Hypertonic nasogastric tube feedings: do they cause diarrhea?

Dietitian's approach to managing enteral nutrition intolerance when a formula change is indicated: A clinical practice survey

BACKGROUND

Enteral nutrition intolerance (ENI) is often defined as one or more gastrointestinal (GI) symptoms related to enteral nutrition (EN) and may have significant impact on patient outcomes. There are multiple strategies to help manage ENI, such as changing the EN formula. The objective of this practice survey was to understand prevalence of ENI, management of ENI symptoms, and EN formula features considered when changing formulas to manage ENI.

METHODS

Canadian clinical dietitians working across care settings (n = 4827) were invited to complete a 28-question online survey if involved in the management of adult and/or pediatric patients receiving EN.

RESULTS

Five hundred seventeen surveys were analyzed. Significantly more dietitians in adult vs pediatric settings (83.4% and 59.1%, respectively; P = 0.0012), reported ENI in <40% of patients. Assessing medications, elevating the head of the bed, and changing EN infusion rate, volume, or feeding regimen were the highest-ranked strategies to manage ENI symptoms. Most (>90%) respondents change the EN formula <50% of the time to manage ENI. Dietitians consider caloric density and protein form as the most important EN features to manage upper-GI symptoms vs fiber source, osmolality, and form of protein to manage lower-GI symptoms. EN with real-food ingredients was ranked higher in importance for managing upper- and lower-GI symptoms by dietitians in pediatric vs adult settings.

CONCLUSION

To manage ENI symptoms, dietitians consider multiple strategies before deciding to change the EN formula. When a formula change is indicated, dietitians consider different EN features for the management of upper- and lower-GI symptoms.

Effects of a low-FODMAP enteral formula on diarrhea on patients in the intensive care unit

BACKGROUND/OBJECTIVES

A dietary restriction on the intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been reported to be effective in the treatment of gastrointestinal (GI) tract complications. Enteral nutrition (EN) is widely used for patients who cannot obtain their nutritional requirements orally, but many studies have reported EN complications, especially diarrhea, in up to 50% of patients.

SUBJECTS/METHODS

We performed a single-center, non-randomized, controlled trial to determine the effects of a low-FODMAP enteral formula on GI complications in patients in intensive care units (ICUs). Patients in the ICU who needed EN (n = 66) were alternately assigned to the low-FODMAP group (n = 33) or the high-FODMAP group (n = 33).

RESULTS

Anthropometric and biochemical parameters were measured, and stool assessment was performed using King's Stool Chart. We excluded patients who received laxatives, GI motility agents, proton pump inhibitors, antifungal agents, and antibiotics other than β-lactams. There were no differences in GI symptoms during 7 days of intervention, including bowel sound, abdominal distension, and vomiting between the 2 groups. However, diarrhea was more frequent in the high-FODMAP group (7/33 patients) than the low-FODMAP group (1/33 patients) (P = 0.044).

CONCLUSIONS

Our results suggest that a low-FODMAP enteral formula may be a practical therapeutic approach for patients who exhibit enteral formula complications. Our study warrants further randomized clinical trials and multicenter trials.

Trial Registration

Clinical Research Information Service Identifier: KCT0005660

Correcting hypokalaemia in a paediatric patient with Bartter syndrome through oral dose of potassium chloride intravenous solution

Bartter syndrome is a rare autosomal recessive disorder characterized by hypokalaemia. Hypokalaemia is defined as low serum potassium concentration ˂3.5 mmol/L, which may lead to arrhythmia and death if left untreated. The aim of this case report was to normalize serum potassium concentration without the need for intravenous intervention. A 5-month-old male of 2.7 kg body weight diagnosed with Bartter syndrome was admitted to the general paediatric ward with acute severe hypokalaemia and urinary tract infection. The main challenge was the inability to administer drugs through intravenous route due to compromised body size. Therefore, we shifted the route of administration to the nasogastric tube/oral route. A total of 2 mL of concentrated intravenous potassium chloride (4 mEq potassium) were dissolved in distilled water and administered through nasogastric tube. Serum potassium concentration was rapidly normalized, which culminated in patient discharge. In conclusion, shifting drug administration from intravenous to oral route in a paediatric patient with Bartter syndrome includes numerous advantages such as patient convenience, minimized risk of cannula-induced infection, and reduced nurse workload.

