1. Overcoming Barriers to Enteral Feeding in the ICU
Beth Taylor, DCN, RDN, CNSC, FCCM
Nutrition Support Specialist
Surgical ICU
Barnes-Jewish Hospital, St. Louis, MO

2. Initiate Enteral Feeding
EN should be initiated in ICU pt unable to maintain PO
EN preferred over PN for nutrition support therapy
Initiate EN within hrs of onset of illness
Overt signs of contractility not required to start
Absent BS predict intolerance, dz severity,
need for vigilence
Initiate EN in the stomach2
Divert lower if intolerant, high aspiration risk
Withhold EN with hemodynamic instability
Restart with caution if requiring low dose vasopressor support3
1Nguyen (J Crit Care 2013;28:537) 2 Deane (Crit Care 2013:17:R125)
3 Khalid (Amer J Crit Care 2010;19:261)

3. Early EN (24 – 48 hrs) is recommended!
Infectious Complications
Mortality
Taylor, B; McClave S, Martindale R
SCCM/ASPEN 2015 in prep

4. The Gut as Regulator of Inflammatory Response
Gut disuse:
inflammation
Feed the Gut: inflammation

5. THE COMMON VICIOUS CYCLE - GI ISSUES
Multiple causes
GI Dysfunction and
its consequences
Right time
Best route
Determine Deficits
Protocols
Team approach
No Luminal Nutrient
GI intolerance
Unnecessary NPO None or little enteral feedings
Nutrition therapy – Not ‘If” But ‘When’

6. RD
Meet the Fab RDs

7. Hemodynamic Instability
Low Flow state: requires pharmacologic or mechanical support
Clinical Signs: hypotension, abnormal heart rate, cold extremities, peripheral cyanosis, mottling, decreased UOP
Fluid Resuscitation Ischemic Reperfusion Injury (IRI)
McAllister et al. Ann of Pharm 2005;39:383.

8. Weisner et al. Radiology 2003;226:635
Consequences of IRI
Microvilli height shortened, integrity compromised = bacterial translocation and malabsorption
Esposto et al. J Leukocyte Bio 2007;81:1032

9. Feeding on Pressors Vasopressin (alone):
Increased splanchnic vasoconstriction and decreased blood flow
Increased lactate release/acidosis
Norepinephrine (Levophed) – 1st line therapy for septic shock:
Increases pH
Increases microcirculation if fluid resuscitated
Decreases microcirculation if volume depleted

10. Feeding the Critically Ill Patient
Study conclusions:
Defined “high-dose” catecholamine ≅ 12.5 mcg/min of
norepinephrine
Patients receiving higher doses of IV vasopressors and
dopamine or vasopression
should be monitored closely
for signs of GI intolerance if
receiving EN
Incidence of bowel ischemia/perforation was low (0.9%)
Mancl EE. JPEN, 2013.

11. Non-Occlusive Bowel Necrosis
Incidence 0.3 – 1.5%
Symptoms – often after out of ICU/off pressors: diarrhea, abd distention high NGT out, hypotension, lactic acidosis
Mortality near 90%

12. Feeding on Pressors Fluid resuscitate first if patient in shock
Start slow ml/hr w/ isotonic formula
If multiple being used - delay advancement beyond trophic amount
If only low dose of levophed needed (or aiming for higher MAP) and evidence of end organ perfusion --- advance toward goal
Physical Exam

13. Early enteral feeding in patients with open abdomen
Multicenter Prospective cohort study – pts w/ exp lap
Evaluating safety and effect of immediate EN
1000 patient study (Glue Grant) 100 patients met criteria
32 immediate EN / 68 delayed EN (> 36 hours)
Similar severity of injury
Results:
Time to closure: 6.47 vs 8.55 days (NS)
No difference in MOF, ICU days, Ventilator days, mortality
Rate of pneumonia 43.8 vs 72.1 % (p=0.008)
Conclusion:
Immediate EN safe
Trend toward faster closure
Significant reduction in pneumonia
Dissanaike S et al J Am Coll Surg 2008

