1. Practical Aspects of Nutrition Support in the ICU John W. Drover, MD, FRCSC, FACS Associate Professor Queen’s University Kingston, ON Canada www.criticalcarenutrition.com

2. Disclosure Information None www.criticalcarenutrition.com

4. Objectives At the end of the session the participant will be able to: List 3 strategies to maximize the benefits of enteral nutrition. List 2 advantages of post-pyloric enteral feeding. Identify 1 method of gaining post-pyloric access at the bedside in the ICU.

5. Outline Review the rationale for enteral feeding. Focus on the data regarding post-pyloric feeding. –Specifically RCT’s –Clinically important outcomes Review the risks of and obstacles to post-pyloric feeding. Develop a recommendation www.criticalcarenutrition.com

6. Case #1 Day #1 50 yo female COPD with CAP Intubated, resuscitated Who would start EN within 24 hours of admission? Who would attempt to place a post- pyloric feeding tube?

7. Case #2 Day #5 50 yo female COPD with CAP Intubated, resuscitated feeding tube in stomach Receiving metoclopromide Achieving 400ml Who would recommend placement of a post-pyloric feeding tube?

8. Nutrition in the Critically ill Enteral nutrition strongly recommended Early enteral nutrition recommended Optimize the benefits and minimize risks –Use of feeding protocols –Motility agents for gastric feeding –Small bowel feeding

9. Intra-gastric feeding The good: Easy access Early initiation Often tolerated well The bad: Gastric residual volumes (GRV’s) Gastro-pharyngeal reflux Respiratory aspiration Unrealized nutritional goals

10. Post-pyloric feeding 2 RCT’s that have evaluated aspiration 33 patients, 1 st 3 days –GE regurg 24.9% vs. 39.8% (p=0.04) –Further into small bowel less aspiration 54 patients, twice weekly –Low rate of aspiration –7% vs 13% aspiration Heyland et al, CCM, 2001 Esparaza et al, Int Care Med, 2001

11. Post-pyloric feeding 11 RCT’s of SB vs Gastric feeding –Med/Surg (4), Med (3), Trauma (2), Neuro (2) –N=664 –One study used arginine containing diets –Variable design for selection –Different methods of enteral access Outcomes –No difference in mortality, LOS, vent days Heyland et al, JPEN 2002

12. Post-pyloric feeding Taylor et al. CCM, 1999 –Neurotrauma, n=82 Standard gastric feeding –15ml/h increase Q8h Aggressive SB feeding (when feasible) –SB access only 34% –Start at target rate and adjust Outcomes –Pneumonia 44% vs 63%(NS)

13. Post-pyloric feeding Nutritional outcomes Small bowel feeding associated with –Reaching nutritional goals sooner –Better success at meeting goals Meta-analysis not possible –Variable gastric feeding strategies –Goals and success reported in different ways

14. Post-pyloric feeding Infections – pneumonia (9 studies) 8 clinical criteria; 1 bronchoscopy SB feeding associated with reduced pneumonia –RR=0.77(0.60-1.0), p=0.05 –23% risk reduction With Taylor study removed –RR=0.83(0.6-1.15), p=0.3

15. Post-pyloric feeding

17. Controversy “A comparison of early gastric feeding in critically ill patients: a meta-analysis” No difference in outcomes Same RCT’s Exclude Taylor Use studies of reflux Didn’t count all pneumonia in Montecalvo study Ho et al, ICM 2006

18. Post-pyloric feeding Problems associated with: –Difficult to achieve –Once achieved may move –Doesn’t overcome all issues (eg. ACS, short bowel, enteric fistula) Bowel necrosis – rare event not clearly associated with enteral nutrition Zaloga: Nutrition Week 2005 Canadian survey says 10%

19. The ENTERIC Study The Early Nasojejunal Tube To Meet Energy Requirements In Intensive Care Study Study Investigators: Andrew R Davies Rinaldo Bellomo D Jamie Cooper Gordon S Doig Simon R Finfer Daren K Heyland For the ANZICS Clinical Trials Group