Free flap reconstruction in paediatric patients with head and neck cancer: clinical considerations for comprehensive care

Free flap reconstruction after resection in paediatric patients with head and neck cancer (HNC) has various clinical challenges, which have not yet been fully investigated. This retrospective study was implemented to investigate these factors. Paediatric patients (≤14 years old) who underwent free flap reconstructions following surgery for HNC at a tertiary referral centre during the years 2009-2018 were included. Clinical, pathological, and imaging data were collected and analysed. Overall, 47 patients were included, 26 male and 21 female. Thirty-four patients were ASA status I and 13 were ASA status II. The median operative time was 415 minutes, while the median intraoperative blood loss was 500 ml. Seventeen patients had a tracheotomy. Fourteen medical complications (six pulmonary infection, six diarrhoea, two pulmonary aspiration) and six surgical complications (one haematoma beneath flap, two wound dehiscence, one salivary fistula, one effusion, one tracheotomy haemorrhage) were observed. Tracheotomy was associated with medical complications (P = 0.003) and total complications (P = 0.024). It was confirmed that microvascular reconstruction can be adopted in paediatric HNC patients, while tracheotomy and nasal feeding tubes should be used with caution. Comprehensive preoperative assessment, gentle handling of the tissues during operative procedures, and appropriate postoperative management will reduce the risk of complications.

The Use of Transpyloric Enteral Nutrition in the Critically Ill Child

To assess the use and complications of transpyloric enteral nutrition (TEN) in the critically ill child we evaluated prospectively all children who received TEN in a pediatric intensive care unit (PICU) of a tertiary university hospital. The type of nutrition used, its duration, medication administered, tolerance, gastrointestinal complications (vomiting, abdominal distension or excessive gastric residue, diarrhea, and pulmonary aspiration), nongastrointestinal complications, and mortality were assessed. A comparative analysis was made between the first 2 years of the study and the remaining period. Over a period of 4.5 years, 152 patients between the ages of 3 days and 17 years received TEN for a duration of 19 ± 32.3 days (range 1–240 days). Forty-one patients received TEN during the first 2 years; 100 patients received TEN in the postoperative period after cardiac surgery (66%). One hundred seventeen patients (77%) received sedation and 65 (43%) received muscle relaxants, presenting no extra complications. Twenty-four patients (15.8%) presented with gastrointestinal complications: abdominal distension and/or excessive gastric residue in 17 and diarrhea in 11. Gastrointestinal intolerance was associated with pulmonary infection ( p < 0.05), altered hepatic function ( p < 0.001), and hypokalemia or hypocalcemia ( p < 0.05). Diarrhea was more frequent in patients with shock ( p < 0.05), altered hepatic function ( p < 0.05), excessive gastric residue ( p < 0.001), and hypokalemia or hypocalcemia ( p < 0.05). In the second study period, the number of patients on TEN and the doses of sedatives, muscle relaxants, and vasoactives were higher ( p < 0.05), with no increase in the incidence of complications. TEN is a useful method of nutrition with few complications in the critically ill child.

Role of FODMAP content in enteral nutrition-associated diarrhea

Gastrointestinal symptoms including diarrhea are common complications of enteral nutrition (EN); however, the cause is unclear. Mode of EN delivery that alters digestion and possibly absorption is suggested to contribute to the high incidence of diarrhea; however, enteral formula is frequently blamed. Most research has focused on fiber-supplemented EN, with a meta-analysis showing that fiber reduces the incidence of diarrhea in non-intensive care unit studies. Other hypotheses include formula osmolality and FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) content. FODMAPs are poorly absorbed short-chain carbohydrates that exert an osmotic effect. Dietary FODMAPs have been shown to reduce gastrointestinal symptoms, including diarrhea, in those with irritable bowel syndrome and, given a high-enough dose, will induce a laxative effect in most people. As FODMAPs are commonly added to enteral formula and EN is frequently used as the main source of nutrition, it is reasonable to hypothesize that EN provides more FODMAPs than usual dietary intake and increases risk for developing diarrhea. This hypothesis was assessed through a retrospective study showing that the standard-use enteral formula Isosource 1.5 had a protective effect of developing diarrhea. The only characteristic unique to Isosource 1.5 was the lower FODMAP content as determined through methodologies previously validated for food analysis. Methodologies for application to enteral formulas are currently undergoing formal validation. Once confirmed for application in enteral formula, future directions include FODMAP analysis of specific ingredients to increase understanding of potential problems associated with enteral formula and a randomized, controlled trial investigating the role of formula FODMAP content.

Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit

OBJECTIVE

Diarrhoea in the enterally tube fed (ETF) intensive care unit (ICU) patient is a multi-factorial problem. Diarrhoeal aetiologies in this patient cohort remain debatable; however, the consequences of diarrhoea have been well established and include electrolyte imbalance, dehydration, bacterial translocation, peri anal wound contamination and sleep deprivation. This study examined the incidence of diarrhoea and explored factors contributing to the development of diarrhoea in the ETF, critically ill, adult patient.

