aspects of nutrition support in the icu在icu患者营养支持方面的实践课件

Practical Aspects of Nutrition Support in the ICU,John W. Drover, MD, FRCSC, FACS Associate Professor Queens University Kingston, ON Canada,,Disclosure Information,None,,Objectives,At the end of the session the participant will be able to: List 3 strategies to maximize the benefits of enteral nutrition. List 2 advantages of post-pyloric enteral feeding. Identify 1 method of gaining post-pyloric access at the bedside in the ICU.,Outline,Review the rationale for enteral feeding. Focus on the data regarding post-pyloric feeding. Specifically RCTs Clinically important outcomes Review the risks of and obstacles to post-pyloric feeding. Develop a recommendation,,Case #1,Day #1 50 yo female COPD with CAP Intubated, resuscitated Who would start EN within 24 hours of admission? Who would attempt to place a post-pyloric feeding tube?,Case #2,Day #5 50 yo female COPD with CAP Intubated, resuscitated feeding tube in stomach Receiving metoclopromide Achieving 400ml Who would recommend placement of a post-pyloric feeding tube?,Nutrition in the Critically ill,Enteral nutrition strongly recommended Early enteral nutrition recommended Optimize the benefits and minimize risks Use of feeding protocols Motility agents for gastric feeding Small bowel feeding,Intra-gastric feeding,The good: Easy access Early initiation Often tolerated well The bad: Gastric residual volumes (GRVs) Gastro-pharyngeal reflux Respiratory aspiration Unrealized nutritional goals,Post-pyloric feeding,2 RCTs that have evaluated aspiration 33 patients, 1st 3 days GE regurg 24.9% vs. 39.8% (p=0.04) Further into small bowel less aspiration 54 patients, twice weekly Low rate of aspiration 7% vs 13% aspiration,Heyland et al, CCM, 2001,Esparaza et al, Int Care Med, 2001,Post-pyloric feeding,11 RCTs of SB vs Gastric feeding Med/Surg (4), Med (3), Trauma (2), Neuro (2) N=664 One study used arginine containing diets Variable design for selection Different methods of enteral access Outcomes No difference in mortality, LOS, vent days,Heyland et al, JPEN 2002,Post-pyloric feeding,Taylor et al. CCM, 1999 Neurotrauma, n=82 Standard gastric feeding 15ml/h increase Q8h Aggressive SB feeding (when feasible) SB access only 34% Start at target rate and adjust Outcomes Pneumonia 44% vs 63%(NS),Post-pyloric feeding,Nutritional outcomes Small bowel feeding associated with Reaching nutritional goals sooner Better success at meeting goals Meta-analysis not possible Variable gastric feeding strategies Goals and success reported in different ways,Post-pyloric feeding,Infections pneumonia (9 studies) 8 clinical criteria; 1 bronchoscopy SB feeding associated with reduced pneumonia RR=0.77(0.60-1.0), p=0.05 23% risk reduction With Taylor study removed RR=0.83(0.6-1.15), p=0.3,Post-pyloric feeding,Post-pyloric feeding,Controversy,“A comparison of early gastric feeding in critically ill patients: a meta-analysis” No difference in outcomes Same RCTs Exclude Taylor Use studies of reflux Didnt count all pneumonia in Montecalvo study,Ho et al, ICM 2006,Post-pyloric feeding,Problems associated with: Difficult to achieve Once achieved may move Doesnt overcome all issues (eg. ACS, short bowel, enteric fistula) Bowel necrosis rare event not clearly associated with enteral nutrition,Zaloga: Nutrition Week 2005,Safe,Canadian survey says 10%,The ENTERIC Study,The Early Nasojejunal Tube To Meet Energy Requirements In Intensive Care Study,Study Investigators: Andrew R Davies Rinaldo Bellomo D Jamie Cooper Gordon S Doig Simon R Finfer Daren K Heyland For the ANZICS Clinical Trials Group,Conclusions,SB feeding improves time to reach target goals success at achieving target goals SB feeding may be associated with less pneumonia,Discussion,Routine use: Difficulties of SB access Blind Endoscopic Flouroscopic Patients with gastric intolerance Patients with other risk factors GERD unable to nurse semi-recumbent (eg. C-spine injury),Discussion,If your unit has feasible access Go for it If your unit has ability with effort Use it for patients at risk i.e. inotropes, sedatives, paralytics, high GRVs If your unit has great difficulty Use in patients who do not tolerate gastric feeding,Bedside placement into SB,Feeding tube in stomach Wire with 30o bend, 3cm from end Zaloga, Chest 1991 Insufflate stomach with 500ml Salasidis, CCM 1998 Rotate while advancing Samis and Drover, ICM 2004,Thank You!,Choosing an approach to: MAXIMIZE BENEFIT Minimize risk,Questions,1) What strategies can be utilized to optimize the delivery of enteral nutrition? Feeding protocols Motility agents Post pyloric feeding All of the above,Questions,2) Post-pyloric feeding is associated with a reduced incidence of ventilator associated pneumonia. True or False 3) Small bowel necrosis associated with post-pyloric feeding is a rare event. True or False,Questions Answer Key,D (reference 1) True (reference 1) True (reference 2),Reference List,(1) Clinical Practice Guidelines Website: . (2) Drover JW, Dhaliwal R, Heyland DK. Post pyloric enteral feeding: Not all it is cracked up to be! International Journal of Intensive Care 2002;9:139-45. (3) Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the Benefits and Minnimizing the Risks of Enteral Nutrition in the Critically Ill: Role of Small Bowel Feeding. J Parenter Enteral Nutr 2002;26:51-7. (4) Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med 2001 Aug;29(8):1495-501. (5) Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. Journal of Trauma-Injury Infection 46(6):992-6.,Reference List,(6) Montecalvo MA, Steger KA, Farber HW, Smith BF, Dennis RC, Fitzpatrick GF, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med 1992 Oct;20(10):1377-87. (7) Davies AR, Froomes PR, French CJ, Bellomo R, Gutteridge GA, Nyulasi, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med 2002 Mar;30(3):586-90. (8) Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med 2000 Jun;28(6):1742-6. (9) Minard G, Kudsk KA, Melton S, Patton JH, Tolley EA. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. Journal of Parenteral 29(10):1916-9.,Reference List,(11) Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999 Nov;27(11):2525-31. (12) Day L, Stotts NA, Frankfurt A, Stralovich-Romani A, Volz M, Muwaswes M, et al. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. J Neurosci Nurs 155 Sep 20;33(3):148-9. (13) Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates