Showing posts with label intubation. Show all posts
Showing posts with label intubation. Show all posts

Tuesday, August 20, 2019

When should we start enteral nutrition in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 

🎩 tip to the authors! 

- EJ

Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54. 

Sunday, October 1, 2017

How to position your patient prior to intubation: ramped vs. sniffing

We still don’t know what’s the best way to position our patients to intubate them; ramped position (torso and head elevated) which has had some theoretical OR benefits vs. sniffing position (torso supine, neck flexed forward, and head extended). Patients did worse with the ramped position. An important takeaway is listed below. I do recommend that you add the Cormack-Lehane Grade views to your airway notes. This, combined with what medications you used, what size glidescope or blade you used definitely helps with future intubations. You should learn to look for prior intubation notes to prepare for difficult airways. All it takes is one bad one and your confidence will be shattered. Don’t let it happen to you. A hat tip to the investigators. 

A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Semler, Matthew W.Janz, David R. et al.

Pre-intubation Checklist

This was essentially a negative trial but I do feel the checklist they used is very helpful for house-staff; especially those who take call without direct supervision (as I did just a few short years ago). A hat tip to the investigators. Article linked below.

A multicenter, randomized trial of a checklist for endotracheal intubation of critically ill adults. Janz DR1, Semler MW2, Joffe AM3, Casey JD2, Lentz RJ2, deBoisblanc BP4, Khan YA4, Santanilla JI5, Bentov I3, Rice TW2; Check-UP Investigators; Pragmatic Critical Care Research Group.
Chest. 2017 Sep 13. pii: S0012-3692(17)32685-5. doi: 10.1016/j.chest.2017.08.1163.