Early EN Research Articles

Early enteral nutrition versus early supplemental parenteral nutrition in patients undergoing major abdominal surgery: a secondary analysis of 2 randomized clinical trials

BackgroundThe effect of early isoenergetic feeding routes [early enteral nutrition (E-EN) or early supplemental parenteral nutrition (E-SPN)] on the outcome of patients undergoing major abdominal surgery is controversial. ObjectivesThe aim of this study was to investigate the impact of early isoenergetic EN compared with early isoenergetic SPN on nosocomial infections in patients undergoing major abdominal surgery. MethodsThis study is a secondary, post hoc analysis of data from 2 open-label randomized clinical trials. Participants were recruited from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and with Nutritional Risk Screening 2002 score ≥3. All eligible patients were categorized into 2 groups based on their achievement of the 100% energy target on postoperative day (POD) 3: the E-EN group (n = 199) and the E-SPN group (n = 115). The primary outcome was the incidence of nosocomial infections between POD 3 and hospital discharge. ResultsIn total, 314 patients [mean (SD) age, 59.2 (11.4) y; 113 (36.0%) females] were included. Patients in the E-EN group showed no significant difference in nosocomial infections compared with those in the E-SPN group {17/199 [8.5%] compared with 10/115 [8.7%], risk difference, 0.2% [95% confidence interval (CI): –6.3, 6.6]}. The hematological nutritional status of the E-EN group showed a significant improvement at discharge compared with the E-SPN group (albumin: 38.0 ± 6.0 g/L compared with 35.5 ± 7.6 g/L; mean difference, –2.5 g/L; 95% CI: –4.0, –1.0 g/L; prealbumin: 200.0 ± 8.0 mg/L compared with 158.4 ± 38.1 mg/L; mean difference, –41.6 mg/L; 95% CI: –41.7, –36.1 mg/L). Other indicators were comparable between groups. ConclusionE-EN compared with isoenergetic SPN may not be associated with a reduced rate of nosocomial infection in patients undergoing major abdominal surgery, but may be associated with improved hematological nutritional status. Trial registration numberThis trial was registered at clinicaltrials.gov as NCT03115957 (https://clinicaltrials.gov/ct2/show/NCT03115957) and NCT03117348 (https://clinicaltrials.gov/ct2/show/NCT03117348).

Early enteral versus early parenteral nutrition in critically ill patients with respiratory distress: a case–control study

BackgroundNutritional support is essential as enteral or parenteral nutrition to reduce catabolism, to lower the complications rate, and to improve outcomes in critically ill patients.ResultsThe median, range age of the cohort was (median 10, range 6–18.8 months). One-hundred thirteen (62.8%) were males, and 67 (37.2%) were females. The higher frequency of sepsis, ventilator-acquired pneumonia (VAP), and mortality founded in the group received PN. Frequency of sepsis was 15 (16.7%), VAP was 5 (5.6%), and the mortality rate was 11.1% in EN group, while frequency of sepsis was 37 (41.1%), VAP was 23 (25.6%), and the mortality rate was 27.8% in PN group (P = 0.001, 0.001, 0.01, respectively). Median of weight gain on the EN group was 0.17 kg at 2nd week which was more than those in PN group (P = 0.001). The mean ± SD time for reaching the caloric target for those receiving early EN was 4.0 ± 1.9 days which is earlier than that of PN group (6.2 ± 1.7 days) (P = 0.001). There is no significant difference between both groups as regard pediatric intensive care unit (PICU) stay length and mechanical ventilation stay length.ConclusionEarly EN remains the preferred route for nutrient delivery as the PN route was accompanied by a lot of complication such as sepsis, VAP, and high mortality rate.

Role of Early Enteral Nutrition in Mechanically Ventilated COVID-19 Patients.

