Establishing Early Enteral Nutrition With the Use of Self‐Advancing Postpyloric Feeding Tube in Critically Ill Children

Introduction: Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%?80%. The authors report on their experience with a 14Fr polyurethane self‐advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors’ knowledge, there have been no reports of its use in the pediatric age group. Case Series: The authors present 7 critically ill patients 8–19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. Conclusion: The self‐advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.     

Self‐Insertion of a Nasogastric Tube for Home Enteral Nutrition

Background: Enteral tube feeding can be a source of discomfort and reluctance from patients. We evaluated for the first time the tolerability of self‐insertion of a nasogastric (NG) tube for home enteral nutrition (EN). Materials and Methods: All patients requiring enteral tube feeding for chronic diseases were enrolled in a therapeutic patient education (TPE) program at Nancy University Hospital. Results: In our department, between November 2008 and August 2012, 66 patients received EN with an NG tube. Twenty‐nine of 66 had self‐insertion of the NG tube (median age, 44 years), 17 had an anatomical contraindication, and 20 were excluded because of cognitive disability or language barrier or refusal. Twenty‐eight of 29 patients completed the TPE program. One patient died of pancreatic cancer in palliative care during the study. Median follow‐up was 20 months (interquartile range [IQR], 4–31). Median gain weight was 3.1 kg (IQR, 1.8–6.0) (P = .0002). Median duration of self‐insertion of the NG tube was 3 months (IQR, 2–5), and it was well tolerated by all 29 patients. Two patients described minor adverse events: abdominal pain and nausea for 1 patient and epistaxis leading to temporary discontinuation of EN for another patient. A group of 10 consecutive patients previously had a long‐term NG tube for EN. If they had the choice between a self‐inserted NG tube and a long‐term NG tube, all 10 patients reported they would prefer to start again with the self‐inserted NG tube. Conclusion: This pilot study suggests that self‐insertion of an NG tube may be efficacious and well tolerated in patients receiving EN for chronic conditions.     

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch‐up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014–May 2015 (intervention) and May 2012–June 2013 (baseline). Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28‐ay ventilator‐free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31–0.89; P = .017) after adjusting sex and Injury Severity Score. Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.     

Gastric Emptying in Critically Ill Children

Background: Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. We examined the correlation between (a) bedside EN intolerance assessments, including gastric residual volume (GRV); (b) delayed GE; and (c) delayed EN advancement. Materials and Methods: We prospectively enrolled patients ≥1 year of age, eligible for gastric EN and without contraindications to acetaminophen. Gastric emptying was determined by the acetaminophen absorption test, specifically the area under the curve at 60 minutes (AUC₆₀). Slow EN advancement was defined as delivery of <50% of the prescribed EN 48 hours after study initiation. EN intolerance assessments (GRV, abdominal distension, emesis, loose stools, abdominal discomfort) were recorded. Results: We enrolled 20 patients, median 11 years (4.4–15.5), 50% male. Sixteen (80%) patients had delayed GE (AUC₆₀ <600 mcg·min/mL) and 7 (35%) had slow EN advancement. Median GRV (mL/kg) for patients with delayed vs normal GE was 0.43 (0.113–2.188) vs 0.89 (0.06–1.91), P = .9635. Patients with slow vs rapid EN advancement had median GRV (mL/kg) of 1.02 mL/kg (0.20–3.20) vs 0.27 mL/kg (0.06–1.62), P = .3114, and frequency of altered EN intolerance assessments of 3/7 (42.9%) vs 5/13 (38.5%), P = 1. Median AUC₆₀ for patients with slow vs rapid EN advancement was 91.74 mcg·min/mL (53.52–143.1) vs 449.5 mcg·min/mL (173.2–786.5), P = .0012. Conclusions: A majority of our study cohort had delayed GE. Bedside EN intolerance assessments, particularly GRV, did not predict delayed GE or rate of EN advancement. Delayed gastric emptying predicted slow EN advancement. Novel tests for delayed GE and EN intolerance are needed.     

