Provision Of Enteral Nutrition Research Articles

Hypocaloric Enteral Nutrition Protects against Hypoglycemia Associated with Intensive Insulin Therapy Better than Intravenous Dextrose

Intensive insulin therapy treats hyperglycemia but increases the risk of hypoglycemia. Typically, intravenous dextrose is given to prevent hypoglycemia; however, enteral nutrition is preferred. We hypothesized that the provision of hypocaloric enteral nutrition would protect against hypoglycemia. A retrospective analysis was performed evaluating patients treated with intensive insulin therapy comparing the use of enteral nutrition versus a dextrose-only intravenous solution. Nutrition in the 2 hours before each blood glucose test was assessed, and the association with hypoglycemia (50 mg/dL or less) evaluated. Risk of hypoglycemia as a function of nutrition type and rate was estimated by multivariable regression. A total of 26,140 blood glucose tests were collected on 1289 patients. Hypoglycemia occurred in 6.4 per cent of patients. In regression models, enteral nutrition was the strongest protective factor against hypoglycemia (P < 0.001) with the largest risk reduction (steepest portion of the curve) occurring at 60 per cent goal. Hypocaloric enteral nutrition showed a greater risk reduction than a peripheral dextrose-only intravenous solution alone. In the setting of intensive insulin therapy, the provision of enteral nutrition, even if hypocaloric, is sufficient to protect against hypoglycemia. Future prospective studies should evaluate the efficacy of enteral nutrition in reducing the risk of hypoglycemia and whether lower rates of hypoglycemia correspond to improved outcomes.

A practice change initiative to improve the provision of enteral nutrition to intensive care patients.

To describe a practice change initiative that improved the provision of enteral nutrition (EN) to patients in a New Zealand tertiary intensive care unit (ICU). The project reviewed and summarized EN literature, amended local policy, and an evidence-based EN delivery algorithm was developed. The EN practice change initiative was implemented and evaluated. Data was collected and analyzed in a pre-audit (2009) and a post-audit (2013). Comparison of the pre-audit (N = 25) and the post-audit (N = 40) data demonstrated improvements in three areas of EN delivery. The commencement of early EN within 24 h of admission was evident for a large proportion of patients in both 2009 and 2013 audits. There was a large reduction in time between the two audits for both ICU admission to achievement of EN goal rate (M = 57·71 h versus M = 33·79 h, p = 0·006) and also for EN commencement to achievement of EN goal rate (M = 31·65 h versus M = 10·15 h, p = 0·000). The volume of prescribed EN delivered on days 2, 4 and 6 was greater in the 2013 audit in comparison to the 2009 audit. Staff compliance with adhering to the EN policy and algorithm improved from 46% in 2009, to 95% in 2013. The practice change has significantly improved the practice delivery of EN for patients in the local ICU resulting in optimal care. Malnutrition is highly prevalent among intensive care patients. Strategies and initiatives that improve the delivery of enteral nutrition to the critical care population is therefore vitally important. This article describing such an initiative is thus highly relevant to all health care professionals delivering enteral nutrition in intensive and critical care units.

Enteral Nutrition in the Critically Ill

Nutritional support is an essential component of the management of critically ill and injured ICU patients. Optimal provision of calories and protein has been demonstrated to reduce morbidity, mortally, and length of ICU and hospital stay. Yet, a large proportion of ICU patients receive inadequate nutrition. To provide an evidence-base assessment of factors leading to inadequate enteral nutrition support in critically ill patients. Search of PubMed database and manual review of bibliographies from selected articles. A number of common myths and misconceptions appear to play a major role in limiting the provision of enteral nutrition in the critically ill. This article provides scientific data to debunk the most common myths and misconceptions related to enteral nutrition.

