Enteral Nutrition Interruptions Research Articles

Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study

BackgroundThe incidence of clinically avoidable enteral nutrition interruptions is high. ICU nurses, as the implementers and monitors of enteral nutrition, have a close relationship between their cognitive level of enteral nutrition interruption and the incidence of enteral nutrition interruption. The level of ICU nurses’ cognition of enteral nutrition interruption and the key factors influencing the level of ICU nurses’ cognition of enteral nutrition interruption are not known.ObjectivesThis study aims to explore the cognitive level of ICU nurses on enteral nutrition interruption and delve into the key factors that affect their cognitive level from the perspective of management.DesignA sequential explanatory mixed methods research design was used.MethodsWith the convenience sampling method, an online survey questionnaire was distributed to ICU nurses in Chongqing, and 336 valid questionnaires were collected. After the survey, ICU managers were invited to participate in qualitative interviews, in which 10 participants from five hospitals completed face-to-face individual semi-structured interviews and were analyzed with thematic analysis.ResultsThe survey found that ICU nurses had a good level of cognition towards enteral nutrition interruption but poor knowledge about the definition, causes, and consequences of enteral nutrition interruption, as well as negative attitudes toward active learning, assessment, and communication. And the longer work time in the ICU, joining the nutrition team, receiving systematic training, and acquiring relevant knowledge from academic journals more frequently were favorable to improving ICU nurses’ knowledge level of enteral nutrition interruption. Personal interviews further identified the key factors affecting their cognitive level, including (1) lack of knowledge, (2) lack of proactive thinking, (3) lack of enteral nutrition management programs, and (4) lack of quality management tools for enteral nutrition interruption.ConclusionAlthough ICU nurses demonstrate a relatively high level of cognition, there is still room for improvement. ICU administrators must take specific measures to improve the knowledge of ICU nurses, especially in non-tertiary hospitals, in order to prevent nurse-induced enteral nutrition interruption in all ICUs and improve medical quality.Trial registrationNot applicable.

Challenges Encountered in the Provision of Enteral Nutrition in Pediatric Intensive Care Unit: An Observational Study.

Background Enteral nutrition (EN) represents the preferred modality for nutrient administration in critically ill patients. However, it is fraught with challenges such as delayed initiation and recurrent interruptions, which can significantly impact patient clinical outcomes. A substantial proportion of these interruptions can be mitigated. In the present investigation, our objective was to scrutinize the practice of EN in the Pediatric Intensive Care Unit (PICU). We sought to ascertain the frequency and underlying causes of EN interruptions and assess their ramifications for nutrient delivery. Study design We conducted an observational study within the PICUof Mahatma Gandhi Mission's (MGM) Medical College and Hospital, Aurangabad. The study encompassed children admitted to the PICU for a period exceeding 24 hours who were receiving enteral feeds. We documented the time of commencing EN from the point of PICU admission, instances of enteral feeding interruptions, the number and duration of each interruption episode, and the reasons behind these interruptions. Subsequently, we categorized the causes of feeding interruptions into avoidable and non-avoidable determinants. Results Out of the 100 patients enrolled in this study, only 34% presented with normal nutritional status upon admission. Sixty-five percent of patients had their nutritional support initiated within the first 48 hours of admission to the PICU. The median duration from PICU admission to the initiation of EN was 32.5 hours, with a median interruption duration per patient of 40.96 hours. Common causes of interruptions included radiological procedures, respiratory distress, altered sensorium, presence of gastric aspirates, and surgical procedures. Upon analysis, it was determined that a substantial majority, constituting 74%, of these interruptions were avoidable. Conclusions The primary challenges associated with EN in the PICU encompass delayed initiation of enteral feeds and frequent interruptions. Importantly, a significant proportion of these issues are avoidable.

