1. Early Enteral Nutrition in the Critically Ill

2. Objectives To define early enteral nutrition To review the benefits of early enteral nutrition To explain how to initiate early enteral nutrition

3. Definition Early Enteral Nutrition: Enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury Zaloga GP. Crit Care Med 1999;27:259

4. Early Enteral Feeding: Goal To maintain intestinal mucosal integrity –Normal microvilli  Height and number –Normal intestinal barrier –Intestinal mucosal immunity

5. Early Enteral Feeding: Rationale Provide nutrients required during metabolic stress Maintain GI integrity Reduce morbidity compared with parenteral nutrition Reduce cost compared with parenteral nutrition

6. Parenteral Nutrition vs. Early Enteral Nutrition (a meta-analysis) Moore F, et al. Ann Surg 1992;216:172-183 Early enteral feeding, compared to parenteral nutrition, reduces postoperative septic complications Eight prospective, randomized controlled trials Objective: to compare efficacy of parenteral vs. enteral nutrition Study groups well matched Isonitrogenous intakes

7. Parenteral Nutrition vs. Early Enteral Nutrition (a meta-analysis) Enteral therapy reduced postoperative septic complications Moore F, et al. Ann Surg 1992;216:172-183 Total Septic Complications Pneumonia Others Catheter Sepsis Intra-abdominal Abscess Bacteremia p < 0.05 Percentage of Patients 010203040 Parenteral Enteral

8. Parenteral Nutrition vs. Early Enteral Nutrition (a meta-analysis) Conclusions Fewer septic complications: – Enteral nutrition: 18% – Parenteral nutrition: 35% Early nutrition therapy is possible in the immediate postoperative period, and reduces morbidity from septic complications Moore F, et al. Ann Surg 1992;216:172-183

9. Enteral vs. Parenteral Nutrition Percentage of patients Pneumonia Intra-Abdominal Catheter Sepsis Abscess Kudsk KA, et al. Ann Surg 1992;215:503-513 Septic Morbidity 0 5 10 15 20 25 30 35 ENT NPT 0 5 10 15 20 25 30 0 5 10 15 20 25 30 EN PN

10. Benefits of Enteral Nutrition Appropriate enteral feeding helps maintain: Intestinal morphology and function Immune function Nitrogen retention Advantages: Fewer medical complications Preservation of immune response Decreased incidence of sepsis Lower delivery costs

11. Early Enteral Feeding How Slow rate initiated with pump Where Proximal jejunum When Between 24 – 48 hours postoperatively for hemodynamically stable patients What Special nutrients, including glutamine, arginine, and hydrolyzed proteins may provide additional benefits

12. Early Enteral Nutrition Reduces Resting Metabolic Expenditure (RME) Under Experimental Conditions Percentage RME Increase Animal Study Mochizuki H, et al. Ann Surg 1984;200:297-310 Day 2Day 6 0 10 20 30 40 50 60 Grupoconnutrición temprana175 kcal/Kg/día, 2 hr-14días Nutriciónretardada,grupoI 175 kcal/Kg/día, 3-14días Nutrición retardada,grupoII 200 kcal/Kg/día, 3-14días Day6Day6 Day 9Day 13 0 10 20 30 40 50 60 0 10 20 30 40 50 60 Early Feeding Group 175 kcal/kg/day, 2 hr – 14 days Delayed Feeding Group I 175 kcal/kg/day, 3 – 14 days Delayed Feeding Group II 200 kcal/kg/day, 3 – 14 days

13. Very Early Enteral Nutrition in Burn Patients Results   Urinary catecholamines   Plasma glucagon   Plasma insulin  Earlier positive nitrogen balance Clinical Implications  Lower catabolic response with very early enteral nutrition Chiarelli A, et al. Am J Clin Nutr 1990;51:1035-1039

14. Early Bowel Sounds Not an Indicator for Feeding Stomach 24 hours Small Intestine 4-8 hours Colon 3-5 days Adapted from Waldhausen J, et al. Ann Surg 1990;211:777-785

15. ICU Feeding Tolerance Predictive Criteria Cutoff criteria Heart rate < 2 L/min/m 2 Arterial BP < 70 mmHg with alpha-sympathetic stimuli Oxygen saturation 60% and > 5 cm positive end-expiration pressure Rombeau JL. Enteral nutrition in critical illness. In: Enteral Nutrition. Chapman and Hall; 1994

16. Early Nutrition and Elective GI Surgery Method : Meta-analysis of 11 studies (837 patients) Early enteral nutrition (up to 24 hrs post-op) vs. NPO and elective surgery with jejunal enteral nutrition and/or oral nutrition Results: Decreases in: - Rate of infection (p<0.05) - Hospital stay (p<0.05) - Anastomosis dehiscence - Infection of surgical wound, pneumonia, intra-abdominal abscess - Mortality Increase in risk of vomiting with early enteral nutrition (p<0.05) Conclusion: There are no advantages to fasting after surgery with elective gastrointestinal resection. Early enteral nutrition can be beneficial. Lewis SJ, et al. BMJ 2001;323:773-776

17. Immune Response and Nutrition stimulation suppression

18. Nutrients Related to Immune- Inflammatory Response IMMUNE STIMULATING –Arginine –RNA –Fe –Glutamine ENERGY SUPPORT –Glutamine ANTI-INFLAMMATORY –EPA –GLA –antioxidants ANTI-OXIDANT –Vit. E, A, C –Selenium –Taurine

19. Potential Benefits of Early Enteral Nutrition Preservation of gut mucosal mass Maintenance of the “gut barrier” Mucosal immunity Attenuation of hypermetabolic response

20. Summary Early Enteral Nutrition Begins in the first 24 – 48 hours after hospitalization or injury, in hemodynamically stable patients Improves clinical outcomes Requires continuous administration via infusion pump through a tube placed distally in the proximal jejunum