The safety of enteral and parenteral nutrition in ICU patients receiving vasopressors

Patel JJ, et al. Phase 3 Pilot Randomized Controlled Trial Comparing Early Trophic Enteral Nutrition With “No Enteral Nutrition” in Mechanically Ventilated Patients With Septic Shock. JPEN J Parenter Enteral Nutr. 2020 Jul;44(5):866-873.

Full-text for Emory users.

Results: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the “no EN” arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the “no EN” group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the “no EN” arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the “no EN” arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in “no EN” arm (P = .009).

Conclusion: Our protocol comparing early trophic EN with “no EN” in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.

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A randomised trial of post-discharge enteral feeding following surgical resection of an upper gastrointestinal malignancy

Froghi F, et al. A randomised trial of post-discharge enteral feeding following surgical resection of an upper gastrointestinal malignancy. Clin Nutr. 2017 Dec;36(6):1516-1519.

Full-text for Emory users.

RESULTS: 44 patients (M:F, 29:15) were randomised, 23 received jejunal supplements. There were no differences between the groups. Percentage of calculated energy requirement received was greater in the supplemented group at weeks 3 and 6 (p < 0.0001). Oral energy intake was not different between the groups at any time period. After hospital discharge, there were no differences in MFI-20, EQ5D and QLQ-OES18 scores at any time point. From hospital discharge fatigue improved and plateaued at 6 weeks (p < 0.05 for both groups), independence at 12 weeks (p < 0.05 for both groups). No improvement was seen in quality of life until 24 weeks in the active group alone (p < 0.02) and not at all in the control group.

CONCLUSIONS: Addition of jejunal feeding is effective in providing patients with an adequate energy intake. Increased energy intake however, produced no obvious improvement in measures of fatigue, quality of life or health economics.

Nutritional support of the enterocutaneous fistula patient

Kumpf VJ, et al. ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients With Enterocutaneous Fistula.JPEN J Parenter Enteral Nutr. 2017 Jan;41(1):104-112. doi: 10.1177/0148607116680792.

Free full-text. 

Questions addressed in these guidelines: 

In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas?(6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

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Monitoring gastric residuals in ICU patients: Does it prevent ventilator-associated pneumonia?

One discussion this week involved monitoring gastric residuals in ICU patients.

Reference: Reignier J, et al. Effect of not monitoring residual gastric volume on risk of ventilator-assisted pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized control trial. JAMA. 2013 Jan 16;309(3):249-56. doi: 10.1001/jama.2012.196377.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01137487.

Summary: Monitoring of residual gastric volume is recommended to prevent ventilator-associated pneumonia (VAP) in patients receiving early enteral nutrition. However, studies have challenged the reliability and effectiveness of this measure.

DESIGN, SETTING, AND PATIENTS: Randomized, noninferiority, open-label, multicenter trial conducted from May 2010 through March 2011 in adults requiring invasive mechanical ventilation for more than 2 days and given enteral nutrition within 36 hours after intubation at 9 French intensive care units (ICUs); 452 patients were randomized and 449 included in the intention-to-treat analysis (3 withdrew initial consent).

INTERVENTION: Absence of residual gastric volume monitoring. Intolerance to enteral nutrition was based only on regurgitation and vomiting in the intervention group and based on residual gastric volume greater than 250 mL at any of the 6 hourly measurements and regurgitation or vomiting in the control group.

RESULTS: In the intention-to-treat population, VAP occurred in 38 of 227 patients (16.7%) in the intervention group and in 35 of 222 patients (15.8%) in the control group (difference, 0.9%; 90% CI, -4.8% to 6.7%). There were no significant between-group differences in other ICU-acquired infections, mechanical ventilation duration, ICU stay length, or mortality rates. The proportion of patients receiving 100% of their calorie goal was higher in the intervention group (odds ratio, 1.77; 90% CI, 1.25-2.51; P = .008). Similar results were obtained in the per-protocol population.

CONCLUSION AND RELEVANCE: Among adults requiring mechanical ventilation and receiving early enteral nutrition, the absence of gastric volume monitoring was not inferior to routine residual gastric volume monitoring in terms of development of VAP.

The authors further conclude that “eliminating residual gastric volume monitoring from standard care may have beneficial effects. First, in the present study, absence of residual gastric volume monitoring was associated with improved enteral nutrition delivery. High residual gastric volume values often lead to enteral nutrition discontinuation, which in turn causes underfeeding with increases in morbidity and mortality rates. We found no difference in mortality rates. However, our enteral nutrition protocol was more aggressive than previously reported protocols: enteral nutrition was started at the rate required to meet the calorie target and was stopped gradually in the event of intolerance. Moreover, enteral nutrition solution lost by vomiting, being discarded, or both was not measured, thus resulting in potential overestimation of delivered calories. These factors may have attenuated any mortality difference related to differences in delivered enteral nutrition volume” (p.255).

Calculation of essential metabolites in Total Parenteral Nutrition: the basics

One discussion this week involved how to perform basic TPN metabolite calculations.

Reference: Madsen H and Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Practical Gastroenterology. 2006 July. Retrieved from https://www.practicalgastro.com/pdf/July06/MadsenArticle.pdf.

Summary: This was discussed as a possible question on boards. Below are three tables, taken directly from the article referenced.

table3

(p.48)

table12

 

 

 

 

 

 

 

(p.57)

table20

(p.67)

Metabolic effects of octreotide

One discussion this week involved the effects of octreotide.

Reference: Octreotide: a drug often used in the critical care setting but not well understood. Chest. 2013 Dec;144(6):1937-1945. doi:10.1378/chest.13-0382.

Summary: While a majority of octreotide is metabolized by the liver, 30-35% of octreotide acetate is excreted in the urine. Thus, octreotide accumulates in patients with moderate to severe renal or hepatic insufficiency.

Compared with SST-14, it exhibits 45-fold more potent inhibition of growth hormone, 11-fold more of glucagon, and 1.3-fold more insulin secretion.

octreotide

(p.1940)

Octreotide inhibits insulin secretion in the following ways (p.1943):

  • Binds to SSTR-5 present on pancreatic B islet cells, inhibiting the formation of cAMP and reducing influx of calcium into the cytoplasm, thus preventing insulin secretion.
  • Inhibition of direct phosphorylation of specific proteins required for secretion of insulin-containing vesicles.

Additional reading:  Adabala M, et al. Severe hyperkalaemia resulting from octreotide use in a haemodioalysis patient. Nephrology, Dialysis, Transplantation. 2010 Oct;25(10):3439-3442. doi:10.1093/ndt/gfq381.