Montejo JC.
Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units.
Crit Care Med. 1999 Aug;27(8):1447-53. doi: 10.1097/00003246-199908000-00006.
Abstract/Text
OBJECTIVE: To evaluate the frequency of gastrointestinal complications (GICs) in a prospective cohort of critically ill patients receiving enteral nutrition and to assess its effect on nutrient administration and its relationship to the patient's outcome.
DESIGN: Multicenter, prospective cohort study.
SETTING: Thirty-seven multidisciplinary intensive care units (ICUs) in Spain.
PATIENTS: Prospective cohort of 400 consecutive patients admitted to the ICU and receiving enteral nutrition.
INTERVENTIONS: Noninterventional, follow-up study.
MEASUREMENTS AND MAIN RESULTS: Enteral nutrition-related GICs and their management were defined by consensus before data collection. A set of variables related to enteral nutrition administration and the presence of GICs was recorded. During the 1-month study period, 400 patients were enrolled, and a total of 3,778 enteral feeding days were analyzed. The mean time of enteral nutrition was 9.6+/-0.4 days. Mean elapsed time from ICU admission to the start of enteral feeding was 3.1+/-0.2 days. A total of 265 patients (66.2%) received a standard polymeric formula, and 132 (33.8%) received a disease-specific one. Enteral feeds were administered mainly through a nasogastric tube (91%). One or more GICs were presented by 251 patients (62.8%) during the feeding course. The frequency of each particular GIC was as follows: high gastric residuals, 39%; constipation, 15.7%; diarrhea, 14.7%; abdominal distention, 13.2%; vomiting, 12.2%; and regurgitation, 5.5%. Enteral nutrition withdrawal as a consequence of noncontrollable GICs occurred in 15.2% of patients. The volume ratio (expressed as the ratio between administered and prescribed volumes) was calculated daily and was used as an index of diet administration efficacy. Patients with GICs had a lower volume ratio than did patients without GICs (63.1+/-1.20% vs. 93.3+/-0.3%) (p < .001), a longer length of stay (20.6+/-1.2 vs. 15.2+/-1.3 days) (p < .01), and higher mortality (31% vs. 16.1%) (p < .001).
CONCLUSIONS: The frequency of enteral nutrition-related GICs in critically ill patients is high. High gastric residuals is the most frequent GIC. These complications decreased nutrient intake and, if persistent, could expose the patients to undernutrition. Enteral feeding gastrointestinal intolerance seems to have an evolutive effect in prolonging the ICU stay and increasing patient mortality.
Luft VC, Beghetto MG, de Mello ED, Polanczyk CA.
Role of enteral nutrition in the incidence of diarrhea among hospitalized adult patients.
Nutrition. 2008 Jun;24(6):528-35. doi: 10.1016/j.nut.2008.02.004. Epub 2008 Apr 15.
Abstract/Text
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.
ASPEN Board of Directors and the Clinical Guidelines Task Force.
Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.
JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.
Abstract/Text
Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J; A.S.P.E.N. Board of Directors.
Enteral nutrition practice recommendations.
JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):122-67. doi: 10.1177/0148607108330314. Epub 2009 Jan 26.
Abstract/Text
Nutrition Support Journal 2000;1:9.
Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-Schuitema C, Lichota M, Nyulasi I, Schneider SM, Stanga Z, Pironi L.
ESPEN guideline on home enteral nutrition.
Clin Nutr. 2020 Jan;39(1):5-22. doi: 10.1016/j.clnu.2019.04.022. Epub 2019 May 30.
Abstract/Text
This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers about the indications and contraindications for HEN, and its implementation and monitoring. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. This guideline will also inform interested patients requiring HEN. The guideline is based on current evidence and expert opinion and consists of 61 recommendations that address the indications for HEN, relevant access devices and their use, the products recommended, the monitoring and criteria for termination of HEN, and the structural requirements needed to perform HEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.
Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.
Scott R, Bowling TE.
Enteral tube feeding in adults.
J R Coll Physicians Edinb. 2015 Mar;45(1):49-54. doi: 10.4997/JRCPE.2015.112.
Abstract/Text
Enteral tube feeding is usually a relatively straightforward method of nutritional support, and should be facilitated by a multiprofessional team. For short-term use (<4 weeks) a fine bore feeding nasogastric tube is indicated but if longer term feeding is required then a gastrostomy is appropriate, usually inserted endoscopically (a percutaneous endoscopic gastrostomy tube). The most common serious complication of a nasogastric tube is not identifying a misplaced tube within the lungs: there are clear recommendations from the National Patient Safety Agency as to how to check tube placement. Nasojejunal tubes are required in patients with gastroparesis. Tube blockage is common and is prevented by careful and regular flushing. Diarrhoea is the most complication of feeding and is often related to other medication. Clinicians need an algorithm for systematically dealing with such a problem. Refeeding syndrome may occur in malnourished patients and is characterised by low levels of potassium, phosphate, and/or magnesium, as well as disorders of water and salt balance. Identifying the at-risk patient with careful monitoring is crucial.
Rushdi TA, Pichard C, Khater YH.
Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial.
Clin Nutr. 2004 Dec;23(6):1344-52. doi: 10.1016/j.clnu.2004.04.008.
Abstract/Text
BACKGROUND AND AIMS: Enteral fiber-free diets alter intestinal transit and produce diarrhea or constipation. This prospective double blind, controlled study evaluates the use of guar gum, a soluble fiber and a candidate prebiotic in enteral feeds, to prevent diarrhea and potential health benefits in intensive care unit patients.