OBJECTIVES:Current guidance recommends initiation of early enteral nutrition (early EN) within 24–36 hours of ICU admission in critically ill COVID-19 patients. Despite this recommendation, there is quite limited evidence describing the effect of early EN on outcomes in COVID-19 patients. The association between early EN (within 3 d post intubation) and clinical outcomes in adult COVID-19 patients requiring mechanical ventilation (within 2 d post ICU admission) was evaluated.DESIGN:We performed a nationwide observational cohort study using a nationwide administrative-financial database (Premier) in United States.SETTING:Information pertaining to all COVID-19 patients admitted to ICU from 75 hospitals between April and December 2020 was analyzed.PATIENTS:A total of 861 COVID-19 patients were included.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Clinical outcomes were assessed via regression models to control for patient and hospital characteristics. We identified 513 COVID-19 ICU patients (59.2%) requiring mechanical ventilation who received early EN and had similar baseline characteristics to late EN group. Compared with late EN group, the early EN group had shorter ICU (hazard ratio [HR], 1.39; 95% CI, 1.15–1.68) and hospital length of stays (LOS) (HR, 1.53; 95% CI, 1.23–1.91), fewer mechanical ventilation days (HR, 1.25; 95% CI, 1.01–1.54), and lower cost (–$22,443; 95% CI, –$32,342 to –$12,534). All comparisons were statistically significant (p < 0.05).CONCLUSIONS:In patients with COVID-19 requiring mechanical ventilation, early EN is associated with earlier liberation from mechanical ventilation, shorter ICU and hospital LOS, and decreased cost. Our results are among the first to support guideline recommendations for initiation of early EN in COVID-19 ICU patients. Further, our data show nearly 40% of critically ill COVID-19 patients fail to have early EN initiated, even at 3 d post initiation of mechanical ventilation. These results emphasize the need for targeted strategies promoting initiation of early EN, as this may lead to improved clinical and economic outcomes in severe COVID-19 patients.

Effects on nutritional care practice after implementation of a flow chart-based nutrition support protocol in an intensive care unit.

BackgroundEnteral nutrition (EN) is associated with improved outcome in critically ill patients and is more affordable. We compared nutritional care practice in our ICU before and after modification of our nutrition support protocol: Several comprehensive documents were substituted with one flow chart and early EN was encouraged.DesignRetrospective observational study.MethodsNutritional data were collected from admission up to 7 days in 25 patients before and 25 patients after protocol modification.ResultsThe percentage of patients receiving EN within 72 hr of admission increased from 64% before to 88% after protocol modification. Cumulative percentage energy from EN during ICU days 1–4 increased from 26–89% of total kcal. Overall amount of nutrition administered enterally increased, with a corresponding marked decline in use of parenteral nutrition. Pre‐modification, >80% of patients received >65% of their calculated nutrition requirements by ICU Day 4; post‐modification this goal was achieved by Day 7.

Early Enteral Nutrition Versus Parenteral Nutrition After Resection of Esophageal Cancer: a Retrospective Analysis.

This study aimed to compare the clinical outcomes and hospitalization cost between early enteral nutrition (EEN) and parenteral nutrition (PN) after resection of esophageal cancer. A total of 79 patients with esophageal cancer who underwent surgical treatment in our hospital from July 2010 to July 2013 were enrolled in this study. They were divided into EEN group (n = 39) and PN group (n = 40) based on the nutrition support modes. The clinical factors such as time to first fecal passage, postoperative albumin infusion, differences of serum albumin value, hospital stay, systematic inflammatory response syndrome (SIRS) duration, complications, initial hospitalization cost, and mortality were retrospectively compared. The EEN group had a significantly shorter hospital stay, lower initial hospitalization cost, earlier first fecal passage, and shorter duration of SIRS than PN group (P < 0.05). The dose of albumin infusion was significantly smaller in EEN group (P < 0.05) and the decreased value of serum albumin (Δalb) was more prominent in PN group compared with EEN group (P < 0.05). The percentage of patients having any postoperative complication was much higher in PN group than EEN group (P < 0.05), but there was no significant difference in in-hospital morbidity between two groups. Pneumonia was found significantly more frequent in PN group compared with EEN group (P < 0.05). Early EN started within 48h after esophagectomy is safe, economic, and superior for reduction of postoperative complication, for promoting early recovery of intestinal movement, and for early recovery from systemic inflammation.

SUN-PP068: Gastroschisis and Its Challenges to Neonatologist: Multiple Adaptive Systems

Methods: This prospective cohort study included 94 patients on mechanical ventilation and stayed in ICU for 72 h. APACHE II score, SOFA score, prescribed and delivered nutrition during first 7 days ICU admission, and time of EN initiation were collected. Patients were classified using Nutrition Risk In the Critically ill (NUTRIC) score. Outcome variables included mechanical ventilation days, ICU length of stay and mortality. Linear and logistic regressions were used to determine differences in outcomes using SPSS software. Results: EN was initiated 24±28 h of ICU admission and 89% of patients met the guideline of EN initiation within 48 h of admission. Patients received an average of 814±434 kcal and 39±22 g protein per day, corresponding to 52±26% and 53±29% of energy and protein prescription respectively. Feed interruption throughout ICU stay was 47±34 h per patient. The top two common reasons were fasting for intubation or extubation, and high gastric residual volume, which contributed to 26% (12±4 h) and 16% (7±18 h) of total interruptions per patient, respectively. In patients with high NUTRIC score (n = 74), there were no differences in the outcome variables when adjusted for age, gender, APACHE II score, SOFA score and energy-protein adequacy in the first 7 days of ICU admission. Conclusion: A dietitian blanket referral protocol can ensure early EN initiation. This alone is insufficient to achieve adequacy of EN delivered. Feed interruption plays a significant role in affecting nutritional adequacy and should be addressed in the feeding protocol.

