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Enteral nutrition ICU
- 1. Advancement in ICU Enteral Nutrition DR AMITH SREEDHARAN CRITICAL CARE MEDICINE ASTER MIMS,KANNUR
- 9. • Nutrition status of Indian malnourished patients can be assessed by SGA (B III) • Initial monitoring of nutrition intervention must be done on daily basis and nutrition plans should be modified accordingly (A I) • It is imperative that nutritional assessment is done by well-qualified and trained nutritionists, dedicated to the ICU (A I) • It is desirable that nutritionist-to-critically ill patient ratio be maintained at 1:25 (C) • Wherever feasible, computed tomography (cross-sectional imaging) or ultrasonography (U/S) can be used to assess the lean muscle mass (B V) • Facilitation of nutrition assessment will require good coordination between intensivist and nutritionist
- 13. Weight-based equations are preferred for energy-protein calculations
- 17. 1.Immune-modulating nutrients should not be used routinely (A I) 2.In ICU patients with very severe illness and not tolerating more than 700 mL enteral formulae per day, immune nutrients should not be used (A I) 3. Immune-modulating nutrients could be considered for patients with TBI and perioperative patients in the surgical ICU (A I) 4.Glutamine is not recommended in critically ill patients with multiple organ failure
- 18. Learning Objectives Understand Closed System Enteral Nutrition 1 Utility of Closed System- Hospital and Home Care 2 Case Studies 3
- 19. Compromised GI Function in ICU Patients: Far More Common Than We Believe 30%- 70% of ICU patients have GI dysfunction1 GI dysfunction occurs in 50% of MV patients.1 01 02 03 04 Premorbid conditions (traumatic brain injury)2 Ventilation mode1 Altered metabolic state (inflammation, sepsis, circulating stress hormones, gut hypoperfusion)2 ICU medications (catecholamines, sedatives, opioids)3 1. Mutlu GM, et al. Chest. 2001;119:1222–1241. 2. Hill LT. S Afr J Crit Care. 2013;29(1):11-15. 3. Gungabissoon U, et al . JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. GI: Gastrointestinal; Icu:Intensive care unit
- 20. GI Dysfunction Coupled With Inadequate Intake of Nutrition Leads to Malnourishment in ICU Patients GI dysfunction significantly compromises the delivery of enteral nutrition in ICU patients.1-4 GI dysfunction Malabsorption and intolerance Calorie and protein malnutrition 74% of MV patients fail to attain 80% of their energy targets.2 1. Mutlu GM, et al. Chest. 2001;119:1222–1241. 2. Hill LT. S Afr J Crit Care. 2013;29(1):11-15. 3. Gungabissoon U, et al . JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. 4. Mentec H, et al. Crit Care Med. 2001;29(10):1955-1961. GI: Gastrointestinal; MV: Mechanically ventilated; ICU: Intensive care unit.
- 21. Relationship Between Nutritional Intake and Clinical Outcomes in Critically Ill Patients Relationship between increasing calories/day and 60-day mortality, by BMI Increased nutritional intake is associated with lower mortality rates and increased ventilator-free days BMI: Body mass index. Alberda C, et al. Intensive Care Med. 2009 Oct;35(10):1728-37.
- 22. Factors to Be Considered When Prescribing Enteral Nutrition in Critically Ill Patients Sewify K, et al. J Nutr Food Sci. 2017;7:4. Limitation of microbial contamination of feeds Meeting adequate nutritional needs safely Ease of use and convenience for nurses Cost-effectiveness
- 23. Open vs. Closed/Ready-to-Hang Delivery System Enteral delivery system Open RTH Manipulations Hang time Manipulations required from time of feed preparation to administration Manipulations are minimal, as it is available as a ready-to- hang bag. 4 hours 24-48 hours Nursing time Consumes more nursing time due to more manipulations Ease of use reduces nursing time Sewify K, et al. J Nutr Food Sci. 2017;7:4. RTH: Ready-to-hang.
