Transcript Advantages

‫بسم هللا الرحمن الرحيم‬
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The importance of Enteral Nutrition
in critically ill patients
Dr Mohammad Safarian
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
Why is important? (role of the GI tract )
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Early or late EN?
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Who need nutritional support?
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Oral or Enteral nutrition?
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Indications and contraindications
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Key issues:
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Introduction
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Advantages of enteral feeds
– 70% of nutrients for bowel/digestive organs
derived from luminal contents
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Strict bowel rest only advocated in:
– Extreme short bowel syndrome, severe
hemorrhagic pancreatitis, necrotizing
enterocolitis, prolonged ileus, distal bowel
obstruction
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The role of GI tract
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Immune competence and prevention of
acute phase reactions.
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Metabolic function in amino acid metabolism
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As a mechanical barrier for bacterial
translocation.
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Its importance for infectious complications
such as nosocomial pneumonia.
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The role of GI tract
Thus supporting the health of GI tract should
be a major goal of nutrition support.
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The role of GI tract
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GI tract function depends on :
– Food ingestion,
– Blood flow,
– Defecation,
– Interactions between gut and systemic
immune system.
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An important consideration
NPO should be withhold as soon as possible.
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Common Reasons for NPO
(American Journal of Critical Care. 2004;13:221-227)
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Importance of early EN support
Absolute benefits
Relative benefits
Satisfying nutrient needs
Wound healing
Cost effective
Hospital stay
Bowel mucosal integrity and mass
Decrease infections, and bacterial
translocation
Improve EN tolerance
Avoid PN complications
Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)
Suppress hyper- metabolic
response
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Importance of early EN support
Chest 2006;129;960-967
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The role of GI tract
Thus, early nutrition as EN or oral nutrition is
important and is preferred to PN.
But what is early?
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An important consideration
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Who need nutritional support?
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Malnourished: one or more of the following:
–BMI < 18.5 kg/m²
– weight loss > 10% within the last 3-6 months
–BMI of < 20 kg/m² and weight loss > 5% within
the last 3-6 months
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Who need nutritional support?
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
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Consider oral nutrition support
if patient malnourished/at risk of malnutrition
and
can swallow safely and gastrointestinal tract is working
stop when the patient is established on adequate
oral intake from normal food
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Consider Enteral Nutrition
if patient malnourished/at risk of malnutrition
despite the use of oral interventions
and
has a functional and accessible gastrointestinal
tract
use the most appropriate route of access and mode
of delivery
stop when the patient is established on adequate
oral intake from normal food
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Consider parenteral nutrition
if patient malnourished/at risk of malnutrition
a non-functional,
inaccessible or perforated
gastrointestinal tract
and has either
inadequate or unsafe oral
or enteral nutritional intake
introduce progressively and
monitor closely
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
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Do not consider EN
GI obstruction with no access to GI after
obstruction.
 Ileus
 High-output enteric fistula (>500ml/d)
 Sever vomiting or diarrhea
 Acute pancreatitis.
 Refusal of patient or legal guardian.
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Key questions for EN or PN
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Can GI be used safely?
– No: use PN
– yes: use EN
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Will EN last longer than 4-6 weeks?
– No: use NGT
– yes: use Entrostomy tubes
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Is the patient at risk for aspiration?
– No: use NGT
– yes: use longer NGT or deodenal or jejunal or
Entrostomy tubes
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Is your support provide adequate nutrient?
– No: add PN to your nutrition support protocol
– yes: continue
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Feeding rates
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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.
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Feeding rates
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Intermittent: infusions of 200 to 500 ml over a
20- 40 mins every 3-6 h.
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Advantages
– Convenient and inexpensive
– More physiologic pattern
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DisAdvantages:
– Incrceased risk of aspiration if gastric emptying is
delayed
– May result in nausea vomiting, diarrhea, distention, or
cramps
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Key issues
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Good Nursing Practices:
– Feeding mode and rate
– Temperature
– Appropriate head to bed elevations (>30°)
Keep transfer chain safe and sterile.
 Make sure that the proper EN delivered to
the right patient (labeling).
 Good practice for GRV evaluation.
 Keep eyes on the patient for complications
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At the end
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Enteral feeding is preferable to PN.
 But
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The precise feeding time that maximize
clinical benefits and minimize morbidity?
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How early EN may be considered?
– Is there any role for intraoperative nutrition?
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The optimum composition of formula
regarding to macro and micro nutrients?
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Thank you
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