Factors Associated with Interruptions of Enteral Nutrition and the Impact on Macro- and Micronutrient Deficits in ICU Patients

Feeding interruptions in critical care patients are often unjustified. We aimed to determine the causes, duration, and frequency of enteral nutrition interruptions (ENIs) and to assess macronutrients and antioxidant deficits according to European Society of Parenteral Enteral Nutrition (ESPEN) guidelines. We prospectively enrolled Intensive Care Unit (ICU) patients admitted for more than 48 h with an inability to orally eat from April to December 2019. The type of enteral nutrition, the number of calories administered, the time of feeding initiation, the reasons for delaying feeding, and the causes for ENI were recorded. 81 patients were enrolled, with a median duration of ENIs of 5.2 (3.4-7.4) hours/day. Gastric residual volume (GRV) monitoring-a highly controversial practice-was the most common cause of ENI (median duration 3 (2.3-3) hours/day). The mean energy intake was 1037 ± 281 kcal/day, while 60.5% of patients covered less than 65% of the total energy needs (1751 ± 295 kcal/day, according to mean Body Mass Index (BMI)). The median daily protein intake did not exceed 0.43 ± 0.3 gr/kg/day of the actual body weight (BW), whereas ESPEN recommends 1.3 gr/kg/day for adjusted BW (p < 0.001). The average administration of micronutrients and antioxidants (arginine, selenium, zinc, vitamins) was significantly less than the dietary reference intake (p < 0.01). ENIs lead to substantial caloric, protein, and antioxidant deficits.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children.

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

Evaluation of the provision of enteral nutrition in critically ill patients receiving mechanical ventilation

&lt;div class="WordSection1"&gt;&lt;p&gt;&lt;strong&gt; ABSTRACT&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Providing enteral nutrition to ICU patients is often challenging, leading to sufficient enteral nutrition that is hardly achieved. This condition is caused by gastrointestinal motility disorder and other complications that often happen during enteral nutrition provision. Therefore, it is important to understand the level of nutritional support and the challenges in the form of interruption during enteral nutrition to critically ill patients receiving mechanical ventilation to optimise the benefit of nutritional support for patients, including reducing the duration of hospitalisation and mortality.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objectives:&lt;/strong&gt; This study aims to evaluate the provision of enteral nutrition and identify the cause of interruption for patients with mechanical ventilation in one of the tertiary hospitals in Yogyakarta, Indonesia who receive enteral nutrition.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a cross-sectional study. The subject of the study is patients who fulfil the inclusion and exclusion criteria. Inclusion criteria include patients who were in ICU for ≥72 hours, receiving mechanical ventilation. While the exclusion criteria include patients with contraindications for enteral nutrition such as unstable haemodynamic, bowel obstruction, persistent severe ileus, gastrointestinal bleeding, nasogastric tube (NGT) placement is not possible, patients receiving oral nutrition with non-invasive ventilation, patients with feeding tube before admission, or patients from other ICU or HCU.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Patients needed, on average, 13 hours to receive initial enteral nutrition (SD ± 9.89 hours), with a period between 0 – 50 hours since admission to ICU. The mean time for patients to receive full feeding is 4 days ± 2.4 days. On the other hand, 16 out of 75 patients (21.2%) did not reach the targeted intake during admission. The cause of the interruption of enteral nutrition includes gastric residual volume (GRV), percutaneous dilatation tracheostomy (PDT) procedure, vomiting, bloating, surgery, CT scan, etc.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Many causes of interruption and inadequate intake of enteral nutrition can be prevented. The absence of protocol agreed upon by the patient care team could be one of the influencing factors.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;KEYWORD: &lt;/strong&gt;&lt;em&gt;enteral nutrition; enteral nutrition interruption; mechanical ventilation&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt; &lt;/em&gt;&lt;/p&gt;&lt;/div&gt;

Feeding intolerance during prolonged prone position in overweight and obese patients with severe COVID-19.

