meta-analysis 2 (small bowel vs gastric)
Outcome Pneumonia rate
Marik P, Zaloga G. Crit Care 2003 7 R46
37
Summary 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)

38
But 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

39
The 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

40
Tiger 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
41
Tiger 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
42
Small 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

43
JPEN Sept/Oct 2003 27(5)355-373www.criticalcar
enutrition.com
44
Compared 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.

45
Does 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.

46
Conclusions 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
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