Improving the Provision of Enteral Nutrition in the Intensive Care Unit

Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. The purpose of this article is to describe the development and implementation of a tailored intervention to overcome barriers to enterally feeding critically ill patients. A before-after study was conducted in 5 hospitals in North America. We adopted a pragmatic stepwise approach to developing and implementing a tailored intervention-namely, (1) formation of a guideline implementation team, (2) identification of barriers to the provision of enteral nutrition (ie, guideline-practice gap analysis, staff survey, focus group with key stakeholders), (3) focus group to prioritize these barriers, (4) brainstorming to select interventions to overcome the prioritized barriers, (5) a 12-month implementation phase including bimonthly progress meetings, and (6) evaluation of the tailored intervention. All sites identified and prioritized barriers to target for change and developed a tailored action plan. Three of the 22 potential barriers were prioritized by all sites, resulting in common components to the action plans. However, barriers and interventions that were unique to specific sites were also identified. All sites were successful in implementing most of the selected strategies during the implementation phase, although the degree of implementation varied depending on the type of strategy and the site. This stepwise process to developing and implementing an intervention tailored to barriers is promising and could be considered by dietitians and other providers seeking to improve nutrition practice.

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Introduction: Enteral nutrition (EN) is recommended within the first 24-48 hours following admission to an intensive care unit (ICU) once resuscitation and hemodynamic stability have been achieved; however, hemodynamic stability is not well defined. Hypothesis: The evaluation of EN tolerance and safety in critically ill patients receiving intravenous (IV) vasopressor therapy will improve the provision of EN during critical illness. Methods: A retrospective medical record review was conducted in an urban academic medical center. Adult ICU patients from 2011 were included if they received concomitant EN and IV vasopressor therapy for? 1 hour. Tolerance was defined as an absence of gastric residuals? 300 mL, emesis, positive finding on abdominal imaging and evidence of bowel ischemia/perforation. Nominal data were compared using?2 test of independence, while a 2-sample Student’s t-test or Fisher’s exact test was utilized for continuous data. Brown-Forsythe test was used to assess for unequal variances. If the variances were heterogeneous, Welch’s ANOVA test was used for the comparison. Results: Two-hundred and fifty-nine patients were included who received 346 episodes of concomitant EN and IV vasopressor therapy. Overall EN tolerability was 74.9%. Adverse events included rising serum lactate (30.6%), elevated gastric residuals (14.5%), emesis (9%), positive finding on KUB (4.3%), and bowel ischemia/perforation (0.9%). An inverse relationship was found between maximum norepinephrine equivalent dose and EN tolerability (12.5 mcg/min for patients who tolerated EN vs.19.4 mcg/min, p=0.0009). Patients who tolerated EN were less likely to have cardiogenic shock (20.5% vs. 31.4%, p=0.023) and were less likely to have received dopamine (63.8% vs. 77.6%, p=0.018) or vasopressin (58.9% vs. 77.9%, p=0.0027). Additionally, these patients received concomitant therapy for a shorter duration of time (median 26 vs. 65 hours, p=0.0002) and received more nutrition on a daily basis (13.6 vs. 10.9 kcal/kg/day, p=0.0034). Conclusions: The majority of patients receiving vasopressor therapy tolerate EN. Tolerability was related to the specific vasopressor administered and the maximum cumulative vasopressor dose during overlap.

Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis

Provision of enteral nutrition (EN) has historically been withheld after major abdominal operations until bowel activity returns. Evidence suggests that EN is safe in critically ill patients with a variety of illnesses, specifically after abdominal surgery. There is a strong association between poor nutrition status and worse outcomes in critically ill patients. The fear has been that EN, by virtue of increased luminal pressure or demand to the splanchnic circulation, may compromise the integrity of anastomotic repairs and place patients at risk for complications. In this review, the authors analyze the safety of EN in the setting of the open abdomen, upper gastrointestinal bleeding, and perforation peritonitis, with evidence from published clinical trials and meta-analyses.

Provision of Enteral Nutrition During Vasopressor Therapy for Hemodynamic Instability

Critical illness is associated with many complications that affect both medical and nutrition aspects of patient outcomes. Early enteral feeding is the preferred method of nutrition for patients in the intensive care unit due to apparent benefits in this patient population. However, these patients are also at risk for complications related to enteral nutrition (EN), which may be potentiated with the addition of vasopressors often used in the setting of hemodynamic instability. The clinician is often confronted with the decision of when to proceed with EN in critically ill patients who require vasopressors for hemodynamic support. This article reviews the effects of vasopressors on gastrointestinal blood flow, discusses complications associated with vasopressor use during EN, and proposes important considerations to determine the safety of EN in hemodynamically unstable patients requiring vasopressor support.