the aim of this study was to compare the incidence rate of feeding intolerance (FI) during supine (SP) or prone positioning (PP) in critically ill COVID-19 patients. this was a retrospective cohort study of critically ill patients with overweight or obesity who received enteral nutrition (EN) in prone or supine positioning continuously during the first five days of mechanical ventilation. Nutritional risk, anthropometric measurements and body composition were assessed at the first 24 hours upon Intensive Care Unit (ICU) admission. Biochemical and clinical variables (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Kidney Injury [AKI] or comorbidities diagnosis) were collected. Pharmacotherapy (prokinetics, sedatives or neuromuscular blocking agents) and FI incidence (gastric residual volume [GRV] ≥ 200 ml or ≥ 500 ml, vomiting or diarrhea) were daily recorded. Constipation was defined as the absence of evacuation for five consecutive days. eighty-two patients were included. Higher rate of prophylactic prokinetic prescription was observed in PP (42.8 vs 12.5 %, p = 0.002). GRV ≥ 200 in supine position was not different when compared to PP (p = 0.47). Vomiting episodes in supine compared to PP showed no difference between groups (15 % vs 24 %, p = 0.31). No differences in diarrhea events were detected (10 % vs 4.7 %, p = 0.36). Constipation was common in both groups (95 % vs 82 %, p = 0.06). FI during prone position was not different in comparison to supine position. Routinely use of prokinetics in continuous prone position may help to prevent FI incidence. Algorithm development is necessary for FI prevention and treatment so to avoid EN interruptions and adverse clinical outcomes.

Impact of implementing an evidence-based definition of enteral nutrition intolerance on nutrition delivery: A prospective, cross-sectional cohort study.

Enteral nutrition (EN) interruptions because of EN intolerance impede nutrient delivery. We aimed to examine whether revising the EN intolerance definition of an algorithm would decrease EN interruptions and improve nutrient delivery in critically ill children. We performed a cross-sectional cohort study including patients who were admitted to our intensive care unit (ICU) for >24 h and received EN. The EN intolerance definition in our nutrition algorithm was modified to include two symptoms of EN intolerance. We compared time to 60% EN adequacy (EN delivered/EN prescribed x 100) and EN interruptions before and after this intervention. We included 150 eligible patients, 78 and 72 patients in the preimplementation and postimplementation cohorts, respectively. There were no significant differences in demographics and clinical characteristics. The preimplementation and postimplementation cohorts achieved 60% EN adequacy 4 (2-5) days and 3 (2-5) days after ICU admission, respectively (P = 0.59). The preimplementation cohort had a median of 1 (1-2) interruption per patient and the postimplementation cohort 2 (1-3; P = 0.08). The frequency of interruptions because of EN intolerance within the first 8 days of ICU admission was 17 in the preimplementation and 10 in the postimplementation cohorts. Modifying the EN intolerance definition of a nutrition algorithm did not change the time to 60% EN adequacy or total number of EN interruptions in critically ill children. EN intolerance and interruptions continue to limit nutrient delivery. Research on the best definition for EN intolerance and its effect on nutrition outcomes is needed.

Interruptions to Enteral Nutrition in Critically Ill Patients in the Intensive Care Unit.

BackgroundMalnourishment has been linked with increased morbidity and mortality among critically ill patients. The current study aimed to assess the factors contributing to the interruption of enteral nutrition so that preventive measures can be formulated to avoid the malnourishment of critically ill patients.MethodologyA prospective, observational study was conducted at the Department of Intensive Care Unit, Shifa International Hospital, Islamabad, between November 2020 and May 2021. All patients admitted in the intensive care unit (ICU) during the study period aged between 18 and 80 years, who remained admitted in the medical ICU for at least 72 hours were included in the study. Those who had ileostomy or colostomy were excluded from the study. Diagnostic categories were defined as surgical and medical. Data on clinical parameters including admitting diagnosis and airway-related issues were recorded in a predefined proforma.ResultsThe mean duration of enteral nutrition interruption in males was 13.96 ± 13.12 days while that of females, 12.48 ± 12.43 days. Non-invasive ventilation dependency was significantly associated with an interruption in enteral nutrition (p=0.002). The mean duration of interruption of enteral nutrition was not correlated with airway issues (p=0.569). However, the mean duration of interruption of enteral nutrition was significantly lower in patients who underwent spontaneous breathing trials with T-piece (p = 0.032). Those who were advised nil per oral before surgery had a significantly longer duration of enteral nutrition interruption (p < 0.0001) with a mean length of 30.18 ± 5.83 days. The duration of enteral nutrition interruption was significantly longer in patients who had tracheostomy than those who did not have a tracheostomy (26.3 ± 6.34 vs. 9.54 ± 11.61 days) (p < 0.0001).ConclusionThe present study revealed that at least three-forth of the patients admitted in ICUs had documented orders to the interruption of enteral nutrition. The most significant causes that correlated with interruptions to enteral nutrition were non-invasive ventilation dependency, tracheostomy, spontaneous breathing trials with T-piece, and orders of nil per oral before surgery.

