1. 1 بسم الله الرحمن الرحيم

2. 2 The importance of Enteral Nutrition in critically ill patients Dr Mohammad Safarian

3. 3 Why is important? (role of the GI tract ) Why is important? (role of the GI tract ) Early or late EN? Early or late EN? Who need nutritional support? Who need nutritional support? Oral or Enteral nutrition? Oral or Enteral nutrition? Indications and contraindications Indications and contraindications Key issues: Key issues:

4. 4 Introduction Advantages of enteral feeds Advantages of enteral feeds –70% of nutrients for bowel/digestive organs derived from luminal contents Strict bowel rest only advocated in: Strict bowel rest only advocated in: –Extreme short bowel syndrome, severe hemorrhagic pancreatitis, necrotizing enterocolitis, prolonged ileus, distal bowel obstruction

5. 5 The role of GI tract Immune competence and prevention of acute phase reactions. Immune competence and prevention of acute phase reactions. Metabolic function in amino acid metabolism Metabolic function in amino acid metabolism As a mechanical barrier for bacterial translocation. As a mechanical barrier for bacterial translocation. Its importance for infectious complications such as nosocomial pneumonia. Its importance for infectious complications such as nosocomial pneumonia.

6. 6 The role of GI tract Thus supporting the health of GI tract should be a major goal of nutrition support.

7. 7 The role of GI tract GI tract function depends on : GI tract function depends on : –Food ingestion, –Blood flow, –Defecation, –Interactions between gut and systemic immune system.

8. 8 An important consideration NPO should be withhold as soon as possible.

9. 9 (American Journal of Critical Care. 2004;13:221-227) Common Reasons for NPO

10. 10 Importance of early EN support Absolute benefitsRelative benefits Satisfying nutrient needs Wound healing Cost effective Hospital stay Bowel mucosal integrity and mass Decrease infections, and bacterial translocation Improve EN tolerance Suppress hyper- metabolic response Avoid PN complications Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

11. 11 Importance of early EN support Chest 2006;129;960-967

12. 12 The role of GI tract Thus, early nutrition as EN or oral nutrition is important and is preferred to PN. But what is early?

13. 13 An important consideration

14. 14 Who need nutritional support? Malnourished: one or more of the following: Malnourished: one or more of the following: –BMI < 18.5 kg/m² – weight loss > 10% within the last 3-6 months –BMI of 5% within the last 3-6 months

15. 15 Who need nutritional support? At risk of malnutrition: one or more of the following: At risk of malnutrition: one or more of the following: – NPO for > 5 days and/or likely to be NPO for the next 5 days or longer. – poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs

16. 16 Consider oral nutrition support and stop when the patient is established on adequate oral intake from normal food if patient malnourished/at risk of malnutrition can swallow safely and gastrointestinal tract is working

17. 17 Consider Enteral Nutrition and use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food has a functional and accessible gastrointestinal tract if patient malnourished/at risk of malnutrition despite the use of oral interventions

18. 18 Consider parenteral nutrition use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food or enteral tube feeding and has either introduce progressively and monitor closely if patient malnourished/at risk of malnutrition a non-functional, inaccessible or perforated gastrointestinal tract inadequate or unsafe oral or enteral nutritional intake

19. 19 Do not consider EN GI obstruction with no access to GI after obstruction. GI obstruction with no access to GI after obstruction. Ileus Ileus High-output enteric fistula (>500ml/d) High-output enteric fistula (>500ml/d) Sever vomiting or diarrhea Sever vomiting or diarrhea Acute pancreatitis. Acute pancreatitis. Refusal of patient or legal guardian. Refusal of patient or legal guardian.

20. 20 Key questions for EN or PN Can GI be used safely? Can GI be used safely? –No: use PN –yes: use EN Will EN last longer than 4-6 weeks? Will EN last longer than 4-6 weeks? –No: use NGT –yes: use Entrostomy tubes Is the patient at risk for aspiration? Is the patient at risk for aspiration? –No: use NGT –yes: use longer NGT or deodenal or jejunal or Entrostomy tubes Is your support provide adequate nutrient? Is your support provide adequate nutrient? –No: add PN to your nutrition support protocol –yes: continue

21. 21 Feeding rates Continuous: starts at a tolerable rate and increase 30- 50 ml/h every 24 h. (tolerance should be checked every 4-6 h) Continuous: starts at a tolerable rate and increase 30- 50 ml/h every 24 h. (tolerance should be checked every 4-6 h) – –Advantages – –Decreased risk of distention, bloating, aspiration, and osmotic diarrhea. – –Improved tolerance, especially with hyperosmolar formulas.

22. 22 Feeding rates Intermittent: infusions of 200 to 500 ml over a 20- 40 mins every 3-6 h. Advantages – –Convenient and inexpensive – –More physiologic pattern DisAdvantages: – –Incrceased risk of aspiration if gastric emptying is delayed – –May result in nausea vomiting, diarrhea, distention, or cramps

23. 23 Feeding rates Cycled feeding :continuous feeding at night and eating orally during the day. Advantages – –Convenient for patient to return to oral eating. – –Increase patients appetite. DisAdvantages: – –Maybe boring.

24. 24 Key issues Good Nursing Practices: Good Nursing Practices: –Feeding mode and rate –Temperature –Appropriate head to bed elevations (>30°) Keep transfer chain safe and sterile. Keep transfer chain safe and sterile. Make sure that the proper EN delivered to the right patient (labeling). Make sure that the proper EN delivered to the right patient (labeling). Good practice for GRV evaluation. Good practice for GRV evaluation. Keep eyes on the patient for complications Keep eyes on the patient for complications

25. 25 At the end Enteral feeding is preferable to PN. Enteral feeding is preferable to PN. But But The precise feeding time that maximize clinical benefits and minimize morbidity? The precise feeding time that maximize clinical benefits and minimize morbidity? How early EN may be considered? How early EN may be considered? –Is there any role for intraoperative nutrition? The optimum composition of formula regarding to macro and micro nutrients? The optimum composition of formula regarding to macro and micro nutrients?

26. 26 Thank you