Early feeds not force feeds: Enteral nutrition in traumatic brain injury

Nutritional support for the trauma and emergency general surgery patient: What you need to know

ABSTRACT

Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Clinical Outcomes of Early Versus Late Enteral Nutrition Support in Critically Ill Trauma Patients With Isolated Traumatic Brain Injury

INTRODUCTION

This study aims to compare the impact of early initiation of enteral feeding initiation on clinical outcomes in critically ill adult trauma patients with isolated traumatic brain injuries (TBI).

METHODS

A retrospective cohort analysis of the American College of Surgeons Trauma Quality Program Participant Use File 2017-2021 dataset of critically ill adult trauma patients with moderate to severe blunt isolated TBI. Outcomes included ICU length of stay (ICU-LOS), ventilation-free days (VFD), and complication rates. Timing cohorts were defined as very early (<6 hours), early (6-24 hours), intermediate (24-48 hours), and late (>48 hours).

RESULTS

9210 patients were included in the analysis, of which 952 were in the very early enteral feeding initiation group, 652 in the early, 695 in intermediate, and 6938 in the late group. Earlier feeding was associated with significantly shorter ICU-LOS (very early: 7.82 days; early: 11.28; intermediate 12.25; late 17.55; P < .001) and more VFDs (very early: 21.72 days; early: 18.81; intermediate 18.81; late 14.51; P < .001). Patients with late EF had a significantly higher risk of VAP than very early (OR .21, CI 0.12-.38, P < .001) or early EF (OR .33, CI 0.17-.65, P = .001), and higher risk of ARDS than the intermediate group (OR .23, CI 0.05-.925, P = .039).

CONCLUSION

Early enteral feeding in critically ill adult trauma patients with moderate to severe isolated TBI resulted in significantly fewer days in the ICU, more ventilation-free days, and lower odds of VAP and ARDS the sooner enteral feeding was initiated, with the most optimized outcomes within 6 hours.

Effect of early enteral nutrition on critical care outcomes in patients with acute ischemic stroke

Objective

Stroke-associated pneumonia (SAP) is a comorbidity of ischemic stroke related to clinical outcomes. Early enteral nutrition (EEN; within 48 hours) reduces the incidence of infection and length of intensive care unit (ICU)/hospital stay. The relationship between EEN and critical care outcomes, including SAP, in patients with ischemic stroke has been insufficiently studied.

Methods

We recruited 499 patients in this retrospective observational study. We evaluated SAP incidence within 14 days from admission. Patients were divided into an EEN group and a late EN group (LEN; start later than EEN). We compared groups regarding background and length of ICU/hospital stay.

Results

EN was started within 48 hours in 236 patients. SAP was diagnosed in 94 patients (18.8%), with most in the LEN group (28.1% vs. 8.5%). Median [interquartile range] lengths of hospitalization (22 [12–30] days vs. 35 [20–45] days) and ICU stay (4 [2–5] days vs. 6 [3–8] days) were longer in the LEN group. EEN reduced the incidence of SAP. By contrast, consciousness disturbance and worsening consciousness level increased the SAP incidence. Increased age and National Institutes of Health Stroke Scale score were associated with start of prolonged EN.

Conclusions

We found that EEN may reduce SAP risk.

Clinical observation of individualized nutritional formula on inflammation index, immune status and gastrointestinal tolerance in patients with severe head injury

Objectives:

To evaluate the clinical significance of individualized nutritional formulas on inflammatory factors, immune status and gastrointestinal tolerance in patients with severe head injury.

Methods:

A total of 80 patients with severe head injury who were hospitalized in Baoding No.1 Central Hospital from March 2017 to March 2020 were randomly divided into two groups with 40 cases in each group. Patients in both groups were given enteral nutrition (EN), the control group was given conventional enteral nutrition formula through nasointestinal tube, and the experimental group was given individualized nutrition formula. All patients were tested for tumor necrosis factor(TNF-α), C-reactive protein(CRP), interleukin 6(IL-6), IgA, IgM, IgG, serum intestinal fatty acid binding protein(I-FABP) and D-lactic acid concentration before and after enteral nutrition treatment. The incidence of adverse reactions such as abdominal distension, diarrhea, constipation, and gastric retention within seven days after treatment of two groups were compared and analyzed.

Results:

There was no significant difference in inflammatory factors such as TNF-a, CRP, IL-6, immunoglobulin levels, I-FABP and D-lactic acid concentration between the two groups before treatment (p>0.05). After treatment, the above indicators of the two groups of patients were better than before treatment, the difference was statistically significant (p<0.05), and the experimental group was significantly better than the control group (p<0.05). The experimental group had a gastrointestinal adverse reaction rate of 10%, and the control group had 27.5%, the difference was statistically significant (p=0.04).

Conclusions:

Individualized nutritional formula has more significant advantages than conventional nutritional formula for patients with severe head injury, which can reduce inflammatory response, increase the patient’s immune level, improve the intestinal mucosal barrier function, have good gastrointestinal tolerance, and have a low incidence of adverse reactions.

Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials

OBJECTIVES

Enteral formula delivery strategy is an important part of enteral nutrition. We aimed to synthesize up-to-date studies to clarify the effects of intermittent versus continuous feeding on feeding intolerance during enteral nutrition in critically ill adults.

DESIGN

A meta-analysis of randomized controlled trials.

DATA SOURCES

Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases were searched from inception to 17th of June 2020.

REVIEW METHODS

The Cochrane "risk of bias" tool was used to assess the quality of individual studies, and the quality of each outcome was assessed by GRADE approach. Fixed or random effect meta-analysis was used pending the presence of heterogeneity. Dichotomous data synthesis was presented as risk ratio and 95% confidence interval, and quantitative data synthesis was shown as mean difference and 95% confidence interval.

RESULTS

Fourteen trials with 1025 critically ill adults were included in the meta-analysis. We found that intermittent feeding could significantly increase the occurrence of feeding intolerance (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001) compared with continuous feeding, as well as the incidence of high gastric volume (risk ratio = 3.62, 95% confidence interval = 1.43-9.12, P = 0.006) and aspiration (risk ratio = 3.29, 95% confidence interval = 1.18-9.16, P = 0.02) in > 1-week trial duration, while constipation rate was reduced in intermittent feeding group (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = 0.04). Patients in intermittent feeding group received more calories compared with continuous feeding group (mean difference = 184.81, 95% confidence interval = 56.61-313.01, P = 0.005). The quality of all evidence synthesis was "low" or "very low".

CONCLUSIONS

In critically ill adults, continuous feeding was associated with lower overall incidence of feeding intolerance, especially in high gastric volume and aspiration. However, decreased constipation incidence and more calorie intake were observed in intermittent feeding group. Because quality of the synthesized evidence was "low" or "very low", there is considerable uncertainty about this estimate.

Nutrition in surgical patients: how soon is too soon?

PURPOSE OF REVIEW

Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes.

RECENT FINDINGS

Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based.

SUMMARY

Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.

Cilostazol is Effective to Prevent Stroke-Associated Pneumonia in Patients Receiving Tube Feeding

Stroke-associated pneumonia (SAP) is a frequent complication in acute ischemic stroke (IS) patients, especially those receiving tube feeding (TF). In this retrospective study, we investigated whether or not cilostazol, a pluripotent phosphodiesterase III-specific inhibitor with anti-platelet and vasculogenic effects, can prevent SAP in these patients and reduce their duration of stay in intensive care unit/hospitalization. We recruited 158 IS patients receiving TF. Patients' characteristics (including age, gender, past history), National Institute of Health Stroke Scale and serum albumin level on admission, concomitant medications associated with SAP prevention (including cilostazol), and stroke characteristics (bilateral subcortical white matter lesion, brainstem involvement, large infarction, and asymptomatic hemorrhagic infarction) were compared between the SAP(-) and SAP(+) groups. Cilostazol was more frequently used in the SAP(-) group (20.8% vs. 6.1%, p < 0.05). Duration of intensive care unit was longer in patients with SAP (9 ± 8 vs. 6 ± 6 days, p < 0.05). However, the length of stay in an intensive care unit and duration of hospitalization were not reduced due to the prevention of SAP by cilostazol treatment. Cilostazol administration was associated with reduced SAP incidence in acute IS patients receiving TF.

Enteral nutrition volume is not correlated with lower respiratory tract infection in patients on mechanical ventilation

OBJECTIVE

To evaluate the effect of enteral nutrition volume, gastrointestinal function and the type of acid suppressive drug upon the incidence of lower respiratory tract infections in critically ill patients on mechanical ventilation (MV).

DESIGN

A retrospective secondary analysis was carried out.

SETTING

The Intensive Care Unit of a University Hospital.

PATIENTS OR PARTICIPANTS

Patients≥18-years-old expected to need MV for more than four days, and receiving enteral nutrition by nasogastric tube within 24h of starting MV.

INTERVENTIONS

We correlated enteral nutrition volume administered during the first 10 days, gastrointestinal function and the type of acid suppressive therapy with the episodes of lower respiratory tract infection up until day 28. Cox proportional hazards ratios in univariate and adjusted multivariate models were used. Statistical significance was considered for p<0.05.

MAIN VARIABLES OF INTEREST

Lower respiratory tract infection episodes.

RESULTS

Sixty-six out of 185 patients (35.7%) had infection; 27 patients had ventilator-associated pneumonia; and 39 presented ventilator-associated tracheobronchitis. Uninfected and infected groups were similar in terms of enteral nutrition volume (54±12 and 54±9mL/h; p=0.94) and caloric intake (19.4±4.9 and 19.6±5.2kcal/kg/d; p=0.81). The Cox proportional hazards model showed neurological indication of MV to be the only independent variable related to infection (p=0.001). Enteral nutrition volume, the type of acid suppressive therapy, and the use of prokinetic agents were not significantly correlated to infection.

CONCLUSIONS

Enteral nutrition volume and caloric intake, gastrointestinal dysfunction and the type of acid suppressive therapy used were not associated to lower respiratory tract infection in patients on MV.