Early feeding after percutaneous endoscopic gastrostomy tube placement in patients who require trauma and surgical intensive care: A retrospective cohort study.

Critically ill patients experience interruptions in enteral nutrition (EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy (PEG) tube placement, postprocedure fasting times vary from 1 to 24 h depending on the surgeon's preference. There is no evidence to support delayed feeding (DF) after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with early feeding (EF) after PEG. 150 adult ventilated patients in the trauma and surgical intensive care unit (TSICU) at a level I trauma center underwent PEG placement in March 2015 through May 2018 by one of six surgical intensivists. Retrospective review revealed variable post-PEG fasting practices: one started EN at 1 h, two started at 4 h, two started at 6 h, and one started at 24 h. Time to initiation of EN and complication rates were assessed. Patients were divided into EF (<4) and DF (≥4 h) groups. Median postprocedure fasting time was 5.5 h. The overall complication rate was 3.3%, with a feeding intolerance rate of 0.7% and aspiration rate of 0%. There was no difference in complication rate for EF (3.1%) as compared with DF (3.4%) (odds ratio, 0.92; 95% CI, 0.10-8.52; P = 0.7). Complication rates following PEG placement in ventilated TSICU patients are low and do not change with EF compared with DF. EF is probably safe.

Enteral nutrition interruptions in the intensive care unit: A prospective study

ObjectiveThe aim of this study was to provide insight into the causes, frequency, and periods of enteral nutrition interruption (ENI) that occur in the intensive care unit (ICU). MethodsThis was a prospective, observational cohort study conducted in the ICU. Demographic data, admission and discharge data, mortality, days of intubation, use of prokinetic drugs, initiation time of enteral nutrition, daily calculated targets of calories and protein, actual daily calories and protein delivered, and duration and causes of ENI were recorded and analyzed. ResultsIn total, 165 patients were assessed for eligibility during the study inclusion period, 61 of whom were included in our study. Mean age was 60.8 ± 14.3 y, and the majority (41, 67.2%) of participants were men. In the first four study days, approximately 20% of participants had at least one episode of ENI, which gradually decreased until the seventh study day. A total of 115 ENIs occurred in our 7-d follow-up period. The most ENIs occurred in the first 3 d of ICU admission. In the first 4 d, there was a significant difference between mean percentage of goal feeding reached in the ENI group versus the group without periods of ENI (P < 0.001). ConclusionsThe prevalence of unplanned ENIs in ICU patients is highest in the first 3 d of admission. The main cause of ENIs was diagnostic reasons. The ENIs resulted in an average of approximately 25% of patients failing to meet calculated caloric and protein requirements during the first 4 d of admission.

Fasting does not guarantee empty stomach in the intensive care unit: A prospective ultrasonographic evaluation (The NUTRIGUS study)

BackgroundIn the intensive care unit (ICU), a fasting period is usually respected to avoid gastric aspiration during airway management procedures. Since there are no recognised guidelines, intensive care physicians balance the aspiration risk with the negative consequences of underfeeding. Our objective was to determine the impact of fasting on gastric emptying in critically ill patients by using gastric ultrasound. Material and methodsAmong the 112 patients that met the inclusion criteria, 100 patients were analysed. Gastric ultrasonography was performed immediately before extubation. Patients with either 1/ an absence of visualised gastric content (qualitative evaluation) or 2/ a gastric volume < 1.5 mll/kg in case of clear fluid gastric content (quantitative evaluation) were classified as having an empty stomach. Main findingsIn our study, twenty-six (26%) patients had a full stomach at the time of extubation. The incidence of full stomach was not significantly different between patients who fasted < 6 h or patients who fasted ≥ 6 h. Among the 57 patients receiving enteral nutrition (EN) within the last 48 h, there was no correlation between the duration of EN interruption and the GAA. The absence of EN was not associated with an empty stomach. ConclusionAt the time of extubation, the incidence of full stomach was high and not associated with the fasting characteristics (duration/absence of EN). Our results support the notions that fasting before airway management procedures is not a universal paradigm and that gastric ultrasound might represent a useful tool in the tailoring process. ClinicalTrials.govNCT04245878