- 24. Benefits of Closed/Ready-to-Hang Delivery System Sewify K, et al. J Nutr Food Sci. 2017;7:4. Ease of administration Prolonged hang time Reduced risk of nosocomial infections Reduced healthcare cost Reduced nursing time Closed EN improves the nutritional status of patients and improves patient outcomes. EN: Enteral nutrition.
- 25. Closed delivery systems could be safely used for up to 24 hours and are associated with reduced bacterial contamination. Clinical Evidence on Improved Outcomes After Transition to Closed Enteral Feeding System (1/4) Closed system is 40times less likely to get contaminated Wagner DR, et al. JPEN J Parenter Enteral Nutr. 1994;18(5):453–7. OS: Open system; CS: Closed system; EN: Enteral nutrition.
- 26. Clinical Evidence on Improved Outcomes After Transition to Closed Enteral Feeding System (2/4) Closed System delivers nutrition more precisely Avg % formula received per patient in each enteral system type (p<0.05) Avg % formula received per patient in each enteral system type (p<0.05) EN: Enteral nutrition; OS: Open system; CS: Closed system. Atkins A. MedSurg Matters. 2015:24(4)14–15.
- 27. Clinical Evidence on Improved Outcomes After Transition to Closed Enteral Feeding System (3/4) Reduction in nursing time was observed with closed system compared to open system Luther H, et al. J Burn Care Rehabil. 2003;24(3):167–72 CS: Closed system; OS: Open system; EN: Enteral nutrition. Total daily nursing time in OS and CS delivery systems Management of OS system of EN consumed almost twice as much nursing time daily as CS with supplemental protein flush (36.6±17.1 min vs. 18.6±3.6 min; p=0.051).
- 28. Clinical Evidence on Improved Outcomes After Transition to Closed Enteral Feeding System (4/4) Luther H, et al. J Burn Care Rehabil. 2003;24(3):167–72. ~88% of nurses preferred the closed system over the open system Ease of use of closed and open delivery systems
- 29. Economic Impact of Switching From Open to a Closed Enteral Nutrition Feeding System in Acute Care Setting Comparison of average daily cost to feed adult patients in each enteral system CS: Closed system; OS: Open system. Phillips W, et al. Nutr Clin Pract. 2013;28(4):510–4. CS is more cost-effective when nursing time is taken into consideration.
- 30. Does guideline recommends use of ready-to- hang EN formulas as nutritional support in critically ill patients?
- 31. All major Guidelines Recommend Usage of Liquid Nutrition(Ready-to-Hang) as preferred formulation Commercially produced, pre-filled ready to hang feeds must be used wherever possible as these are least likely to become contaminated during preparation and use.
- 32. Ready-to-Hang Liquid Nutrition in Home Care Settings 5
- 33. Improved Compliance with RTH Liquid Nutrition Ready-to-hang liquid nutrition improves compliance in home care by 20%
- 35. ICU Nutrition is of therapeutic benefit,not just an adjunctive or support, in improving patient outcomes. Early, optimum, and adequate nutrition helps improve patients’ overall prognosis reduce the length of stay. EN is preferable,Scientific nutrition in the form of standard formula feeds should be preferred In comparison to blenderized feeds, the standard formula feeds have benefits of better feed hygiene, certain nutrient delivery, and lesser osmolality and viscosity.
- 36. Key Messages EN: Enteral nutrition.; AKI: Acute kidney injury Clinical evidence indicates that closed or ready-to-hang(RTH) EN system is beneficial over open system RTH reduces risk of nosocomial infections, improves ease of administration and provides nursing convenience It improves compliance in Home Care setting All leading guidelines ASPEN, NHS, Indian Practice Guidelines recommend its use
Editor's Notes
- Welcome to the presentation entitled ‘Practical Guidelines and Current Updates on Enteral Nutrition.’
- The learning objectives of this module are as follows, Understand Indian practice guidelines on enteral nutrition Have an overview of closed enteral nutritional system Discuss current updates on enteral nutrition in special populations
- Mechanical ventilation can contribute to several gastrointestinal (GI) complications, although it is not clear whether there is a direct causal relationship between mechanically ventilated (MV) and GI complications. The slide shows GI complications and their prevalence in mechanically ventilated patients.1 References Mutlu GM, Mutlu EA, Factor P. GI Complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. Hill LT. Gut dysfunction in the critically ill − Mechanisms and clinical implications. S Afr J Crit Care. 2013;29(1):11-15. Gungabissoon U, Hacquoil K2, Bains C, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448.
