Enteral Feeding in Surgical Critically Ill Patients

Authors

  • Kaweesak Chittawatanarat Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  • Chomchark Chuntrasakul Department of Surgery, Siriraj Hospital and Faculty of Medicine, Mahidol University, Bangkok, Thailand

Abstract

Objective: To study current practice in prescribing enteral nutrition for surgical critically ill patients and to identify factors associated with the initiation, successful or tolerance to enteral nutrition and mortality related to feeding character.

Patients and Methods: Forty-four ventilator supported patients who were expected to stay in the ICU for more than 3 days with retained nasogastric tube in surgical intensive care unit, Siriraj Hospital and Faculty of Medicine, were enrolled in this prospective cohort study. Patients who tolerated feeding were followed for at least 7 days or until 11 days if feeding were not tolerated. Patients were ceased to follow-up if they were discharged from the ICU, changed to the other route of feeding, or expired. Time from ICU admission to initiation and tolerance of enteral feeding was recorded and factors associated with these events were examined. We defined tolerance or successful as being able to receive 80% of estimated daily energy requirement for more than 48 hours without gastrointestinal dysfunction (ie, high gastric residuals, vomiting, diarrhea, abdominal distention) and early feeding as the initiation of enteral feeding within 72 hrs after admission to ICU.

Results: All patients were started on enteral feeding with the median time of 4.5 days after admission. The main reasons for late enteral feeding included post-operative abdominal surgery (46.2%), post-operative neurosurgery (30.8%) and absent bowel sound (26.9%). The time required to reach nearly 80% of energy requirement was about 6-7 days after admission. Twenty out of 44 patients (45.4%) achieved tolerance of the regimen. Once started, the enteral feeding was decreased or discontinued if patients experienced gastrointestinal dysfunction or had feeding time longer than 3 days and we found that the most common reason is gastrointestinal dysfunction (37.5%) with the top three reasons being high gastric residuals, abdominal distention and absence of bowel sound. The median time of successful feeding in patients who were on feeding longer than 3 days was 4.5 days (average 4.5 ± 0.57 days). Major reasons for termination of follow-up in non-successful feeding were tolerance of feeding (21.05%), follow-up for more than 10 days (26.31%) and being discharged from ICU (42.11%). We found that in all patients, survival was not correlated with successful or tolerance of feeding and early or late enteral feeding (p = 0.48 and 0.29 respectively). On the other hand, the early feeding group was significantly correlated with successful of feeding (p = 0.019).

Conclusions: Enteral nutrition is not started early in all surgical ICU patients. Approximately half of all patients receiving enteral nutrition achieved tolerance or successful feeding. Post-operative abdominal surgery is the most common reason for delay feeding while gastrointestinal dysfunction causing intolerance to enteral nutrition is the most common reason for discontinuing feeding.

References

1. Chandra RK, Nutrition, immunity and infection. Present knowledge and future direction. Lancet 1983;688-91.

2. Windser JA, Hill GL. Risk factor of postoperative pneumonia. The importance of protein depletion. Ann Surg 1988; 207: 290-302.

3. Carnio CJ, Meakins JL, Marshell JC, et al. Multiple organ failure syndrome. Arch Surg 1986; 121: 196-208.

4. Heyland DK, Mandell LA. Gastric colonization and nosocomial pneumonia: evidence for causative. Chest 1992; 101:187-93.

5. Lo CW, Walder WA. Change in gastrointestinal tract during enteral or parenteral feeding. Nutr Rev 1989; 47: 193-8.

6. Hughes CA, Dawling RH. Speed of onset of adaptive mucosal hypoplasia and hypofunction in the intestine of parenterally fed rats. Clin Sci 1980; 59: 317-27.

7. Ford WD, Boelhouwer RU, King WW, et al. Total parenteral nutrition inhibits intestinal adaptive hyperplasia in young rats: Reversal by feeding. Surgery 1984;96: 527-34.

8. Buchman AL, Monkazel AA, Bhula S, et al. Parenteral nutrition is associated with intestinal morphologic and functional change in human. J Parenteral Enteral Nutri 1995;19:453-60.

9. Hernandez G, et al. Gut mucosal atrophy after a short enteral fasting period in critically ill patient. J Crit Care 1999; 14:73-5.

10. Heyland DK, Cook DJ, Guyatt GH. Enteral nutrition: a critical appraisal of the evidence. Intensive Care Med 1993; 19: 435-42.

