Nutrition In ICU:

Enteral nutrition

96/10/29
Ri盧延榕
Critically ill patient

 Starvation
 Malnutrition
 Hypermetabolic and hypercatabolic state
 Increasing nutrition deficit was associated
with increased morbidity & mortality
What’s the best route for nutrition
support?

 Enteral nutrition (EN)

 Parenteral nutrition (PN)
 Current recommendations:
- Starting EN ASAP
- Maybe inadequate energy support for poor GI
condition
- PN if EN insufficient
Enteral nutrition support in ICU

 More physiological, also cheaper

 Maintain intestinal integrity, immune and gut-
barrier functions
 Decreasing septic morbidity, hospital and
ICU length of stay, and mortality
 Delayed EN with higher mortality
 Whenever nutritional support is indicated, the
enteral route is preferred to parenteral
nutrition
Enteral nutrition support in ICU

 Contraindications
- Non-functional gut: anatomic disruption, obstruction, gut
ischemia
- Generalised peritonitis
- Severe shock states
 Timing
- Early EN (within 24–48hr): severe trauma, burns, highly
catabolic state
- Standard EN (after 2–3 days): moderate stress in a patient
unable to eat
Enteral nutrition support in ICU

 ACCEPT study:
survival from intensive care was improved when larger amounts
of nutrition were delivered consistently
 Daily target caloric prescription
- 20–25 kcal/kg (women)
- 25–30 kcal/kg (men) of admission body weight
 < 30% of the patients
- received≥90% of the prescribed calories
- protein delivery reached only about 70% of requirements
 Only 14% of ICU patients:
- achieved 90% of prescribed calories within 3 days
The target value of nutrition need

 Avoid under- or over- feeding

 Complication of over feeding:
- hyperglycaemia, hyperlipidaemia, hepatic
dysfunction, ventilation weaning difficulties
 Cumulative energy debt for under feeding
- infection rate↑, impaired wound healing
Different increasingly aggressive
options of nutrition support

 Allowing hypocaloric EN
 EN with slow augmentation until
achievement of target delivery
 EN supplemented by PN by day 3 of
attempts at maximisation of EN delivery
 Early combination of EN plus PN started at
admission.
Parenteral nutrition

 Early EN: not beneficial

 Complications: infection, hyperglycemia,
hypertriglyceridemia, gut mucosal atrophy
 Daily practice: PN was often delayed
 Revision: 9 meta-analysis showed early PN
with decreased mortality rate
 Early PN was superior to late PN
Tight glycemic control

 ICU patients:
- increased substrate turnover of carbohydrates, lipids and amino
acids
- altered end-organ perfusion combined with peripheral insulin
 Increased demand for glucose and amino acids:
- derives from protein breakdown
- huge increase in skeletal muscle catabolism
 Tight glycemic control: with survival benefit
 Avoid hypoglycemia
 Poor outcome of TPN:
- lack of glycemic control before?
Revision of dogma

 Recent meta-analysis:
- TPN not involved increased mortality rate
 Apply EN with supplementary PN
- if EN alone fails to meet nutrition needs within 3 days, PN should
be initiated
 Glycemic control
- appropriate nutrition support with insulin
- avoid hypoglycemia
 Combined nutrition support:
- allow protein needs to be met sooner
- RCT was warranted
The opposite opinion

 PN is an unphysiological method, with numerous

complication
 No current clinical data to support the use of
“supllemental” PN in P’t fed enterally or improved
outcome when “caloric target” achieved
 Recent guideline: PN not be started until all
strategies to maximize EN delivery attempted
 Combination of early PN +EN: unless proved by
RCT
Preliminary Evidence for Nutrition Therapy Protocol:
Enteral Feedings for Critically ill P’t

 Evaluate the evidence of specific but common

patient care decisions in support of enteral feedings
 6 specific questions
 Evidence analysis by Quality Management Team of
American Dietetic Association
 Intensive literature search from following database:
Medline, EMBASE, Pubmed, Cinahl, Cochrane
(1985~2003)
6 specific questions

 What is the effect of enteral vs parenteral feeding on

infectious complications, cost, length of hospital stay (LOS),
and mortality?
 Does the timing of enteral feeding influence infectious
complications, LOS, or mortality?
 Does the placement of an enteral feeding tube tip in the
gastric vs postpyloric position affect gastric residual volume
or reflux, aspiration pneumonia, cost, LOS, or mortality?
 What monitoring criteria should be used for enteral feeding
management?
 Does the amount of enteral formula actually delivered
influence infectious complications, cost, LOS, ventilator days,
or mortality?
 Does the use of blue dye aid in the detection of aspiration or
influence mortality?
Effect of enteral vs Parenteral feeding on infectious
complications, cost, length of hospital stay, & mortality?

