When and how to manage enteral feeding intolerance?

Risk prediction model for adult intolerance to enteral nutrition feeding - A literature review

Enteral nutrition is an important clinical nutritional supplementation method, especially for adult patients who are unable to eat normally or require additional nutritional support. However, many patients experience intolerance to enteral nutrition, such as delayed gastric emptying, bloating, and diarrhea, which not only affect the patient's nutritional status but also increase the risk of medical complications. In recent years, medical researchers have been dedicated to identifying and analyzing various factors that contribute to enteral nutrition intolerance, including the patient's disease status, nutritional formula, feeding method, and rate. In addition, research is also exploring the establishment of risk prediction models to more accurately predict which patients may develop enteral nutrition intolerance. These models typically combine clinical parameters, biomarkers, and patient individual characteristics, aiming to assist clinicians in better planning and adjusting nutritional treatment plans, thereby reducing the occurrence of intolerance events. This review summarizes the research progress on enteral nutrition intolerance in adult patients, with a focus on the latest developments in intolerance factors and risk prediction models, providing valuable guidance for clinical practice and helping improve patients' nutritional status and overall health.

Volume-based enteral feeding for ward patients with acute neurological conditions: a pilot prospective cohort study

BACKGROUND

Patients requiring enteral nutrition (EN) after neurological insults experience feeding interruptions, contributing to inadequate nutrition delivery. This prospective cohort study investigated if volume-based enteral feeding (VBF) improved the delivery of prescribed EN volume in ward patients with acute neurological conditions.

METHODS

Over two sequential periods, the usual care group received standard continuous rate-based feeding, and the intervention group received VBF with bi-daily EN rate adjustments to achieve target daily volume. The primary outcome was percentage of prescribed daily EN formula volume delivered. Differences in energy and protein provision, weight, malnutrition and safety were explored. An evaluation survey captured nurse acceptability of the protocol.

RESULTS

The intervention group (n = 32) achieved greater median interquartile range (IQR) EN adequacy of prescribed volume at 92% (88-97) compared to 67% (54-78) for usual care (n = 35) (p < 0.001). VBF compared to rate-based feeding resulted in patients receiving more kilojoules (131 [121-138] kJ/kg vs. 84 [64-99] kJ/kg; p < 0.001) and protein (1.3 [1.2-1.5] g/kg vs. 0.9 [0.6-1.1] g/kg; p < 0.001). There were no differences in gastrointestinal intolerance between groups. Compliance to the VBF protocol was 90%, and 78% of staff reported high confidence using the protocol. The intervention group had less median weight loss at discharge (-1.4 [0.1 to -4.3] kg) than usual care (-3.6 [-1.3 to 8.4] kg; p < 0.011), but no differences in malnutrition status were observed.

CONCLUSION

A VBF protocol delivered greater EN volume, energy and protein following neurological injury. The VBF protocol was feasible with high acceptability from nursing staff.

Prevalence and risk factors of enteral nutrition intolerance in intensive care unit patients: a retrospective study

BACKGROUND

Feeding intolerance (FI) among intensive care unit (ICU) patients undergoing early continuous enteral nutrition (EN) is related to poor outcomes. This study aimed to explore the prevalence and risk factors of FI in ICU patients.

METHODS

We retrospectively enrolled 1057 patients who received early continuous EN via a nasogastric tube between January 2014 and August 2019. The prevalence of FI during the first 7 days of ICU stay was calculated, and the risk factors were investigated using multivariate logistic regression analysis.

RESULTS

The prevalence of FI during the first 7 days of ICU stay was 10.95%. FI occurred in 159 of 1057 (15.04%) patients on ICU day 2, 114 of 977 (11.67%) patients on ICU day 3, and 86 of 715 (12.03%) patients on ICU day 7. Mechanical ventilation (MV) (odds ratio [OR]: 1.928, 95% confidence interval [CI]: 1.064-3.493, P  = 0.03) was an independent risk factor for FI defined by a gastric residual volume (GRV) of 200 mL and/or vomiting, and acute renal failure (OR: 3.445, 95% CI: 1.115-10.707, P  = 0.032) was an independent risk factor of FI defined by a GRV of 500 mL and/or vomiting. Continuous renal replacement therapy (CRRT) was an independent predictor regardless of the FI defined by a GRV of 200 mL (OR: 2.064, 95% CI: 1.233-3.456, P  = 0.006) or 500 mL (OR: 6.199, 95% CI: 2.108-18.228, P  = 0.001) in the ICU patients.

CONCLUSIONS

FI occurs frequently in early ICU days, especially in patients receiving MV and CRRT. However, further investigation of a consensus definition of FI and risk factors is still warranted in future studies.

A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

The intensivist's assessment of gastrointestinal function: A pilot study

Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.

The prevalence and possible causes of enteral tube feeding intolerance in critically ill patients: A cross-sectional study

Background:

Enteral tube feeding intolerance (ETFI) is one of the most common complications of enteral nutrition (EN), which may lead to increased mortality and length of intensive care unit (ICU) stay. This study aimed to determine the prevalence of ETFI and effects on feeding intolerance on nutrition and clinical outcomes in Iran.

Materials and Methods:

This cross-sectional study was conducted in 2019 at the three general ICUs of Imam Reza Hospital in Mashhad, Iran, during 7 days on 245 patients. The collected data included demographic characteristics, primary diagnosis, the Acute Physiology and Chronic Health Evaluation II (APACHE ІІ) score, Sequential Organ Failure Assessment (SOFA) score, duration of mechanical ventilation, and length of ICU stay. Feeding intolerance was assessed using daily questionnaires for 7 days. ETFI was determined as the interruption of EN based on gastrointestinal causes, including large gastric residuals, abdominal distension, vomiting, diarrhea, and subjective discomfort.

Results:

Overall, 245 critically ill patients (122 males and 123 females) were included in this study, with a mean age of 58.43 ± 19.2 years in three general ICUs. The highest prevalence rate of ETFI was 91.8%, which occurred on the 2^nd day although the rate decreased in the following days. The minimum ETFI was observed on the last day (38.8%). Feeding intolerance was associated with the increased APACHE II scores (P = 0.04), SOFA scores (P < 0.001), and duration of mechanical ventilation (P < 0.001) compared with the tolerant patients. The most common causes of ETFI in the patients admitted to the ICU were gastric residual volume (GRV), large GRV, vomiting, and distension.

Conclusion:

ETFI was prevalent in almost two-third (66%) of the critically ill patients receiving EN based on the GRV. ETFI was associated with deteriorated nutritional status and clinical outcomes.