Nutrition Support Traineeship
We have just concluded our first traineeship session with four participants. This month we hosted a nutrition team from Gastonia, NC and a dietitian from Bentonville, Arkansas. We had more ‘players’ at our journal club than ever, and to top it all off we had a film crew from the Japanese Broadcasting Company (NHK) here to film the whole thing! Our teams were filmed for a Japanese audience about American nutrition support practices. It was a lot of work to be well behaved and limit my creative gestures during the entire journal club!
Our article this month is from the August 2004 issue of Clinical Nutrition:
Kompan L, Vidmar G, Spindler-Vesel A, Pecar J. Is
early enteral nutrition a risk factor for gastric intolerance and
pneumonia? Clin Nutr. 2004 Aug;23(4):527-532.
This study was designed to study the effects of early enteral feeding in intubated trauma patients. Fifty-two patients were randomized to receive either early enteral nutrition, or enteral nutrition after 48 hours with a goal for both groups of 1.25 to 1.88gm protein/kg, and 25 non-nitrogen kcals/kg. The primary outcomes were intolerance to enteral feeding (defined as gastric residual > 200 mL on 2 or more consecutive checks, or emesis) and ventilator-associated pneumonia.
All patients received a polymeric formula (Nutricomp) via “intragastric” tube over an 18 hour feeding cycle. Those patients who had a gastric residual over 200 mL received metoclopramide, and TPN was added “to meet nutritional requirements.”
The early group (n= 27) started enteral feedings within 10 hours, and the late group (n= 25) started enteral feeding 38 +/-15 hours after admission. The authors reported that the patients who received early feedings experienced significantly less days with upper digestive intolerance (1.1 Vs 2.2 days) and significantly less patients with pneumonia (9 patients Vs 16 patients).
This study is interesting because it suggests that very early feeding in critically ill patients actually decreased upper digestive intolerance and pneumonia. However, the study has several factors that limit the strength of these conclusions. One factor is that it is not a double-blind study; both the researchers and caregivers knew the patient’s assigned group. Information about narcotic requirements or prokinetic use was not detailed, so it is not known if there were significant differences in medication use between the groups. In trials with relatively small groups this is important to know to make sure your randomization “worked”.
One major factor that must be considered in this study is the use of TPN to provide additional calories. It is important to remember that in the classic trial by Kudsk et al.1 of enteral feeding versus TPN in trauma patients, that pneumonia was the most frequent infection in the TPN group. The late feeding group received less enteral calories than the early group, therefore according to the methods described, the late feeding group should have received more TPN. It is possible that the use of TPN could have contributed to the increased infections (pneumonia) in the late feeding group. There is no detailed information provided in the paper regarding amount of TPN provided between the two groups.
The fact that 64% of patients in the late feeding group were reported to develop pneumonia is concerning, as this is a much higher incidence than that reported in the gastric feeding groups in the trials that have investigated gastric versus jejunal feeding. There is no mention in this paper about a protocol (if any) for positioning the head of the patient’s bed during enteral feeding.
Take home message:
This study is quite interesting because it suggests that early feeding in injured patients may actually improve gastrointestinal tolerance to feeding. However, the “take home” message of our journal club was that the limitations in this study limit the strength of any conclusions. We all agreed that this is not a study that we would offer as “proof” of the benefits of early enteral feeding, but we also agreed that the limitations do not preclude the possibility that very early feeding may indeed improve GI tolerance. It would be valuable to see this study repeated in a larger group of patients, without the confounding factor of TPN.
1. Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA, Poret HA, Kuhl MR, Brown RO. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992 May;215(5):503-11
In other news, Joe’s new article in Practical Gastroenterology on Nutrition Support in Renal Failure – it’s great! (says the series editor…JJ crp). Check it out on our website:
Carol is back from a consensus conference on gastroparesis by the American Motility Society. A document is being designed as a template to treat patients with gastroparesis. She is responsible for the nutritional aspects including, nutritional assessment through nutrition support. The goal is to have it hammered out by May 2005 in time for the American Gastroenterological Association Annual Conference (Digestive Disease Week).
“The truth is that our finest moments are most likely to occur when we are feeling deeply uncomfortable, unhappy, or unfulfilled. For it is only in such moments, propelled by our discomfort, that we are likely to step out of our ruts and start searching for different ways or truer answers.”
- M. Scott Peck
Joe Krenitsky MS, RD
PS – Please feel free to send this on to friends and colleagues.