Enteral Nutrition Interruptions Research Articles

EFICACIA DEL APORTE CALÓRICO EN PACIENTES CON PATOLOGÍA TRAUMÁTICA

the effective contribution of enteral nutrition (EN) in intensive care units (ICU) is due to multiple factors. to determine the efficacy of caloric intake in critically ill patients with traumatic pathology receiving enteral nutrition, and to analyze cause and time of interruption of EN. prospective observational study (November 2015 - August 2016). patient with EN ≥ 48 hours and age ≥ 18 years. patient with oral and/or parenteral nutrition. demographic, day of EN, prescribed and administered kilocalories (kcal), caloric difference, caloric objective and variables related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit's internal protocol. Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient. sixty-nine patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1,112 days of EN were monitored. As of the third day of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake > 80%): 92.43% (72.8-97.5). The optimal caloric goal was maintained in 67.9% of these days. The most frequent causes of interruption of NE were procedures unrelated to airway, with holding time of three (1-7.25) hours. CONCLUSIONS at the third day, the patients with traumatic pathology received at least 80% of the prescribed caloric intake. Among the most frequent causes of interruption of EN were the procedures unrelated to airway.

Abstract O-29: ENTERAL PROTEIN SUPPLEMENTATION IN CRITICALLY ILL CHILDREN: A RANDOMIZED CONTROLLED PILOT STUDY

Aims & Objectives: Protein supplementation may be associated with improved clinical outcomes in critically ill children. The aim of this study was to assess the safety and tolerance of protein supplementation, and its impact on clinical outcomes in critically ill children on enteral nutrition (EN). Methods Pilot, three-arm, controlled trial in critically ill children. Children on mechanic ventilation and on EN therapy were randomized to one of 2 interventional groups; polymeric and oligomeric protein supplementation, or control group receiving standard nutritional therapy. In the interventional groups, the protein supplement was administered to reach the prescribed protein goal by Day 4. Demographic characteristics and clinical outcomes were recorded. EN interruptions, increase in stool frequency and abdominal distension were evaluated as signs of intolerance of the intervention. Blood urea and creatinine values were recorded. Results Among 363 patients admitted, 70 were eligible, and 34 were. At baseline there were no differences between the groups (Table 1). The number of EN interruption and ≥3 defecations/day were similar between groups. Abdominal distension was present in 30% of the control, 12.5% of the polymeric and 0% of the oligomeric group. There were no increases in serum urea and creatinine values in all 3 groups. There were no differences in clinical outcomes between the 3 groups (Table 2).Conclusions Enteral protein supplementation with oligomeric or polymeric modules is safe and well tolerated in critically ill children. Multicenter study with larger sample size is necessary to examine the impact of protein supplementation on clinical outcomes. Trial registration: Brazilian Registry of Clinical Trials n°RBR-3h4x97

Interruption of enteral nutrition in the intensive care unit: a single-center survey

BackgroundInterruption of enteral nutrition (EN) in the intensive care unit (ICU) occurs frequently for various reasons including feeding intolerance and the conduct of diagnostic and therapeutic procedures. However, few studies have investigated the details of EN interruption practices including reasons for and duration of interruptions. There is no standard protocol to minimize EN interruptions.MethodsThis is a retrospective review of 100 patients in the ICU staying more than 72 h and receiving EN in a 12-bed, medical/surgical ICU in a tertiary care center in 2013. Data collected include total time designated for EN; the number of EN interruption episodes; reason for each interruption categorized as diagnostic study, therapeutic intervention, or gastrointestinal (GI) event, and their individual subcategories; duration of each interruption; and the presence of written orders for interruptions.ResultsOne hundred patients staying in the ICU for at least 72 h and receiving EN were included. There were 567 episodes of EN interruption over a median ICU length of stay of 17.1 (interquartile range 8.0–22.0) days. There were a median of three EN interruption episodes per patient. EN interruption was performed for undetermined reasons (166 episodes, 29%), airway manipulation (103 episodes, 18%), GI events (78 episodes, 14%), and intermittent dialysis (71 episodes, 13%). Median duration of EN interruption in all patients was 5.5 (3.0–10.0) h. The cumulative interruption time corresponds to 19% of the total time designated for EN. Duration of EN interruption varied according to reason, including airway manipulation (9.0 [5.0–21.0] h), tracheostomy (9.5 [7.5–14.0] h), and GI events (6.5 [3.0–14.0] h). The average calorie deficits due to interruptions were 11.5% of daily target calories. Only 60 episodes (12%) had clear written orders for interruption.ConclusionsBased on this single-center retrospective chart review, interruption of EN in the ICU is frequent, reasons for and duration of interruption varied, and airway procedures are associated with a relatively longer duration of interruption. Documentation and orders were frequently missing. These results warrant development of a protocol for EN interruption.

Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes.

Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.

Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit

PurposeInadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU). MethodsIn a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate. ResultsFive hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score −0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery. ConclusionEnteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population. Level of evidenceI. Type of studyProspective study.

Current situation of enteral nutrition interruptions in sepsis children in pediatric intensive care unit

To analyze the interruptions of enteral nutrition (EN) and it's relationship to prognosis in children with sepsis in pediatric intensive care unit (PICU). Daily EN intake and reasons for EN interruptions were prospectively observed and recorded in children with sepsis who were admitted to our PICU from November 2012 to April 2013. Clinical prognosis was compared between children with and without EN interruptions by t, rank-sum and χ(2) tests. Totally 60 consecutive children were included, 42 males, median age 9.67 (5.36, 37.0) months; 50 children suffered from EN interruptions, while 10 children did not. Median time to EN initiation was 2.59 (1.53, 3.67) h; EN was interrupted in 83% (50/60) of children, for a total of 108 times and 696 h, the most common reasons were fibrobronchoscopy and radiologic procedures, 27 and 29 times respectively. Children spent 0.04 (0.02, 0.08) of their total observation period without EN nutrition due to EN interruptions, and was not correlated with pediatric critically ill score (r=0.12, P=0.38). Children with EN interruptions suffered from longer PICU duration ((12±7) vs. (7±4) d, t=2.18, P=0.03), but there was no significant difference in the 28(th) hospital day's mortality between these two groups (6 cases vs. 1 case, χ(2)=0.00, P=1.00). EN is frequently interrupted due to procedures needed fasting, EN intolerance and other reasons in children with sepsis. EN interruptions may have something to do with prolonged PICU length of stay, but the relationship needs to be examined in future studies.

Causes of interruptions in postoperative enteral nutrition in children with congenital heart disease.

Perioperative nutritional support has become a hot topic in the clinical management of congenital heart disease (CHD). Postoperative enteral nutrition (EN) offers many benefits, such as protection of the intestinal mucosa, reduced risk of infection, and low clinical costs. Interruptions in EN frequently influence nutritional support and clinical outcomes. We, therefore, aimed to determine the causes of interruptions in postoperative EN in CHD patients and discuss clinical counter measures. We analyzed the data of 360 CHD patients to determine the causes of interruptions in postoperative EN and develop possible clinical strategies to prevent such interruptions. Of the 360 patients (aged from 1 month to 6 years), 198 patients had at least one EN interruption. The total number of interruptions was 498 (average, 2.52 interruptions/ patient). Non-gastrointestinal factors (airway management, fluid overload, invasive procedure, increased intracranial pressure, feeding tube block, and clinical deterioration) accounted for 67.8% (338/498) of all interruptions and gastrointestinal factors (vomiting, gastrointestinal bleeding, diarrhea, constipation, and large gastric residual volume) accounted for 32.2% (160/498). The total number of interruptions and the number of interruptions due to gastrointestinal factors were significantly higher in younger patients (aged from 1-12 months) than in older patients (aged from 1-6 years). Non-gastrointestinal factors were the main causes of interruptions in postoperative EN in CHD patients. Younger patients had a greater number of interruptions as a whole, and more interruptions caused by gastrointestinal factors. Gastrointestinal factors can be reduced by tube feeding and use of gastrointestinal motility drugs.

