May2010.html

University of Virginia Health System

Nutrition Support E-Journal Club

May 2010

 

Greetings,

We had a great traineeship group in May, hailing from Newport News, VA, Washington D.C, Raleigh, NC, Tampa, FL, and St. Johns, Newfoundland, Canada. When we have slightly larger groups, everyone reaps the side benefits of sharing practices from the other facilities, in addition to the planned experiences of the traineeship.

May Citation: 

Woo SH, Finch CK, Broyles JE, et al. Early vs delayed enteral nutrition in critically ill medical patients.  Nutr Clin Pract. 2010;25(2):205-211.

Summary: 

A prospective, observational, single-center study that evaluated the effect of early or delayed enteral nutrition (EN) on length of stay in a medical ICU.   Early EN was defined as receiving at least 20 mL/h within 24 hours of admission to the ICU.  Secondary objectives of the study included evaluation of the time to initiation of EN at the minimum rate (20 mL/h) and determination of the effect of early vs. delayed EN on total hospital length of stay, duration of mechanical ventilation, risk of pneumonia, risk of bloodstream infection, and hospital mortality.

Inclusion and Exclusion Criteria were:

Inclusion criteria:  Patients admitted to the medical ICU, > 18 years of age, and expected to be NPO for > 48 hours.

Exclusion criteria: Patients that:

  • Were candidates for oral intake on admission to the ICU,
  • Receiving parenteral nutrition within the first 48 hours of admission,
  • Had a life expectancy < 48 hours (if death occurred in the first 48 hours),
  • An ICU stay < 48 hours, or
  • A contraindication to enteral feeding.

Patients were considered to have a possible contraindication to enteral feeding if they had one or more of the following: severe nausea and vomiting, severe diarrhea, malabsorptive syndromes, significant small bowel resection, severe pancreatitis, bowel obstruction, perforation, peritonitis, intravenous (IV) dopamine infusion at a rate > 10 mcg/kg/min, or IV norepinephrine infusion at a rate > 10 mcg/min.

Major Results reported by authors:

The investigators reported that of the 146 patients evaluated, 110 patients met one or more exclusion criteria.  Only 36 patients were eligible for inclusion into the study, with 18 patients receiving early EN and 18 patients receiving delayed EN, all via nasogastric tubes. There were no significant differences in the baseline characteristics of the 36 included patients.

  • Median time to start EN was 23.9 hours in the early EN group and 2.1± 4.8 days in the delayed EN group (p < 0.001).
  • The delayed EN group had a significantly longer median ICU stay than the early EN group (8.5 vs 4.7 days, p = 0.02).
  • Median time on the ventilator was significantly shorter in patients who received early EN (3 days) compared with those who received delayed EN (6 days; p = 0.04).
  • Incidence of new pneumonia was significantly higher in the delayed group compared with the EEN group (44% vs 55.5%, p = 0.02).
  • Incidence of new pneumonia was significantly higher in the delayed group compared with the EEN group (44% vs 55.5%, p = 0.02).
  • Total hospital mortality was significantly higher in those patients who received delayed (7 patients) vs early EN (1 patient) (p = 0.04).

Less than 50% of the patients in both the EEN and delayed group reached the goal rate recommended by the ICU dietitian. In those patients in whom EN did reach goal rate, median time to goal rate was similar in both groups.

ICU mortality was not significantly lower in the early EN group. Three of the 7 patients in the delayed group died in the ICU, compared with 1 patient in the EEN group (p = NS).

Author's Conclusions:

Evidence shows improvement in patient outcomes associated with the use of early EN in a diverse population of critically ill patients.

Evaluation:

This was an observational study; therefore it can only describe associations, and should not be used to form cause-and-effect conclusions.  Although APACHE II scores were similar between groups, it is very possible that some factor that discouraged early feeding was also responsible for the less favorable outcomes in the delayed EN group. 

In addition, this observational study had a very modest number of patients that does not necessarily represent the entire ICU population (>75% of patients excluded, and not all admissions captured).  The patients that were included had a modest severity of illness, as evidenced by the fact that < 20% of studied patients required pressors, and the mean ICU LOS was only 6.6 days.

Our Take Home message:

This study adds to the observational data that supports the need for a large, multicenter, randomized study comparing early versus delayed enteral feeding on patient outcomes.  However, it is not strong data to "prove" a benefit of early enteral feeding in the ICU - certainly not the kind that practicing clinicians would bring to ICU physicians to suggest practice changes.

Other News:

Check out the full schedule of webinar programs at:  

                    www.GInutrition.virginia.edu

  • June 15:  Chyle Leaks--Carol Parrish, MS, RD
  • August 17:  Appetite Stimulants -- Joe Krenitsky, MS, RD
  • September 14:  Nutrition Support Issues in the Home Care Setting--Gisela Barnadas, RD, CNSC
  • October 12:  Nutrition Support in the Patient with Gastroparesis--Carol Parrish, MS, RD
  • November 16:  Calorie and Protein Determination--Joe Krenitsky, MS, RD
  • December (date TBA):  Dermatologic Symptoms of Nutrient Deficiency--Maggie Noland, MD

See the latest Practical Gastroenterology article:

      Available at:

                   www.GInutrition.virginia.edu

 

Joe Krenitsky MS, RD

Carol Rees Parrish MS, RD

PS - Please feel free to forward this on to friends and colleagues.