Overcoming Barriers to Enteral Feeding in the ICU

Beth Taylor, DCN, RDN, CNSC, FCCM

Nutrition Support Specialist

Surgical ICU

Barnes-Jewish Hospital, St. Louis, MO

Initiate Enteral Feeding• EN should be initiated in ICU pt unable to maintain

PO

• EN preferred over PN for nutrition support therapy

• Initiate EN within 24-48 hrs of onset of illness

Overt signs of contractility not required to start

Absent BS predict intolerance, dz severity,

need for vigilence

• Initiate EN in the stomach2

Divert lower if intolerant, high aspiration risk

• Withhold EN with hemodynamic instability

Restart with caution if requiring low dose vasopressor support3

1Nguyen (J Crit Care 2013;28:537) 2 Deane (Crit Care 2013:17:R125)3 Khalid (Amer J Crit Care 2010;19:261)

Early EN (24 – 48 hrs) is recommended!

Taylor, B; McClave S, Martindale RSCCM/ASPEN 2015 in prep

Study or Subgroup

Sagar 1979Moore 1986Schroeder 1991Carr 1996Beier-Holgersen 1996Singh 1998Minard 2000Malhotra 2004Kompan 2004Peck 2004Nguyen 2008Moses 2009Chourdakis 2012

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.05; Chi² = 19.58, df = 12 (P = 0.08); I² = 39%Test for overall effect: Z = 2.54 (P = 0.01)

Events

3310276

549

123

1713

130

Total

15321614302112

1002714142934

358

Events

5903

14127

6716116

1912

181

Total

15311614302215

1002513143025

350

Weight

3.1%3.3%0.5%0.6%2.5%7.6%6.6%

20.9%9.4%

17.7%3.5%

14.5%9.8%

100.0%

M-H, Random, 95% CI

0.60 [0.17, 2.07]0.32 [0.10, 1.08]

3.00 [0.13, 68.57]0.14 [0.01, 2.53]0.14 [0.04, 0.57]0.61 [0.30, 1.25]1.07 [0.49, 2.34]0.81 [0.64, 1.01]0.52 [0.28, 0.96]1.01 [0.74, 1.39]0.50 [0.15, 1.61]0.93 [0.61, 1.39]0.80 [0.44, 1.44]

0.74 [0.58, 0.93]

Year

1979198619911996199619982000200420042004200820092012

Early EN Delayed/None Risk Ratio Risk RatioM-H, Random, 95% CI

0.1 0.2 0.5 1 2 5 10Favors Early EN Favors Delayed/None

Infectious Complications

Mortality

The Gut as Regulator of Inflammatory Response

Feed the Gut: inflammation

Gut disuse:

inflammation

THE COMMON VICIOUS CYCLE - GI ISSUES

Unnecessary NPONone or little enteral

feedings

No Luminal Nutrient GI intolerance

Multiple causes

• Right time• Best route• Determine Deficits• Protocols• Team approach

GI Dysfunction and

its consequences

Nutrition therapy – Not ‘If” But ‘When’

RD

Meet the Fab RDs

Hemodynamic Instability

Low Flow state: requires pharmacologic or mechanical support

Clinical Signs: hypotension, abnormal heart rate, cold extremities, peripheral cyanosis, mottling, decreased UOP

Fluid Resuscitation Ischemic Reperfusion Injury (IRI)

McAllister et al. Ann of Pharm 2005;39:383.

Consequences of IRI

Weisner et al. Radiology 2003;226:635

Microvilli height shortened, integrity compromised = bacterial translocation and malabsorption Esposto et al. J Leukocyte Bio 2007;81:1032

Feeding on Pressors

Vasopressin (alone): Increased splanchnic vasoconstriction and

decreased blood flow Increased lactate release/acidosis

Norepinephrine (Levophed) – 1st line therapy for septic shock: Increases pH Increases microcirculation if fluid resuscitated Decreases microcirculation if volume depleted

Feeding the Critically Ill Patient

Study conclusions:• Defined “high-dose”

catecholamine 12.5 mcg/min ≅of

norepinephrine

• Patients receiving higher doses of IV vasopressors and

dopamine or vasopression

should be monitored closely

for signs of GI intolerance if

receiving EN

• Incidence of bowel ischemia/perforation was low (0.9%)

Mancl EE. JPEN, 2013.