Interruption of of enteral nutrition in the intensive care unit: a single center survey

Interruption of enteral nutrition (EN) is common in the intensive care unit (ICU). Frequent episodes of EN interruption can lead to protein and calorie debt with a potential impact on outcomes in critically ill patients [1, 2]. However, few studies have investigated the details of EN interruption practice including the reasons and duration of the interruption [3, 4]. A standard protocol to minimize EN interruption has not been established.

Enteral nutrition: what the dietitian prescribes is not what the burn patient gets!

Enteral nutrition (EN) is commonly interrupted in burn patients for many reasons, which leads to discrepancies between prescribed and actual EN delivery. The magnitude and origin of these discrepancies have never been well documented among burn patients. The purpose of this study was to examine differences between prescribed and actual EN delivery and to identify the specific causes of EN interruption and to quantify these. Retrospective review of patients treated between June 6, 2009 and June 6, 2012 at an adult regional American Burn Association-verified burn center who had ≥10% TBSA burns and who were prescribed EN for at least 24 hours. On postburn days (PBD) 0 to 14 the daily volume of EN prescribed by the dietitian was compared with the actual volume received by the patient. The cause and duration of interruptions to EN delivery were recorded. A total of 90 subjects, [mean (± SD) age 47 ± 18 years, 32% female, median %TBSA burn size 28, median %TBSA full-thickness burn size 11, and a 54% incidence of inhalation injury], were studied. EN was initiated at a median of 9.5 hours after burn center admission. Received calories were significantly less than prescribed calories on every study day. The median daily caloric deficit ranged between 172 and 930 kcal. The median percent of prescribed calories received each day ranged from 19% on PBD 0 to 91% on PBD 14. The mean (± SD) total duration of EN interruption was 8.9 ± 3.0 hours per day. Gradually increasing the feed rate to reach the prescribed EN goal rate ("ramping-in") was the most common cause of a discrepancy between prescribed and actual EN delivery, accounting for 35% of total discrepancy time. Interruptions for surgery accounted for 24% of total discrepancy time. Other causes of discrepancies were physician- or nurse-directed interruptions (16% of time), planned extubation (7%), feed intolerance (11%), tube malfunction (2%), bedside procedures (2%), and dressing changes (3%).Enterally fed burn patients received significantly less nutrition than prescribed. Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices.

A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals*.

To evaluate the impact of implementing an enteral nutrition algorithm on achieving optimal enteral nutrition delivery in the PICU. Prospective pre/post implementation audit of enteral nutrition practices. One 29-bed medical/surgical PICU in a freestanding, university-affiliated children's hospital. Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of more than 24 hours who received enteral nutrition. Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing, and maintaining enteral nutrition in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, enteral nutrition interruptions, parenteral nutrition use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and postintervention cohorts. Time to achieving energy goal was analyzed using Kaplan-Meier statistical analysis. Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the preimplementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating enteral nutrition, or use of postpyloric feeding between the two cohorts. We recorded a significant decrease in the number of avoidable episodes of enteral nutrition interruption (3 vs 51, p < 0.0001) and the prevalence and duration of parenteral nutrition dependence in patients with avoidable enteral nutrition interruptions in the postintervention cohort. Median time to reach energy goal decreased from 4 days to 1 day (p < 0.0001), with a higher proportion of patients reaching this goal (99% vs 61%, p = 0.01). The implementation of an enteral nutrition algorithm significantly improved enteral nutrition delivery and decreased reliance on parenteral nutrition in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice.

Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.

Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study.

Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs). Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis. Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding. A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.

Causes and Consequences of Interrupted Enteral Nutrition

Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU). We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March-December 2012). We categorized EN interruptions as "unavoidable" vs "avoidable" and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality. Ninety-four patients comprised the analytic cohort. Twenty-six percent of interruptions were deemed "avoidable." Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03-8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14-1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41-1.67) vs group 2. In our cohort of critically ill surgical patients, EN interruption was frequent, largely "unavoidable," and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.