Intensive Medical Nutrition Therapy: Methods to Improve Nutrition Provision in the Critical Care Setting

Patients requiring mechanical ventilation in an intensive care unit commonly fail to attain enteral nutrition (EN) infusion goals. We conducted a cohort study to quantify and compare the percentage of energy and protein received between standard care (n=24) and intensive medical nutrition therapy (MNT) (n=25) participants; to assess the percentage of energy and protein received varied by nutritional status, and to identify barriers to EN provision. Intensive MNT entailed providing energy at 150% of estimated needs, using only 2.0 kcal/cc enteral formula and 24-hour infusions. Estimated energy and protein needs were calculated using 30 kcal/kg and 1.2 g protein/kg actual or obesity-adjusted admission body weight. Subjective global assessment was completed to ascertain admission intensive care unit nutritional status. Descriptive statistics and survival analyses were conducted to examine time until attaining 100% of feeding targets. Patients had similar estimated energy and protein needs, and 51% were admitted with both respiratory failure and classified as normally nourished (n=25/49). Intensive MNT recipients achieved a greater percentage of daily estimated energy and protein needs than standard care recipients (1,198±493 vs 475±480 kcal, respectively, P<0.0001; and 53±25 vs 29±32 g, respectively, P=0.007) despite longer intensive care unit stays. Cox proportional hazards models showed that intensive MNT patients were 6.5 (95% confidence interval 2.1 to 29.0) and 3.6 (95% confidence interval 1.2 to 15.9) times more likely to achieve 100% of estimated energy and protein needs, respectively, controlling for confounders. Malnourished patients (n=13) received significantly less energy (P=0.003) and protein (P=0.004) compared with normally nourished (n=11) patients receiving standard care. Nutritional status did not affect feeding intakes in the intensive MNT group. Clinical management, lack of physician orders, and gastrointestinal issues involving ileus, gastrointestinal hemorrhage, and EN delivery were the most frequent clinical impediments to EN provision. It was concluded that intensive MNT could achieve higher volumes of EN infusion, regardless of nutritional status. Future studies are needed to advance this methodology and to assess its influence on outcomes.

Vasoactive Substances and Their Effects on Nutrition in the Critically Ill Patient

Critically ill patients often require specialized nutrition via the enteral route. The benefits of enteral feeding, particularly early in the care of the critically ill patient, are well documented. Controversy exists regarding the provision of enteral nutrition (EN) in critically ill patients with hemodynamic instability who require vasopressors or inotropes. Concerns center on the potential for gut ischemia that may develop in the face of an imbalance between oxygen supply and demand. Current guidelines offer some guidance as to when to it is safe to initiate enteral feeding in patients on vasopressors, but the decision on when to start EN in hemodynamically unstable patients requiring vasoactive substances remains a clinical dilemma for most critical care practitioners. This review focuses on the effects of vasoactive substances such as pressors and inotropes on the gastrointestinal tract, as well as their use in combination with EN.

Gastrostomy tube feeding in adults: the risks, benefits and alternatives

Enteral feeding (or 'tube feeding') is a very common inpatient intervention to maintain nutritional status where the oral route is inadequate, unsafe or inaccessible. A proportion of patients will need to continue tube feeding in the community after their admission and will require a gastrostomy tube. Although gastrostomy insertion is relatively straightforward, it is not without complications in an often frail and vulnerable group of patients and a multidisciplinary approach is necessary to ensure that the procedure is appropriate. Some patients are better managed with careful assisted hand feeding or nasogastric tubes. Particular care needs to be taken in deciding whether patients with dementia should have a gastrostomy in view of data suggesting that this group of patients have a particularly poor prognosis after the procedure. Decisions regarding the provision of enteral nutrition at the end of life or where patients are not competent to make an informed judgement are particularly challenging and need to be made on a case-by-case basis.

