EnteralEnteral Feeding: ItFeeding: It’’s the s the natural waynatural way…….It.It’’s the s the Colorado way.Colorado way.Grand RoundsGrand RoundsJuly 27July 27thth, 2009, 2009Presented By: Jeffrey HarrPresented By: Jeffrey Harr

ObjectivesObjectives

Nutrition / MalnutritionNutrition / Malnutrition

Abnormal Physiology with Lack of Abnormal Physiology with Lack of EnteralEnteral Nutrition / Use of Nutrition / Use of ParenteralParenteralNutritionNutrition

Guidelines for Guidelines for EnteralEnteral NutritionNutrition

Debunking the Debunking the Argument(sArgument(s) Against ) Against EnteralEnteral NutritionNutrition

ConclusionConclusion

Who Needs Nutritional Who Needs Nutritional Support?Support?

WellWell--nourished person who has been without nutrition for 7nourished person who has been without nutrition for 7--10 days10 days Adequate stores to provide nutrients without compromising Adequate stores to provide nutrients without compromising

physiologic functions, altering resistance to infection, or physiologic functions, altering resistance to infection, or impairing wound healingimpairing wound healing

Duration of illness is anticipated to be more than 10 daysDuration of illness is anticipated to be more than 10 days Severe peritonitis or pancreatitisSevere peritonitis or pancreatitis Injury severity score > 15Injury severity score > 15 Extensive Burns (> 20% BSA)Extensive Burns (> 20% BSA)

Malnourished (loss of > 10% of usual body weight over 3 Malnourished (loss of > 10% of usual body weight over 3 months)months) % Weight loss = (Usual weight % Weight loss = (Usual weight –– present weight) present weight) xx 100/Usual 100/Usual

WeightWeight

Caloric RequirementsCaloric Requirements

General: 25 kcal/kg/dayGeneral: 25 kcal/kg/day

HarrisHarris--Benedict FormulaBenedict Formula Male: BMR = 66 + (13.7 Male: BMR = 66 + (13.7 xx weight [kg]) + (5 weight [kg]) + (5 xx height [cm]) height [cm]) ––

(6.8 (6.8 xx age [yr])age [yr]) Female: BMR = 65 + (9.6 Female: BMR = 65 + (9.6 xx weight [kg]) + (1.7 weight [kg]) + (1.7 xx height [cm]) height [cm])

–– (4.7 (4.7 xx age [yr])age [yr])

Patient Condition Basal Metabolic RateNo postoperative complicationsFistula without infection

Normal

Mild peritonitisLong-bone fracture or mild to moderate injury

25% above normal

Severe Injury of infection in ICU patientMultiorgan Failure

50% above normal

Burn of 40-100% of BSA 100% above normal

Malnutrition in Malnutrition in Hospitalized PatientsHospitalized Patients

Estimated that as many as 50% of hospitalized patients may be Estimated that as many as 50% of hospitalized patients may be malnourishedmalnourished11

anorexia (cancer, sepsis, liver disease), GI Obstruction, Motilianorexia (cancer, sepsis, liver disease), GI Obstruction, Motility disorders, GI ty disorders, GI Surgery, Inadequate AbsorptionSurgery, Inadequate Absorption

Risk of Malnutrition in hospitalized patients is a world wide prRisk of Malnutrition in hospitalized patients is a world wide problemoblem Other studies conducted in England, Germany, and Australia reporOther studies conducted in England, Germany, and Australia report t

malnutrition in 25 malnutrition in 25 –– 70% of their patients70% of their patients

Effects of MalnutritionEffects of Malnutrition Increased morbidity and mortalityIncreased morbidity and mortality Increase in length of hospital staysIncrease in length of hospital stays Increase in hospital costsIncrease in hospital costs Increase risk of readmissionIncrease risk of readmission

Largely undiagnosed problemLargely undiagnosed problem Lack of simple lab tests (difficult to interpret) or monitoringLack of simple lab tests (difficult to interpret) or monitoring Poor documentationPoor documentation Patients leave hospital without action to treat malnutritionPatients leave hospital without action to treat malnutrition Screening tools are underused and not enforcedScreening tools are underused and not enforced

MalnutritionMalnutrition

Protein DeficientProtein Deficient Serum Albumin < 2.5 Serum Albumin < 2.5 g/dLg/dL Weight maintainedWeight maintained Peripheral edemaPeripheral edema

Calorie DeficientCalorie Deficient 20% below usual weight or 20% below usual weight or hxhx of weight lossof weight loss Overt muscle wastingOvert muscle wasting Serum proteins maintained: Albumin > 2.9 Serum proteins maintained: Albumin > 2.9 g/dLg/dL