Prevalence, Risk Factors, Clinical Consequences, and Treatment of Enteral Feed Intolerance During Critical Illness

We aimed to determine the incidence of enteral feed intolerance and factors associated with intolerance and to assess the influence of intolerance on nutrition and clinical outcomes. We conducted a retrospective analysis of data from an international observational cohort study of nutrition practices among 167 intensive care units (ICUs). Data were collected on nutrition adequacy, ventilator-free days (VFDs), ICU stay, and 60-day mortality. Intolerance was defined as interruption of enteral nutrition (EN) due to gastrointestinal (GI) reasons (large gastric residuals, abdominal distension, emesis, diarrhea, or subjective discomfort). Logistic regression was used to determine risk factors for intolerance and their clinical significance. A sensitivity analysis restricted to sites specifying a gastric residual volume ≥200 mL to identify intolerance was also conducted. Data from 1,888 ICU patients were included. The incidence of intolerance was 30.5% and occurred after a median 3 days from EN initiation. Patients remained intolerant for a mean (±SD) duration of 1.9 ± 1.3 days . Intolerance was associated with worse nutrition adequacy vs the tolerant (56% vs 64%, P < .0001), fewer VFDs (2.5 vs 11.2, P < .0001), increased ICU stay (14.4 vs 11.3 days, P < .0001), and increased mortality (30.8% vs 26.2, P = .04). The sensitivity analysis demonstrated that intolerance remained associated with negative outcomes. Although mortality was greater among the intolerant patients, this was not statistically significant. Intolerance occurs frequently during EN in critically ill patients and is associated with poorer nutrition and clinical outcomes.

Critical care 24 × 7: But, why is critical nutrition interrupted?

Background and Aims:Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN.Materials and Methods:Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others.Results:Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to “procedures inside CCU”.Conclusion:Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.

Nutrition Therapy for the Critically Ill Surgical Patient With Aortic Aneurysmal Rupture

Our goal is to define nutrition therapy in critically ill patients after surgical repair of acute ruptured or dissecting aortic aneurysm to identify opportunities for quality improvement. International, prospective studies in 2007-2009 and 2011 were combined. Sites provided institutional and patient characteristics including from intensive care units (ICUs) admission to ICU discharge for a maximum of 12 days. We selected patients with aortic aneurysmal rupture or acute dissection staying in the ICU for ≥ 3 days. There were 104 eligible patients from 72 distinct ICUs analyzed. Overall, 86.5% received artificial nutrition. There were 50.0% patients who received enteral nutrition (EN) only, 29.8% patients received a combination of EN and parenteral nutrition (PN), 6.7% patients received PN only, and 13.5% did not receive any nutrition. The mean time from admission to initiation of EN was 3.0 days (SD ± 2.4 days). The adequacy of calories from nutrition support was 46.8% (range 0%-111%) with a mean of 10.0 kcal/kg/day. Of the total of 83 patients who received EN, 53 patients (63.8%) had interruption of EN. The reasons included fasting, intolerance, patients deemed too sick for enteral feeding, and loss of enteral feeding route. For patients with gastrointestinal intolerance, 3/30 patients (10%) received small bowel feeding and 23/30 patients (76.7%) of patients received motility agents. Postoperative critically ill patients with aortic aneurysmal rupture or acute dissection are at high risk for inadequate nutrition therapy, and there may be inadequate utilization of strategies to improve nutrition uptake.

Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients

Background: Previous studies have shown that ICU patients receive only a fraction of their calculated nutritional goals, and that cumulative caloric deficit in the ICU has been correlated with poor outcome. One reason for this underfeeding is the frequent interruption of enteral nutrition. Many ICU patients receive enteral feeding formula via a nasogastric (NG) tube. Feeding is typically held for several hours prior to procedures due to the theoretical risk of aspiration. An alternative is to continue feeding up until the procedure begins, then stop the feeding and place the NG to suction. This evacuates the contents of the stomach and minimizes the risk of aspiration, while reducing the interruption of feeding that can result in malnutrition. Methods: This study is a review of prospectively gathered data including 55 sequential patients who underwent bedside percutaneous endoscopic gastrostomy (PEG) placement in a mixed ICU under a reduced fasting protocol. This was compared with a historical cohort of 33 critically ill trauma patients who fasted for at least 8 hours prior to the procedure. Under the reduced fasting protocol, enteral feeding via NG was continued up until the time of the procedure. The NG was then placed to suction, and sedation was given. The NG was left in place until the esophagus was cannulated, then it was removed. The PEG was placed in standard fashion, and feeding was resumed via the PEG immediately following the procedure. Results: We have documented no peri-procedural vomiting or aspiration. New diagnosis of pneumonia within 3 days occurred in 2/55 of the feeding group and 4/33 of the fasting group. Overall mortality was higher for the feeding group: 13/55 vs. 1/33, however when adjusted for baseline characteristics, the difference was no longer significant. Under our protocol, the interruption of feeding averaged approximately one hour, rather than the 8 or 9 hour interruption required by standard protocols. This saved an average of approximately 700 kilocalories per patient. Conclusion: We believe that continuing feeding via NG up until the time of bedside PEG is safe and advantageous for intubated patients in the ICU. Since there was minimal gastric content, it may also be safe for other procedures.

A Pilot Study to Explore the Safety of Perioperative Postpyloric Enteral Nutrition

The practice of holding enteral nutrition (EN) 8 hours prior to surgery is common. We hypothesized that it was safe to continue postpyloric EN, and we developed an institutional practice pattern to investigate our hypothesis. Our pilot study included intubated patients in the surgical intensive care unit at Froedtert Memorial Lutheran Hospital who received EN via a nasojejunal (NJ) feeding tube and underwent 1 or more surgical procedures. Demographic, illness, and injury information were collected as well as length of time to NJ placement, time to initiation of EN, EN interruptions, and complications. Additional hours of EN were calculated by totaling the number of hours a patient received EN past midnight on the day of surgery. A total of 14 patients with mean (SD) age 44.3 (19.9) were included. Patients had a mean (SD) Injury Severity Score (ISS) of 26.1 (9.2) on admission and underwent a total of 38 operations following placement of a feeding tube. The most frequent operation performed was an orthopedic procedure (n = 17; 46.1%). The mean (SD) length of EN interruptions for a single procedure was 222.4 (206.9) minutes. Patients received an additional 11.9 (4.7) hours of EN over the course of their hospitalization and an additional 1064.9 (490) kcal/d per operation. There were no adverse events. Perioperative continuation of postpyloric EN is feasible in some critically ill surgical patients and can result in additional calories provided. A multidisciplinary approach and an institutional policy can increase the likelihood of meeting nutrition goals in these patients.

Adequacy of early enteral nutrition in adult patients in the intensive care unit

To evaluate the adequacy of energy and protein intake of patients in a Korean intensive care unit in the first four days after initiation of enteral feeding and to investigate the factors that had impact on adequate intake. Underfeeding is a common problem for patients hospitalised in the intensive care unit and is associated with severe negative consequences, including increased morbidity and mortality. A prospective, cohort study was conducted in a medical intensive care unit of a university hospital in Korea. A total of 34 adult patients who had a primary medical diagnosis and who had received bolus enteral nutrition for the first four days after initiation of enteral nutrition were enrolled in this study. The data on prescription and intake of energy and protein, feeding method and feeding interruption were recorded during the first four days after enteral feeding initiation. Underfeeding was defined as the intake <90% of required energy and protein. Most patients (62%) received insufficient energy, although some (29%) received adequate energy. More than half of patients (56%) had insufficient protein intake during the first four days after enteral feeding was initiated. Logistic regression analysis showed that the factors associated with underfeeding of energy were early initiation of enteral nutrition, under-prescription of energy and prolonged interruption of prescribed enteral nutrition. Underfeeding is frequent in Korean critically ill patients owing to early initiation, under-prescription and prolonged interruption of enteral feeding. Interventions need to be developed and tested that address early initiation, under-prescription and prolonged interruption of enteral nutrition. Findings from this study are important as they form the foundation for the development of evidence-based care that is badly needed to eliminate underfeeding in this large vulnerable Korean intensive care unit population.

Have the metabolic support pendulums in the intensive care unit stopped swinging?

Have the metabolic support pendulums in the intensive care unit stopped swinging?