Tolerance Of Early Enteral Nutrition Research Articles

Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support.

Background: Enteral nutrition (EN) is recommended within the first 24–48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery.Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay.Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306).Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.

How Differences in the Disease Process of the COVID-19 Pandemic Pose Challenges to the Delivery of Critical Care Nutrition.

Purpose of ReviewThe COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support.Recent FindingsProlonged hyperinflammation, unlike any previously described pattern of response to injury, causes metabolic perturbations and deterioration of nutritional status. High ventilatory demands, hypercoagulation with the risk of bowel ischemia, and threat of aspiration in patients with little or no pulmonary reserve, thwart initial efforts to provide early enteral nutrition (EN). The obesity paradox is invalidated, tolerance of EN is limited, intensivists are reluctant to add supplemental parenteral nutrition (PN), and efforts to give sufficient nutritional therapy remain a low priority.SummaryThe nature of the disease and difficulties providing traditional critical care nutrition lead to dramatic deterioration of nutritional status. Institutions should not rely on insufficient gastric feeding alone but focus instead on redoubling efforts to provide postpyloric deep duodenal/jejunal EN or re-examine the role of supplemental PN in this population of patients with such severe critical illness.

Analysis of clinical effects of early enteral nutrition standardized treatment process management on patients with acute exacerbation of chronic obstructive pulmonary disease on invasive mechanical ventilation

To investigate the effect of early enteral nutrition (EN) standardized treatment process management on the ventilation treatment effect and prognosis of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) on invasive mechanical ventilation. Forty-three patients with AECOPD on invasive mechanical ventilation admitted to Shenzhen Baoan District People's Hospital from January 2017 to December 2018 were enrolled. According to the start time of the continuous quality improvement project of nutritional support treatment for critically ill patients in the hospital, 20 patients from January 1st to December 31st in 2017 were enrolled in the routine EN group, and 23 patients from January 1st to December 31st in 2018 were enrolled in the early EN group. In the early EN group, when the patient was hemodynamically stable within 24 hours after intensive care unit (ICU) admission and there was no contraindication for EN, early trans nasal intestinal EN was started, and the infusion rate was adjusted or parenteral nutrition was added according to the EN tolerance score. The target feeding amount was 104.6-125.5 kJ×kg-1×d-1, and achieve complete EN. The conventional EN group started EN after patients had experienced the early stress stage, the vital signs were stable, and 48 hours after ICU admission. The management process was the same as the early EN group. The ventilation indicators including rapid shallow breathing index (RSBI), arterial blood pH value, arterial oxygen partial pressure (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and base excess (BE) at weaning, PaCO2, CO2 retention rate at 2 hours after weaning, as well as critical management indicators including the incidence of ventilator-associated pneumonia (VAP), duration of invasive mechanical ventilation, length of ICU stay, total hospitalization cost and re-intubation rate between the two groups were compared. After the early EN standardized treatment process management, the RSBI at weaning of the patients in the early EN group was significantly lower than that in the conventional EN group (times×min-1×L-1: 36.68±16.12 vs. 52.63±14.81, P < 0.05), but no significant difference in pH value, PaO2, PaCO2 or BE was found as compared with the conventional EN group. The PaCO2 and CO2 retention rate at 2 hours after weaning in the early EN group were significantly lower than those in the conventional EN group [PaCO2 (mmHg, 1 mmHg = 0.133 kPa): 52.48±7.62 vs. 58.32±8.43, CO2 retention rate: (10.25±2.86)% vs. (18.46±3.21)%, both P < 0.05]. Compared with the conventional EN group, the incidence of VAP [8.7% (2/23) vs. 15.0% (3/20)], duration of invasive mechanical ventilation (hours: 52.64±14.81 vs. 53.78±12.75), length of ICU stay (days: 4.92±1.26 vs. 5.24±1.84), total hospitalization costs (thousand Yuan: 20.9±4.8 vs. 21.0±6.9) and re-intubation rate [13.0% (3/23) vs. 20.0% (4/20)] were slightly decreased in the early EN group without statistically significance (all P > 0.05). The management of early EN standardized treatment process for patients with AECOPD on invasive mechanical ventilation may alleviate the respiratory muscle fatigue status, and does not increase the complications.

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage.

Therapeutic moderate hypothermia (MH; T core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH. Patients were randomized to 72 hours of MH or normothermia (NT; T core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test. Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2). In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.

