The route of nutritional support in the critically ill: physiological and economical considerations

Kinked and retained nasogastric tube in polytrauma patient; a case report

Enteral feeding is an important and preferred technique of feeding in head injury patient to provide nutrition. As inadequate nutrition causes decrease in physical ability, neurological impairment and takes a long time for improvement or delayed deterioratation. With our best knowledge kinked and retained nasogastric tube in stomach is a very rare complication of feeding in head injuries patients. Predisposing factors that can cause kinking is excess tube length, tube in situ for long time and small bore tube. We are reporting one such case of kinked and retained nasogastric tube in the stomach of a polytrauma patient which was retrieved by upper GI endoscope.

Normograde, minimally invasive technique for oesophagostomy in cats

A percutaneous technique to place oesophageal feeding tubes in cats is described. Nineteen traumatised cats underwent different surgical procedures for facial and/or oral trauma and subsequent oesophagostomy. The tube placement was easy to perform, requiring a 14G over-the-needle vascular catheter, a curved forceps and a 1.2mm feeding tube. During insertion, the tube was directed aborally (normograde direction) to its definitive position in a one-step procedure. The tube was removed when the patient started to eat voluntarily. A major limit of this technique was represented by the small diameter of the feeding tube, requiring the use of a liquid diet. However, considering the absence of complications, the rapidity of the procedure and its cost efficacy, it was considered as an effective alternative to more complicated and invasive techniques, in particular if a short period of starvation is predictable.

Na+-dependent neutral amino acid transporter ASCT2 is downregulated in seriously traumatized human intestinal epithelial cells

OBJECTIVE

Serious trauma to the body often is associated with changes in protein metabolism in multiple organs and tissues. Clinically, the catabolic response results in a generalized negative nitrogen balance. Nutrition support has been an important component of the care of seriously traumatized patients. However, during states of severe trauma, enterocyte transport function remains unclear. This study aims to quantitate the Na+-dependent neutral amino acid transport and expression of its transporter in traumatically injured Caco-2 cell lines.

MATERIALS AND METHODS

Transport and transporter of Na+-dependent neutral amino acid in Caco-2 cell lines were characterized. Then the cell lines were cultured under hypoxic, nutrient-deprived, and ischemic conditions for 1, 2, 4, and 6 hours. After severe trauma was performed, we investigated the transport of Na+-dependent neutral amino acids and the expression of transporter protein and mRNA in apical membrane vesicles.

RESULTS

Among the neutral amino acid transporters, only ASCT2 mRNA was amplified successfully. Under nutrient-deprived and ischemic conditions, transport of L-alanine and L-glutamine decreased significantly compared with control (P < 0.01), whereas hypoxia had no significant effect. The changes were associated with a decrease in maximum transport velocity without an influence on transport affinity. Expression of relative transporter proteins and mRNA decreased significantly compared with control (P < 0.01).

CONCLUSIONS

Na+-dependent neutral amino acid transport and its key transporter are differently regulated during state of traumatic injury. It may be of use to provide some strategies targeting the special nutrient requirements and transport capabilities of seriously traumatized patients.

Glutamine transporter ASCT2 was down-regulated in ischemic injured human intestinal epithelial cells and reversed by epidermal growth factor

BACKGROUND

Clinically, nutrition support has been an important component of the care of the hypoperfusion traumatized patient who is unable to accept complete volitional nutrition. However, enterocyte transport function during states of intestinal hypoperfusion remains unclear. Glutamine is essential for the viability and growth of intestine epithelial cells, and the Na(+)-dependent neutral amino acid transporter ASCT2 is thought to mainly mediate glutamine transport. This study aims to quantify the change of glutamine transporter ASCT2 expression in ischemic injured Caco-2 cell lines and the regulatory action of epidermal growth factor (EGF) on glutamine transport and its transporter.

METHODS

Cells were cultured under ischemic conditions for 2 hours. After ischemia was performed, Caco-2 cells were incubated with or without EGF (100 microg/mL) for 0-8 hours. Then we studied the cell membrane l-glutamine transport, the expression of ASCT2 protein, and mRNA.

RESULTS

After ischemia was performed, Caco-2 cell membrane glutamine transport decreased significantly (p < .01), and the expression of ASCT2 proteins decreased significantly compared with control (p < .01). Under ischemic conditions, expression of ASCT2 mRNA was down-regulated by a real-time polymerase chain reaction (PCR) method. After EGF incubation for 1-2 hours, the proteins and mRNA of ASCT2 were reversed to normal levels (p > .05).

CONCLUSIONS

In ischemic injured Caco-2 cells, ASCT2 protein expression and mRNA transcription were involved in the down-regulation of Na(+)-dependent glutamine transport. The decrease of glutamine transport and its transporter under ischemic conditions could be reversed by EGF action. These findings may help in the choice of the nutrition support manner and clinical therapy of ischemia-damaged intestinal epithelial cells.

The Open Abdomen: Enteral Access Results in Cost Savings

Purpose

To evaluate the cost savings of using enteral access for drug and nutrition delivery in patients requiring open peritoneal cavity management (laparosotomy).

Methods

A review of 14 patients who required laparostomy and received at least 4 consecutive days of enteral nutrition treated at our tertiary care facility between January 1999 and May 2001. Data collected included age, sex, reason for laparostomy, enteral formulation, medications, and side effects (diarrhea and gastric reflux). Cost savings were calculated as the difference between the cost of intravenous (IV) and enteral nutritional formulation and drug dosage costs.

