Harvy L. Snider

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.

OBJECTIVE To evaluate those factors that impact on the delivery of enteral tube feeding. DESIGN Prospective study. SETTING Medical intensive care units (ICU) and coronary care units at two university-based hospitals. PATIENTS Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding. INTERVENTIONS Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented. MEASUREMENTS AND MAIN RESULTS Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes. CONCLUSIONS The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis.

BACKGROUND This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis. METHODS Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission. RESULTS Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN (

Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings.

3294 vs

Invited Review: Use of Indirect Calorimetry in Clinical Nutrition

761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth. CONCLUSIONS TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.

Autonomic influence on cardiovascular performance in diabetic subjects

High gastric residual volumes (RVs) are a frequent cause for cessation of total enteral nutrition (TEN). This study was designed to determine the RV that indicates intolerance or inadequate gastric emptying and to compare the RV findings in a blinded fashion with those findings obtained on physical examination and radiography. Twenty healthy normal volunteers (HNV), 8 stable patients with gastrostomy tubes (GTP), and 10 critically ill patients (CIP) were evaluated prospectively for 8 hours while receiving TEN. No subjects were clearly intolerant (ie, vomiting, aspiration). Of the total RVs recorded, 13.1% were greater than or equal to 150 mL in the CIP group, whereas only 2.4% of the RVs were greater than or equal to 150 mL in the HNV group. None of the RVs in the GTP group were greater than or equal to 150 mL. Objective scores on physical examination failed to correlate with RV (p = .397), as did objective scores on radiography (p = .742). However, objective scores on physical examination were significantly related to scores on radiography (p = .016). Abnormal physical examination findings were found in 4 out of 11 patients (GTP + CIP) with RVs less than 100 mL and in 6 out of 7 with RVs greater than or equal to 100 mL. Abnormal radiographic results were found in 6 out of 11 patients with RVs less than 100 mL, in 7 out of 7 patients with RVs greater than or equal to 100 mL, and in 4 out of 20 HNVs. There was no difference in RVs obtained from the supine or right lateral decubitus positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary pulmonary lymphoma: a clinical and immunohistochemical study of six cases

The tremendous variability in resting energy expenditure makes efforts to predict caloric requirements difficult. Indirect calorimetry has provided a valuable tool in assessing energy expenditure, evaluating the way in which the body uses nutrient fuel, and designing nutritional regimens that best fit the clinical condition of the patient. The many indirect calorimetric instruments available vary in their application to clinical nutrition. The best metabolic studies are achieved by controlling the testing environment, accounting for the many clinical factors that may affect measurements, and eliminating potential sources for error. Although indirect calorimetry would seem to reduce the likelihood of complications from overfeeding, its greatest effect may be in cost savings by avoiding unnecessary nutritional support and in providing a means for clinical research.

NUTRITIONAL MANAGEMENT IN ACUTE AND CHRONIC PANCREATITIS

PURPOSE Cardiomyopathy, coronary artery atherosclerosis, or autonomic neuropathy may affect the cardiovascular performance of the diabetic patient. To evaluate the role of parasympathetic nervous system activity on cardiovascular performance, 25 diabetic subjects who lacked symptoms, signs, or objective measurements of ischemia or cardiomyopathy were studied. PATIENTS AND METHODS Diabetic subjects were classified according to their RR variation, an index of cardiac parasympathetic nervous system activity. Fourteen diabetic subjects had a normal RR variation of greater than 30 (D-NOR), and 11 diabetic patients had an abnormal RR variation of less than 20 (D-ABN). Fifteen age- and weight-matched, healthy, nondiabetic subjects (NOR) constituted the control group. All subjects had oxygen consumption, multigated acquisition determination of cardiac output, and work product measured before and during supine bicycle maximum exercise testing. RESULTS There was no difference in the resting cardiac output among the groups. Resting work product, however, was greatest in the D-ABN group when compared with performance in the other two groups (D-ABN: 11,500 +/- 800; D-NOR: 9,000 +/- 600; NOR: 8,700 +/- 400; p less than 0.0025). This was due to an increase in both heart rate (p less than 0.025) and systolic blood pressure (p less than 0.015). In the diabetic subjects, there was an inverse relationship between the RR variation and resting work product (r = 0.47, n = 25, p less than 0.005). In response to exercise, the percent increase in cardiac output at matched percent maximum oxygen uptake was greatest in the NOR, D-NOR, and D-ABN groups, respectively (analysis of variance, p less than 0.01). In the diabetic subjects, there was a significant relationship between the RR variation and the maximum percent change in cardiac output (r = 0.41, n = 25, p less than 0.02). Compared with the NOR group, the maximum increase in work product was impaired in diabetic subjects (p less than 0.002) and not different between the D-NOR and D-ABN groups. CONCLUSIONS The increase in resting work product and the poor cardiac output responses to exercise in the D-ABN group are due to a decrease in cardiac parasympathetic nervous system activity and can be suggested by an abnormal RR variation. This index of parasympathetic nervous system activity can help the physician identify that subset of diabetic patients that may need special consideration when exercise training is prescribed.

Immunonutrition and enteral hyperalimentation of critically Ill patients

Six patients with lymphomatous lesions primarily involving the pulmonary parenchyma were studied. In these patients, both the history and physical findings were vague and minimal. The laboratory findings also were nonspecific, although the findings of large multiple lesions in the lungs and pleural adhesion or effusion were more consistent with lymphoma. Histologic examination revealed lymphocytic infiltration of the pulmonary parenchyma in all six patients and presence of germinal or growth centers in some areas of the lesions in four. The hilar or mediastinal lymph nodes were not involved in five patients so examined. Immunocytochemical study of cytoplasmic immunoglobulin revealed monoclonal lymphocytic proliferation in five patients and negative staining in one patient. Clinical, histologic, or immunohistochemical studies alone may not be sufficient to detect all of the lymphomatous lesions. The combined use of all of these parameters is more advantageous for accurate diagnosis of these lesions. Treatment is surgical resection. Radiotherapy or chemotherapy are used when residual disease is present after surgery. Three patients died of disseminated lymphoma 96, 42, and 8 months after diagnois, respectively, and three patients are still alive at 18, 24, and 4 months, respectively.

Review Article: Clinical Nutrition in Pancreatitis

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.

The effect of an aldose reductase inhibitor on cardiovascular performance in patients with diabetes mellitus

Physicians need to be maximally aggressive in their use of total enteral nutrition (TEN) in the critically ill patient, due to its lower cost, better physiology, and lower complication rate when compared to parenteral therapy. Various components in TEN such as glutamine, arginine, RNA nucleotides, omega-3 fish oils, and fiber, may have important roles in immunonutrition by maintaining gut integrity, stimulating the immune system, and preventing bacterial translocation from the gut. For each patient, the physician must choose the optimal enteral formula for that particular disease or organ failure state to maximize nutrient substrate assimilation and tolerance. Total parenteral nutrition (TPN) should be used only when a true contraindication to enteral feedings exists or as adjunctive therapy when full nutritional requirements cannot be met by TEN alone.