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