Non-Occlusive Bowel Necrosis

Incidence 0.3 – 1.5%

Symptoms – often after out of ICU/off pressors: diarrhea, abd distention high NGT out, hypotension, lactic acidosis

Mortality near 90%

Feeding on Pressors

1. Fluid resuscitate first if patient in shock

2. Start slow 10-20 ml/hr w/ isotonic formula

3. If multiple being used - delay advancement beyond trophic amount

4. If only low dose of levophed needed (or aiming for higher MAP) and evidence of end organ perfusion --- advance toward goal

5. Physical Exam

Early enteral feeding in patients with open abdomen Multicenter Prospective

cohort study – pts w/ exp lap

Evaluating safety and effect of immediate EN

1000 patient study (Glue Grant) 100 patients met criteria

32 immediate EN / 68 delayed EN (> 36 hours)

Similar severity of injury

Results:Time to closure: 6.47

vs 8.55 days (NS)No difference in MOF,

ICU days, Ventilator days, mortality

Rate of pneumonia 43.8 vs 72.1 % (p=0.008)

Conclusion:Immediate EN safeTrend toward faster

closure Significant reduction

in pneumonia

Dissanaike S et al J Am Coll Surg 2008

Protein loss from open abdominal exudate – BJH

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 200

5

10

15

20

25

30

35

40

45

50

Average Daily Protein (g) lost/day/patient

Gra

ms o

f P

rote

in

Taylor and Southard, unpublished

Feeding Across a New Anastomosis

• Meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to anastomosis within 24 hrs of GI surgery compared to traditional postop management

• Examined 15 studies with 1240 patients

• No significant difference in Mortality/Anastomic Leak……this is a good thing!

Osland, E et al. JPEN 35:2011

OR for Anastomotic Leak

Nutritional AssessmentSet Goals of Therapy

• Caloric requirements

25-30 Kcal/kg/d

Published predictive equations no more accurate

Indirect calorimetry

• Protein requirements

Greater emphasis

(at least 80%)

Higher doses

1.2–2.5 gm/kg/d

MJ Allingstrup (Clin Nutr 2012;31:462) P Weijs (JPEN 2012;36:60

M. Nicolo (JPEN 2015 epub)

Survival1

Pt’s getting >80% prescribed protein x 4 days in ICU, 33% less risk of dying

Yeh D. et al JPEN 2015 epub

News Flash

“Adequate”

Feeding in the

SICU – may

keep you alive

and get you

home!!

Prospective, observational cohort study

Nutrition Outcomes (all patients)

Total CanadaAustralia and NZ

USAEurope and

South Africa

Latin America

Asiap values†

N3174 361 602 670 416 442 683

Prescribed kcal/kg/day Mean (SD)

24.1(5.5) 23.3 (5.3) 25.5(5) 21.5 (6.2) 24.6(5) 24. 5(4.6) 25.4 (5.2) <0.001

Adequacy of calories % Mean (SD)

56 (30.6 ) 63.4(27.3 ) 59.5(27.7 ) 47.8(27.2 ) 54.4(30.3 ) 53.4(27.9 ) 59.8(37.2 ) <0.001

Adequacy of protein % Mean (SD)

51.5(29.2 ) 59.7(27.2 ) 53.9(27.3 ) 44.1(27.0 ) 49.5(29.6 ) 51.1(28.1 ) 53.9(32.7 ) <0.001

Prevalence of iatrogenic underfeeding 2467 (77.7%) 255 (70.6%) 450 (74.8%) 599 (89.4%) 309 (74.3%) 372 (84.2%) 482 (70.6%) <0.001

Time to initiate EN from ICU admission in hours

Mean (SD) 41.7 (43.6) 37.0 (42.8) 32.6 (39.9) 52.3 (43.8) 39.5 (41.7) 48.6 (42.3) 39.2 (46.4) <0.001

78% of patients failed to meet ≥ 80% of energy

target

www.criticalcarenutrition.com

Need for EN in High Risk Patients:Utilize Strategies to Increase EN Delivery

• Over-order calories• Volume-based feeding

(vs rate-based)

