Showing posts with label nutrition. Show all posts
Showing posts with label nutrition. Show all posts

Wednesday, August 21, 2019

Can early enteral nutrition decrease mortality?

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.


Link to Abstract

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.

In my quest for sort out the answer of when to initiate enteral nutrition in my critically ill ICU patients, the data leans toward starting early. In this meta-analysis that was published in 2009, despite the sample sizes being very small, they were able to find a benefit regarding mortality and pneumonias when you start feeding patients within 24 hours. How small you ask? Well, 234 in the group that determined a benefit in mortality and just 80 in the group that determined a benefit towards pneumonia of early feeding. We need larger studies. All these authors admit this. We need some super ambitious RD's out there to take this bull by the horns and definitely answer these questions for us! A 🎩 tip to the authors!


-EJ


Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. Intensive Care Med. 2009;35(12): 2018-2027.

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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. 

Friday, August 16, 2019

Enteral nutrition in the ICU: How we should be feeding our critically ill patients.


Link to Article

Link to PDF

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

These are the ASPEN guidelines that were published in 2016. They were created to assist us in providing patients with appropriate nutrition while they recover from critical illness. This paper is free and although the 53 pages seem intimidating, the last 11 pages are the references. Also, the font is large and the format is easy to digest as it is laid out in a question/answer type format. I honestly look forward to the updated guidelines but these have a bunch of goodies that I do not feel the vast majority of my colleagues are aware of. I must admit, the majority of the recommendations are based on consensus rather than solid data. If that's what we have, though, we must make do while asking healthy questions.

Fun facts I've picked up on re-reading these guidelines that I had missed out on previous reads and that I may or may not have known:
- clear liquid diet is not necessary after post-op. Patients can be provided with solid food.
- patients should be getting 1.2-2.0g/kg of body weight of protein/ day. Some standard tube feeds may not reach this target in certain patients.
- I knew this but it begs reminding: DO NOT CHECK RESIDUALS!
- fancy formulas may be more confusing that practical for a standard patient in the MICU at the time of this publication.
- they made no recommendations for probiotics but I have found data stating otherwise.
- don't bother with high-fat low carb formulations for reps failure
- check phosphorus levels regularly in respiratory failure patients. That was you can replace the K with K/Phos instead of compartmentalizing the electrolytes.
A 🎩 tip to the many contributors to this guideline.

That's enough for today
-EJ


 

Wednesday, August 14, 2019

Enteral Nutrition Can Be Given to Patients on Vasopressors



Link to Article (Not Free)

I have always been interested in the nutritional status of our patients in the ICU and I don't quite have my mind made up regarding a lot of things. Actually, within the next few months I am going to be asking my registered dietician colleagues here for help with a number of clinical questions.
Truth is that there is a void of solid data regarding nutrition, when to start, how much, how much protein, etc. I understand the ASPEN guidelines have provided some consensus, but much of it is expert opinion rather than actual data. I digress. A topic for another day.
Regarding this article that was published yesterday, the author detailed the vasopressors doses at which one should start feeds (or not start, norepinephrine > 0.3-0.5mcg/kg/min is a no-no), resuscitation markers that should make us feel more comfortable with starting feeds such as decreasing downtrending vasopressor doses.  He also describes the feeding strategy of starting with tropic feeds at 10-20cc/hr.  Lastly, he describes signs of intolerance including residuals > 500cc, note, not 250, not 300... 500.
I have some honest questions for which I personally do not know the answer, though. I need help with this if someone knows the answer. From an evolutionary standpoint, we do not eat when we are ill. Just remember your appetite for a big delicious meal when you last had a significant viral illness. Should we really start to immediately feed these patients? Also, I do not feel that our bodies are accustomed to this whole continuous feeds phenomenon. We normally bolus feed ourselves. Are we shocking the system by doing continuous feeds? See? This is why I need help from some badass registered dietitians.
🎩 tip to the author!

-EJ