14. Protein loss from open abdominal exudate – BJH
Taylor and Southard, unpublished

15. Feeding Across a New Anastomosis
• Meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to anastomosis within 24 hrs of GI surgery compared to traditional postop management
• Examined 15 studies with 1240 patients
• No significant difference in Mortality/Anastomic Leak……this is a good thing!
Osland, E et al. JPEN 35:2011

16. OR for Anastomotic Leak

17. Nutritional Assessment Set Goals of Therapy
Caloric requirements
25-30 Kcal/kg/d
Published predictive equations no more accurate
Indirect calorimetry
Protein requirements
Greater emphasis
(at least 80%)
Higher doses
1.2–2.5 gm/kg/d
Survival1
Over 200 predictive equations published – accuracy rates range from 40-75% when compared to IC – no single equation emerges as being more accurate in the ICU. Advantage of using a weight-based equation is its simplicity.
MJ Allingstrup (Clin Nutr 2012;31:462)
P Weijs (JPEN 2012;36:60
M. Nicolo (JPEN 2015 epub)
Pt’s getting >80% prescribed protein x 4 days in ICU, 33% less risk of dying

18. “Adequate” Feeding in the SICU – may keep you alive and get you home!!
News Flash
“Adequate” Feeding in the SICU – may keep you alive and get you home!!
Study participation completed if oral intake, d/c from ICU, 14 days on EN or death. Adjusted for BMI and APACHE II in multivariable models
Used Caloric targets of kcal/kg and 1.5 – 2.0 gm/kg day (actual wt unless BMI >30 – then IBW.
Prospective, observational cohort study
Yeh D. et al JPEN 2015 epub

19. Nutrition Outcomes (all patients)
Total
Canada
Australia and NZ
USA
Europe and South Africa
Latin America
Asia
p values† N
3174
361
602
670
416
442
683
Prescribed kcal/kg/day
Mean (SD)
24.1(5.5)
23.3 (5.3)
25.5(5)
21.5 (6.2)
24.6(5)
24. 5(4.6)
25.4 (5.2)
<0.001
Adequacy of calories %
56 (30.6 )
63.4(27.3 )
59.5(27.7 )
47.8(27.2 )
54.4(30.3 )
53.4(27.9 )
59.8(37.2 )
Adequacy of protein %
51.5(29.2 )
59.7(27.2 )
53.9(27.3 )
44.1(27.0 )
49.5(29.6 )
51.1(28.1 )
53.9(32.7 )
Prevalence of iatrogenic underfeeding
2467 (77.7%)
255 (70.6%)
450 (74.8%)
599 (89.4%)
309 (74.3%)
372 (84.2%)
482 (70.6%)
Time to initiate EN from ICU admission in hours
41.7 (43.6)
37.0 (42.8)
32.6 (39.9)
52.3 (43.8)
39.5 (41.7)
48.6 (42.3)
39.2 (46.4)
78% of patients failed to meet ≥ 80% of energy target
Prescribed cals 1708 US to 1979 AUS/NZ
Protein\; 95 USA AU/NZ 90gm
On average, patients received only 56.0% of prescribed calories and 51.5% protein.
There were significant differences in nutrition outcome variables across different geographic regions, with ICUs from Canada typically having the best outcomes and ICUs from the United States having the worst outcomes.
On average, patients in Canada were fed 32.6 hours after admission to ICU whereas patients in the United States were fed after 52.3 hours from admission to ICU.
. This failure rate varied significantly across various geographic regions, from 70.6 % in Canada and Asia to 89.4% failure rate in the United States.