ProteinProtein--Calorie DeficientCalorie Deficient 20% below usual weight or 20% below usual weight or hxhx of weight lossof weight loss Serum albumin < 2.9 Serum albumin < 2.9 g/dLg/dL

Moderate: 2.5 Moderate: 2.5 –– 2.9 2.9 g/dLg/dL Severe: < 2.5 Severe: < 2.5 g/dLg/dL

Overt signs of muscle wastingOvert signs of muscle wasting

Risks of TPN / Lack of ENRisks of TPN / Lack of EN

Loss of intestinal integrityLoss of intestinal integrity22

Mucosal AtrophyMucosal Atrophy Increase in IFNIncrease in IFN--gammagamma

Increase apoptosis and decreased Increase apoptosis and decreased IgAIgA secretionsecretion Impaired GALTImpaired GALT

Decrease in ILDecrease in IL--1010 Decrease expression of tight junction and Decrease expression of tight junction and adherenadheren junction junction

proteinsproteins Increase in serum intestinal fatty acid binding protein (Increase in serum intestinal fatty acid binding protein (ii--

FABP) in trauma patientsFABP) in trauma patients33

Early presence of intestinal epithelial cell damage Early presence of intestinal epithelial cell damage associated with shock and injury severity within first dayassociated with shock and injury severity within first day

Bacterial TranslocationBacterial Translocation

Risks of TPN / Lack of ENRisks of TPN / Lack of EN

DecompensatedDecompensated Liver DiseaseLiver Disease44

SteatohepatitisSteatohepatitis, , cholestasischolestasis, , cholelithiasischolelithiasis Decrease in liver mononuclear cells and LPS receptorsDecrease in liver mononuclear cells and LPS receptors

Impaired hepatic immunityImpaired hepatic immunity

Impaired Respiratory Tract ImmunityImpaired Respiratory Tract Immunity55

Decreased Decreased IgAIgA--dependent upper respiratory tract immunity with TPNdependent upper respiratory tract immunity with TPN Preserved with ENPreserved with EN Independent of GALTIndependent of GALT

Associated with lateAssociated with late--onset ARDS (Retrospective 6 year Review N=2346)onset ARDS (Retrospective 6 year Review N=2346)66

28.7% of those exposed to TPN met criteria for late28.7% of those exposed to TPN met criteria for late--onset ARDSonset ARDS 3.9% of those not exposed to TPN developed late3.9% of those not exposed to TPN developed late--onset ARDSonset ARDS

Impaired peritoneal host defense systemImpaired peritoneal host defense system77

ParenteralParenteral nutrition decreased the number of nutrition decreased the number of intraperitonealintraperitoneal macrophages and macrophages and had a blunted nuclear factor had a blunted nuclear factor kappaBkappaB activationactivation

American Society for American Society for ParenteralParenteraland and EnteralEnteral Nutrition (ASPEN) Nutrition (ASPEN)

GuidelinesGuidelines Initiate Initiate EnteralEnteral FeedingFeeding7,87,8

Traditional nutritional assessment tools are not validated in crTraditional nutritional assessment tools are not validated in critical itical carecare

Albumin, Albumin, prealbuminprealbumin, , transferrintransferrin, and retinol binding protein are a , and retinol binding protein are a reflection of the acute phase responsereflection of the acute phase response

Critically ill patients who are unable to maintain volitional inCritically ill patients who are unable to maintain volitional intake take should receive should receive enteralenteral nutritionnutrition99--1212

Maintains tight junctions between intraepithelial cellsMaintains tight junctions between intraepithelial cells Stimulates blood flowStimulates blood flow Induces the release of Induces the release of trophictrophic endogenous agents (CCK, endogenous agents (CCK, GastrinGastrin, ,

BombesinBombesin, Bile Salts), Bile Salts) Maintains villous heightMaintains villous height Supports Supports secretorysecretory IgAIgA--producing producing immunocytesimmunocytes Contributes to distant site mucosalContributes to distant site mucosal--associated lymphoid tissue (lungs, associated lymphoid tissue (lungs,

liver, kidneys).liver, kidneys).

