Nasojejunal tube placement in paediatric intensive care

Nasojejunal delivery of enteral feeds is a safe and effective alternative to parenteral nutrition in critically ill children in whom intra-gastric feeding is usually poorly tolerated. A guideline for bedside placement of nasojejunal tubes (NJTs) was developed by a mulit-disciplinary group. An audit of practice was carried out following implementation of the guideline. During the audit period 27 NJTs were successfully passed in 21 patients. The result of this innovation has been early initiation of nasojejunal feeding and an increase in bedside placement of NJTs within the PICU. Paediatric radiologists have reported a reduction in requests for NJT placement under X-ray screening and there has been a reduction in the use of medication and X-ray to place NJTs. Based on the audit data, 58 per cent of the children would have definitely or probably commenced parenteral nutrition had NJT placement and feeding been unsuccessful. The audit also demonstrated that 26 out of 27 nurses and doctors reported they found the guidelines easy or very easy to follow. Reducing variations in practice through the use of guidelines increases the frequency of jejunal feeding. This benefits critically ill patients by improving tolerance of enteral feeding for better nutritional outcomes.     

Review: nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding. Background. The literature reports varying nutritional practices in intensive care. Design. Systematic review. Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria. Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under‐ and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes. Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re‐evaluation of energy recommendations and improved delivery of enteral nutrition. Relevance to clinical practice. This review supports the multi‐disciplinary development and implementation of an evidence‐based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.     

Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU

Aim. To test whether a feeding algorithm could improve the nutritional support of intensive care patients. Background. Numerous factors may impede delivery of both enteral and parenteral nutrition to patients in the intensive care unit. Often there is a discrepancy between what is prescribed and actual delivery of nutrients. The purpose of this study was to test the effect of a nutritional support algorithm in an intensive care unit mainly by using the enteral route and if necessary by combining enteral and parenteral nutrition. Methods. In this prospective study, nutritional data were collected from routinely fed critically ill patients (controls, n = 21) during the first three days following admission to the intensive care unit. A nutritional support algorithm was then implemented and nutritional data were collected from critically ill patients who participated in this intervention (intervention group, n = 21). Data collected included the total amount of calories prescribed vs. received, onset of delivery of enteral nutrition, enteral vs. parenteral nutrition, and the use and size of enteral feeding tubes. Results. Patients in the intervention group were both prescribed and actually received significantly larger amounts of nutrients than patients in the control group. They also received a larger proportion of their nutrients in the form of enteral nutrition. In addition, the nutritional support algorithm led to greater consistency in nursing practices with respect to aspiration of gastric content and rate of increment in enteral feeding. Conclusion. The study confirms that a nutritional support algorithm improved the delivery of nutrients to critically ill patients. The algorithm was most effective with respect to the delivery of enteral nutrition. The effect was primarily because of early and more rapid increment in the delivery of enteral nutrition administered by nurses based on improved physician orders. The combination of enteral and parenteral nutrition may contribute to meeting adequate nutritional requirements. Relevance to clinical practice. By using a nutritional algorithm focused on enteral nutrition, but including parenteral nutrition as a supplement, it is possible to improve the delivery of clinical nutrition in the intensive care unit patients.     

Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens.

This study examined the effect of gastric feeding regimens, either continuous or intermittent, on fourth hourly gastric residual volumes (GRV) in a group of critically ill paediatric patients where delayed gastric emptying is defined as a GRV greater than 5ml/kg. A randomised controlled trial was conducted in a tertiary paediatric intensive care unit (PICU), with 45 participants being randomly assigned to either the continuous (n=22) or intermittent (n=23) gastric feeding groups. Participants remained in the assigned group for the duration of the study and, fourth hourly, GRV were assessed to monitor the incidence of delayed gastric emptying. Both groups were similar in age, weight, gender, diagnosis, paediatric index mortality (PIM) score, and usage of pharmacological agents known to affect the gastrointestinal tract. No differences emerged in study duration or the volume of administered enteral formula (ml/kg/day). The intermittent feeding group commenced enteral feeding earlier in the PICU admission (13.0 hours versus 18.5 hrs, p=0.05). Repeated measures analysis revealed no overall difference in median GRV/kg values between treatment groups over the 72 hour study period. Additionally, the incidence of fourth hourly GRV, greater than 5ml/kg, was not different between the continuous and intermittent feeding groups. The provision of enteral nutrition via the gastric route is a common treatment in the PICU, and GRV are frequently used as a measure of gastric tolerance. The result of this analysis provides some support for the theoretical definition of delayed gastric emptying being >5ml/kg. However, further work is required to confirm this finding and to determine its relevance when providing enteral nutrition to the critically ill paediatric patient.     