Circadian Rhythm of Energy Expenditure and Oxygen Consumption

Background: This study aimed to evaluate the effect of continuous and intermittent methods of enteral nutrition (EN) administration on circadian rhythm. Materials and Methods: Thirty‐four individuals, aged between 52 and 80 years, were fed through a nasoenteric tube. Fifteen individuals received a continuous infusion for 24 hours/d, and 19 received an intermittent infusion in comparable quantities, every 4 hours from 8:00 to 20:00. In each patient, 4 indirect calorimetric measurements were carried out over 24 hours (A: 7:30, B: 10:30, C: 14:30, and D: 21:30) for 3 days. Results: Energy expenditure and oxygen consumption were significantly higher in the intermittent group than in the continuous group (1782 ± 862 vs 1478 ± 817 kcal/24 hours, P = .05; 257 ± 125 vs 212 ± 117 mL/min, P = .048, respectively). The intermittent group had higher levels of energy expenditure and oxygen consumption at all the measured time points compared with the continuous group. Energy expenditure and oxygen consumption in both groups were significantly different throughout the day for 3 days. Conclusion: There is circadian rhythm variation of energy expenditure and oxygen consumption with continuous and intermittent infusion for EN. This suggests that only one indirect daily calorimetric measurement is not able to show the patient's true needs. Energy expenditure is higher at night with both food administration methods. Moreover, energy expenditure and oxygen consumption are higher with the intermittent administration method at all times.     

Tolerability and Safety of Enteral Nutrition in Critically Ill Patients Receiving Intravenous Vasopressor Therapy

Background: Enteral nutrition (EN) is recommended within the first 24–48 hours following admission to an intensive care unit (ICU) once resuscitation and hemodynamic stability have been achieved; however, hemodynamic stability is not well defined. Objective: To evaluate the tolerability and safety of EN in critically ill patients receiving intravenous (IV) vasopressor therapy. Methods: A retrospective medical record review was conducted in an urban academic medical center and included adult ICU patients from 2011 who received concomitant EN and IV vasopressor therapy for ≥1 hour. EN tolerance was defined as an absence of gastric residuals ≥300 mL, emesis, positive finding on abdominal imaging, and evidence of bowel ischemia/perforation. Results: Two hundred fifty‐nine patients received 346 episodes of concomitant EN and IV vasopressor therapy. Overall EN tolerability was 74.9%. Adverse events included rising serum lactate (30.6%), elevated gastric residuals (14.5%), emesis (9.0%), positive finding on kidney/ureter/bladder radiograph (4.3%), and bowel ischemia/perforation (0.9%). An inverse relationship was found between maximum norepinephrine equivalent dose and EN tolerability (12.5 mcg/min for patients who tolerated EN vs 19.4 mcg/min, P = .0009). This relationship remained statistically significant after controlling for other variables (P = .019). Patients who tolerated EN were less likely to have received dopamine (63.8% vs 77.6%, P = .018) or vasopressin (58.9% vs 77.9%, P = .0027). These patients received concomitant therapy for less time and received more nutrition. Conclusions: Most patients receiving IV vasopressor therapy tolerate EN. Tolerability was related to the maximum cumulative vasopressor dose and may be related to the specific vasopressor administered.     

Volume‐Based Feeding in the Critically Ill Patient

Introduction: Critically ill patients placed on enteral nutrition (EN) are usually underfed. A volume‐based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate‐based feeding (RBF) method. Methods: This single‐center, randomized (3:1; VBF/RBF) prospective study evaluated critically ill patients on mechanical ventilation expected to receive EN for ≥3 days. Once goal rate was achieved, the randomized feeding strategy was implemented. In the VBF group, physicians used a total goal volume of feeds to determine an hourly rate. For the RBF group, physicians determined a constant hourly rate of infusion to meet goal feeds. Results: Sixty‐three patients were enrolled in the study with a mean age of 52.6 years (60% male). Six patients were excluded after randomization because of early extubation. The VBF group (n = 37) received 92.9% of goal caloric requirements with a mean caloric deficit of ?776.0 kcal compared with the RBF group (n = 20), which received 80.9% of goal calories (P = .01) and a caloric deficit of ?1933.8 kcal (P = .01). Uninterrupted EN was delivered for 51.7% of all EN days in VFB patients compared with 54.5% in RBF patients. On days when feeding was interrupted, VFB patients overall received a mean 77.6% of goal calories (while RBF patients received 61.5% of goal calories, P = .001). No vomiting, regurgitation, or feeding intolerance occurred due to VBF. Conclusions: A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate‐based strategy.     