- Impaired GI function is associated with malabsorption and intolerance, which in turn can cause calorie and protein malnutrition. Poor clinical outcomes associated with GI dysfunction and intolerance are as follows:1-4 High mortality rates High risk of infectious complications Longer ICU stay Reduced nutritional adequacy References Mutlu GM, Mutlu EA, Factor P. GI Complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. Hill LT. Gut dysfunction in the critically ill − Mechanisms and clinical implications. S Afr J Crit Care. 2013;29(1):11-15. Gungabissoon U, Hacquoil K2, Bains C, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: Frequency, risk factors, and complications. Crit Care Med. 2001;29(10):1955-1961.
- Evidence suggests that inadequate nutritional intake and a calorie deficit results in poor clinical outcomes in critically ill patients. Patients with poor nutritional, as demonstrated by low body mass index, are at increased risk of adverse effects from underfeeding; or benefit the most from receiving an increased nutritional intake, in the forms of protein and energy. In this regard, in a study, the relationship between the amount of energy and protein administered and clinical outcomes, and the extent to which pre-morbid nutritional status influenced this relationship, was evaluated. In this observational cohort study, nutritional practices in 167 intensive care units across 37 countries were assessed. The type and amount of nutrition received by these patients were recorded daily for 12 days. The study involved 2772 mechanically ventilated patients who received 1034 kcal/day and 47g protein/day. These critically ill patients were followed up prospectively to determine 60-day mortality and ventilator-free days. Body mass index was used as a marker to evaluate nutritional status. The study noted that an increase in calorie intake was associated with lower mortality rates and with increased ventilator-free days in critically ill patients with poor nutritional status, with a BMI <25 or ≥35 kg/m2. Reference Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009 Oct;35(10):1728-37.
- Factors to be considered when prescribing an enteral nutrition delivery system for critically ill patients include: Limitation of microbial contamination of feeds Meeting adequate nutritional needs safely Ease of use and convenience for nurses Cost-effectiveness of the feeds Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- Enteral feeds could be delivered to critically ill patients with the aid of an open or closed delivery system. The closed EN delivery system is also referred to as ready-to-hang delivery system. Let us understand the differences between open and closed delivery systems. The open system includes ready-to-use cans and powdered or sterilized formulas that require reconstitution with water. This system involves many manipulations, in terms of selection of ingredients, reconstitution of the mixture with water, storage or transport of the feed, transfer to the container, assembly of the feeding system, and finally administration of the feed. Recommended hang time for these mixtures is 4 hours. This system consumes more nursing time. The other preferred EN delivery system is the ready-to-hang system. This is a completely closed non-air-dependent collapsible bag system requiring minimal handling and minimal manipulations, with a recommended hang time of 24 to 48 hours. The ease of use associated with this system reduces nursing time and is also safe, due to a minimal risk of contamination. Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- Let us now discuss the beneficial effects of closed/RTH system as compared to open system. Owing to minimal handling and minimal manipulations, the RTH system is associated with a reduced risk of nosocomial infections; the ease of administration reduces nursing time. Although RTH is more expensive compared to the open delivery system, this system significantly reduces healthcare expenditure due to reduced nursing time. Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- A study analyzed quantitative factors, such as preparation time, waste, and contamination, associated with three different feeding systems for peptide-based diets. Critically ill patients admitted to the ICU were randomized to receive a peptide-based diet in 1500-mL prefilled delivery systems including: Sterile closed-system containers (CS) infused for more than 24 hours Open systems decanted from cans (OS-Can) Open systems mixed from powder (OS-Powder) Samples were taken for culture during preparation and after infusion. Preparation time, initial and final microbial concentrations, and total waste were quantified. The study noted that preparation time was significantly shorter for CS than for OS-Can or for OS-Powder (2 minutes vs. 7.5 minutes vs. 13.0 minutes) and that bacterial contamination was the highest in the open delivery system. Reference Wagner DR, Elmore MF, Knoll DM, et al. Evaluation of "closed" vs "open" systems for the delivery of peptide-based enteral diets. JPEN J Parenter Enteral Nutr. 1994 Sep-Oct;18(5):453–7.