ASPEN GuidelinesASPEN Guidelines

EnteralEnteral feeding should be started within 24feeding should be started within 24--48 hrs 48 hrs following admission and advanced to goal over next following admission and advanced to goal over next 4848--72 hrs.72 hrs. Early feeding associated with less gut permeability, Early feeding associated with less gut permeability,

diminished activation and release of inflammatory diminished activation and release of inflammatory cytokinescytokines1313

Decreased ICU Mortality and Infections compared to Decreased ICU Mortality and Infections compared to delayed delayed enteralenteral feedingfeeding

ASPEN GuidelinesASPEN Guidelines

If early EN is not feasible or available the first 7 If early EN is not feasible or available the first 7 days following admission to the ICU, days following admission to the ICU, NONO nutrition nutrition support therapy should be providedsupport therapy should be provided If patient was previously healthyIf patient was previously healthy No evidence of proteinNo evidence of protein--calorie malnutritioncalorie malnutrition

MetaMeta--analyses comparing PN with EN/STD analyses comparing PN with EN/STD therapy in critically ill patientstherapy in critically ill patients14,1514,15

reduced infectious morbidity with EN/STD therapy reduced infectious morbidity with EN/STD therapy (RR = 0.77; (RR = 0.77; pp < 0.05) < 0.05)

Increased mortality with PN (RR = 1.78; Increased mortality with PN (RR = 1.78; pp <0.05) and <0.05) and trend toward greater rate of complicationstrend toward greater rate of complications

ASPEN GuidelinesASPEN Guidelines

Effort to provide > 50% Effort to provide > 50% -- 65% of goal calories should 65% of goal calories should be madebe made10,1610,16--1818

TrophicTrophic feeds are sufficient to prevent mucosal feeds are sufficient to prevent mucosal atrophy, but insufficient in other endpointsatrophy, but insufficient in other endpoints

Achieving > 50% Achieving > 50% -- 65% of goal calories is required for:65% of goal calories is required for: Preventing increase in intestinal permeability in burn Preventing increase in intestinal permeability in burn

and boneand bone--marrow transplant patientsmarrow transplant patients Promoting faster return of cognitive function in head Promoting faster return of cognitive function in head

injury patientsinjury patients Improving outcomes in immuneImproving outcomes in immune--modulating modulating enteralenteral

formulations in critically ill patientsformulations in critically ill patients

Nutrition ProtocolsNutrition Protocols

Implementation of an evidencedImplementation of an evidenced--based nutritional based nutritional support algorithm improved the proportion of support algorithm improved the proportion of patients meeting > 80% of caloric goalspatients meeting > 80% of caloric goals19,2019,20

Proportion of goal caloric intake improved from 56% Proportion of goal caloric intake improved from 56% to 83%to 83%

50% Reduction in Days to Feeding50% Reduction in Days to Feeding

Decrease of clinically nonDecrease of clinically non--indicated use of indicated use of parenteralparenteral nutrition.nutrition.

CostsCosts

An economic analysis of a multicenter Department ofAn economic analysis of a multicenter Department ofVeterans Affairs randomized, controlled trial of Veterans Affairs randomized, controlled trial of perioperativeperioperative total total parenteralparenteral nutrition (TPN)nutrition (TPN)2121

The cost of providing TPNThe cost of providing TPN for an average of 16.15 days for an average of 16.15 days before and after surgery was $2405before and after surgery was $2405

PerioperativePerioperative TPN did not result in decreasedTPN did not result in decreased costs for any costs for any subgroup of patients.subgroup of patients.

A prospective, randomized clinically controlled trial A prospective, randomized clinically controlled trial evaluated the potential clinical, metabolic, and economic evaluated the potential clinical, metabolic, and economic advantages of advantages of enteralenteral nutrition over total nutrition over total parenteralparenteralnutritionnutrition2222

EnteralEnteral nutrition was fournutrition was four--fold less expensive than TPN fold less expensive than TPN ($25 vs. $90.60/day, respectively)($25 vs. $90.60/day, respectively)

ConclusionConclusion

EnteralEnteral Nutrition is superior to STD nutrition for Nutrition is superior to STD nutrition for reducing risk of infection and hospital mortalityreducing risk of infection and hospital mortality

EnteralEnteral Nutrition is superior to Nutrition is superior to ParenteralParenteral nutrition for nutrition for reducing risk of infection and hospital mortalityreducing risk of infection and hospital mortality

STD nutrition is superior to STD nutrition is superior to ParenteralParenteral nutrition if no nutrition if no evidence of malnourishmentevidence of malnourishment

Enforced protocols can ensure adequate nutrition to Enforced protocols can ensure adequate nutrition to maintain protective physiologymaintain protective physiology

EnteralEnteral Nutrition is less expensive than Nutrition is less expensive than parenteralparenteralnutritionnutrition

And FinallyAnd Finally……

Do you think this guy has ever seen a drop of TPN?Do you think this guy has ever seen a drop of TPN?

