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Enteral nutrition in critically ill patients

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Where Should We Feed critically ill patients? Done by Dr ... absorbs and uses gut motility for rapid transport to the upper ... Mesh-terms: Critical Illness ... – PowerPoint PPT presentation

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Title: Enteral nutrition in critically ill patients


1
Enteral Nutrition might save life
Where Should We Feed critically ill patients?
Done by Dr KHALED AL SEWIFY
MD, MRCP, EDIC
2
Artificial Nutritional Support
3
Enteral nutrirition
  • Preserves the intestinal mucosal integrity
  • Maintains mucosal immunity.
  • Prevents of increased mucosal permeability.
  • Decreases bacterial translocation.
  • Marik, Zaloga CCM 2005

4
The Gut is the Motor of Sepsis
5
Theory of BT
  • SB and colon contain 1010 anaerobes and 107 Gram
    ve and Gram -ve aerobes and Enough Endotoxins to
    kill us 1000 X.


  • Magnotti
    Deitch 2005 JOABA

6
Saving lives in severe sepsis with the help of
enteral nutrition
  • EN enriched with eicosapentaeonic acid,
    ?-linolenic acid antioxidants in ARDS patients
    with severe sepsis mortality with
  • ARR of 19.4.
  • Pontes-Arruda-Crit Care Med,Sept.2006
    34. 2325-2333.
  • Pontes-Arruda-Crit Care Med  2006
    34. 2325-2333.

7
Effect of EN enriched with EPA/GLA ON MORTALITY
8
Ventilator Free days////ICU Free days
P lt 0.001
7.6 more ventilator-free days
6.2 more ICU-free days
9
PaO2/FIO2
10
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11
Advantages of gastric feeding 
  • It is more physiological, is easier to begin and
    more convenient.
  • Spare both gastropancreatic reflexes and gastrin
    release.
  • Buffers gastric acid well.

12

Intragastric feeding buffer gastric acid better
than post-pyloric feeding
13
What are The Problems Associated with Gastric
Feeding in Critical Illiness ?
14
Gastric Ilieus
15
  • Syndrome of Upper (GIT) Intolerance of EN


16
Incidence of UGIT Intolerance to Gastric
Feeding
Mentec H (2001) Crit Care Med 29
1955-1961
17
What are the sequelae of upper GIT intolerance
to enteral nutrition?
18
1-Inadequate Caloric Supply
19
Prospective survey in Australian ICUs
De Beaux (2001)EN in the critically ill
Anaesth. Intensive Care 29619-622
20
Hazards of UGIT Intolerance
Incidence of Nosocomial Pneumonia
2-Patients with Upper GIT Intolerance Had
Increased Incidence Of Nosocomoial Pneumonia

Feeding intolerance
21
Hazards of UGIT Intolerance
Mortality Rate
2-Patients With Upper GIT Intolerance Had
Increased Mortality

Feeding intolerance
22
Hazards of UGIT Intolerance
ICU Length Of Stay
4-Patients With Upper GIT Intolerance Had
Longer Duration of ICU Stay

Feeding intolerance
23
  • So probably the gastric feeding may not always be
    as safe as it is sometimes considered.
  • The net result is Aspiration Syndrome.
  • Heyland DK 199-AM J Respir Crit Care Med
    1591249-1256.

24
Aspiration Is A Real Threat
25
Aspiration Syndrome
  • 1. 70 with altered LOC.
  • 2. gt 70 of trauma patients at injury.
  • 3. gt 40 of patients with EN.
  • Bowman, et al CCNQ 2005

26
So ICU clinicians are facing a dilemma
27
they have to balance between
28
Prokinetic therapy for feed intolerance in
critical illnes one drug or two ?
  • Erythromyicin is superior to Metoclopramide.
  • Combination therapy had greater feeding success,
    received more daily calories, and had a lower
    requirement for postpyloric feeding less
    incidence of tachyphylaxis.
  • Should be considered as first line therapy in
    treatment of feed intolerance in criticall
    illness.
  • Reignier J - Crit Care Med.2002,
    301237-1241.
  • Nguyen NQ - Crit Care Med. 2007
    Nov35(11)2561-7.

29
But Pro-kinetic drugs are not free from side
effects
30
What is new ?
  • Motilin derivatives
  • Long term efficacy is unknown.
  • Very rapid tachyphylaxis.
  • Cholecystokinin antagonist Loxiglumide
  • Very recent.
  • Accelerate gastric emptying in healthy
    humans.
  • No trials in critically ill patients.
  • Castllo E, et al .Am J Physiol
    2004287G363-G369
  • Cremonini F,et al.Am J Gastroenterol
    2005100625-663

31
? ? ? ?
  • Where Best To Deliver Enteral Nutrition In
    Critically Ill Patients ?
  • Is Small Bowel Feed The Answer ?
  • What Are The Advantages Of Small Bowel Feed?

32
Advantages of Small Bowel Feed
  • Improved absorptive capacity.
  • Less impairment of motility.
  • Better respiratory function as it prevents
    gastric distension.
  • Greater distance between the delivery site and
    the pharynx respiratory tree.

33
Evidence-Based Medicine
34
  • www.criticalcarenutrition.com

35
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39
Conclusions OF THE META-ANALYSIS
  • Small bowel feeding compared with gastric
    feeding
  • Associated with a reduction in pneumonia .
  • Improves calorie and protein intake and is
    associated with less time taken to reach target
    rate of EN.
  • No difference in mortality or MV days.
  • Drover JW - Gastrointest Endosc Clin N Am -
    01-OCT-2007 17(4) 765-75

40
Comparison of early gastric and post-pyloric feed
in ccritically ill patients a meta-analysis
  • By contrast to the previous meta-analysis there
    was no significant benefits on the risk of
    diarrhea, length of ICU stay, mortality or risk
    of aspiration pneumonia.
  • Intensive Care Med 2006 32639

41
Canadian Clinical Practice Guidelines
Recommendations
  • Routine use of SB feedings in units where SB
    access is feasible.
  • In units where obtaining access involves more
    logistic difficulties, SB feedings should be
    considered for patients at high risk for UGIT
    intolerance.
  • When obtaining SB access is not feasible, SB
    feedings should be considered for selected
    patients with high gastric residuals repeatedly
    and are not tolerating gastric feed.
  • Heyland DK - JPEN J Parenter Enteral Nutr
    200327355- Updated Jan 2007

42
Benefits in head injury
  • Grahm et al also found a decrease in infectious
    complications for patients with head injuries who
    received early enteral feeding into the jejunum.
  • Grahm T, Zadrozny D, Harrington T. The
    benefits of early jejunal hyperalimentation in
    the head-injured patient.
  • Neurosurgery. 198925729735

43
Comparison Between Gastric Versus Jejunal Feeding
Incidence of Nosochomial Pneumonia
101 patients
Nosocomial Pneumonia
Gastric
Jejunal
P value 0.4
Jejunal feeding
with early gastric feeding in critically ill
patients Juan C.
Montejo - Crit.Care Med 2002 ,30769-800
44
Benefits in acute pancreatitis 
  • By bypassing the mouth, stomach and duodenum,
    jejunal feeding minimize the stimulation of
    pancreatic exocrine secretions .
  • Accumulating evidence has suggested that
    post-pyloric feeding is safe and may also reduce
    complications.
  • Ragins, H . Am J Surg 1973 126606.
  • Wolfe, BM. Surg Gynecol Obstet 1975
    Feb140(2)241-5.

45
The Disadvantages Of Small Bowel FeedING
  • Difficulty in Placement and Ease of
  • Displacement.
  • Frequent occlusion of small bore tube
    especially with viscid feed and medications.
  • Intestinal perforation.
  • Feeding Intolerance with dumping syndrome.

46
IS IT REALLY DIFFICULT TO PASS NAS-JEJUNAL TUBE ?
47
Blind placement of SB tube
  • Erythromycin appeared useful in 3 studies but
    metocopramide only in one trial.
  • A recent systemic review concluded that
    erythromycin should be administered when blindly
    placing a small bowel tube.
  • Booth CM. A systemic review of the
    evidence.Critc Care Med 2002,301429-1435.
  • Griffith DP . A double blind, RCT . Crit Care
    Med 2003,3139- 44.

48
Blind Placement of sb tube
49
Non blind Placement of SB tube
  • Flouroscopy ensures 90 post pyloric and more
    than 50 into the jejunum.
  • Endoscopically-placed tubes appear to have the
    highest success rates 98 for tube placement into
    the jejunum.
  • US guided, 67 duodenal.
  • EMG guided.
  • Davis AR . Critic Care Med 2002, 30
    586- 590
  • G Gubler, et al.Endoscopy 2006.Dec.
    38 (12)1256-60

50
Distal Duodenal Tube
Chest. 2004125587-591.)
51
JejunaL Tube
52
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53
EMG Guided Post Pyloric Tube
Chest. 2004125587-591.)
54
  • Small bowel tubes

55
TIGER TUBE
  • Provides high insertion success rates (gt90).
  • Cost effective.
  • Self migrating.
  • So it will be left in the stomach and it will
    migrate peristalsis to the jejunum.
  • Samis AJ,. Evaluation of 3 different
    strategies for post pyloric placement of enteral
  • feeding tubes. Intensive Care Med 2004, 30S
    149( abst)

56
Tiger Tube
57
Bengmark Tube
  • Very effective
  • 92.5 crossed the pylorus
  • 89.14 reached the first jejunal loop
  • 3.4 in the duodenum
  • 7.5 stopped in the stomach
  • Reached final position within 5.2 hours, 8
    instantly and all within 24 hours.
  • Start feed immediately
  • G Mangiant, et al.Chir Ital. 52 (5)573-8

58
CORTRAK Monitor
  • Displays track of the feeding tube during
    placement

www.criticalcarenutrition.com
59
Key Benefits
  • Safer
  • 100 success rate in avoiding lung placement in
    clinical trial
  • More Accurate
  • Guides the clinician through the placement
    process by indicating the path of the tube as it
    is placed
  • Less Expensive
  • Fewer X-rays
  • Reduced use of TPN
  • No Fluoro
  • Faster
  • During clinical trials, placements averaged 10.5
    minutes

60
Summary
  • Feed Early Feed Enteral
  • Elevate The Head Of The Bed
  • Consider Small Bowel Feed if UGIT Intolerance/
    failed to respond to prokinetics
  • Remember that patients with high doses
    Catecohlamines , Muscle Relaxants, Opiates
    Benzo. will never tolerate naso-gastric feed

61
  • The use of EN enriched with EPA, GLA
    Antioxidant in ARDS patients with severe sepsis
    and septic shock is associated with
  • An improvement in oxygenation status.
  • Reduced mechanical ventilation time.
  • Fewer days in ICU less new organ
    dysfunction.
  • A19.4 absolute risk reduction in mortality
    rate.

62
THANK
YOU
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