Transcript More Evidence For The Safety and Efficacy of Post Pyloric

Practical Aspects of Nutrition
Support in the ICU
John W. Drover, MD, FRCSC, FACS
Associate Professor
Queen’s University
Kingston, ON
Canada
www.criticalcarenutrition.com
Disclosure Information
• None
www.criticalcarenutrition.com
Objectives
At the end of the session the participant will be able to:
• List 3 strategies to maximize the benefits
of enteral nutrition.
• List 2 advantages of post-pyloric enteral
feeding.
• Identify 1 method of gaining post-pyloric
access at the bedside in the ICU.
Outline
• Review the rationale for enteral feeding.
• Focus on the data regarding post-pyloric
feeding.
– Specifically RCT’s
– Clinically important outcomes
• Review the risks of and obstacles to
post-pyloric feeding.
• Develop a recommendation
www.criticalcarenutrition.com
Case #1
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Day #1
50 yo female COPD with CAP
Intubated, resuscitated
Who would start EN within 24
hours of admission?
• Who would attempt to place a postpyloric feeding tube?
Case #2
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Day #5
50 yo female COPD with CAP
Intubated, resuscitated
feeding tube in stomach
Receiving metoclopromide
Achieving <30% of goal; GRV
>400ml
• Who would recommend placement
of a post-pyloric feeding tube?
Nutrition in the Critically ill
• Enteral nutrition strongly recommended
• Early enteral nutrition recommended
• Optimize the benefits and minimize risks
– Use of feeding protocols
– Motility agents for gastric feeding
– Small bowel feeding
Intra-gastric feeding
The good:
• Easy access
• Early initiation
• Often tolerated well
The bad:
• Gastric residual volumes (GRV’s)
• Gastro-pharyngeal reflux
• Respiratory aspiration
• Unrealized nutritional goals
Post-pyloric feeding
2 RCT’s that have evaluated aspiration
• 33 patients, 1st 3 days
– GE regurg 24.9% vs. 39.8% (p=0.04)
– Further into small bowel less aspiration
Heyland et al, CCM, 2001
• 54 patients, twice weekly
– Low rate of aspiration
– 7% vs 13% aspiration
Esparaza et al, Int Care Med, 2001
Post-pyloric feeding
• 11 RCT’s of SB vs Gastric feeding
– Med/Surg (4), Med (3), Trauma (2), Neuro (2)
– N=664
– One study used arginine containing diets
– Variable design for selection
– Different methods of enteral access
• Outcomes
– No difference in mortality, LOS, vent days
Heyland et al, JPEN 2002
Post-pyloric feeding
• Taylor et al. CCM, 1999
– Neurotrauma, n=82
• Standard gastric feeding
– 15ml/h increase Q8h
• Aggressive SB feeding (when feasible)
– SB access only 34%
– Start at target rate and adjust
• Outcomes
– Pneumonia 44% vs 63%(NS)
Post-pyloric feeding
Nutritional outcomes
• Small bowel feeding associated with
– Reaching nutritional goals sooner
– Better success at meeting goals
• Meta-analysis not possible
– Variable gastric feeding strategies
– Goals and success reported in different
ways
Post-pyloric feeding
• Infections – pneumonia (9 studies)
• 8 clinical criteria; 1 bronchoscopy
• SB feeding associated with reduced
pneumonia
– RR=0.77(0.60-1.0), p=0.05
– 23% risk reduction
• With Taylor study removed
– RR=0.83(0.6-1.15), p=0.3
Post-pyloric feeding
Post-pyloric feeding
Controversy
“A comparison of early gastric feeding in
critically ill patients: a meta-analysis”
• No difference in outcomes
• Same RCT’s
• Exclude Taylor
• Use studies of reflux
• Didn’t count all pneumonia in
Montecalvo study
Ho et al, ICM 2006
Post-pyloric feeding
• Problems associated with:
– Difficult to achieve
– Once achieved may move
– Doesn’t overcome all issues
Canadian survey says
10%
• (eg. ACS, short bowel, enteric fistula)
• Bowel necrosis – rare event not clearly
associated with enteral nutrition
Zaloga: Nutrition Week 2005
The ENTERIC Study
The Early Nasojejunal Tube To Meet
Energy Requirements In Intensive Care
Study
Study Investigators: Andrew R Davies
Rinaldo Bellomo
D Jamie Cooper
Gordon S Doig
Simon R Finfer
Daren K Heyland
For the ANZICS Clinical Trials Group
Conclusions
• SB feeding improves
– time to reach target goals
– success at achieving target goals
• SB feeding may be associated with
less pneumonia
Discussion
• Routine use:
– Difficulties of SB access
• Blind
• Endoscopic
• Flouroscopic
• Patients with gastric intolerance
• Patients with other risk factors
– GERD
– unable to nurse semi-recumbent
• (eg. C-spine injury)
Discussion
• If your unit has feasible access
– Go for it
• If your unit has ability with effort
– Use it for patients at risk
• i.e. inotropes, sedatives, paralytics, high GRV’s
• If your unit has great difficulty
– Use in patients who do not tolerate gastric
feeding
Bedside placement into SB
• Feeding tube in stomach
• Wire with 30o bend, 3cm from end
• Zaloga, Chest 1991
• Insufflate stomach with ~500ml
• Salasidis, CCM 1998
• Rotate while advancing
• Samis and Drover, ICM 2004
Thank You!
• Choosing an approach to:
• MAXIMIZE BENEFIT
• Minimize risk