METHOD

After institutional ethical review and approval, a single centre medical chart audit was undertaken to examine the incidence of diarrhoea in ETF, critically ill patients. Retrospective, non-probability sequential sampling was used of all emergency admission adult ICU patients who met the inclusion/exclusion criteria.

RESULTS

Fifty patients were audited. Faecal frequency, consistency and quantity were considered important criteria in defining ETF diarrhoea. The incidence of diarrhoea was 78%. Total patient diarrhoea days (r=0.422; p=0.02) and total diarrhoea frequency (r=0.313; p=0.027) increased when the patient was ETF for longer periods of time. Increased severity of illness, peripheral oxygen saturation (Sp02), glucose control, albumin and white cell count were found to be statistically significant factors for the development of diarrhoea.

CONCLUSION

Diarrhoea in ETF critically ill patients is multi-factorial. The early identification of diarrhoea risk factors and the development of a diarrhoea risk management algorithm is recommended.

Diarrhoea in the enterally fed patient

Diarrhoea complicating enteral feeding is very common in all clinical settings. The major risk factor is the use of concomitant antibiotics. The underlying mechanisms for the diarrhoea mainly relate to alterations in the colonic flora and physiological responses to the mode of feed delivery although a clear understanding of what is actually happening in vivo remains elusive. Management of diarrhoea includes rationalising medications, excluding relevant comorbidity and using antidiarrhoeal medications. Altering the method and site of feed delivery-for example, continuous to bolus, gastric to postpyloric-can also be tried in the more difficult cases.

Role of enteral nutrition in the incidence of diarrhea among hospitalized adult patients

OBJECTIVE

This study examined the risk of diarrhea as a result of providing enteral nutrition in the hospital setting, adjusting for other clinical and therapeutic factors.

METHODS

Adults admitted to a general tertiary care university hospital, in clinical or surgical units, were enrolled in the study between June 2004 and May 2005 and prospectively followed during their hospital stay. For each patient treated with enteral nutrition (n = 302), a comparable non-treated patient from the same ward (who also received antibiotics previously) and was similarly cared for by the same hospital staff was included in the study (n = 302), constituting a double-cohort study. All patients were seen three times per week, on alternating days, until the occurrence of diarrhea or hospital discharge. Cox's regression analyses were applied for adjustments.

RESULTS

The incidence of diarrhea was 18% for patients receiving enteral nutrition and 6% for non-treated patients (P < 0.01). In multivariate analyses, enteral nutrition was independently associated with diarrhea (hazard ratio 2.7, 95% confidence interval 1.6-4.7), even adjusting for age (hazard ratio 1.02, 95% confidence interval 1.00-1.03) and hospitalization during the summer months (hazard ratio 2.4, 95% confidence interval 1.5-3.9). Patients for whom strict adherence to delivery-set washing-and-changing procedures was observed (on >75% of days) presented a lower incidence of diarrhea (6.5% versus 20.3%, P = 0.02; and 5.9% versus 19.8%, P = 0.05, respectively).

CONCLUSION

Providing enteral nutrition to the hospitalized elderly during the summer months is associated with a higher risk of diarrhea. Strategies aimed toward improvement in the quality of enteral nutrition practices should be evaluated to minimize this deleterious clinical outcome.

What's new on defining diarrhea in tube-feeding studies?

Nurses who are involved in studies of tube feeding tolerance or who review the literature on this topic are confronted with a myriad of definitions and methods of reporting diarrhea. In a 1992 study, the authors reported that these definition differences influenced results. In a review of the current literature, they determined that little progress had been made toward standardizing definitions and reports of diarrhea in studies of tube feeding. A secondary analysis of stool characteristics of hospitalized patients using various definitions of diarrhea showed there was a positive association between stool frequency and consistency. Criteria for stool consistency in the definitions of diarrhea appeared to have a greater influence on diarrhea outcomes when stool frequency was low. The authors suggest recognition of a taxonomy of definitions of diarrhea in the absence of consensus, which will help guide the design of future investigations and facilitate the evaluation and utilization of research.

Critical care of the head and neck patient

The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.

An overview of diarrhea in the patient receiving enteral nutrition

Many healthcare providers associate enteral tube feedings with diarrhea. Research suggests an incidence of diarrhea in patients receiving enteral tube feedings of 2% to 63%. This wide variation in incidence is due, in part, to the lack of a universal definition of diarrhea and other suspected factors that influence stool output such as malabsorption, infection, bacterial contamination of the feeding, medical diagnosis of the patient, medication therapy, or formula-related causes. An understanding of digestion, the role of fiber and fat in the diet, and the control for other influences will aid nurses in identifying interventions that promote a normal stool consistency in patients receiving enteral tube feedings. The need for further research regarding the causes and management of diarrhea is also supported.