ReferencesReferences

1.1. BistrianBistrian BR,BR, Blackburn GL,Blackburn GL, Vitale J,Vitale J, et al:et al: Incidence of malnutrition in general medical Incidence of malnutrition in general medical patients. patients. JAMAJAMA 1976;1976; 235:1567235:1567--15701570

2.2. Yang H, Yang H, FengFeng Y, et al. Y, et al. EnteralEnteral versus versus parenteralparenteral nutrition: effect on intestinal barrier function. nutrition: effect on intestinal barrier function. Ann NY Ann NY AcadAcad Sci. 2009 May;1165:338Sci. 2009 May;1165:338--4646

3.3. De De HaanHaan JJ, Lubbers T. et al. Rapid development of intestinal cell damaJJ, Lubbers T. et al. Rapid development of intestinal cell damage following sever ge following sever trauma: a prospective observational cohort study. trauma: a prospective observational cohort study. CritCrit Care. 2009 Jun 8;13 (3)Care. 2009 Jun 8;13 (3)

4.4. OmataOmata J, et al., J, et al., EnteralEnteral nutrition rapidly reverses total nutrition rapidly reverses total parenteralparenteral nutritionnutrition--induced impairment induced impairment of hepatic immunity in a of hepatic immunity in a murinemurine model, clinical Nutrition (2009), model, clinical Nutrition (2009), doidoi: : 10.1016/j.clnu.2009.05.01510.1016/j.clnu.2009.05.015

5.5. KudskKudsk KA, Li J, KA, Li J, RenegarRenegar KB. Loss of upper respiratory tract immunity with KB. Loss of upper respiratory tract immunity with parenteralparenteralfeeding. Ann feeding. Ann SurgSurg 1996;223:6291996;223:629--35.35.

6.6. PluradPlurad, David, et al. A 6, David, et al. A 6--year review of total year review of total parenteralparenteral nutrition use and association with latenutrition use and association with late--onset acute respiratory distress syndrome among ventilated traumonset acute respiratory distress syndrome among ventilated trauma a victiomsvictioms. Injury . Volume . Injury . Volume 40, Issue 5, May 2009; 51140, Issue 5, May 2009; 511--515. 515.

7.7. Ueno C, Ueno C, FukatsuFukatsu K, Kang W, K, Kang W, MaeshimaMaeshima Y, Moriya T, Hara E et al. Route and type of Y, Moriya T, Hara E et al. Route and type of nutrititionnutrititioninfluence nuclear factor influence nuclear factor kappaBkappaB activation in peritoneal resident cells. Shock 2005;24:382activation in peritoneal resident cells. Shock 2005;24:382--7.7.

ReferencesReferences

7.7. Martindale RG, Martindale RG, MaerzMaerz LL. Management of LL. Management of perioperativeperioperative nutrition support. nutrition support. CurrCurr OpinOpin CritCrit Care. Care. 2006;12:2902006;12:290--294.294.

8.8. RagusoRaguso CA, CA, DupertuisDupertuis YM, YM, PichardPichard C. The role of visceral proteins in the nutritional C. The role of visceral proteins in the nutritional assessment of intensive care unit patients. assessment of intensive care unit patients. CurrCurr OpinOpin ClinClin NutrNutr MetabMetab Care. 2003;6:211Care. 2003;6:211--216. 216.

9.9. KudskKudsk KA. Current aspects of mucosal immunology and its KA. Current aspects of mucosal immunology and its influinflu-- enceence by nutrition. Am J Surg. by nutrition. Am J Surg. 2002;183:3902002;183:390--398.398.

10.10. JabbarJabbar A, Chang WK, Dryden GW, A, Chang WK, Dryden GW, McClaveMcClave SA. Gut immunology and the differential response SA. Gut immunology and the differential response to feeding and starvation. to feeding and starvation. NutrNutr ClinClin PractPract. 2003;18:461. 2003;18:461--482.482.

11.11. Kang W, Kang W, KudskKudsk KA. Is there evidence that the gut contributes to mucosal immunKA. Is there evidence that the gut contributes to mucosal immunity in humans? ity in humans? JPEN J JPEN J ParenterParenter EnteralEnteral NutrNutr. 2007;31:246. 2007;31:246--258.258.