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

Background: The aim of this study was to determine the tube‐related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G‐tube) feeding. Materials and Methods: We performed a chart review of 335 infants discharged from our NICU with home NG tube or G‐tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube–related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. Results: There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G‐tube, n = 238), with available outpatient data for the 6‐month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube‐related complication. The incidence of tube‐related complications requiring an ED visit was significantly higher in the G‐tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G‐tube–related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G‐tube group (P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. Conclusion: Home NG tube feeding is associated with fewer ED visits for tube‐related complications compared with home G‐tube feeding. Some infants could benefit from a trial home NG tube feeding.     

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients

Background: To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients. Materials and Methods: International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60‐day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses. Results: Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66–1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72–1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87–1.55; P = .307) after adjusting for confounders. Conclusions: Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.     

The effect of early enteral nutrition on hyperthermic intraoperative intraperitoneal chemotherapy-induced mucosal permeability following gastrectomy

Aim: To investigate (1) the effect of hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) on intestinal permeability of patients with advanced gastric cancer and (2) the protective effect of postoperative enteral nutrition (EN) on patients. Methods: >All patients were divided randomly into 3 groups: the EN group, treated with EN during postoperative period; the EN+HIIC group, treated with HIIC and postoperative EN; and the PN+HIIC group, treated with HIIC and postoperative parenteral nutrition. The lactulose/mannitol (L/M) ratio was used to evaluate the permeability of intestinal mucous. Results: Compared with the ratio of L/M on the day before operation (POD‐1), the ratio of L/M on POD+3 increased significantly in all 3 groups (P < .0001) and then decreased gradually. The L/M ratio of the EN and EN+HIIC groups recovered to the baseline on POD+12. In contrast, the PN+HIIC group still had an elevated L/M ratio until POD+12. The ratios of L/M in the EN+HIIC group on POD+7 and POD+12 were significantly different from those of the PN+HIIC group (0.0855 ± 0.0462 vs 0.1298 ± 0.063, P = .007; 0.0336 ± 0.0235 vs 0.0616 ± 0.0430, P = .038, respectively). Conclusion: Gastric cancer radical resection resulted in a significant increase in intestinal permeability. HIIC aggravated the injury of intestinal mucous permeability, which could be reversed by EN.     

Intra‐abdominal Pressure as a Prognostic Factor for Tolerance of Enteral Nutrition in Critical Patients

Background: The purpose of this study is to establish a relationship between tolerance of enteral nutrition (EN) and intra‐abdominal pressure (IAP) in critical patients, establish an objective measure for monitoring tolerance, and determine a threshold value for IAP. Materials and Methods: Prospective and observational study at the critical care unit. Seventy‐two patients were recruited with an expected stay of more than 72 hours and scheduled to receive EN. We recorded IAP and clinical and laboratory variables to describe predictive ones for tolerance of EN at the start of nutrition. Results: The largest group was polytrauma patients (41.7%). Of the patients, 40.3% had undergone surgery prior to inclusion in the study. Most patients (87.5%) were fed via nasogastric tube. Physiological POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) on admission was 26.4 ± 7.6, and surgical POSSUM was 22.4 ± 8.0. The mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 13.6 ± 6.0. Mortality was 31.9%. In all, 70.8% tolerated EN. The univariate analysis revealed a statistically significant relation between tolerance of EN and surgical POSSUM, APACHE II, and baseline IAP. The multivariate analysis showed a relationship between APACHE II score, baseline IAP, and the tolerance of EN. So, on the basis of these 2 variables, logistic regression analysis can predict whether a patient will tolerate the diet with an overall precision of 80.3%. Conclusions: In critically ill patients, there is a relation between IAP values and the tolerance of EN. The baseline IAP with the APACHE II score can predict the tolerance of EN.     