- Adequate nutrition plays a key role in the care of critically ill patients. In this regard, a study assessed the nutritional adequacy of EN feeds delivered via OS and CS in terms of the volume of feeds received by patients. The study collected retrospective data on patients who had received EN through OS. The study included patients who were receiving feeds through CS. A total of 325 feeding days of 30 patients who received formula via OS and 237 feeding days of 30 adults receiving formula via CS were analyzed in the study. The study noted that patients receiving formula through OS received an average of 74% of ordered volume and that patients receiving formula through CS received an average of 84% of ordered volume. Reference Atkins A. Delivery of enteral nutrition improved after transition to closed enteral feeding system. MedSurg Matters. 2015:24(4)14–15.
- A study assessed the time required for nurses for managing open as well as closed nutrition delivery systems in critically ill patients. Initiating closed system feeding involved the following tasks: procuring a new feeding container, spiking and hanging the new bottle, and restarting the pump. Initiating open system feeding involved the following tasks: securing the mixed formula from the refrigerator, correctly rinsing and flushing the feeding bag and the tubing, addition of 4-hour supply feeding to the bag, and priming and restarting the pump. The study noted that the management of open delivery system of enteral nutrition consumed almost twice as much nursing time daily as the closed system with supplemental protein flush (36.6±17.1 min vs. 18.6±3.6 min; p=0.051). Reference Luther H, Barco K, Chima C, et al. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil. 2003 May-Jun;24(3):167–72.
- The nurses were provided an 11-question survey to detail their perceptions on the ease of use of open and closed enteral feeding systems. The majority of nurses (87.5%) preferred the closed system over the open system, in view of the improved ease of use of the former. Reference Luther H, Barco K, Chima C, et al. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil. 2003 May-Jun;24(3):167–72.
- To summarize, the CS has several clinical benefits compared to the OS. However, the cost of potential waste associated with CS is a major concern; in this regard, a study analyzed the economic impact of switching from OS to CS. In the study, when the average daily cost was calculated using delivered EN formula as a measure, OS was found to be more cost-effective. When the average daily cost was calculated considering both delivered volume and wasted formula, OS was found to be more cost-effective compared to CS. However, when nursing time was taken into consideration for calculating the average daily cost, CS was found to be more cost-effective. Reference Phillips W, Roman B, Glassman K. Economic impact of switching from an open to a closed enteral nutrition feeding system in an acute care setting. Nutr Clin Pract. 2013 Aug;28(4):510–4.
- Does guideline recommends use of ready-to-hang EN formulas as nutritional support in critically ill patients?
- Guidelines recommend use of commercially produced, pre-filled ready to hang feeds to be used wherever possible as these are least likely to become contaminated during preparation and use.
- In this section, we will discuss the benefits of ready-to-hang liquid nutrition in home care settings.
- In home care settings, as in hospital set-up, the modular feeds were significantly more contaminated at the start of administration with over 75% of feeds contaminated compared with 28% of ready-to-use feeds. This significant difference was maintained by the end of administration when all modular feeds were contaminated compared with nearly two thirds of ready-to-use feeds.
- To summarize, Indian practice guidelines recommend standard polymeric formula in critically ill patients. Clinical evidence indicates that closed or ready-to-hang EN system is beneficial over open or blenderized nutrition, in view of the reduced risk of nosocomial infections, ease of administration, reduced nursing time, and reduced healthcare expenditure associated with the former. Peptide-based enteral formulas are the preferred choice of nutrition in acute kidney injury patients. Diabetes-specific EN formula, as opposed to standard formula, can significantly improve glucose control in diabetic patients. Immuno-enhanced EN is more effective than standard EN in cancer patients.