Association Between Anticholinergic Drug Burden and Adequacy of Enteral Nutrition in Critically Ill, Mechanically Ventilated Pediatric Patients.

Enteral nutrition delivery is limited by intolerance and interruptions in critically ill children. Anticholinergic properties of frequently administered medications may contribute to altered gastric motility and enteral nutrition intolerance in this population. We examined the association between the anticholinergic burden of administered medications using the Anticholinergic Drug Scale and adequacy of enteral nutrition delivery. Secondary analysis of data from a previously characterized PICU cohort. Multidisciplinary PICU in a quaternary academic medical center. Younger than or equal to 18 years, on mechanical ventilation and received enteral nutrition within the first 3 days of PICU admission. Daily Anticholinergic Drug Scale score, demographic data, and clinical data were obtained from the primary study. Percent enteral energy adequacy ([kcal delivered ÷ kcal prescribed] × 100) during the first 3 days of PICU admission was calculated. Forty-two patients received enteral nutrition, with median age (interquartile range) 5 years (1.09-12.54 yr), and 62% were male. Median Anticholinergic Drug Scale score was inversely correlated with energy adequacy, with a median 9% decline in energy adequacy per 1-point increase in Anticholinergic Drug Scale score (coefficient, -9.3; 95% CI, -13.43 to -5.27; R2 = 0.35; p < 0.0001). Median hours of enteral nutrition interruptions directly correlated with Anticholinergic Drug Scale score (coefficient, 1.5; 95% CI, 0.531-2.54; R2 = 0.19; p = 0.004). Severity score was greater in patients with less than or equal to 25% enteral energy adequacy and directly correlated with median Anticholinergic Drug Scale score. Anticholinergic burden from medications administered in the PICU is a potentially modifiable factor for suboptimal enteral nutrition delivery.

Nutrition profile of very low birth weight infants with extrauterine growth restriction in NICU.

Extrauterine growth restriction (EUGR) is associated with long-term complications such as neurodevelopmental dysplasia, increased mortality, and chronic metabolic disease. The incidence of EUGR in very low birth weight infants (VLBWIs) is generally high. This study's objectives were to (1) evaluate the nutritional support of VLBWIs with EUGR in our hospital NICU in the past 2y and (2) provide guidance for improving clinical practice. Preterm infants (birth weight<1500g) admitted to our hospital from February 2017 to July 2019 were enrolled in the study. Nutrient intakes were recorded daily, and growth parameters were regularly measured. Based on whether the infants reached the 10th percentile of the 2013 Fenton growth curve at discharge, the infants were divided into a EUGR group (n=134) and a non-EUGR group (n=34) and their nutrition support were compared with current ESPGHAN guidelines. A total of 138 VLBWIs were enrolled in the study. Growth restriction was 18.1% at birth and 75.4% at discharge for weight. Enteral nutrition (EN) was initiated late compared with the guidelines. The cumulative EN interruption time was long, especially in the EUGR group. Insufficient energy and amino acid intakes were prevalent, and cumulative energy and amino acid deficits failed to be compensated at discharge. Lower Z-score at birth (OR=0.055, 95% CI=0.018-0.172, p<0.001) and long cumulative interruption time (OR=1.058, 95% CI=1.001-1.119, p=0.046) were risk factors for EUGR incidence. In general, the nutritional support for VLBWIs was inadequate, conservative enteral feeding was the main reason.

The prevalence and possible causes of enteral tube feeding intolerance in critically ill patients: A cross-sectional study.