Comparative Analysis of the Efficacy and Complications of Nasojejunal and Jejunostomy on Patients Undergoing Pancreaticoduodenectomy

Background: The efficacy and feeding‐related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy (PD) was investigated with a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital. Methods: Sixty‐eight patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: 34 patients received enteral feeding via a nasojejunal tube (NJT group) and 34 patients received enteral feeding via a jejunostomy tube (JT group). The assessment of clinical outcome was based on postoperative investigation of complications. The second part of the assessment included tube related complications and an index on catheter efficiency. Results: There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group, and there was no significant difference in the rate of infectious complications between the 2 groups. The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group (P < .05). Catheter‐related complications were more common in the JT group as compared with the NJT group (35.3% vs 20.6%, P < .05). The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group. The postoperative hospital stay in the NJT group was significantly decreased (P < .05), and there was no hospital mortality in this study. Conclusion: Nasojejunal feeding is safer than jejunostomy, and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay.     

Fat‐Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter,Single‐Blind,Randomized Controlled Trial

Background: Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat‐modified enteral formula on feeding tolerance in critically ill patients. Materials and Methods: This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat‐modified enteral formula containing medium‐chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator‐free days of 28 days, length of ICU stay, length of hospital stay, and in‐hospital mortality) were collected. Results: Daily calories and protein intake were increased in the interventional feed group compared with the control feed group (P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group (P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1–5 (P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group (P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group (P = .03). No significant differences existed in outcomes between the 2 groups. Conclusions: The fat‐modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.     

Peritonitis after gastrostomy tube replacement: a case series and review of literature

Background: The placement of feeding gastrostomy (G) tubes through a percutaneous endoscopic gastrostomy (PEG) technique has become common because of its simplicity and safety. The majority of the serious complications are reported to occur within a few days of initial tube placement and happen in fewer than 3% of cases. Long‐term reported complications of this procedure include occlusion or breakage of the G‐tube, requiring reinsertion. This report describes the complication of intraperitoneal placement and the development of peritonitis after replacement of an established PEG tube and reviews the pertinent world literature. Methods: A retrospective review of cases of intraperitoneal insertion of replacement G‐tubes was done as well as a Medline search for cases of intraperitoneal insertion of replacement G‐tube or development of peritonitis after replacement tube insertion. Results: Three new cases of inadvertent intraperitoneal insertion of a replacement G‐tube in adult patients with mature tracts are reported. An additional 5 cases have been previously described in adults. Significant morbidity was associated with this complication, and 4 deaths were related to it. Methods used to determine whether the replacement G‐tube was intragastric were not uniform. Conclusions: There have been few reports of intraperitoneal insertion of replacement G‐tubes in patients with mature (>30 days) stoma sites. The cases presented in this report highlight for the clinician the importance of considering this complication, particularly if there are any difficulties with the reinsertion. Prospective studies are needed to determine the frequency of this complication and the optimal protocol for PEG replacement.     

Successful Identification of Anatomical Markers and Placement of Feeding Tubes in Critically Ill Patients via Camera‐Assisted Technology with Real‐Time Video Guidance

Background: Enteral feeding via feeding tube (FT) provides essential nutrition support to critically ill patients or those who cannot intake adequate nutrition via the oral route. Unfortunately, 1%–2% of FTs placed blindly at bedside enter the airway undetected (as confirmed by x‐ray), where they could result in adverse events. Misplaced FTs can cause complications including pneumothorax, vocal cord injury, bronchopleural fistula, pneumonia, and death. X‐ray is typically performed to confirm FT placement before feeding, but may delay nutrition intake, may not universally identify misplacement, and adds cost and radiation exposure. Methods: A prospective case series was conducted to evaluate a novel FT with a camera to provide real‐time visualization, guiding placement. The primary end point was the clinician's ability to identify anatomical markers in the gastrointestinal tract and/or airway using the camera. Results: The Kangaroo Feeding Tube with IRIS Technology tube was placed in 45 subjects with 1 misplaced tube; 3 placements were postpyloric, with the remainder gastric. Clinicians correctly identified the stomach in 44 of 45 placements at a median depth of 60.0 cm (range 45.0–85.0 cm). A stomach image was obtained in 42 subjects (93.3%). Agreement between camera image and radiographic confirmation of placement was 93% (P = .014) with small deviations in recognizing stomach vs small bowel. No device‐related adverse events occurred. Conclusions: Direct visualization of the stomach using a camera‐equipped FT can assist with FT placement, help avoid misplacements, and with further studies to evaluate the safety of eliminating confirmatory x‐ray before feeding, could potentially preclude the need for radiographic confirmation.     