• Multi-Strategy De-escalation (Top-Down or PEP-uP) Start at goal Start with prokinetics Volume-based feed Probiotics (oropharynx and tube) Caloric balance Small peptide formula SB infusion Elevate HOB

• Nurse-driven protocols for EN (Set ramp up, vol, GRV, NPO, etc)• Alter NPO status for diagnostic tests, procedures, surgery• Bundle with nutrition elements (set of action statements)

McClave (JPEN 2014; Online June 1) Heyland (CCM 2013;41:2743)

FIGURE OUT YOUR BARRIERS THEN STRATEGIZE!

Confucius says: When it is obvious that the goals cannot be reached, don’t adjust the goals,

adjust the action steps!

Barriers to Early ENTube Occlusion

Timely Tube Placement

Gastric Residual Volume

Emesis

Diarrhea

Surgery

Tests/Procedures

Tube

Issues

GI Issues

NPO ileus

New anastomosis

Pressor Use

Small Bowel vs Gastric Risk Factors for Aspiration

Intubation Decreased level of consciousness Neuromuscular diseases Structural abnormalities of the upper GI Recent stroke Recent major abdominal surgery History of aspiration Prolonged supine position Persistently high GRV (your threshold)

Tube Placement TeamQuicker Bedside Placement!

SB Tube Team at BJH Too much for one person – too many

patients and patient areas Coverage 365 days a year, 24 hours a

day Same care – no matter the day or time,

or intensive care unit RDs and RNs – both competent To date our NSS team has placed over

9000 tubes in intensive care patients Overall success rate is 86% Success rates (1st attempt) vary with

experience - not discipline: dietitian 1- 93%, dietitian 3 – 80%, ICU RN- 87%

Successful bedside SB tube placement

✔ Early enteral feeds – good for ICU pts

✔ Team approach to small bowel tube placement – best way to go!

✔ RDs can lead the team OR lead the effort to form a team

✔ Teams can be multidisciplinary

✔ Bedside placement safest and most convenient approach

Barriers to Early ENTube Occlusion

Timely Tube Placement

Gastric Residual Volume

Emesis

Diarrhea

Surgery

Tests/Procedures

Tube

Issues

GI Issues

NPO ileus

New anastomosis

Pressor Use

No GRVs! Wonder how that will go over?

Data on GRVs

• GRVs should not be used as part of routine care1

Montejo Multicenter RCT 1 GI Complications %Goal Feeds500cc GRV (n=160) 47.8% * 89% *

200cc GRV (n=169) 63.6% 83%

Reignier Multicenter RCT 2 VAP Infect Mortality DeficitNo GRV used (n=227) 16.7% 26.4% 27.8% 319

kcalRoutine GRV (n=222) 15.8% 27.0% 27.5% 509

kcal

1 JC Montejo (Intens Care Med 2010;36:1386) 2 J Reignier (JAMA 2013;309:249)

 

What to Use Instead? Use your abdominal physical assessment skills

If you are not sure ask for 2nd opinion Presence of diarrhea or constipation – know

causes and treatments; drive the discussion!

EN Formula Selection

• Avoid routine use commercial mixed fiber formula for prophylaxis

• Persistent diarrhea

Consider mixed fiber formula (3 trials)

Inconsistent data – 1 trial diarrhea better 1, 2 no different 2,3

Consider small peptide/MCT

Avoid BOTH soluble/insoluble fiber if high risk for ischemia

1 Chittawatanarat K (Asia Pac J Clin Nutr 2010;19:458)2 Dobb GJ (Int Care Med 1990;16:252) 3 Schultz AA (Amer J Crit Care 2000;9:403)

Barriers to Early ENTube Occlusion

Timely Tube Placement

Gastric Residual Volume

Emesis

Diarrhea

Surgery

Tests/Procedures

Tube

Issues

GI Issues

NPO ileus

New anastomosis

BJH STICU audit – patients only received 37% of prescribed volume of EN

Pressor Use

FEED ME PROTOCOL

Feed Early Enteral Diet adequately for

Maximum Effect

Patient Demographics

Nutrition Care Practices

Continuous Quality Improvement Project

Rate-Based Protocol Rate – Based No make up for lost time Info on EN product No info on BG control MDs – practice 1.5

kcal/ml product, goal of 1400 kcal

Feeds to goal in 48 hr Gastric feeds primary RD consult in 48 hrs GRV > 350 ml Prokinetic not automatic