20. Need for EN in High Risk Patients: Utilize Strategies to Increase EN Delivery
Over-order calories
Volume-based feeding
(vs rate-based)
Multi-Strategy De-escalation (Top-Down or PEP-uP)
Start at goal Start with prokinetics
Volume-based feed Probiotics (oropharynx and tube)
Caloric balance Small peptide formula
SB infusion Elevate HOB
Nurse-driven protocols for EN (Set ramp up, vol, GRV, NPO, etc)
Alter NPO status for diagnostic tests, procedures, surgery
Bundle with nutrition elements (set of action statements)
McClave (JPEN 2014; Online June 1) Heyland (CCM 2013;41:2743)

21. Figure out your barriers then strategize!
Confucius says: When it is obvious that the goals cannot be reached, don’t adjust the goals, adjust the action steps!

22. Barriers to Early EN Tube Issues GI Issues NPO Tube Occlusion
Timely Tube Placement
Emesis
GI Issues
Gastric Residual Volume
Diarrhea
NPO
ileus
Surgery
New anastomosis
Tests/Procedures
Pressor Use

23. Small Bowel vs Gastric Risk Factors for Aspiration
Intubation
Decreased level of consciousness
Neuromuscular diseases
Structural abnormalities of the upper GI
Recent stroke
Recent major abdominal surgery
History of aspiration
Prolonged supine position
Persistently high GRV (your threshold)

24. Quicker Bedside Placement!
Tube Placement Team
Quicker Bedside Placement!

25. SB Tube Team at BJH
Too much for one person – too many patients and patient areas
Coverage 365 days a year, 24 hours a day
Same care – no matter the day or time, or intensive care unit
RDs and RNs – both competent
To date our NSS team has placed over 9000 tubes in intensive care patients
Overall success rate is 86%
Success rates (1st attempt) vary with experience - not discipline: dietitian 1- 93%, dietitian 3 – 80%, ICU RN- 87%

26. Successful bedside SB tube placement
Early enteral feeds – good for ICU pts
Team approach to small bowel tube placement – best way to go!
RDs can lead the team OR lead the effort to form a team
Teams can be multidisciplinary
Bedside placement safest and most convenient approach

27. Barriers to Early EN Tube Issues GI Issues NPO Tube Occlusion
Timely Tube Placement
Emesis
GI Issues
Gastric Residual Volume
Diarrhea
NPO
ileus
Surgery
New anastomosis
Tests/Procedures
Pressor Use

28. No GRVs! Wonder how that will go over?

29. Data on GRVs GRVs should not be used as part of routine care1
Montejo Multicenter RCT 1 GI Complications %Goal Feeds
500cc GRV (n=160) % * % * 200cc GRV (n=169) % %
Reignier Multicenter RCT VAP Infect Mortality Deficit
No GRV used (n=227) % % % kcal
Routine GRV (n=222) % % % kcal
1 JC Montejo (Intens Care Med 2010;36:1386) 2 J Reignier (JAMA 2013;309:249)

30. What to Use Instead? Use your abdominal physical assessment skills
If you are not sure ask for 2nd opinion
Presence of diarrhea or constipation – know causes and treatments; drive the discussion!

31. EN Formula Selection
Avoid routine use commercial mixed fiber formula for prophylaxis
Persistent diarrhea
Consider mixed fiber formula (3 trials)
Inconsistent data – 1 trial diarrhea better 1, 2 no different 2,3
Consider small peptide/MCT
Avoid BOTH soluble/insoluble fiber if high risk for ischemia
1 Chittawatanarat K (Asia Pac J Clin Nutr 2010;19:458)
2 Dobb GJ (Int Care Med 1990;16:252) 3 Schultz AA (Amer J Crit Care 2000;9:403)

32. Barriers to Early EN Tube Issues GI Issues NPO Tube Occlusion
Timely Tube Placement
Emesis
GI Issues
Gastric Residual Volume
Diarrhea
NPO
ileus
Surgery
New anastomosis
Tests/Procedures
Pressor Use
BJH STICU audit – patients only received 37% of prescribed volume of EN

33. Feed Early Enteral Diet adequately for Maximum Effect
FEED ME PROTOCOL
Feed Early Enteral Diet adequately for
Maximum Effect