11. Alverdy J, Chi HS, Childon G. The effect of parenteral nutrition on gastrointestinal immunity: the importance of enteral immunity. Ann Surg 1985; 202: 681-4.

12. Saito H, Trochi O, Alexander JW, et al. The effect of route of administration on the nutrition state, catabolic hormone secretion and gut mucosal integrity after burn injury. J Parenteral Enteral Nutri 1987; 11: 1-7.

13. Moore FA, Moore EE, Jones TN, et al. TEN versus TPN following major abdominal trauma-reduces septic morbidity. J Trauma 1989;29:916-23.

14. Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces septic complications: The result of a meta-analysis. Ann Surg 1992; 216:172-83.

15. Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 1992; 215: 503-15.

16. Chuntrasakul C, Siltharm S, Chinswangwatanakul V Pongprasopchai T, Chockvivatanavanit S, Sunnak A. Early nutritional support in severe traumatic patients: a prospective randomized study. J Med Assoc Thai 1996; 79: 21-6.

17. Zaloga GP, Bortenschlager L, Black KW, et al. Immediate postoperative enteral feeding decreases weight loss and improves healing after abdominal surgery in rats. Crit Care Med 1992;20:115-18.

18. Mochizuki H, Trocki O, Dominioni L, et al. Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann Surg 1984; 200: 297-308.

19. Inoue S, Epstein MD, Alexander JW, et al. Prevention of yeast translocation across the gut by a single enteral feeding after burn injury. J Parenteral Enteral Nutri 1989; 13: 565-71

20. Kompan L, Kremzar B, Gadzijev E, Prosek M. Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury. Intensive Care Med 1999; 25: 157-61.

21. Galanos AN, Pieper CF, Kussin PS, et al. Relationship of BMI to subsequent mortality among seriously ill hospitalized patients. Crit Care Med 1997;25: 1962-8.

22. Moore FA, Weisbrodt NW. Nutrition and Critical Care. Nestle Nutrition Workshop Series Clinical & Performance Program 2003; 8: 149-70.

23. P'Zaloga G. Early enteral nutritional support improves outcome: Hypothesis or fact? Cri Care Med 1999;27: 259-61.

24. Ibrahim EH, Mehringer L, Prentice D, et al. Early versus late enteral feeding of mechanically ventilated patients: result of a clinical trial. J Parenteral Enteral Nutri 2002; 29: 2264-70.

25. De Jonghe B, De Vechi AC, Fournier M, et al. A prospective survey of nutritional support practices in intensive care unit patients: what is prescribed? What is delivered? Cri Care Med 2001;29:8-12.

26. Marcia K, Charles W, Allen IH. Caloric requirements and supply in critically ill surgical patients. Cri Care Med 1992;20: 344-7.

27. Heyland D, Cook D. Enteral nutrition in the critically ill patient- a prospective survey. Crit Care Med 1995; 23: 1055-60.

28. Schroeder D, Gillanders L, Mahr K, et al. Effects of immediate postoperative enteral nutrition on body composition muscle function and wound healing. J Parenteral Enteral Nutri 1991;15:376-83.

29. Carr CS, Ling KDE, Boulos P, et al. Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. Br Med J 1996:312:869-71.

30. Schwarz NT, Beer SD, Simmons RL, Bauer AJ. Pathogenesis of paralytic ileus: Intestinal manipulation opens a transient pathway between the intestinal lumen and the leukocytic infiltrate of the jujunal muscularis. Ann Surg 2002; 235: 31-40.

31. Kueppers PM, Miller TA, Chen CY, et al. Effect of total parenteral nutrition plus morphine on bacterial translocation in rats. Ann Surg 1993; 217: 286-92.

32. McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Cri Care Med 1999; 27: 1252-6.

Downloads

Published

2006-03-31

How to Cite

1.
Chittawatanarat K, Chuntrasakul C. Enteral Feeding in Surgical Critically Ill Patients. Thai J Surg [Internet]. 2006 Mar. 31 [cited 2024 Apr. 25];27(1):5-10. Available from: https://he02.tci-thaijo.org/index.php/ThaiJSurg/article/view/242044

Issue

Vol. 27 No. 1 (2006): January - March

Section

Original Articles

License

Articles must be contributed solely to The Thai Journal of Surgery and when published become the property of the Royal College of Surgeons of Thailand. The Royal College of Surgeons of Thailand reserves copyright on all published materials and such materials may not be reproduced in any form without the written permission.