Early vs Delayed Enteral Nutrition in Critically Ill Medical Patients

This study was conducted to identify current practice in provision of enteral nutrition (EN) and to determine effects of early enteral nutrition (EEN) on length of stay in the medical intensive care unit (ICU). In this prospective, observational study, medical ICU patients were evaluated to determine their candidacy for EEN. If patients were candidates for EN and expected to remain nothing-by-mouth for 48 hours, they were classified as receiving EEN (within 24 hours of admission) or delayed EN. Thirty-six patients were candidates for EEN. Eighteen received EEN and 18 received delayed EN. In the delayed group, the median time to start of EN was 2.1 +/- 4.8 days. Median ICU length of stay was 4.7 +/- 3.5 days in the EEN group compared with 8.5 +/- 8.3 days in the delayed group. Although hospital length of stay was shorter in the EEN group, this was not statistically significant (10.4 +/- 6.9 vs 16.9 +/- 11.5 days). Time on the ventilator was significantly shorter in the EEN group vs delayed (n = 30, 3.0 +/- 4.2 vs 6.0 +/- 9.2 days). The incidence of new pneumonia was lower in the EEN group (5.5% vs 44%), but no difference was found in the incidence of bacteremia. Hospital mortality was lower in the EEN group (1 vs 7 deaths). Given its association with numerous benefits, EEN within 24 hours of admission should be encouraged and implemented by clinicians in medical ICU patients, but additional research is needed.

The Acute Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a devastating disease with high rates of mortality and morbidity. The major risk factors for ICH include chronic arterial hypertension and oral anticoagulation. After the initial hemorrhage, hematoma expansion and perihematoma edema result in secondary brain damage and worsened outcome. A rapid onset of focal neurological deficit with clinical signs of increased intracranial pressure is strongly suggestive of a diagnosis of ICH, although cranial imaging is required to differentiate it from ischemic stroke. ICH is a medical emergency and initial management should focus on urgent stabilization of cardiorespiratory variables and treatment of intracranial complications. More than 90% of patients present with acute hypertension, and there is some evidence that acute arterial blood pressure reduction is safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration. However, early optimism that outcome might be improved by the early administration of recombinant factor VIIa (rFVIIa) has not been substantiated by a large phase III study. ICH is the most feared complication of warfarin anticoagulation, and the need to arrest intracranial bleeding outweighs all other considerations. Treatment options for warfarin reversal include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and rFVIIa. There is no evidence to guide the specific management of antiplatelet therapy-related ICH. With the exceptions of placement of a ventricular drain in patients with hydrocephalus and evacuation of a large posterior fossa hematoma, the timing and nature of other neurosurgical interventions is also controversial. There is substantial evidence that management of patients with ICH in a specialist neurointensive care unit, where treatment is directed toward monitoring and managing cardiorespiratory variables and intracranial pressure, is associated with improved outcomes. Attention must be given to fluid and glycemic management, minimizing the risk of ventilator-acquired pneumonia, fever control, provision of enteral nutrition, and thromboembolic prophylaxis. There is an increasing awareness that aggressive management in the acute phase can translate into improved outcomes after ICH.

Medical management of pediatric intestinal failure

The outcome for children with congenital enteropathies or massive surgical resections has improved significantly over the past two decades. Advances in understanding of the pathophysiology of intractable diarrhea and of the mutations causing many of the congenital enteropathies have enabled initiation of preventive measures for intractable diarrhea, and have enabled clinicians to provide focused treatment of immune-mediated congenital diarrheal illnesses. Children with surgical short bowel syndrome also face an improved outcome because of improvements in the composition of parenteral nutrition (TPN) and in enteral alimentation strategies. It is now recognized that, through adaptation, small intestinal surface area and absorptive function may improve over time to facilitate emancipation from parenteral nutrition. Beyond provision of enteral nutrition, ancillary therapies such as judicious use of acid suppression, antibiotics, prokinetic agents, and soluble fiber seem to accelerate the rate of adaptation in young children. In the future, trophic hormones such as epidermal growth factor (EGF) or glucagon-like peptide 2 (GLP-2) may become routine members of the therapeutic armamentarium for surgical short bowel syndrome, thus further improving outcomes.

