Nutrition Support Traineeship
Hello everyone ! We just managed to fit in our journal club before the month ended. We reviewed the articles below.
I chose the first article because our MICU has proned patient on and off with ARDS. This is the first data looking at possible increased risk of feeding intolerance. The January issue of Critical Care Medicine also has a review of mechanics and physiology of why proning may help oxygenation in ARDS if you are interested in this topic. ……”Modifying the characteristics of the chest wall (e.g., by prone positioning) is a potent mechanism for altering regional differences of transpulmonary pressure.”
Reignier J, Thenoz-Jost N, Fiancette M, Legendre E, Lebert C, Bontemps F, Clementi E, Martin-Lefevre L. Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med. 2004 Jan;32(1):94-9.
The article in Critical Care Medicine by Reignier et. al, is a prospective study that looked at feeding tolerance in patients who were placed in the prone position in order to improve oxygenation. It was a five-day prospective study that compared the feeding tolerance in 34 patients who were placed in the prone position due to severe hypoxemia, with 37 patients who did not have severe hypoxemia and were maintained in the supine position. Patients who were proned were turned every six hours, and in the prone position “the head was kept slightly elevated on a pillow.” All patients were fed with a 14 french NG, and residuals were checked every 6 hours. Feedings were held for six hours and patients were started on IV erythromycin as a prokinetic if residuals were > 250 mL. Patients were fed on an 18-hour cycle, except 24-hour feeds used when on an insulin drip. Feedings were started at 30 mL an hour and the rate was advanced q d until patients were receiving 2000 mL of formula.
The results that are reported were:
The authors concluded that prokinetics, or postpyloric feedings and semirecumbancy should be considered for patients who are fed in the prone position.
Evaluation: The primary point raised in the journal club was that this study had a significant selection bias because it was not a randomized study. Patients who are more hypoxic/require proning may be more likely to experience feeding intolerance because they are “sicker”. Noteworthy is the fact that in the prone position group, 30 episodes of vomiting occurred while the patient was prone, and 26 episodes actually occurred while the patient was supine. It was also discussed that since postpyloric feedings increase reflux of gastric contents (Lien HC, et al. The effect of jejunal meal feeding on gastroesophageal reflux. Scand J Gastroenterol 2001 Apr;36(4):343-6) it is not clear that postpyloric feedings would necessarily be safe. There are a number of other smaller points – but we’re trying to keep this shorter than the original article ! J
Take home message: Practically speaking, despite degree of illness or body position, patients who are proned appear to be at risk for feeding intolerance. There is inadequate data to guide us in the best method of feeding this patient population. Consideration should be made for:
Schloerb PR, Wood JG, Casillan AJ, Tawfik O, Udobi K. Bowel necrosis caused by water in jejunal feeding. JPEN 2004 Jan-Feb ; 28, No 1: 27-29.
The second article reviewed was recently published in JPEN by Schloerb et. al. It describes the case study of a male patient with burn injury who developed 3 duodenal perforations 1 week after starting laparoscopic jejunostomy feedings with 400 mL distilled water flushes q 2 hours. The authors also described intestinal epithelial changes in rat intestine after infusion of distilled water bolus, as compared with isotonic saline flush.
Evaluation: The rat intestine model is not a good model for intestinal changes in humans, as evidenced by studies of translocation in the rat on TPN, which does not occur in humans. There is no evidence presented that tap water flushes via jejunostomy in reasonable volumes pose any risk to humans.
"Man's mind stretched to a new idea never goes back to its original dimension."
- Oliver Wendell Holmes
…COMING IN FEBRUARY:
Scheinkestel CD, et al. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition. 2003 Nov-Dec;19(11-12):909-16.
Other UVAHS NST Info:
Thought this was a way cool web site, just register (it's free), & log in---be sure to check out the Jamarillo Endoscopy Atlas.
The visible human experience is also awesome.