Results

Patients were fed via nasojejunal feeding tube. Average duration of enteral nutrition (EN) was 19.1 ± 12.3 days. Gastric reflux and diarrhea occurred in five (36%) and six (42%) patients, respectively. These were easily treated and did not require conversion to IV nutrition or medications. Drug and electrolyte levels were therapeutic at appropriate enteral doses. A total of 267 days of EN were utilized in these 14 patients. The cost difference between the parenteral nutrition that would have been used during that time and the actual enteral formula utilized was $25,373. The use of enteral rather than IV medications also resulted in a cost savings of $7,058. Thus, the combined cost savings of enteral medication and nutrition therapy for the 14 patients was $32,431.

Conclusion

EN and drug therapy can be utilized in patients requiring open peritoneal cavity management. The resultant cost savings can be substantial, and these methods of cost reduction can also be applied to other patients.

Nutrition and the critically ill horse

A nutritional plan should be incorporated into every treatment plan of the critically ill patient. Weight loss and cachexia are the result of prevalence of catabolic processes over anabolic processes in addition to absolute or relative increased demands and decreased food intake.

The incidence and immediate respiratory consequences of pulmonary aspiration of enteral feed as detected using a modified glucose oxidase test

Pulmonary micro-aspiration of enteral feed in intubated critically ill patients has been reported to occur commonly. In this prospective observational study the incidence of micro-aspiration, diagnosed by a modified glucose oxidase test, is reported in 25 enterally fed critically ill and tracheally intubated patients on a general intensive care unit. Episodes of microaspiration were correlated with changes in PaO2/FiO2 ratio as an index of changes in degree of lung injury. The modified glucose oxidase test differs from the traditional glucose oxidase test because of the enrichment of the feed with glucose (10 g glucose added to 500 ml enteral feed resulting in a tenfold increase in glucose concentration). Pulmonary aspiration of feed was detected by exposing a glucose oxidase strip to tracheal secretions. The feed was enriched with glucose to improve the ability of the reagent strip to detect the feed. The incidence of aspiration of feed was 44% with a prevalence of 6.9% per day of intubation. Only 43% of these episodes of aspiration were detected by the feed being seen in the tracheal secretions. Aspiration was associated with a mean fall in the PaO2/FiO2 ratio of 5.6 kPa from 27.1 kPa to 21.5 kPa (P = 0.002). Aspiration of enteral feed is common and causes a demonstrable morbidity. Detection using this simple bedside test may alert the clinician to institute measures to minimize further aspiration.

Enteral nutrition and surgical patient

Enterai nutrition can be applicated alone or in combination with, parenteral nutrition. Enterai feeding should be applicated as early as possible in preoperative preparation or in postoperative period in respect of contraindications and everyday evaluation of patients. Immunomodulatory substances like arginin, 3-o-fat acids, ribonucleic acid and glutamine are incorporated in "ready to use" solution for enterai feeding. Enterai feedings oral or via tubes are safe if some precautions are taken: like sitting position and control of feeding tubes position. Use of jejunostomy and promotility agents improved enterai feeding after major abdominal surgery and acute pancreatitis. Enterai feeding and immunonutrition improved postoperative course in reduction of hospital stay, incidence of postoperative complications especially infections. The aim of this review article is to validate pro and con for enterai nutrition in preoperative and postoperative course.

Enteral nutrition in the critically ill: a prospective survey in an Australian intensive care unit

Nutritional support is routine practice in critically ill patients and enteral feeding is preferred to the parenteral route. However this direct delivery of nutrients to the gut is potentially ineffective for a variety of reasons. We performed a prospective audit of 40 consecutive intensive care patients to determine whether enteral feeding met the nutritional requirements of our patients. The ideal requirements for each patient were calculated using the Harris-Benedict equation with an adjustment determined by the patient's diagnosis. We compared the amount of feed delivered with the daily requirements over a seven-day period Successful feeding was defined as the achievement of 90% of the ideal calorie requirement for two consecutive days. The mean calculated (+/- SD) energy requirement was 9,566 kJ (+/- 2,586). Patients received only 51% (SD 38) of their energy requirements throughout the study period. Only 10 patients (25%) were successfully fed for at least any two-day period in the seven days. Feeding was limited mainly by gastrointestinal dysfunction or by the need to fast the patient for medical, surgical and airway procedures. Success of feeding was not related to the use of sedative orparalysing agents and had no correlation with plasma albumin concentration. There was no difference in the volume of feed delivered to patients who survived or died. Prokinetic agents were used in 25 patients and in these patients there was a trend towards improved delivery of feed.

A spoonful of sugar--improving the sensitivity of the glucose oxidase test strip method for detecting subclinical pulmonary aspiration of enteral feed

A 74-year-old woman was admitted to the intensive care unit (ICU) with respiratory failure. Following intubation and mechanical ventilation, nasogastric enteral feeding was begun. The sensitivity of the glucose oxidase strip method for detecting aspiration of enteral feed has been questioned because the glucose levels in commonly used feeds are similar to those of normal tracheal aspirates. In order to increase the glucose concentration of the feed, 10 g of glucose was added to each 500 ml feed carton. Testing oral and tracheal secretions with standard glucose oxidase strips allowed the accurate detection of both pharyngeal regurgitation and tracheal aspiration. An episode of subclinical aspiration was detected and this was associated with a fall in the PaO2/FiO2 ratio. There were no further episodes of aspiration following the introduction of a gastric motility agent, maintaining the patient in the semi-recumbent position and an increase in the positive end expiratory pressure (PEEP).