INTRODUCTION

Adequate nutrition in critically ill is standards in medical and surgical care. Enteral nutrition is preferred due to its relative simplicity, safety, cost as well its ability to maintain gut mucosal barrier function. Improves nitrogen balance Wound balance Host immune functions Augments cellular anti-oxidant system Decrease hypermetabolic response and tissue injury Preserves interstial mucosal integrity Malnourished patients have poorer outcomes, more infections and use more resources. Nutri Clin Pract 2007 Clinic Nutrition 2006
Effect of Enteral and Parenteral Nutriton on Gut Mucosa Am J Resp & Critical care med 1995/152 Burns Patient Studies on Host Defense Early feeding Vs starvation Critical care med 1994 /22 Influence of Early Post-operative Enteral Nutrition Vs Placebo on Cell Mediated Immunity Sacd J GE 1999 34: 98-102

GOALS FOR NUTRITION

Enteral nutrition All critically ill patient with functioning small bowel should be fed enterally C/I to be excluded Ileus , GI bleed, pending GI procedures, recent GI procedures with enterostomy or anastomosis

Targets:
Caloric intake25-30kcals/kg/day and protein of 1-1.5g/kg/day based on estimated ideal IBW Jevity 1-1.5mls/kg/hr Nepro 0.5-.75kcals/kg/hr Special situation: ARF Standard feeding in acutely stressed patient High dose RRT Feeding to be augmented by 50% Type 2 RF 1.5Kcals of low carb and high fat with pulmocare and aim of 0.7-1ml/kg/hr Poor Gastric Emptying 1.5kcal/ml high cal jevity

WESTMEAD NUTRITION PROTOCOL

WHY DO I NEED TO KNOW THIS TOO?

Motility disorders in Critical Care Motility disturbances remains unsolved is associated with morbidity & mortality rate

Physiology
The motility regulation is a complex interaction of stimulation and feedback that involves a large number of hormones and neuroendocrine peptides Myentric plexus intrinsically collect information for the appropriate control of digestion. Extrinsic innervations provide data of fluid and energy homeostasis mediating immune, inflammatory response and pathological process

Current Opinion in Clinical Nutrition Metabolic Care 2009, 12:161167

Mentec H (2001) Crit Care Med 29 : 1955-1961

MOTILITY DISORDERS IN CRITICAL CARE

Pathophysiological Antro-Pylorio-Duodenal Motor Dysfunction results in gastroparesis and has led to a better knowledge of gut function Humoral Mechanism with deranged feedback as a result of CCK

Disorganised MMC Phase: Phase 1, Phase 2, Retrograde Phase 3

Multifactorial cause and risk factor Use of Sedation, Opiods, Vasopressors, Hyperglycaemia, Dyselectrolytemia Abdominal Sx, Head and Spinal injuries, Sepsis & Fluid overload

Mentec H (2001) Crit Care Med 29 : 1955-1961

I C U L O S

M O R T A L I T Y

Early Commencing of Enteral Nutrition Early Achievement of Optimum Caloric Needs Facing Problem of Upper GIT intolerance & its related Sequels

WHAT IS A BALANCE THEN

HYPOTHETICALLY SB FEEDS
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

A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Ho KM, Dobb GJ, Webb SA. ICM 2006 11 RCTs of SB vs Gastric feeding 2 Reviewers for the quality of studies and data collection Med/Surg (4), Med (3), Trauma (2), Neuro (2) (N 667)

META-ANALYSIS OF POST PYLORIC FEEDING

Clinical trails Variable designs Most evident difference between the studies is the position of the tip of tube 5 studies placed tube in duodenum while 3 in jejunum and 2 no mention Impotant consideration that is not equally controlled for in each study is the possible displacement of feeding tubes Decision to suction the gastric secretions in the small bowel feeding group. 3 studies placed a nasogastric tube for suction or free drainage other not Definition of pneumonia: 2 Studies used radiolabelled enteral feed to detect aspirations the other studies clinical methods and criteria Use of prokinetic during gastric feeding may negate any potential adv of SB feeds Perception of feed intolerance

STUDIES ON ASPIRATION RISK

2 RCTs that have evaluated aspiration 33 patients, 1st - 3 days GE regurgitation 24.9% vs. 39.8% (P=0.04) Further into small bowel less aspiration
Heyland et al, CCM, 2001

54 patients, twice weekly Low rate of aspiration 7% vs 13% aspiration

Esparaza et al, Int Care Med, 2001

CONCLUSIONS OF THE META-ANALYSIS

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.

All studies are underpowered and a large heterogeneity exist between studies Infection complication and Incidence of pneumonia Definition of early feeding
Meta-analysis not possible Variable gastric feeding strategies Goals and success reported in different ways

INDICATION AND CONTRAINDICATION

Basis of 2 studies Montegio et al Critical care med 2002 Boulton- Jones et al Clin nutrition 2004 American and European Guidelines recommend post pyloric feeding only in a subset of critically ill patients with the following indications Gastroparesis Recurrent aspiration Severe hyperemesis Acute pancreatitis C/I Obstruction in the different parts of GI tract at esophagus, gastric outlet, intestine from various causes Absolute C/I being bowel obstruction and perforation Migration of the tube

METHODS AVAILABLE
Non blind methods Fluoroscopy Endoscopically

US guided
EMG guided Small bowel tubes Tiger tube Provides high insertion success rate Cost effective Self migrating So it will be left in the stomach and it will migrate peristalsis to jejunum

DISADVANTAGES
Difficulty placement and ease of displacement Frequent occlusion of small bore tube especially with viscid feeds and medications Intestinal perforation Feeding intolerance with dumping syndrome

SUMMARY
Feed Early Feed Enterally Elevate The Head Of The Bed Consider Small Bowel Feed If Feed Intolerant/Failed to Prokinetics Remember that patients with high doses of caecholamines, muscle relaxants, opiates and benzodiazepines will never tolerate naso-gastric feeds