SUN-PP067: Caloric and Protein Intake in Critically III Patients and Outcome

Methods: This prospective cohort study included 94 patients on mechanical ventilation and stayed in ICU for 72 h. APACHE II score, SOFA score, prescribed and delivered nutrition during first 7 days ICU admission, and time of EN initiation were collected. Patients were classified using Nutrition Risk In the Critically ill (NUTRIC) score. Outcome variables included mechanical ventilation days, ICU length of stay and mortality. Linear and logistic regressions were used to determine differences in outcomes using SPSS software. Results: EN was initiated 24±28 h of ICU admission and 89% of patients met the guideline of EN initiation within 48 h of admission. Patients received an average of 814±434 kcal and 39±22 g protein per day, corresponding to 52±26% and 53±29% of energy and protein prescription respectively. Feed interruption throughout ICU stay was 47±34 h per patient. The top two common reasons were fasting for intubation or extubation, and high gastric residual volume, which contributed to 26% (12±4 h) and 16% (7±18 h) of total interruptions per patient, respectively. In patients with high NUTRIC score (n = 74), there were no differences in the outcome variables when adjusted for age, gender, APACHE II score, SOFA score and energy-protein adequacy in the first 7 days of ICU admission. Conclusion: A dietitian blanket referral protocol can ensure early EN initiation. This alone is insufficient to achieve adequacy of EN delivered. Feed interruption plays a significant role in affecting nutritional adequacy and should be addressed in the feeding protocol.

Study of enteral nutrition on patients with severe tetanus

Objective To study the effect of enteral nutrition on patients with severe tetanus. Methods The patients totaled 60 cases were divided into two groups with 30 cases in each. The patients in EN group were treated with enteral nutrition on basis of routine treatment, control group was treated with total parenteral nutrition (TPN). The indicators values of BMI, TSF, MAMC, TP, PAm, m, ALB and Hb were tested on the day before nutrition supports and after nutrition supports 10 days later in two groups. Adverse reaction and the treatment effect were observed simultaneously. Results With nutritional supports 10 days later, two groups had no obvious decline in BMI, TSF and MAMC. TP, PA, ALB and Hb of EN group were higher than those of control group (P＜0.05) . Complication rate of EN group was lower than that of control group, there was significant differences (P＜0.05) . Conclusions Early EN may improve protein metabo lism in patients with severe tetanus and nutritional status. Key words: Severe tetanus; Enteral nutrition; Total parenteral nutrition; Nutritional support

Shakespeare in Slow Motion

ary scholars in the contexts of Shakespeare’s plays, from political, social, religious, and cultural history to biography. Studies of the court, of the “middling sort,” of women in early modern En gland, of witchcraft, of race and exoticism, of travel, of economics, of philosophy and theories of per sonhood and power, of affect and emotion in the period—all these have come increasingly to occupy the attention of scholars. Textual studies have often focused on the history of the book and the book trade, as well as on questions of editing, bibliography, authenticity, and textual variants. Stage history and the history of productions, film, and adaptation offer another kind of context through the permutations of material culture. My objective in “Shakespeare in Slow Motion” is to slow down the move to context, if not reverse it altogether, by redirecting attention to the lan guage of the plays, scene by scene, act by act, moment by moment, word by word. Let “Shakespeare” be the designation we give to the author of the plays published under his name. Let us not speculate on his personal or professional motives, his inner thoughts, his relationships with his wife or children, his cultural aspirations, his finances, his religion, or his attitude toward the reigning monarch. Let us discuss not “the opinions or creed of the being whom we sometimes oddly call ‘Shakespeare the man,’” to quote A. C. Bradley, writing skeptically about such matters a little more than a hundred years ago (6), but rather the text of the play and what it tells us.