Hospital Inpatient Admissions With Dehydration and/or Malnutrition in Medicare Beneficiaries Receiving Enteral Nutrition: A Cohort Study

Background: Enteral nutrition (EN) supports many older and disabled Americans. This study describes the frequency and cost of acute care hospitalization with dehydration and/or malnutrition of Medicare beneficiaries receiving EN, focusing on those receiving home EN. Methods: Medicare 5% Standard Analytic Files were used to determine Medicare spending for EN supplies and the proportion and cost of beneficiaries receiving EN, specifically home EN, admitted to the hospital with dehydration and/or malnutrition. Results: In 2013, Medicare paid $370,549,760 to provide EN supplies for 125,440 beneficiaries, 55% of whom were also eligible for Medicaid. Acute care hospitalization with dehydration and/or malnutrition occurred in 43,180 beneficiaries receiving EN. The most common principal diagnoses were septicemia (21%), aspiration pneumonitis (9%), and pneumonia (5%). In beneficiaries receiving EN at home, >one‐third (37%) were admitted with dehydration and/or malnutrition during a mean observation interval of 231 ± 187 days. Admitted patients were usually hospitalized more than once with dehydration and/or malnutrition (1.73 ± 1.30 admissions) costing $23,579 ± 24,966 per admitted patient, totaling >$129,685,622 during a mean observation interval of 276 ± 187 days. Mortality in the year following enterostomy tube placement was significantly higher for admitted compared with nonadmitted patients (40% vs 33%; P = .05). Conclusion: Acute care hospitalizations with dehydration and/or malnutrition in Medicare beneficiaries receiving EN were common and expensive. Additional strategies to reduce these, with particular focus on vulnerable populations such as Medicaid‐eligible patients, are needed.     

“Cool” Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

Background: Therapeutic moderate hypothermia (MH; T_core 33°C–34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH. Materials and Methods: Patients were randomized to 72 hours of MH or normothermia (NT; T_core 36°C–37°C). Harris‐Benedict (BMR‐HB) and Penn‐State equation (BMR‐PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1–3. Patients with MH received trophic semi‐elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)–related adverse events, and ventilator‐associated pneumonia (VAP) were analyzed with a double‐sided matched pairs t test. Results: Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours (P = .046). Average daily EN calories received D0–3: 398 (MH) vs 1006 (NT) (P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI‐related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1–3, BMR‐HB remained stable (1331 kcal), BMR‐PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2). Conclusions: In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.     

Enteral feeding induces early intestinal adaptation in a parenterally fed neonatal piglet model of short bowel syndrome

Background: Successful small intestinal (SI) adaptation following surgical resection is essential for optimizing newborn growth and development, but the potential for adaptation is unknown. The authors developed an SI resection model in neonatal piglets supported by intravenous and enteral nutrition. Methods: Piglets (n = 33, 12–13 days old) were randomized to 80% SI resection with parenteral nutrition feeding (R‐PN), 80% SI resection with PN + enteral feeding (R‐EN), or sham SI transection with PN + enteral feeding (sham‐EN). In resected pigs, the distal 100 cm of ileum (residual SI) and 30 cm of proximal SI were left intact. All pigs received parenteral nutrition postsurgery. Enteral nutrition piglets received continuous gastric infusion of elemental diet from day 3 (40:60 parenteral nutrition:enteral nutrition). Piglets were killed 4, 6, or 10 days postsurgery. Results: By 10 days, R‐EN piglets had longer residual SI than R‐PN and sham‐EN pigs (P < .05). At days 6 and 10, R‐EN piglets had greater weight per length of intact SI (P < .05) and isolated mucosa (P < .05) compared to other groups. Greater gut weight in R‐EN piglets was facilitated by a greater cellular proliferation index (P < .01) by 4 days compared to other groups and greater overall ornithine decarboxylase activity vs R‐PN piglets (P < .05). Conclusions: This new model demonstrated profound SI adaptation, initiated early postsurgery by polyamine synthesis and crypt cell proliferation and only in response to enteral feeding. These changes translated to greater gut mass and length within days, likely improving functional capacity long term.