The Physiologic Response and Associated Clinical Benefits From Provision of Early Enteral Nutrition

Provision of enteral nutrition (EN) to critically ill patients early upon admission to the intensive care unit exerts a beneficial physiologic effect that downregulates systemic immune responses, reduces oxidative stress, and improves patient outcome. Adding specific pharmaconutrient agents to EN in certain patient populations has a synergistic effect, magnifying the degree of this favorable physiologic response. In contrast, failure to provide enteral nutrients creates a physiologic profile that exacerbates oxidative stress and increases the systemic inflammatory response syndrome. Unfortunately, parenteral nutrition (PN) in the form and manner currently provided in North America does not appear to mimic the same physiologic response seen with EN. In the future, use of alternative fuel sources, steps to promote better tolerance of EN, and innovative strategies for delivery of both EN and PN may serve to further enhance the physiologic effect of nutrition therapy and to achieve even greater improvement in patient outcome.

Outcomes After Percutaneous Endoscopic Gastrostomy Insertion in Children

Percutaneous endoscopic gastrostomy (PEG) insertion is indicated for provision of enteral nutrition when oral feeding is not possible or inadequate. The aim of this study was to review the early and late morbidity of percutaneous gastrostomy insertion in children including major and minor complications. Methods: A retrospective chart review of children who underwent percutaneous endoscopic gastrostomy by the Dept of Gastroenterology, RCH in the last 4 years was undertaken. Patient demographics, indications for gastrostomy, and the incidence of major and minor complications were recorded. Early complications were defined as those occurring within one week of insertion and late complications as those occurring after the first week. Results: 60 patient charts have been reviewed to date. The median age of insertion was 5 years (range 2months-15.5years). Indications for PEG insertion included inadequate intake (39/60, 65%), unsafe swallow or aspiration risk (19/60, 32%), and complicated metabolic requirements (2/60, 3%) in two patient's with glycogen storage disorders. Four patients (6.6%) developed major complications after insertion. Two patients developed early complications with presumed peritonitis after the procedure requiring intravenous antibiotics and gut rest. Late complications included one patient with buried bumper syndrome at the time of conversion to a skin level device 3 months after initial PEG placement. The other patient developed pneumoperitoneum on conversion to gastrostomy button. Minor complications however were common and occurred in 80% (48) of patients. Most occurred late and included granulation tissue formation (56%, 34), site infection (8%, 5), inadvertent device avulsion (8%, 5), gastric ulcer related to the gastrostomy device (1.5%,1) and skin stomal pressure ulcer (5%, 3). All patients with major complications (6.6%) were managed successfully without any surgical intervention. Patients with inadvertent tube avulsion were able to be converted easily to a skin level device and did not require any further intervention. Other minor complications were managed conservatively. All patients were still alive at 12 months follow up. Conclusions: Major complications after PEG insertion are rare and do not impact significantly on long-term patient morbidity. Minor complications however are common and usually occur late, of which granulation tissue formation is the most frequent. PEG insertion is a safe procedure in children for the provision of enteral nutrition.

The Patient With Circulatory Shock: To Feed or Not to Feed?

Controversy continues to surround the appropriate form and timing of nutrition support for the patient with circulatory shock. Clinical studies have demonstrated improvements in outcome with the administration of enteral nutrition to critically ill patients; however, the provision of enteral nutrition to critically ill patients with ongoing shock remains controversial. This article reviews gut perfusion during normal states and during circulatory shock as well as alterations in perfusion when enteral feeding is provided. Pharmaconutrients studied during ischemia and reperfusion are discussed.

