Enteral Nutrition might save life Where Should We Feed critically ill patients? Done by Dr KHALED AL SEWIFY MD, MRCP, EDIC

Artificial Nutritional Support Improves wound healing Improves outcome Decreases complications Decreases the hypermetabolic response to tissue injury (DO2/VO2)

Enteral nutrirition  Preserves the intestinal mucosal integrity :  Maintains mucosal immunity.  Prevents of increased mucosal permeability.  Decreases bacterial translocation. Marik, Zaloga CCM 2005

 SB and colon contain anaerobes and 10 7 Gram +ve and Gram -ve aerobes and Enough Endotoxins to kill us 1000 X. Magnotti & Deitch 2005 JOABA

EN enriched with eicosapentaeonic acid, ɣ -linolenic acid & antioxidants in ARDS patients with severe sepsis mortality with ARR of 19.4%. Pontes-Arruda- Crit Care Med,Sept. 2006; Pontes-Arruda- Crit Care Med 2006;

P < more ventilator-free days6.2 more ICU-free days

 It is more physiological, is easier to begin and more convenient.  Spare both gastropancreatic reflexes and gastrin release.  Buffers gastric acid well.

Intragastric feeding buffer gastric acid better than post-pyloric feeding

High doses Opiates Benzodiazepines Muscle relaxants Catecholamines

Syndrome of Upper (GIT) Intolerance of EN

Mentec H (2001)– Crit Care Med 29 :

De Beaux (2001)EN in the critically ill : Anaesth. Intensive Care 29:

Mentec H (2001)– Crit Care Med 29 : Feeding intolerance Incidence of Nosocomial Pneumonia 2-Patients with Upper GIT Intolerance Had Increased Incidence Of Nosocomoial Pneumonia

Mentec H (2001)– Crit Care Med 29 : Feeding intolerance Mortality Rate 2-Patients With Upper GIT Intolerance Had Increased Mortality

Mentec H (2001)– Crit Care Med 29 : Feeding intolerance ICU Length Of Stay 4- Patients With Upper GIT Intolerance Had Longer Duration of ICU Stay

 So probably the gastric feeding may not always be as safe as it is sometimes considered.  The net result is Aspiration Syndrome. Heyland DK 199-AM J Respir Crit Care Med 159:

1. 70% with altered LOC. 2. > 70% of trauma patients at injury. 3. > 40% of patients with EN. B owman, et al CCNQ 2005

Early commencing of enteral nutrition Early achievement of optimum caloric needs Facing the problem of upper GIT intolerance & its realted Sequaele

 Erythromyicin is superior to Metoclopramide.  Combination therapy had greater feeding success, received more daily calories, and had a lower requirement for postpyloric feeding & less incidence of tachyphylaxis.  Should be considered as first line therapy in treatment of feed intolerance in criticall illness. * Reignier J - Crit Care Med.2002, 30: *Nguyen NQ - Crit Care Med Nov;35(11): Prokinetic therapy for feed intolerance in critical illnes : one drug or two ?

 Motilin derivatives : # Long term efficacy is unknown. # Very rapid tachyphylaxis.  Cholecystokinin antagonist : Loxiglumide # Very recent. # Accelerate gastric emptying in healthy humans. # No trials in critically ill patients. * Castllo E, et al.Am J Physiol 2004;287:G363-G369 * Cremonini F,et al.Am J Gastroenterol 2005;100:

 Where Best To Deliver Enteral Nutrition In Critically Ill Patients ?  Is Small Bowel Feed The Answer ?  What Are The Advantages Of Small Bowel Feed?

 Improved absorptive capacity.  Less impairment of motility.  Better respiratory function as it prevents gastric distension.  Greater distance between the delivery site and the pharynx & respiratory tree.