 EN was associated with reducing infectious

disease when compared with PN
 EN was associated with reduced cost when
compared with PN
 Insufficient evidence for EN vs PN on reducing
LOS
 Insufficient evidence for EN vs PN on mortality
Does the timing of enteral feeding influence infectious
complications, LOS, or mortality?

 Early EN is associated with reduced

incidence for infection
 Early EN maybe associated with reduced
LOS stay
 Significant difference in mortality due to
timing was not demonstrated
Does the placement of an enteral feeding tube tip in the gastric
vs post-pyloric position affect GRV or reflux, aspiration pneumonia,
cost, LOS, or mortality?

 The site of the NG tube in postpyloric position was

associted with reduced GRV which related to
reduced reflux
 Small bowel feeding tube maybe useful in high risk
patients such as with supine position, sedation or P’t
with large GRV
 Effect on aspiration pneumonia: not available
 No adequate powerful study on mortality LOS & cost
of nutrition
What monitoring criteria should be used for enteral
feeding management?

 Accepting an isolated GRV of 250 ml, and evaluating

the clinical situation with 2 or more consecutive
volumes of 250 ml before stopping/holding the feeding is
associated with greater formula of delivery
 Use of promotility agent is associated with reduced
GRV
 Feeding P’ts positioned in a 45’ head of bed elevation
during NG feeding with a decreased incidence of
aspiration pneumonia &decreased reflux of gastric
contents into the pharynx & esophagus
Does the amount of enteral formula actually
delivered influence infectious complications, cost, LOS,
ventilator days, or mortality?

 Actural delivery of enteral formula of

approximatedly 14~18 Kcal/kg/day or 60%~70%
of enteral feeding goal, in the first week of ICU
admission, is associated with shortened LOS & time
on ventilation & reduced infectious complications
 Initial evidence suggests that achieving greater than
70 % of goal intake may have less positive outcomes
for medical ICU & surgical P’t with obesity when
compared with P’ts received less enteral nutrition
 No powerful trial determine the influence of nutrient
intake on cost of medical care or mortality
Does the use of blue dye aid in the detection of
aspiration or influence mortality?

 The work group members recommended that

blue dye should be abandoned in enteral
feedings in ICU
 Blue dye is not sensitive in detecting
aspiration
 There may be increased mortality risk
when the dye administered in excessive
dose or to P’ts with increased gut
permeability
The myth of Gastric residual volume (GRV)

 One of most feared complication of enteral feeding:

aspiration hypoxia/ pneumonia
 Clinically, GRV measurements was frequently used
as markers to predict aspiration & pneumonia
 Elevated GRV: associated with comorbidities such
as vasopressor use, sedation sepsis, vomiting
 GRV: no significance between GRV> 200ml & GRV
> 400ml , low sensitivity as a marker of aspiration

The myth of the gastric residual volume, Crit. Care Med 2005; Volume 33, No. 2
Gastric residual volume (GRV)

 GRV:
- also frequently used to monitor GI intolerance
- Unfortunately, the level was unknown
 GRV is unreliable for predict regurgitation &
aspiration
 Utility of bedside measurement was unknown
 Standard technique for measuring GRV as valid
indicator of GI content was also unclear
Reference

1. Claudia-Paula Heidegger1. Is it now time to promote mixed

enteral and parenteral nutrition for the critically ill patient? ,
Intensive Care Medicine 2007;6: Volume 33, Number 6
2. Teresa A. Williams, Gavin D. Leslie. Evidence for a Medical
Nutrition Therapy Protocol: Enteral Feedings for Critically Ill
Patients , Journal of the American Dieteric Association
2006;8
3. The myth of the gastric residual volume, Crit. Care Med 2005;
Volume 33, No. 2
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