Influencing factors and interventional strategies for early enteral nutrition after gastric carcinoma surgery.

The aim of this study is to investigate the factors influencing early enteral nutrition (EN) to develop guidelines after gastric carcinoma (GC) surgery, and to propose appropriate interventions. A total of 118 GC patients have administrated EN 24 h after surgery and were divided into standard-achieving and nonstandard-achieving groups based on meeting 60% of energy needs. The clinical data of these two groups were retrospectively analyzed and compared. The intraoperative blood loss, proportion of those with body mass ≤60 kg, and those cases tolerating EN in the standard-achieving group were significantly greater than in the nonstandard-achieving group, and the differences were statistically significant (P < 0.05). Gender, age, operative time, catheter length, American Society of Anesthesiologists risk class, and postoperative exhaust time showed no statistically significant differences (P > 0.05). However, logistic regression analysis revealed that intraoperative blood loss, body mass, and EN tolerance were independent risk factors influencing achievement of standards for early postoperative EN in GC patients (P < 0.05). Individual differences should be considered when performing EN, and individualized nutritional support should be provided to improve the standard-achieving rate.

Early Enteral Nutrition in Adults Receiving Venoarterial Extracorporeal Membrane Oxygenation

Despite its benefits, early enteral nutrition (EN) is considered controversial in critically ill patients with severe hemodynamic failure. To evaluate the tolerance and safety of early EN in a consecutive group of patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for severe hemodynamic failure. Prospective observational study performed in a cardiac surgical intensive care unit (ICU) during a 1-year period. All adult patients receiving VA ECMO for severe hemodynamic failure unresponsive to conventional therapies were included. Nutrition support was provided during the study period following the established ICU nutrition protocol. Energy target was 25 kcal/kg, to be reached over 4 days. Nutrition tolerance was defined as the ratio of delivered nutrition to target nutrition, expressed as a percentage. Special interest was made to detect possible adverse effects attributable to EN. The authors performed a descriptive statistical analysis. Of 553 patients admitted in the cardiac surgical ICU during the study period, 7 were treated with ECMO. EN was the only nutrition source. More than 70% nutrition tolerance was achieved within the first week in all cases. No serious adverse events that could be attributable to EN were noted. The present study shows that, under proper medical supervision, early EN is possible and safe in patients with severe hemodynamic failure receiving VA ECMO. No serious adverse events were attributable to EN. More studies are warranted to confirm these findings.

Early enteral nutrition in mechanically ventilated patients in the prone position

To assess the tolerance of early enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position. Prospective, comparative study. General intensive care unit in a university-affiliated hospital. A total of 71 consecutive patients receiving invasive mechanical ventilation with early nasogastric enteral nutrition were studied for 5 days while being treated continuously in the supine position (supine position group, n = 37) or with intermittent prone positioning for severe hypoxemia (prone position group, n = 34). Inclusion occurred within 24 hrs of mechanical ventilation initiation. Daily 18-hr enteral nutrition via a 14F gastric tube was initiated. Prone position patients were turned every 6 hrs as long as PaO2/FiO2 remained at <150, with a FiO2 of 0.6 and positive end-expiratory pressure of 10; the head was slightly elevated. When supine, patients in both groups were semirecumbent. Residual gastric volume was measured every 6 hrs, and enteral nutrition was discontinued if it exceeded 250 mL or vomiting occurred. The groups were similar for age, sex, Simplified Acute Physiology Score II, mortality, and risk factors for enteral nutrition intolerance. At baseline, PaO2/FiO2 was lower in prone position patients than in supine position patients (127 +/- 55 vs. 228 +/- 102; p <.001). As compared with supine position patients, prone position patients had significantly greater residual gastric volumes on days 1, 2, and 4 and experienced more vomiting episodes (median, 1 [interquartile range, 0-2] vs. 0 [interquartile range, 0-1]; p <.05). Enteral nutrition was stopped in 82% of prone position patients and 49% of supine position patients (p <.01) so that daily enteral nutrition volumes were lower with prone position patients. In the prone position group, vomiting occurred more frequently in the prone than in the supine position (relative risk, 2.5; 95% confidence interval, 1.5-4.0; p <.001). In critically ill patients receiving invasive mechanical ventilation in the prone position, early enteral nutrition is poorly tolerated. Prokinetic agents or transpyloric feeding and semirecumbency should be considered to enhance gastric emptying and to prevent vomiting in patients receiving mechanical ventilation in the prone position.