FEED ME Protocol Volume – Based Make up for lost time No EN product info Info on BG control MD – practice 1.5 kcal/ml

product, goal 1400 kcal Feeds to goal in 24 hr Gastric feeds primary RD consult in 48 hrs GRV > 350 ml Prokinetic not automatic

How to make it easy for the bedside nurse?

Success – Happy Stomachs!

Implementing a New Protocol

Prospective interventional study (n=5800 ICU days)

NUTSIA Protocol over 3 three-month periods (2005, 2006, 2007)

Before Protocol After Protocol With Enforcement

(n=198 pts) (n=179 pts) (n=195 pts) Results

Rx (kcal/kg/d) 11.4 +7.9 13.9 +8.0 15.4 +9.6 ** ICU kcal balance -7180 +5008 -6133 +3854 -5568 +5194 ** Hosp LOS (days) 31.1 +52.2 24.1 +21.0 23.2 +22.1** ICU mortality 8.1% 10.2% 12.3%

Soguel L, Revelly JP, Berger MM (CCM 2012;40;1-7)

Who are the Enforcers?

All of us!!!

Efficacy of EN Protocols

Author/JournalStudy Parameters

Study Design Outcome

Adam and Baston, ICM, 1997 Barriers and Enablers to EN 193 patients % EN deliveredProtocol - 78% No Protocol – 66% P <0.001

Pinilla, JPEN, 2001 Comparisons of 2 protocols with different GRV thresholdsProtocol 1 – GRV 150 mlProtocol 2 – GRV 250 ml

80 patients % EN deliveredProtocol 1 – 70%Protocol 2 – 76%P < 0.02

Arabi, NCP, 2004 Before/After Protocol Implementation

203 patients % EN deliveredBefore – 53.9%After – 64.5 %P = 0.001

Barr, Chest, 2004 Before/After ProtocolImplementation

200 patients % EN deliveredBefore – 68%After – 78%P = 0.11

Martin, CMAJ, 2004 Before/After Feeding AlgorithmPN started if EN not tolerated in 24 hrs

452 patients Use of EN (days), P=0.042Algorithm 6.7 daysNo Algorithm 5.4 daysHosp LOS, P=0.003Algorithm 25 daysNo Algorithm 35 days

Efficacy of EN Protocols

Author/JournalStudy Parameters

Study Design Outcome

Mackenzie, JPEN, 2005 Before/After Protocol Implementation

123 patients % of pts that received 80% of EN goalBefore – 20%After – 60%P < 0.001

Woien, J Clin Nurs, 2006 Before/After AlgorithmImplementation

42 patients % of EN calories delivered, P=0.047Before – 52%After – 69%

Desachy, ICM, 2008 Comparison of 2 protocolsProtocol 1 – start at goalProtocol 2 – start low rate

100 patients % of EN calories delivered, P=0.0001Protocol 1 – 95%Protocol 2 – 76%

Heyland, JPEN, 2010 Comparison of ICUs with/without EN protocol

269 ICUs & calories delivered from any sourceWith – 61.2%Without – 51.7%P=0.0036

Rice, JAMA, 2012 Comparison of 2 protocolsProtocol 1 – start at goalProtocol 2 – start low rate

1000 patients Avg daily kcal intakeProtocol 1 – 1300 caloriesProtocol 2 – 400 calories

Sheean, J Acad Nutr Diet, 2012 Comparison of 2 protocolsProtocol 1 – standardProtocol 2 – 150% of needs

49 patients Avg daily kcal intakeProtocol 1 – 475 +/- 480Protocol 2 - 1198 +/- 493P=0.007

Summary

Identify Barriers to EN Meet with key leaders in your area Strategize/Define/Educate/Implement a plan Evaluate Progress toward goal (audit) Revise/Re-Educate

Make it Happen!!!

Questions