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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
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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)
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Early EN (24 – 48 hrs) is recommended!
Infectious Complications Mortality Taylor, B; McClave S, Martindale R SCCM/ASPEN 2015 in prep
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The Gut as Regulator of Inflammatory Response
Gut disuse: inflammation Feed the Gut: inflammation
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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’
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RD Meet the Fab RDs
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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.
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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
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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
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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.
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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%
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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
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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
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Protein loss from open abdominal exudate – BJH
Taylor and Southard, unpublished
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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
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OR for Anastomotic Leak
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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
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“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
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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.
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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)
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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!
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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
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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)
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Quicker Bedside Placement!
Tube Placement Team Quicker Bedside Placement!
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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%
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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
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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
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No GRVs! Wonder how that will go over?
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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)
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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!
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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)
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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
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Feed Early Enteral Diet adequately for Maximum Effect
FEED ME PROTOCOL Feed Early Enteral Diet adequately for Maximum Effect
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Patient Demographics
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Nutrition Care Practices
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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?
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Success – Happy Stomachs!
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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)
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Who are the Enforcers? All of us!!!
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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
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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
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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!!!
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Questions
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