Procalcitonin and enteral nutrition tolerance in critically ill patients.

Serum procalcitonin concentrations have been reported to be elevated in patients with bacterial infection. Early enteral nutrition (EN) has been shown to decrease infections in trauma patients. The purpose of this study was to characterize procalcitonin and other serum proteins during EN of trauma patients based on EN tolerance and presence of infection. Twenty traumatized patients received a high-protein enteral formulation within 5 days of injury. Serum for procalcitonin, C-reactive protein, and prealbumin was analyzed on days 1 and 7 of EN. The procalcitonin/prealbumin and C-reactive protein/prealbumin ratios were calculated the same days. Patients who were infected during the study were compared with those not infected, and enteral-tolerant patients were compared with enteral-intolerant patients using these measurements. In the 20 trauma patients, procalcitonin (10.35 +/- 27.87 versus 1.03 +/- 1.24 ng/mL, p < .001) and procalcitonin/prealbumin ratio (1.70 +/- 4.20 versus 0.18 +/- 0.28, p < .01) decreased significantly over the 7-day period of EN. In the 12 patients who had infection, procalcitonin (16.33 +/- 35.31 versus 1.37 +/- 1.41 ng/mL, p < .004) and procal- citonin/prealbumin ratio (2.74 +/- 5.31 versus 0.26 +/- 0.33, p < .01) decreased significantly over the 7-day period of enteral nutrition. There were no significant changes in the measurements for 8 patients without infection. In the 15 patients who were enteral-tolerant, procalcitonin (12.56 +/- 32.84 versus 1.07 +/- 1.23 ng/mL, p < .004) and procalcitonin/prealbumin ratio (2.03 +/- 4.93 versus 0.20 +/- 0.29, p < .01) decreased significantly. Procalcitonin serum concentrations decrease significantly during EN in enteral-tolerant, critically ill patients with infection.

Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection

Background: Nonocclusive bowel necrosis (NOBN) has been associated with early enteral nutrition (EN). The purpose of this study was to determine the incidence of this complication in our trauma intensive care unit population and to define a typical patient profile vulnerable to NOBN.Methods: Thirteen cases of NOBN were identified among 4,311 patients (0.3%) over a 64-month period ending October 1998. Their charts were analyzed for a variety of clinical data, including prospective EN tolerance data in 4.Results: Twelve (92%) patients were enterally fed prior to diagnosis for 10 ± 8 days (range 3 to 21). Tachycardia (n = 12, 92%); fever/hypothermia, (n = 12, 92%), and an abnormal white blood cell count (n = 11, 85%) were consistently present. Abdominal distention was common but tended to be a late sign (n = 12). Seven (56%) survived. In 4 patients with tolerance data, 3 reached the goal rate of feeds prior to diagnosis. Two became distended at >12 hours from diagnosis. Gastric tonometry demonstrated a decreased NgpHi (<7.30) after starting EN in all 3 in whom it was monitored.Conclusions: NOBN developed in 0.3% of our trauma patients. Onset occurs in the second week in high-acuity patients who have had a period of EN tolerance. Clinical findings resemble bacterial sepsis with tachycardia, fever, and leukocytosis. Gastrointestinal specific signs are not consistent or occur late. Thus, we could not identify an early, useful clinical indicator. Gastric carbon dioxide tonometry may detect a vulnerable subgroup of patients.

Early enteral nutrition in severe burns.

The method of early enteral nutrition (EEN) in extensively burned patients was started at the Bratislava Burns Department in January 1992. EEN was instituted in all patients with burns exceeding 20% of the BSA who were admitted to the department not later than 6 hours post burn. The nutrition itself was started with administration of milk, and later on, if good tolerance was observed, the milk was replaced by standard tube feeding formulas. The feeding was adjusted to the actual needs of the individual patients according to nutritional balance calculations and regular control of the patients' weights. During a period of 18 months 20 patients met the criteria for EEN. Twelve of them survived and 8 died due to complications of extensive burns. The overall tolerance of EEN was very good in both the survivors and nonsurvivors groups of patients. EEN proved to be safe and effective in maintaining nutritional balance of the patients and eliminating particularly the occurrence of Curling's ulcers.