12.12. Kang W, Gomez FE, Kang W, Gomez FE, LanLan J, Sano Y, Ueno C, J, Sano Y, Ueno C, KudskKudsk KA. KA. ParenteralParenteral nutrition impairs gutnutrition impairs gut--associated lymphoid tissue and associated lymphoid tissue and mucosalimmunitymucosalimmunity by reducing by reducing lymphotoxinlymphotoxin beta receptor beta receptor expression. Ann Surg. 2006;244:392expression. Ann Surg. 2006;244:392--399. 399.

13.13. HeylandHeyland DK, DK, DhaliwalDhaliwal R, Drover JW, R, Drover JW, GramlichGramlich L, L, DodekDodek P; Canadian Critical Care Clinical P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelPractice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in ines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J mechanically ventilated, critically ill adult patients. JPEN J ParenterParenter EnteralEnteral NutrNutr. 2003;27:355. 2003;27:355--373.373.

ReferencesReferences

14.14. BraunschweigBraunschweig CL, Levy P, CL, Levy P, SheeanSheean PM, Wang X. PM, Wang X. EnteralEnteral compared with compared with parenteralparenteral nutrition: a nutrition: a metameta--analysis. Am J analysis. Am J ClinClin NutrNutr. 2001;74:534. 2001;74:534--542.542.

15.15. HeylandHeyland DK, MacDonald S, Keefe L, Drover JW. Total DK, MacDonald S, Keefe L, Drover JW. Total parenteralparenteral nutrition in the critically ill nutrition in the critically ill patient: a metapatient: a meta--analysis. JAMA. 1998;280:2013analysis. JAMA. 1998;280:2013--2019. 2019.

16.16. Taylor SJ, Taylor SJ, FettesFettes SB, SB, JewkesJewkes C, Nelson RJ. Prospective, randomized, controlled trial to C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced determine the effect of early enhanced enteralenteral nutrition on clinical outcome in mechanically nutrition on clinical outcome in mechanically ventilated patients suffering head injury. ventilated patients suffering head injury. CritCrit Care Med. 1999;27:2525Care Med. 1999;27:2525--2531.2531.

17.17. Barr J, Hecht M, Barr J, Hecht M, FlavinFlavin KE, Khorana A, Gould MK. Outcomes in critically ill patients beKE, Khorana A, Gould MK. Outcomes in critically ill patients before and fore and after the implementation of an evidenceafter the implementation of an evidence--based nutritional management protocol. Chest. 2004; based nutritional management protocol. Chest. 2004; 125:1446125:1446--1457.1457.

18.18. Ziegler TR, Smith RJ, Ziegler TR, Smith RJ, OO’’DwyerDwyer ST, ST, DemlingDemling RH, Wilmore DW. Increased intestinal RH, Wilmore DW. Increased intestinal permeability associated with infection in burn patients. Arch Supermeability associated with infection in burn patients. Arch Surg. 1988;123:1313rg. 1988;123:1313--1319.1319.

19.19. Mackenzie, Shannon, et al. Implementation of a Nutrition SupportMackenzie, Shannon, et al. Implementation of a Nutrition Support Protocol Increases the Protocol Increases the Proportion of Mechanically Ventilated Patients Reaching Proportion of Mechanically Ventilated Patients Reaching EnteralEnteral Nutrition Targets in the Adult Nutrition Targets in the Adult Intensive Care Unit. JPEN J Intensive Care Unit. JPEN J ParenterParenter EnteralEnteral NutrNutr 2005;29;742005;29;74

20.20. KozarKozar RA, RA, McQuigganMcQuiggan MM, Moore EE, MM, Moore EE, KudskKudsk KA, KA, JurkovichJurkovich GJ, Moore FA. GJ, Moore FA. PostinjuryPostinjury enteralenteraltolerance is reliably achieved by a standardized protocol. J tolerance is reliably achieved by a standardized protocol. J SurgSurg Res. 2002;104:70Res. 2002;104:70--75.75.

ReferencesReferences

21.21. Eisenberg, John, et al. Does Eisenberg, John, et al. Does perioperativeperioperative total total parenteralparenteral nutrition reduce medical nutrition reduce medical care costs? Journal of care costs? Journal of ParenteralParenteral and and EnteralEnteral Nutrition. (1993) 17:3; 201Nutrition. (1993) 17:3; 201--209.209.

22.22. Braga, Marco, et al. Early postoperative Braga, Marco, et al. Early postoperative enteralenteral nutrition improves gut nutrition improves gut oxygenation and reduces costs compared with total oxygenation and reduces costs compared with total parenteralparenteral nutrition. Critical nutrition. Critical Care Medicine, February 2001; 29:2;242Care Medicine, February 2001; 29:2;242--248.248.