Successful Enteral Nutritional Support in the Neurocritical Care Unit

Adequate caloric intake is associated with improved outcome in neurocritical illness, but factors influencing the provision of enteral nutrition (EN) have not been systematically evaluated. The primary goal of the study was to determine the EN intake of neurosurgical intensive care unit (ICU) patients within the first week of illness and investigate the factors contributing to achieving caloric goals. A retrospective cohort of adult patients admitted to the neurosurgery service (NS) during August 2005-August 2006 were randomly selected and stratified into three groups based on their ICU-admission Glasgow Coma Scale Score (GCS) (GCS > 11, GCS 8-11, GCS 4-7). Daily EN intake, GCS, and other clinical data were collected. A total of 71 patients were included (GCS > 11 = 23, GCS 8-11 = 23, GCS 4-7 = 25). Admitting diagnoses included traumatic brain injury (TBI) (32%), subarachnoid hemorrhage (SAH) (32%), and intracerebral hemorrhage (17%). The overall in-hospital mortality was 23.9%. Overall, the maximum daily mean calories provided was 1,100 kcal (mean of 55% of caloric goal on hospital day 6). The median time to feeding was approximately 3 days in each group. GCS did not appear to significantly affect the mean % of caloric goal administered in patients with a minimum daily GCS < or = 11 (P = 0.053). Multivariate analysis revealed that clinical care factors, such as time to EN orders and enteral access confirmation, were significant impediments to EN provision (P = 0.001). System-based clinical care factors appear to have great impact on the successful provision of EN in the first week of neurocritical illness.

Nutrition Support in Acute Pancreatitis: A Systematic Review of the Literature

Failure to use the gastrointestinal (GI) tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to greater incidence of complications and prolonged hospitalization. The objectives of this study were to determine the optimum route for nutrition support, whether nutrition therapy is better than no artificial nutrition support, whether specific additives to enteral or parenteral therapy can further enhance their efficacy, and whether methodologic differences in delivery of enteral nutrition (EN) influence tolerance. A computerized search was performed of MEDLINE, Cochrane database, EMBASE, and reference lists of pertinent review articles for prospective randomized trials in adult patients with acute pancreatitis that evaluated interventions with nutrition therapy. Primary outcome data and surrogate endpoint parameters (for nutrition indices, stress markers, and measures of the inflammatory/immune response) were extracted in duplicate independently. Where appropriate, meta-analysis was performed by random-effects model. From 119 articles screened, 27 randomized controlled trials were included and analyzed. In patients admitted for acute pancreatitis, meta-analysis of 7 trials showed that use of EN was associated with a significant reduction in infectious morbidity (risk ratio [RR] = 0.46; 95% confidence interval [CI], 0.29 - 0.74; p = .001) and hospital length of stay (LOS; weighted mean difference [WMD] = -3.94; 95% CI, -5.86 to -2.02; p < .0001), a trend toward reduced organ failure (RR = 0.59; 95% CI, 0.28-1.27; p = .18), with no effect on mortality (RR = 0.88; 95% CI, 0.43-1.79; p = .72) when compared with use of parenteral nutrition (PN). Results from individual studies suggest that EN in comparison to PN reduces oxidative stress, hastens resolution of the disease process, and costs less. Insufficient data exist to determine whether EN improves outcome over standard therapy (no artificial nutrition support) in patients admitted for acute pancreatitis. However, in those patients requiring surgery for complications of acute pancreatitis, meta-analysis of 2 trials indicates that provision of EN postoperatively may reduce mortality (RR = 0.26; 95% CI, 0.06 - 1.09; p = .06) compared with standard therapy. PN provided early within 24 hours of admission was shown to worsen outcome, whereas PN provided later after full-volume resuscitation appeared to improve outcome when compared with standard therapy. In early individual studies, specific supplements added to EN, such as arginine, glutamine, omega-3 polyunsaturated fatty acids, and probiotics, may be associated with a positive impact on patient outcome in acute pancreatitis, compared with EN alone without the supplements, but studies are too few to make strong treatment recommendations. Supplementation of PN with parenteral glutamine was shown to reduce oxidative stress and improve patient outcome (reduced duration of nutrition therapy and decreased hospital LOS) compared with PN alone in patients with acute pancreatis. A wide range of tolerance to EN exists, irrespective of known influences such as mode (continuous vs bolus) and level of infusion within the GI tract (gastric vs postpyloric). Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome. In this sense, EN is the preferred route and has eclipsed PN as the new "gold standard" of nutrition therapy. When PN is used, it should be initiated after 5 days. The favorable effect of both EN and PN on patient outcome may be further enhanced by supplementation with modulators of inflammation and systemic immunity. Individual variability allows for a wide range of tolerance to EN, even in severe pancreatitis.