METHODS: Twenty patients on enteral nutrition with persistent diarrhea were randomized to receive a new enteral feed either enriched with 2% soluble guar gum (study group, n = 10) or fiber-free (control group, n = 10) for 4 successive days.
RESULTS: The number of liquid stools in response to a soluble fiber-enriched diet was 2.0+/-0.9 (first day) vs. 1.0+/-0.7 (fourth day) (P < 0.01), and in the control group 1.2+/-0.7 (first day) vs. 2.1+/-0.8 (fourth day) (P < 0.05). In the fiber-enriched feed group, plasma glucose and cholesterol levels at termination of the study, respectively, reached 126+/-81 and 164+/-71 mg dl(-1), as compared to 333+/-108 and 378+/-26 mg dl(-1) on Day first (P < 0.01). In the control group, these values on the fourth day were, respectively, 267+/-94 and 263+/-79 vs. 247+/-115 and 315+/-78 on Day first (P > 0.05).
CONCLUSIONS: Guar gum-enriched enteral nutrition was related to a decrease of diarrheal episodes in ICU patients with preexisting diarrhea; and to a trend for lower plasma glucose and cholesterol levels.
Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG; Acute Pancreatitis Werkgroep Nederland.
[Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial].
Ned Tijdschr Geneeskd. 2008 Mar 22;152(12):685-96.
Abstract/Text
OBJECTIVE: To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications.
DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial.
METHOD: A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949.
RESULTS: Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004).
CONCLUSION: In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.
McFarland LV.
Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.
Am J Gastroenterol. 2006 Apr;101(4):812-22. doi: 10.1111/j.1572-0241.2006.00465.x.
Abstract/Text
CONTEXT: Antibiotic-associated diarrhea (AAD) is a common complication of most antibiotics and Clostridium difficile disease (CDD), which also is incited by antibiotics, is a leading cause of nosocomial outbreaks of diarrhea and colitis. The use of probiotics for these two related diseases remains controversial.
OBJECTIVE: To compare the efficacy of probiotics for the prevention of AAD and the treatment of CDD based on the published randomized, controlled clinical trials.
DATA SOURCES: PubMed, Medline, Google Scholar, NIH registry of clinical trials, metaRegister, and Cochrane Central Register of Controlled Trials were searched from 1977 to 2005, unrestricted by language. Secondary searches of reference lists, authors, reviews, commentaries, associated diseases, books, and meeting abstracts.
STUDY SELECTION: Trials were included in which specific probiotics given to either prevent or treat the diseases of interest. Trials were required to be randomized, controlled, blinded efficacy trials in humans published in peer-reviewed journals. Trials that were excluded were pre-clinical, safety, Phase 1 studies in volunteers, reviews, duplicate reports, trials of unspecified probiotics, trials of prebiotics, not the disease being studied, or inconsistent outcome measures. Thirty-one of 180 screened studies (totally 3,164 subjects) met the inclusion and exclusion criteria.
DATA EXTRACTION: One reviewer identified studies and abstracted data on sample size, population characteristics, treatments, and outcomes.
DATA SYNTHESIS: From 25 randomized controlled trials (RCTs), probiotics significantly reduced the relative risk of AAD (RR = 0.43, 95% CI 0.31, 0.58, p < 0.001). From six randomized trials, probiotics had significant efficacy for CDD (RR = 0.59, 95% CI 0.41, 0.85, p = 0.005).
CONCLUSION: A variety of different types of probiotics show promise as effective therapies for these two diseases. Using meta-analyses, three types of probiotics (Saccharomyces boulardii, Lactobacillus rhamnosus GG, and probiotic mixtures) significantly reduced the development of antibiotic-associated diarrhea. Only S. boulardii was effective for CDD.
Elia M, Engfer MB, Green CJ, Silk DB.
Systematic review and meta-analysis: the clinical and physiological effects of fibre-containing enteral formulae.
Aliment Pharmacol Ther. 2008 Jan 15;27(2):120-45. doi: 10.1111/j.1365-2036.2007.03544.x. Epub 2007 Oct 8.
Abstract/Text
BACKGROUND: Enteral nutrition can be associated with gastrointestinal side effects and fibre supplementation has been proposed as a means to normalize bowel function.
AIM: To evaluate systematically the effects of fibre supplementation of enteral feeds in healthy volunteers and patients both in the hospital and community settings.
METHODS: Electronic and manual bibliographic searches were conducted. Controlled studies in adults or children, comparing fibre-supplemented vs. fibre-free formulae given as the sole source of nutrition for at least 3 days, were included.
RESULTS: Fifty-one studies (including 43 randomized-controlled trials), enrolling 1762 subjects (1591 patients and 171 healthy volunteers) met the inclusion criteria. Fibre supplementation was generally well tolerated. In the hospital setting, the incidence of diarrhoea was reduced as a result of fibre administration (OR 0.68, 95% CI: 0.48-0.96; 13 randomized-controlled trials). Meta-regression showed a more pronounced effect when the baseline incidence of diarrhoea was high. In both patients and healthy subjects, fibre significantly reduced bowel frequency when baseline frequency was high and increased it when it was low, revealing a significant moderating effect of fibre.
CONCLUSIONS: The review indicates that the fibre-supplemented enteral formulae have important physiological effects and clinical benefits. There is a need to use a consistent approach to undertake more studies on this issue in the community setting.