Background:Enteral tube feeding intolerance (ETFI) is one of the most common complications of enteral nutrition (EN), which may lead to increased mortality and length of intensive care unit (ICU) stay. This study aimed to determine the prevalence of ETFI and effects on feeding intolerance on nutrition and clinical outcomes in Iran.Materials and Methods:This cross-sectional study was conducted in 2019 at the three general ICUs of Imam Reza Hospital in Mashhad, Iran, during 7 days on 245 patients. The collected data included demographic characteristics, primary diagnosis, the Acute Physiology and Chronic Health Evaluation II (APACHE ІІ) score, Sequential Organ Failure Assessment (SOFA) score, duration of mechanical ventilation, and length of ICU stay. Feeding intolerance was assessed using daily questionnaires for 7 days. ETFI was determined as the interruption of EN based on gastrointestinal causes, including large gastric residuals, abdominal distension, vomiting, diarrhea, and subjective discomfort.Results:Overall, 245 critically ill patients (122 males and 123 females) were included in this study, with a mean age of 58.43 ± 19.2 years in three general ICUs. The highest prevalence rate of ETFI was 91.8%, which occurred on the 2nd day although the rate decreased in the following days. The minimum ETFI was observed on the last day (38.8%). Feeding intolerance was associated with the increased APACHE II scores (P = 0.04), SOFA scores (P < 0.001), and duration of mechanical ventilation (P < 0.001) compared with the tolerant patients. The most common causes of ETFI in the patients admitted to the ICU were gastric residual volume (GRV), large GRV, vomiting, and distension.Conclusion:ETFI was prevalent in almost two-third (66%) of the critically ill patients receiving EN based on the GRV. ETFI was associated with deteriorated nutritional status and clinical outcomes.

Feed intolerance and postpyloric feeding in the critically ill child

: Feeding intolerance (FI) is a common problem in critically ill children that results in feed interruptions impacting heavily on outcome. The lack of consistent and validated definition for FI makes difficult to know the real prevalence of this problem in these patients and precludes obtaining conclusive results on predictors and outcomes. Gastric dysmotility (GD) is the principal mechanism underlying FI. The aetiology of GD is largely unknown but many factors (vasoactive drugs, sedatives, opioids, muscle relaxation drugs, hypoperfusion) may be involved in its appearance. Future research must focus on clarifying the potential mechanisms of FI during critical illness as well as finding a proper and validate definition of FI. Several actions are used in clinical practice to reduce FI in critically ill children as prokinetic agents, change from polymeric to semi-elemental formulation and change of feed delivery method from intermittent bolus to continuous feeding. However, the evidence does not support the routine use of these methods to manage FI. Transpyloric enteral nutrition (TEN) is another option to manage FI in sick children as it has proven to be safe and well tolerated with few complications in these patients. TEN promote early nutrition and reduce the volume of gastric residues and the number of enteral nutrition interruptions increasing energy intake. Children with shock, acute kidney injury (AKI) and in the recovery of cardiac surgery may benefit from this technique. However, feeding tube insertion is difficult and it is not exempt of problems. Staff must be trained to detect and decrease complications associated with its utilization.

Fatores de interrupção de nutrição enteral em unidades de terapia intensiva adulto: revisão integrativa

Objetivo: identificar na literatura os principais fatores de interrupção de nutrição enteral em unidades de terapia intensiva adulto. Método: revisão integrativa da literatura, viabilizada através de coleta de dados nas bases de dados da LILACS, Medline e Scopus, com recorte cronológico de 2010 a 2020. Foram utilizados os descritores de busca: “Nutrição Enteral” ou “Enteral Nutrition”, “Cuidados Críticos” ou “Critical Care”, “Desnutrição” ou “Malnutrition”. Resultados: Dos 10 artigos selecionados para leitura e análise, foi possível identificar que os principais motivos de interrupção de dieta enteral foram: 08 (80%) pausa para exames, procedimentos e cirurgias, 06 (60%) intolerância gastrointestinal, 03 (30%) extração ou dificuldades com acesso enteral, 02 (20%) diarreia e 02 (20%) por instabilidade clínica. Conclusão: A pesquisa permitiu identificar na literatura os principais fatores causadores de interrupção de dieta enteral em unidades de terapia intensiva, apontando alguma similaridade entre os diferentes países e cenários. Emergindo assim, a recomendação de novas pesquisas sobre o tema, que proponham avaliar o conhecimento de profissionais de saúde acerca da temática da terapia nutricional, a fim de nortear a elaboração de planos educacionais e de treinamento.

Impact of enteral nutrition interruptions on underfeeding in intensive care unit

Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care. This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available. In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p<0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p<0.001). The daily average caloric provision was 77±36% vs. 106±29% in the trial days with and without ENI (p<0.001) and protein provision was 0.96±0.5 vs. 1.3±0.5g/kg, respectively (p<0.001). The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.

Rapid Advancement in Enteral Nutrition Does Not Affect Systemic Inflammation and Insulin Homeostasis Following Pediatric Cardiopulmonary Bypass Surgery.

To determine impact of enteral nutrition delivery on the relationship among inflammation, insulin resistance, and outcomes following pediatric cardiopulmonary bypass surgery. Pilot, randomized study analyzed according to intention-to-treat analysis. Pediatric cardiac ICU. Infants (≤ 6 mo) undergoing cardiopulmonary bypass. Patients randomly assigned to receive rapid escalation to enteral nutrition reaching goal feeds by 27 hours or standard feeding practice reaching goal feeds by 63 hours. Feeds were initiated on the first postoperative day. Fifty patients were randomized equally to study arms. Patients were a median (interquartile range) of 16 days old (7-110 d old), undergoing biventricular surgery (88%) with a median cardiopulmonary bypass time of 125 minutes (105-159 min). Serial blood samples were drawn before and after cardiopulmonary bypass, cardiac ICU admission, and every 12 hours (up to 96 hr) for glucose, insulin, and cytokines (interleukin-1α, interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α) levels. Glucose-insulin ratio was calculated to quantify insulin resistance. Patient characteristics, time to enteral nutrition initiation, enteral nutrition interruptions, and insulin administration were similar across intervention arms. FF reached goal feeds at similar intervals as standard feeding (39 hr [30-60 hr] vs 60 hr [21-78 hr]; p = 0.75). No difference in cytokine, insulin, or glucose-insulin ratio was noted between groups. Higher inflammation was associated with increased glucose-insulin ratio and higher risk of adverse events. In multivariable models of interleukin-8, FF was associated with increased glucose-insulin ratio (estimate of effect [95% CI], 0.152 [0.033-0.272]; p = 0.013). Although higher interleukin-8 was associated with an elevated risk of adverse event, this relationship was possibly mitigated by FF (odds ratio [95% CI], 0.086 [0.002-1.638]; p = 0.13). A FF strategy was not associated with changes to early enteral nutrition delivery. Inflammation, insulin resistance, and morbidity were similar, but FF may modify the relationship between inflammation and adverse event. Multicenter nutrition studies are possible and necessary in this vulnerable population.

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit.

Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

Interrupted Nutrition Support in Patients With Burn Injuries: A Single-Centre Observational Study.

Enteral nutrition (EN) is essential to meet the increased metabolic requirements of burn-injured patients. However, feeds are often suspended for care. This study examines the interruptions in EN (IEN). To determine the frequency and duration of IEN and whether these interruptions are predictable or unpredictable. This retrospective chart review of 27 adult burn patients examined age, sex, body mass index, percentage of total body surface area, length of hospital stay, predicted energy requirements from equations and indirect calorimetry, EN start time, time EN reached goal rate, and interruptions to EN. Predictable interruptions accounted for 74.5% (frequency) and 81.6% (duration) of total interruptions. The most frequent and time-consuming interruptions were perioperative period, extubation, and tests/procedures (predictable) versus high gastric residual volume, emesis/nausea, and feeding tube displacement (unpredictable). Most IEN were due to predictable events. Based on these findings, compensating for predictable interruptions to meet nutritional requirements in burn patients is recommended.