 Small bowel feeding compared with gastric feeding: *Associated with a reduction in pneumonia. *Improves calorie and protein intake and is associated with less time taken to reach target rate of EN. *No difference in mortality or MV days. Drover JW - Gastrointest Endosc Clin N Am - 01-OCT-2007; 17(4) :

 By contrast to the previous meta-analysis there was no significant benefits on the risk of diarrhea, length of ICU stay, mortality or risk of aspiration pneumonia. Intensive Care Med 2006 ; 32:639

Canadian Clinical Practice Guidelines Recommendations  Routine use of SB feedings in units where SB access is feasible.  In units where obtaining access involves more logistic difficulties, SB feedings should be considered for patients at high risk for UGIT intolerance.  When obtaining SB access is not feasible, SB feedings should be considered for selected patients with high gastric residuals repeatedly and are not tolerating gastric feed. Heyland DK - JPEN J Parenter Enteral Nutr 2003;27:355- Updated Jan 2007

 Grahm et al also found a decrease in infectious complications for patients with head injuries who received early enteral feeding into the jejunum. Grahm T, Zadrozny D, Harrington T. The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery. 1989;25:729–735

Comparison Between Gastric Versus Jejunal Feeding Gastric Jejunal Absolute Risk Reduction = 8% Incidence of Nosochomial Pneumonia Nosocomial Pneumonia Jejunal feeding with early gastric feeding in critically ill patients Juan C. Montejo - Crit.Care Med 2002,30: patients P value 0.4

 By bypassing the mouth, stomach and duodenum, jejunal feeding minimize the stimulation of pancreatic exocrine secretions.  Accumulating evidence has suggested that post-pyloric feeding is safe and may also reduce complications. *Ragins, H. Am J Surg 1973; 126:606. *Wolfe, BM. Surg Gynecol Obstet 1975 Feb;140(2):241-5.

 Difficulty in Placement and Ease of Displacement.  Frequent occlusion of small bore tube especially with viscid feed and medications.  Intestinal perforation.  Feeding Intolerance with dumping syndrome.

 Erythromycin appeared useful in 3 studies but metocopramide only in one trial.  A recent systemic review concluded that erythromycin should be administered when blindly placing a small bowel tube. *Booth CM. A systemic review of the evidence.Critc Care Med 2002,30: *Griffith DP. A double blind, RCT. Crit Care Med 2003,31:

 Flouroscopy ensures 90% post pyloric and more than 50% into the jejunum.  Endoscopically-placed tubes appear to have the highest success rates 98% for tube placement into the jejunum.  US guided, 67% duodenal.  EMG guided. *Davis AR. Critic Care Med 2002, 30: * G Gubler, et al.Endoscopy 2006.Dec. ;38 (12):

Chest. 2004;125: )

Small bowel tubes

 Provides high insertion success rates (>90%).  Cost effective.  Self migrating.  So it will be left in the stomach and it will migrate peristalsis to the jejunum. Samis AJ,. Evaluation of 3 different strategies for post pyloric placement of enteral feeding tubes. Intensive Care Med 2004, 30:S 149( abst)

 Very effective : #92.5% crossed the pylorus #89.14% reached the first jejunal loop #3.4% in the duodenum #7.5% stopped in the stomach  Reached final position within 5.2 hours, 8% instantly and all within 24 hours.  Start feed immediately G Mangiant, et al.Chir Ital. ;52 (5):573-8

 Displays track of the feeding tube during placement

 Safer  100% success rate in avoiding lung placement in clinical trial  More Accurate  Guides the clinician through the placement process by indicating the path of the tube as it is placed  Less Expensive  Fewer X-rays  Reduced use of TPN  No Fluoro  Faster  During clinical trials, placements averaged 10.5 minutes

 Feed Early Feed Enteral  Elevate The Head Of The Bed  Consider Small Bowel Feed if UGIT Intolerance/ failed to respond to prokinetics  Remember that patients with high doses Catecohlamines, Muscle Relaxants, Opiates & Benzo. will never tolerate naso-gastric feed

 The use of EN enriched with EPA, GLA & Antioxidant in ARDS patients with severe sepsis and septic shock is associated with: # An improvement in oxygenation status. # Reduced mechanical ventilation time. # Fewer days in ICU & less new organ dysfunction. # A19.4% absolute risk reduction in mortality rate.

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