The research of enteral and parenteral nutrition support after gastrointestinal surgery

Objective To investigate the efficacy of early enteral nutrition support. Methods Sixty cases with gastrointestinal tumor resection patients in our hospital were divided into early enteral nutrition group(EN) and parenteral nutrition (PN) group. Two groups of nutrition indicators,the recovery of intestinal function,complications rates were compared. Results Postoperative nutrition indicators had no significant difference, but the EN group had the earlier recovery of intestinal function, the low rate of complications, little hospitalization time. Conclusions Early postoperative EN treatment can reduce the complication rate,hospitalization time,which is a simple,safe and economical method. Key words: Enteral nutrition; Parenteral nutrition; Nursing

474 Simultaneous Nasogastric Decompression with Mid-Jejunal Feeding Avoids Total Parenteral Nutrition (TPN) and Early Surgery in the Management of Complicated Acute Pancreatitis and Gastric Outlet Obstruction

G A A b st ra ct s Methods: During 2003-2007, all patients with predicted severe acute pancreatitis (Acute Physiology and Chronic Health Evaluation [APACHE-II] score ≥8, or Imrie/modified Glasgow score ≥3, or C-reactive protein [CRP] >150 mg/L) were prospectively included in 15 hospitals in the Dutch ‘probiotics in acute pancreatitis trial' (PROPATRIA). All patients received EN via a nasojejunal feeding tube. The time between admission and start of EN, however, varied between patients (at the discretion of the treating physician).Two groups were retrospectively defined: 1) the ‘early EN group' (start of EN within 48 hours after admission) and 2) the ‘standard EN group' (start after 48 hours after admission). Groups were compared for the total number of infectious complications: pneumonia, bacteremia and infected necrosis. Multivariate logistic regression was used to adjust for differences at baseline (p<0.2) and predicted disease severity (APACHE-II score). Results: The early (n= 184) and standard (n=112) EN groups were highly comparable at baseline for APACHE-II score, C-reactive protein, Imrie-score, computed tomography severity index and the presence of (multi)organ failure. Infectious complications occurred in 49 patients (27%) in the early EN group versus in 38 patients (34%) in the standard EN group (adjusted odds ratio [OR] 0.659, 95%-confidence interval [CI] 0.33-1.33, p=.244). Early EN was associated with a reduction of bacteremia (14% versus 27%; adjusted OR 0.389, 95%-CI 0.17-0.88, p=.024). No reduction of infected necrosis (11% versus 13%, p=.853) or pneumonia (16% versus 14%, p=.861) was observed. Conclusion: An early start of enteral nutrition may prevent bacteremia and hence improve outcome in patients with predicted severe acute pancreatitis. To this end, the Dutch Pancreatitis Study Group has recently started a nationwide randomized controlled trial comparing an early start of EN with standard therapy in predicted severe acute pancreatitis.

Are Enterally Fed ICU Patients Meeting Clinical Practice Guidelines?

The 2003 Canadian clinical practice guidelines (CPGs) for nutrition support in mechanically ventilated, critically ill patients recommended early EN and maintaining a 45-degree head-of-bed (HOB) angle during EN administration. Current practices at University Health Network have not been examined with regard to these guidelines. The purpose of this study was to determine the proportion of mechanically ventilated, enterally fed intensive care unit patients meeting the CPG recommendations for early EN and HOB elevation. This was a cross-sectional study involving data collection in 2 parts. Early EN data were collected via chart review and HOB data through observation of HOB angle reader. Reasons for not meeting each recommendation were obtained when data were collected via chart review and feedback from nurses. data analysis was conducted using frequency distributions. sixty-six percent of patients met the recommendation for early en. of those not meeting this recommendation, the most common reason for the delay was hemodynamic instability (28.1%). for the hob recommendation, 4.9% of patients met the 45 degree recommendation, and 52.5% had an hob angle between 21 and 30 degrees. the most common reason for not attaining the 45-degree angle was reported as unknown (29.5%). The proportion of patients meeting clinical practice guidelines compares favorably to similar studies. In some cases, patients' clinical conditions or unit HOB angle protocol explained not meeting guidelines. However, there were cases where reasons for not meeting guidelines were unknown.

Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus

Major abdominal surgery, and also radical cystectomy, is followed by a delayed return of bowel function attributable to postoperative ileus (POI), which, in addition, stands out as one of the most frequent complications that causes increased length of stay (LOS). Some variability exists in the definition of POI since time to return of peristalsis and time to first passage of flatus, which are commonly referred to as indicators of bowel activity, have their own weaknesses, observer dependent and time dependent, among other variables. A number of causes have been recognized to induce or maintain the condition of ileus. Some among them are part of the perioperative period. The practices of mechanical bowel preparation (MBP) and of fasting before surgery have been challenged and can be safely abandoned. The perception of pain is an acknowledged promoter of POI; therefore, providing complete pain control constitutes the rationale in favor of administering anesthesia and analgesia combined, both in the form of concurrent general and epidural anesthesia (i.e., at the thoracic level, T9, T11), and represents the mainstay of intraoperative measures. Hypovolemia is also associated with an increased risk of POI. The use of nasogastric tubing (NGT) has been associated with increased pulmonary complications; moreover, bowel resection can be performed safely without postoperative NGT. Early postoperative provision of artificial nutrients has shown beneficial effects, both in the form of total parenteral and enteral nutrition (PEN, EN). We devised a perioperative care regimen, adopting a multimodality approach aimed at minimizing the effects of the above listed factors to ascertain if they could contribute to preventing or reducing POI and the complications associated with radical cystectomy and intestinal urinary diversion. In addition, we investigated the impact of early artificial nutrition, combining PEN and EN via a jejunal nutrition cannula. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of POI, and incidence and nature of complications constituted the study end points. Of 143 consecutive patients, 107 who underwent radical cystectomy with intestinal urinary reconstruction were able to be evaluated for results and complications. The male to female ratio was 86:21, the mean age was 74 years, and more than two-third belonged to the American Society of Anesthesiologists categories II and III. Pathologic stages of disease were bladder confined in 48 patients, locally advanced in 33, and extravesical in 26. Urinary diversion with intestine consisted in the configuration of heterotopic reservoirs in 39 patients, orthotopic substitution in 38, and uretero-ileo-cutaneostomy in 30. Bowel movements returned after a median time of 2 days (range, 1-6), and the median time to reinstitution of a regular diet was 4 days (range, 3-9). POI beyond postoperative day 4 was observed in 17.7% of the patients. Overall, a total of 28 patients (26.1%) experienced complications, specifically, medical complications in 19 patients and surgical complications leading to relaparotomy in 11. The mortality rate was 3.7%. No effects were observed on postoperative protein depletion, despite the provision of early artificial nutrition. Our results suggest that a short median time of return of both peristalsis and flatus, and to regular diet resumption with a low incidence of POI, can be obtained in the majority of patients with a perioperative regimen aimed at reducing the effect of some of the causes associated with induction or maintenance of POI. Further studies of multimodality perioperative care plans, similar to that used in the present study, are required.

The use of PS tube in total gastrectomy

目的 探讨彭氏管在预防、治疗胃癌全胃切除术后食道空肠吻合口瘘中的作用.方法对1997年1月至2003年12月的107例全胃切除术患者应用彭氏管情况进行总结.结果 107例患者恢复良好,其中1例术后发生食道空肠吻合口瘘,经禁食、彭氏管进行肠内营养支持、腹腔引流、应用有效抗生素而愈.结论应用彭氏管对胃癌全胃切除术患者术后早期进行肠内营养支持,对患者术后恢复、预防术后并发症是有价值的。

Effects of early eschar excision en masse at one operation for prevention and treatment of organ dysfunction in severely burned patients.

We sought to determine whether early eschar excision en masse (EEE) at one operation would be effective in the prevention and treatment of postburn organ dysfunction (OD) and multiple organ dysfunction syndrome (MODS). A total of 60 patients, with total body surface burned area over 35% and a third degree burn area over 20% were studied and divided into two groups, the EEE group (35 cases) and the group treated with repeated escharectomies by stages (repeated escharectomy group, 25 cases). Other than the different operations undertaken, the patients in both groups received identical conventional treatment. Before, during, and after operation the hemodynamic and blood gas indices, plasma levels of endotoxin and tumor necrosis factor (TNF), and the injurious effects of burn patients' sera on endothelial cells in vitro were determined in patients of the EEE group. The incidence of OD and MODS was decreased significantly (11.4%) in patients of the EEE group, and the cure rate increased greatly (85.7%). The cardiac output dropped to 77.8% of its preoperative level at the end of escharectomy but began to rise at 2 hours and returned to its baseline levels at 24 hours after operation. Plasma levels of endotoxin and TNF and levels of lactic dehydrogenase and 6-keto-prostaglandin F(1|ga) in the endothelial cell culture media were all reduced profoundly. The cultured endothelial cells maintained their original morphology. The findings substantiate the hypothesis that eschar excision en masse at one operation is feasible and effective in preventing and treating early postburn OD and MODS, mainly by alleviating systemic inflammatory response syndrome and endothelial cell injury.