Improvements in the outcome of children with meningococcal disease

Recent years have seen a marked reduction in the mortality of children with meningococcal disease in paediatric intensive care units (PICU); the reasons for this improvement are multifactorial. The mortality rates for critically ill children overall have improved and reasons for this are probably increased centralisation of PICU services and that fewer critically ill children are now looked after on adult units. Specific treatment pathways for sepsis have improved with the publication of clinical guidelines for children and initiatives such as the Surviving Sepsis Campaign. There is a continuing need to focus on the care delivered to children before reaching PICU and to minimise the morbidity suffered by survivors of this disease.     

Renutrition en réanimation pédiatrique

Denutrition is a frequent issue in the paediatric intensive care unit (ICU). Features are specific in relation to the child??s growth. Requirements of critically ill children cannot be adapted from energetic needs of adult or sane children. Recent studies demonstrated that caloric requirements of ICU children are lower than those in healthy children despite normal protein needs. Indirect calorimetry should help precise monitoring of caloric requirements in critically ill children to limit the risk of overfeeding syndrome. In the presence of functional digestive tract, enteral feeding should be preferred due to its better tolerance and less frequent infectious complications.     

Nutritional intake in the critically ill: improving practice through research.

Enteral feeding is the preferred method of nutritional support in the critically ill; however, evidence suggests that many critically ill patients do not meet their nutritional goals. The implementation of enteral feeding protocols has improved nutritional delivery, although protocols can be widely variable. Similarly, enteral feeding related nursing practice is also inconsistent within and between intensive care units (ICUs). These variations in enteral feeding practice can be linked to the shortage of reliable and valid research into the many issues associated with the effective delivery of enteral nutrition. In the absence of a strong research tradition and practice, rituals are embraced and rarely challenged, further contributing to the wide variations in enteral feeding practice. Of particular importance are practice issues related to the commencement of enteral feeding and the assessment of feeding tolerance. This article seeks to review the literature related to commencing enteral feeding, with particular reference to the suitability of enteral nutrition, methods of enteral feeding and adjustment of enteral feeding rates. Issues relating to feeding intolerance, including the assessment of gastric residual volume and the development of diarrhoea, will also be explored.     

Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation.

BACKGROUND: Published reports consistently describe incomplete delivery of prescribed enteral nutrition. Which specific step in the process delays or interferes with the administration of a full dose of nutrients is unclear. OBJECTIVES: To assess factors associated with interruptions in enteral nutrition in critically ill patients receiving mechanical ventilation. METHODS: An observational prospective study of 59 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an 18-bed medical intensive care unit of an academic center. Data were collected prospectively on standardized forms. Steps involved in the feeding process from admission to discharge were recorded, each step was timed, and delivery of nutrition was quantified. RESULTS: Patients received approximately 50% (mean, 1106.3; SD, 885.9 Cal) of the prescribed caloric needs. Enteral nutrition was interrupted 27.3% of the available time. A mean of 1.13 interruptions occurred per patient per day; enteral nutrition was interrupted a mean of 6 (SD, 0.9) hours per patient each day. Prolonged interruptions were mainly associated with problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%), weaning (11.7%), and other reasons (22.8%). Placement and confirmation of placement of the small-bore feeding tube were significant causes of incomplete delivery of nutrients on the day of admission. CONCLUSIONS: Delivery of enteral nutrition in critically ill patients receiving mechanical ventilation is interrupted by practices embedded in the care of these patients. Evaluation of the process reveals areas to improve the delivery of enteral nutrition.     

Nutritional assessment and enteral support of critically ill children

Critical care nurses play an important role in feeding of critically ill children. Many procedures and caregiving interventions, such as placement of feeding tubes, registration of gastric retention, observation and care of the mouth, and administration of nutrition (enteral or parenteral), are within the nursing domain. This article discusses nutritional assessment techniques and enteral nutrition in critically ill children.     

儿科ICU护士肠内营养相关决策行为的现况调查

目的 调查儿科ICU护士肠内营养相关决策行为的现状,为推进儿科ICU肠内营养管理的发展提供参考。方法 采用便利抽样法,于2020年1月抽取南京市儿童医院NICU、PICU、CCU、SICU的护士作为研究对象,采用“儿科ICU护士肠内营养相关决策行为问卷”对其进行调查。结果 共发放177份问卷,有效回收142份。仅有57.0%的护士熟知本科室的肠内营养护理流程;胃管留置长度和位置核实方法方面,高达54.2%~94.4%的护士依旧采用传统方法;喂养不耐受监测方面,91.5%的护士每次喂养前都评估胃残留量,当问及如何处理胃残留时,高达60.6%的护士将胃残留全部丢弃;本调查还发现仅有7.0%的护士总是主动采取非药物方式预防或减少喂养不耐受的发生与发展。结论 儿科ICU护士肠内营养的实施与护理措施大多沿用传统方法,欠缺对新方法的学习与探索。建议加强儿科ICU肠内营养相关指南和新理念的培训,制定科学严谨的肠内营养实施与操作流程,规范护理行为,加强营养专科护理人才的培养,营造良好的工作氛围以提高儿科ICU护士工作主动性,从而优化危重患儿肠内营养的管理。     

Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis

Introduction

The largest cohort of critically ill patients evaluating intragastric and small intestinal delivery of nutrients was recently reported. This systematic review included recent data to compare the effects of small bowel and intragastric delivery of enteral nutrients in adult critically ill patients.

Methods

This is a systematic review of all randomised controlled studies published between 1990 and March 2013 that reported the effects of the route of enteral feeding in the critically ill on clinically important outcomes.

Results

Data from 15 level-2 studies were included. Small bowel feeding was associated with a reduced risk of pneumonia (Relative Risk, RR, small intestinal vs. intragastric: 0.75 (95% confidence interval 0.60 to 0.93); P = 0.01; I² = 11%). The point estimate was similar when only studies using microbiological data were included. Duration of ventilation (weighted mean difference: -0.36 days (-2.02 to 1.30); P = 0.65; I² = 42%), length of ICU stay (WMD: 0.49 days, (-1.36 to 2.33); P = 0.60; I² = 81%) and mortality (RR 1.01 (0.83 to 1.24); P = 0.92; I² = 0%) were unaffected by the route of feeding. While data were limited, and there was substantial statistical heterogeneity, there was significantly improved nutrient intake via the small intestinal route (% goal rate received: 11% (5 to 16%); P = 0.0004; I² = 88%).

Conclusions

Use of small intestinal feeding may improve nutritional intake and reduce the incidence of ICU-acquired pneumonia. In unselected critically ill patients other clinically important outcomes were unaffected by the site of the feeding tube.     

Implementing an educational program to improve critical care nurses' enteral nutritional support

BackgroundAlthough international nutrition societies recommend enteral nutrition guidelines for patients in intensive care units (ICUs), large gaps exist between these recommendations and actual clinical practice. Education programs designed to improve nurses' knowledge about enteral nutrition are therefore required. In Korea, there are no educational intervention studies about evidence-based guidelines of enteral nutrition for critically ill patients.ObjectivesWe aimed to evaluate the effects of an education program to improve critical care nurses' perceptions, knowledge, and practices towards providing enteral nutritional support for ICU patients.MethodsA quasi-experimental, one-group study with a pre- and post-test design was conducted from March to April 2015. Nurses (N = 205) were recruited from nine ICUs from four tertiary hospitals in South Korea. The education program comprised two sessions of didactic lectures. Data were collected before (pre-test) and 1 month after (post-test) the education program using questionnaires that addressed nurses' perceptions, knowledge, and practices relating to providing enteral nutritional support for ICU patients.ResultsAfter the program, nurses showed a significant improvement in their perceptions and knowledge of enteral nutrition for ICU patients. There was a significant improvement in inspecting nostrils daily, flushing the feeding tube before administration, providing medication that needs to be crushed correctly, changing feeding sets, and adjusting feeding schedules.ConclusionsThe findings indicate that an enteral nutrition education program could be an effective strategy to increase critical care nurses' support for the critically ill. This education program can be incorporated into hospital education or in-service training for critical care nurses to strengthen their perceptions and knowledge of nutritional support in the ICU. This may improve the clinical outcomes of ICU patients.     

Gastric versus postpyloric feeding

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.     

Metabolic and nutritional support of critically ill patients: consensus and controversies

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.     

Preventing common enteral feeding complications in critically ill adult patients

Nutritional support provides critically ill patients with energy and nutrients required to face the demands of their illness and stress. For those unable to ingest orally, enteral feeding rather than parenteral feeding is recommended, as the former better preserves gut integrity, reduces risk of infection, and costs less. Early enteral feeding in critically ill patients is also associated with decreased disease severity, reduced complications, and shortened length of stay. Risks associated with enteral feeding include aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. This article reviews current knowledge on enteral feeding and addresses correct feeding tube placement, proper feeding sites, assessing and managing gastric residual volume, and preventing feeding tube occultation. We also review information related to identifying and controlling risk factors for enteral feeding complications such as aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. Nurses can use this information to provide high quality care for enteral feeding patients and develop institutional protocols, guidelines, and standards of care for such patients in intensive care units.