20. Conclusions SB feeding improves –time to reach target goals –success at achieving target goals SB feeding may be associated with less pneumonia

21. Discussion Routine use: –Difficulties of SB access Blind Endoscopic Flouroscopic Patients with gastric intolerance Patients with other risk factors –GERD –unable to nurse semi-recumbent (eg. C-spine injury)

22. Discussion If your unit has feasible access –Go for it If your unit has ability with effort –Use it for patients at risk i.e. inotropes, sedatives, paralytics, high GRV’s If your unit has great difficulty –Use in patients who do not tolerate gastric feeding

23. Bedside placement into SB Feeding tube in stomach Wire with 30 o bend, 3cm from end Zaloga, Chest 1991 Insufflate stomach with ~500ml Salasidis, CCM 1998 Rotate while advancing Samis and Drover, ICM 2004

25. Thank You! Choosing an approach to: MAXIMIZE BENEFIT Minimize risk

26. Questions 1) What strategies can be utilized to optimize the delivery of enteral nutrition? A.Feeding protocols B.Motility agents C.Post – pyloric feeding D.All of the above

27. Questions 2) Post-pyloric feeding is associated with a reduced incidence of ventilator associated pneumonia. –True or False 3) Small bowel necrosis associated with post-pyloric feeding is a rare event. –True or False

28. Questions – Answer Key 1)D (reference 1) 2)True (reference 1) 3)True (reference 2)

29. Reference List (1) Clinical Practice Guidelines Website: http://www.criticalcarenutrition.com. http://www.criticalcarenutrition.com (2) Drover JW, Dhaliwal R, Heyland DK. Post pyloric enteral feeding: Not all it is cracked up to be! International Journal of Intensive Care 2002;  :139-45. (3) Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the Benefits and Minnimizing the Risks of Enteral Nutrition in the Critically Ill: Role of Small Bowel Feeding. J Parenter Enteral Nutr 2002;  :51-7. (4) Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med 2001 Aug;29(8):1495-501. (5) Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. Journal of Trauma-Injury Infection & Critical Care 1999 Jun;46(6):992-6.

30. Reference List (6) Montecalvo MA, Steger KA, Farber HW, Smith BF, Dennis RC, Fitzpatrick GF, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med 1992 Oct;20(10):1377-87. (7) Davies AR, Froomes PR, French CJ, Bellomo R, Gutteridge GA, Nyulasi, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med 2002 Mar;30(3):586-90. (8) Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med 2000 Jun;28(6):1742-6. (9) Minard G, Kudsk KA, Melton S, Patton JH, Tolley EA. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. Journal of Parenteral & Enteral Nutrition 2000 May;24(3):145-9. (10) Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med 2001 Oct;29(10):1916-9.

31. Reference List (11) Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999 Nov;27(11):2525-31. (12) Day L, Stotts NA, Frankfurt A, Stralovich-Romani A, Volz M, Muwaswes M, et al. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. J Neurosci Nurs 155 Sep 20;33(3):148-9. (13) Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med 2001 Apr;27(4):660-4. (14) Neumann DA, DeLegge MH. Gastric versus small- bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med 2002;  (  ):1436-8.

32. Reference List (15) Montejo JC, Grau T, Acosta J, Ruiz-Santana S, Planas M, Garcia-De-Lorenzo A, et al. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med 2002 Apr;30(4):796-800. (16) Spain DA, DeWeese RC, Reynolds MA, Richardson JD. Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications. Journal of Trauma-Injury Infection & Critical Care 1995 Dec;39(6):1100-2. (17) Grahm TW, Zadrozny RN, Harrington T. The Benefits of Early Jejunal Hyperalimentation in the Head-Injured Patient. Neurosurgery 1989;  (  ):729-35. (18) Strong RM, Condon SC, Solinger MR, Namihas BN, Ito-Wong LA, Leuty JE. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. Jpen: Journal of Parenteral & Enteral Nutrition 1992 Jan;16(1):59-63.