34. Patient Demographics

35. Nutrition Care Practices

36. Continuous Quality Improvement Project
Rate-Based Protocol
Rate – Based
No make up for lost time
Info on EN product
No info on BG control
MDs – practice 1.5 kcal/ml product, goal of 1400 kcal
Feeds to goal in 48 hr
Gastric feeds primary
RD consult in 48 hrs
GRV > 350 ml
Prokinetic not automatic
FEED ME Protocol
Volume – Based
Make up for lost time
No EN product info
Info on BG control
MD – practice 1.5 kcal/ml product, goal 1400 kcal
Feeds to goal in 24 hr
Gastric feeds primary
RD consult in 48 hrs
GRV > 350 ml
Prokinetic not automatic
How to make it easy for the bedside nurse?

38. Success – Happy Stomachs!

39. Implementing a New Protocol
Prospective interventional study
(n=5800 ICU days)
NUTSIA Protocol over 3 three-month periods (2005, 2006, 2007)
Before Protocol After Protocol With Enforcement
(n=198 pts) (n=179 pts) (n=195 pts)
Results
Rx (kcal/kg/d) **
ICU kcal balance **
Hosp LOS (days) **
ICU mortality % % %
Soguel L, Revelly JP, Berger MM (CCM 2012;40;1-7)

40. Who are the Enforcers?
All of us!!!

41. Efficacy of EN Protocols
Author/Journal
Study Parameters
Study Design
Outcome
Adam and Baston, ICM, 1997
Barriers and Enablers to EN
193 patients
% EN delivered
Protocol - 78%
No Protocol – 66%
P <0.001
Pinilla, JPEN, 2001
Comparisons of 2 protocols with different GRV thresholds
Protocol 1 – GRV 150 ml
Protocol 2 – GRV 250 ml
80 patients
Protocol 1 – 70%
Protocol 2 – 76%
P < 0.02
Arabi, NCP, 2004
Before/After Protocol Implementation
203 patients
Before – 53.9%
After – 64.5 %
P = 0.001
Barr, Chest, 2004
Before/After Protocol
Implementation
200 patients
Before – 68%
After – 78%
P = 0.11
Martin, CMAJ, 2004
Before/After Feeding Algorithm
PN started if EN not tolerated in 24 hrs
452 patients
Use of EN (days), P=0.042
Algorithm 6.7 days
No Algorithm 5.4 days
Hosp LOS, P=0.003
Algorithm 25 days
No Algorithm 35 days

42. Efficacy of EN Protocols
Author/Journal
Study Parameters
Study Design
Outcome
Mackenzie, JPEN, 2005
Before/After Protocol Implementation
123 patients
% of pts that received 80% of EN goal
Before – 20%
After – 60%
P < 0.001
Woien, J Clin Nurs, 2006
Before/After Algorithm
Implementation
42 patients
% of EN calories delivered, P=0.047
Before – 52%
After – 69%
Desachy, ICM, 2008
Comparison of 2 protocols
Protocol 1 – start at goal
Protocol 2 – start low rate
100 patients
% of EN calories delivered, P=0.0001
Protocol 1 – 95%
Protocol 2 – 76%
Heyland, JPEN, 2010
Comparison of ICUs with/without EN protocol
269 ICUs
& calories delivered from any source
With – 61.2%
Without – 51.7%
P=0.0036
Rice, JAMA, 2012
1000 patients
Avg daily kcal intake
Protocol 1 – 1300 calories
Protocol 2 – 400 calories
Sheean, J Acad Nutr Diet, 2012
Protocol 1 – standard
Protocol 2 – 150% of needs
49 patients
Protocol 1 – 475 +/- 480
Protocol /- 493
P=0.007

43. Summary Make it Happen!!! Identify Barriers to EN
Meet with key leaders in your area
Strategize/Define/Educate/Implement a plan
Evaluate Progress toward goal (audit)
Revise/Re-Educate
Make it Happen!!!

44. Questions