Is early enteral feeding of benefit?

A review of the nursing care of enteral feeding tubes in critically ill adults: part I

Enteral tubes are frequently used in critically ill patients for feeding and gastric decompression. Many of the nursing guidelines to facilitate the care of patients with enteral tubes have not been based on current research, but on ritual and opinion. Using a computerised literature search and an evidence-based classification system as described by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tube management. Several nursing practices related to enteral tube management are described. Evidence to support alternate methods of tube placement assessment other than abdominal X-ray was inconclusive. Enteral feeding should continue if gastric residual volumes are not considered excessive, as feeding is often withheld unnecessarily. Frequency of checking gastric residual volumes is largely opinion based and varies considerably, but prokinetics that aid gastric emptying should be used if absorption of feeds is problematic. Other recommendations include continuous rather than intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspiration and diligent artificial airway cuff management. Contamination of feeds can be minimised by minimal, meticulous handling and the use of closed rather than open systems. Generally, there was little high quality evidence to support practice recommendations leaving significant scope for further research by nurses in the management of patients with enteral tubes.

Bio-ecological control of perioperative and ITU morbidity

BACKGROUND

Perioperative and intensive therapy unit (ITU) morbidity and mortality has remained unchanged during the past several decades, and this at an unacceptably high level. It is most likely, in the EU countries annually, that more than 1 million people suffer severe sepsis and some 300,000 die. Pharmaceutical attempts at prevention and treatment have, despite extensive efforts, hitherto failed to improve outcome more significantly. Much supports the fact that sepsis and its severe consequences are results of a malfunctioning innate immune system, impaired by both lifestyle and disease. A series of mostly simple measures to prevent further deterioration of the immune system, and to boost it, is recommended. Among the measures recommended are some modifications of surgical and postoperative management: restricted use of antibiotics, attempts made to maintain salivation and GI secretions, omission of prophylactic gastric decompression, postoperative drainage and preoperative bowel preparation, restricted use of stored blood, avoidance of overload with nutrients, uninterrupted enteral nutrition but also tight blood glucose control, supply of antioxidants, administration of prebiotic fibre and probiotic lactic acid bacteria. Nutritional control of postoperative morbidity includes use of so-called synbiotics, e.g. a combination of bioactive lactic acid bacteria (LAB) and bioactive plant fibres.

RESULTS

Dramatic reduction in (in reality, almost abolishment of) septic morbidity is reported following supplementation of specific bioactive lactic bacteria in combination with prebiotic plant fibres, as tried in controlled studies in connection with extensive abdominal operations, liver transplantation and severe acute pancreatitis.

Improvements of postburn renal function by early enteral feeding and their possible mechanisms in rats

AIM: To investigate the protective effects of early enteral feeding (EEF) on postburn impairments of renal function and their possible mechanisms.

METHODS: Wistar rats with 30% of total body surface area (TBSA) full-thickness burn were adopted as the experimental model. The effects of EEF on the postburn changes of gastric intramucosal pH(pHi), endotoxin levels in portal vein, water contents of renal tissue, and blood concentrations of tumor necrosis factor (TNF-α), urea nitrogen (BUN), creatinine (Cr), as well as the changes of clearance of creatinine (CCr) were dynamically observed within 48 h postburn.

RESULTS: EEF could significantly improve gastric mucosal acidosis, reduce portal vein endotoxin levels and water contents of renal tissue, as well as blood concentrations of TNF-α after severe burns (P < 0.01). The postburn elevations of BUN and BCr were not found to be recovered by EEF. However, the CCr in EEF group was greatly increased by 4.67-fold compared with that of the non-feeding burned control (16.43 ± 2.90 vs. 3.52 ± 0.79, P < 0.01).

CONCLUSION: EEF has beneficial effects on the improvement of renal function in severely burned rats, which may be related to its increase of splanchnic blood flow, decrease of the translocation of gut-origin endotoxin and the release of inflammatory mediators.

Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy

OBJECTIVE

To compare the outcomes of intensive care unit patients fed through a nasogastric vs. a nasal-small-bowel tube including the time from tube placement to feeding, time to reach goal rate, and adverse events.

DESIGN

Sixty patients were prospectively randomized to receive gastric or small-bowel tube feedings. Nursing staff attempted to place a feeding tube in the desired position, and placement was confirmed radiographically after each bedside attempt. After two unsuccessful attempts, the feeding tube was placed under fluoroscopy. Feedings were started at 30 mL/hr and advanced to the patient's specific goal rate.

SETTING

Twenty-bed medical intensive care unit.

PATIENTS

Sixty medical patients admitted/transferred to the intensive care unit.

INTERVENTIONS

Tube feeds were held for 2 hrs if any residual was >200 mL.

MEASUREMENTS

Times were recorded at the initial tube insertion, onset of feeding, achievement of goal rate, and termination of feeding. Adverse outcomes included witnessed aspiration, vomiting, and clinical/radiographic evidence of aspiration. Patients were followed up for the duration of feeding, until leaving the intensive care unit, or for a maximum of 14 days.

MAIN RESULTS

Patients fed in the stomach received nutrition sooner from initial placement attempt (11.2 hrs vs. 27.0 hrs) and with fewer attempts (one vs. two) than those fed in the small bowel. Patients achieve goal rate sooner (28.8 hrs vs. 43.0 hrs) with gastric feeding compared with small-bowel feeding. There was no difference in aspiration events.

CONCLUSIONS

Gastric feeding demonstrates no increase in aspiration or other adverse outcomes compared with small-bowel feeding in the intensive care unit. Gastric feeding can be started and advanced to goal sooner with fewer placement attempts than small-bowel feeding.

Protective effect of early enteral feeding on postburn impairment of liver function and its mechanism in rats

AIM: To study the protective effect of early enteral feeding (EEF) on the postburn impairment of liver function and its mechanism.

METHODS: Wistar rats with 30% of total body surface area (TBSA) full-thickness burn were employed. The effects of EEF on the postburn changes of gastric intramucosal pH, endotoxin levels in portal vein, water contents of hepatic tissue, blood concentrations of tumor necrosis factor (TNF-α), plasma activities of alanine aminotransferase (ALT) and asparate amin otransferase (AST), as well as the blood contents of total (TB) and direct bilirubin (DB), total protein (TP) and albumin (ALB) were serially determined within 48 h postburn.

RESULTS: EEF could significantly improve gastric mucosalacidos is, reduce portal vein endotoxin level and water content of hepatic tissue, as w ell as plasma concentrations of TNF-α at all timepoints after seve re burns (P < 0.01); postburn elevation of the plasma activities of ALT, AST and the contents of TB, DB were effectively prevented, whereas the plasma conce ntrations of TP and ALB were markedly increased 24 h and 48 h posturn in EEF group compared with that of the burn without EEF group (P < 0.01).

CONCLUSION: EEF has significant beneficial effects on the impro vement of hepatic function in rats after severe burn, and is probably related with an increase in splanchnic blood flow, reduction of the absorption of gut-origin endotoxin and the consequent release of inflammatory mediators.