Gastric residual volumes in critically ill paediatric patients: A comparison of feeding regimens

This study examined the effect of gastric feeding regimens, either continuous or intermittent, on fourth hourly gastric residual volumes (GRV) in a group of critically ill paediatric patients where delayed gastric emptying is defined as a GRV greater than 5ml/kg. A randomised controlled trial was conducted in a tertiary paediatric intensive care unit (PICU), with 45 participants being randomly assigned to either the continuous (n=22) or intermittent (n=23) gastric feeding groups. Participants remained in the assigned group for the duration of the study and, fourth hourly, GRV were assessed to monitor the incidence of delayed gastric emptying. Both groups were similar in age, weight, gender, diagnosis, paediatric index mortality (PIM) score, and usage of pharmacological agents known to affect the gastrointestinal tract. No differences emerged in study duration or the volume of administered enteral formula (ml/kg/day). The intermittent feeding group commenced enteral feeding earlier in the PICU admission (13.0 hours versus 18.5 hrs, p=0.05). Repeated measures analysis revealed no overall difference in median GRV/kg values between treatment groups over the 72 hour study period. Additionally, the incidence of fourth hourly GRV, greater than 5ml/kg, was not different between the continuous and intermittent feeding groups. The provision of enteral nutrition via the gastric route is a common treatment in the PICU, and GRV are frequently used as a measure of gastric tolerance. The result of this analysis provides some support for the theoretical definition of delayed gastric emptying being >5ml/kg. However, further work is required to confirm this finding and to determine its relevance when providing enteral nutrition to the critically ill paediatric patient.

Enteral Nutrition in Acute Pancreatitis: A Survey of Practices in Canadian Intensive Care Units

Enteral nutrition (EN) is becoming the standard of care for the artificial nutrition support of the patient with severe acute pancreatitis. This study was designed to describe nutrition support practices for acute pancreatitis in Canadian intensive care units (ICUs) and to identify any barriers to the provision of EN in this patient population. After an initial letter of invitation, a survey was sent to all Canadian ICUs with a census of > or = 8 beds. At each center, the critical care dietitian was asked 13 questions about usual practice of providing nutrition support to critically ill patients with acute pancreatitis. Out of 62 ICUs successfully contacted through the initial letter that met entry criteria, responses were obtained from 54 (87%). EN was provided to patients with pancreatitis routinely in 13% (7/54) of units, occasionally in 72% (39/54), and never in 15% (8/54) of the ICUs. Technical difficulty obtaining small bowel access, reported by 38 units (72%), and lack of physician support for EN, as noted in 25 units (47%), were identified as the most common barriers to EN in this population. Enteral access was most commonly obtained via the nasojejunal route. The time frame from ICU admission to initiation of EN (when provided) differed widely between centers, varying from up to 24 hours to 48 hours in 22 units (48% of 46 ICUs), 3 to 5 days in 19 units (41%), and >5 days in 5 units (11%). Supplemental parenteral nutrition (PN) was commonly added to EN, routinely at 8 centers (18% of 45 ICUs) and only occasionally in another 20 units (44%). The duration of supplemental PN when used in conjunction with EN was <7 days in 83% (24/29) of the ICUs. When EN was not initiated, PN was used in all but one ICU. Although EN is being commonly provided to patients with acute pancreatitis, PN use remains prominent in many ICUs across Canada. Technical difficulty obtaining small bowel access and lack of physician support seem to be the most common barriers impeding use of EN.