Practical Aspects of Nutrition Support in the ICU John W. Drover, MD, FRCSC, FACS Associate...
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Transcript of Practical Aspects of Nutrition Support in the ICU John W. Drover, MD, FRCSC, FACS Associate...
Practical Aspects of Nutrition Support in the ICU
John W. Drover, MD, FRCSC, FACSAssociate ProfessorQueen’s University
Kingston, ONCanada
www.criticalcarenutrition.com
Disclosure Information
• None
www.criticalcarenutrition.com
Objectives
At the end of the session the participant will be able to:
• List 3 strategies to maximize the benefits of enteral nutrition.
• List 2 advantages of post-pyloric enteral feeding.
• Identify 1 method of gaining post-pyloric access at the bedside in the ICU.
Outline
• Review the rationale for enteral feeding.
• Focus on the data regarding post-pyloric feeding.– Specifically RCT’s– Clinically important outcomes
• Review the risks of and obstacles to post-pyloric feeding.
• Develop a recommendation
www.criticalcarenutrition.com
Case #1
• Day #1• 50 yo female COPD with CAP• Intubated, resuscitated• Who would start EN within 24
hours of admission?• Who would attempt to place a
post-pyloric feeding tube?
Case #2
• Day #5• 50 yo female COPD with CAP• Intubated, resuscitated• feeding tube in stomach• Receiving metoclopromide• Achieving <30% of goal; GRV
>400ml• Who would recommend placement
of a post-pyloric feeding tube?
Nutrition in the Critically ill
• Enteral nutrition strongly recommended
• Early enteral nutrition recommended• Optimize the benefits and minimize
risks– Use of feeding protocols– Motility agents for gastric feeding– Small bowel feeding
Intra-gastric feeding
The good:• Easy access• Early initiation• Often tolerated wellThe bad:• Gastric residual volumes (GRV’s)• Gastro-pharyngeal reflux• Respiratory aspiration• Unrealized nutritional goals
Post-pyloric feeding
2 RCT’s that have evaluated aspiration• 33 patients, 1st 3 days
– GE regurg 24.9% vs. 39.8% (p=0.04)– Further into small bowel less aspiration
• 54 patients, twice weekly– Low rate of aspiration– 7% vs 13% aspiration
Heyland et al, CCM, 2001
Esparaza et al, Int Care Med, 2001
Post-pyloric feeding
• 11 RCT’s of SB vs Gastric feeding– Med/Surg (4), Med (3), Trauma (2), Neuro
(2)– N=664– One study used arginine containing diets– Variable design for selection– Different methods of enteral access
• Outcomes– No difference in mortality, LOS, vent days
Heyland et al, JPEN 2002
Post-pyloric feeding
• Taylor et al. CCM, 1999– Neurotrauma, n=82
• Standard gastric feeding– 15ml/h increase Q8h
• Aggressive SB feeding (when feasible)– SB access only 34%– Start at target rate and adjust
• Outcomes– Pneumonia 44% vs 63%(NS)
Post-pyloric feeding
Nutritional outcomes• Small bowel feeding associated with
– Reaching nutritional goals sooner– Better success at meeting goals
• Meta-analysis not possible– Variable gastric feeding strategies– Goals and success reported in different
ways
Post-pyloric feeding
• Infections – pneumonia (9 studies)• 8 clinical criteria; 1 bronchoscopy• SB feeding associated with
reduced pneumonia– RR=0.77(0.60-1.0), p=0.05– 23% risk reduction
• With Taylor study removed– RR=0.83(0.6-1.15), p=0.3
Post-pyloric feeding
Post-pyloric feeding
Controversy
“A comparison of early gastric feeding in critically ill patients: a meta-analysis”
• No difference in outcomes• Same RCT’s• Exclude Taylor• Use studies of reflux• Didn’t count all pneumonia in
Montecalvo studyHo et al, ICM 2006
Post-pyloric feeding
• Problems associated with:– Difficult to achieve– Once achieved may move– Doesn’t overcome all issues
• (eg. ACS, short bowel, enteric fistula)
• Bowel necrosis – rare event not clearly associated with enteral nutrition Zaloga: Nutrition Week 2005
Canadian survey says10%
The ENTERIC Study
The Early Nasojejunal Tube To Meet Energy Requirements In Intensive Care Study
Study Investigators: Andrew R DaviesRinaldo BellomoD Jamie CooperGordon S DoigSimon R FinferDaren K Heyland
For the ANZICS Clinical Trials Group
Conclusions
• SB feeding improves– time to reach target goals– success at achieving target
goals
• SB feeding may be associated with less pneumonia
Discussion
• Routine use:– Difficulties of SB access
• Blind• Endoscopic• Flouroscopic
• Patients with gastric intolerance• Patients with other risk factors
– GERD– unable to nurse semi-recumbent
• (eg. C-spine injury)
Discussion
• If your unit has feasible access– Go for it
• If your unit has ability with effort– Use it for patients at risk
• i.e. inotropes, sedatives, paralytics, high GRV’s
• If your unit has great difficulty– Use in patients who do not tolerate
gastric feeding
Bedside placement into SB
• Feeding tube in stomach• Wire with 30o bend, 3cm from end
• Zaloga, Chest 1991
• Insufflate stomach with ~500ml• Salasidis, CCM 1998
• Rotate while advancing• Samis and Drover, ICM 2004
Thank You!
• Choosing an approach to:
•MAXIMIZE BENEFIT
• Minimize risk