Enteral nutrition in intensive care patients: a practical approach.

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of these patient's management. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decision-making when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.     

重症急性胰腺炎的肠内营养支持

重症急性胰腺炎病人处于高分解代谢状态,必须加强营养支持.经空肠肠内营养不刺激胰腺分泌,是安全可行的.目前,认为肠内营养支持能改善重症急性胰腺炎病人的营养状况,保护肠屏障功能,减少细菌和内毒素移位,调节炎症反应,降低住院费用.因此,重症急性胰腺炎病人应尽可能采用经空肠肠内营养,而非肠外营养支持.     

Enteral access for nutrition in the intensive care unit

PURPOSE OF REVIEW: Enteral nutrition is the preferred route for nutrition support in the intensive care unit setting. This is usually delivered through nasoenteric feeding tubes in patients with an otherwise functional gastrointestinal tract. Placement of nasoenteric feeding tubes, however, may be difficult in this setting. Nasoenteric feeding tubes may be placed by multiple methods, each with their particular advantages and disadvantages. This review summarizes the recent literature on different methods of nasoenteric feeding tube placement with emphasis on critically ill patients. RECENT FINDINGS: Bedside assisted methods using electromyogram, electrocardiogram, and magnetic fields to provide immediate positional feedback to help guide tube advancement appear promising. Bedside methods using specific protocols, modified feeding tubes, prokinetics or magnetic assistance were also successfully reported. None of these methods has been prospectively compared with more commonly practiced methods in large studies. Endoscopic nasoenteric tube placement methods including transnasal approaches using ultra-thin endoscopes have been recently described and appear to be equivalent to fluoroscopic placement. All these recently reported techniques, however, may require more specialized equipment or training than is currently widely available. SUMMARY: Feeding tubes can be placed using bedside, fluoroscopic, and endoscopic means. Novel bedside methods have been recently described using immediate positional feedback or new assistive methods. Endoscopic techniques have similar success rates to fluoroscopic techniques and provide data on upper gastrointestinal abnormalities. There is no clear universal standard method. When feeding tube placement is required the technique used depends on local institutional resources and expertise.     

Enteral nutrition in the cardiothoracic intensive care unit: challenges and considerations

Cardiovascular disease is a common preexisting condition among hospitalized patients. Acute myocardial infarction and cardiac surgery account for 2 of the most common reasons patients are admitted to the intensive care unit. Determining how and when to feed these patients is a constant challenge presented to nutrition support practitioners. Enteral nutrition has emerged as the preferred route of feeding particularly in critical illness. By providing enteral nutrition instead of parenteral nutrition, the natural physiologic pathway is being followed and gut immunity preserved. However, obstacles such as upper gastrointestinal intolerance, hypoperfusion vasopressor support, and glycemic control make the task of initiating feeds a challenge. Once a patient has successfully tolerated feeds, the nutrition support clinician must still determine how much to feed and if specialty formulas such as those containing omega-3 fatty acids are beneficial for their patient. The purpose of this review is to present recent research on the feeding challenges in the critical care population with a focus on the cardiothoracic population and an emphasis on improving patient outcomes.     

肠内营养减少大鼠急性重症胰腺炎继发感染

目的：探讨肠内营养（EN）能否减少急性重症胰腺炎（SAP）大鼠胰腺继发感染的发生。方法：SD大鼠32只，随机分成4组：急性重症胰腺炎全肠外营养（TPN）组（A组）、模拟手术TPN组（B组）、急性重症胰腺炎EN组（C组）和模拟手术EN组（D组）。观察5天后肠道细菌移位情况、大鼠生存率及血生化变化。结果：SAP大鼠均无死亡，C组和D组大鼠对EN耐受良好；C组肠系膜淋巴结及胰腺组织细菌培养阳性率均为37．5％，明显低于A组的87．5％（P＝0．033），培养出的细菌多为肠道常见细菌。各组血生化指标相似。结论：EN能减少SAP大鼠肠道细菌移位的发生，从而减少胰腺继发感染。     

Enteral nutrition and cardiovascular medications in the pediatric intensive care unit

BACKGROUND: Enteral nutrition has multiple benefits for critically ill patients. However, the administration of enteral nutrition to patients requiring medications for cardiovascular support is controversial secondary to concerns of altered splanchnic perfusion. The objective of this study is to evaluate the tolerance of enteral nutrition in pediatric patients receiving cardiovascular medications. METHODS: This was a retrospective chart review of patients admitted to the pediatric intensive care unit at Children's Healthcare of Atlanta at Egleston in a 1-year period. Patients were eligible for the study if they received enteral nutrition during or within 24 hours of requiring continuous infusion of dopamine, dobutamine, epinephrine, norepinephrine, or neosynephrine. RESULTS: Fifty-five admissions (52 patients) met study criteria. Patients ranged in age from 1 month to 20 years old. Although a large number (71%) of patients experienced at least 1 feeding interruption, the majority (70%) of reasons cited for stopping or slowing feedings were not related to gastrointestinal (GI) tolerance. Only 29% of patients had feedings held for perceived intolerance. Vomiting was the most often-cited reason for these interruptions. Constipation was reported in 36% of patients but cited only 4 times as a reason for feeding interruption. Four patients exhibited evidence of GI bleeding. This bleeding was considered clinically insignificant in 2 patients and appeared unrelated to enteral feedings in the others. CONCLUSIONS: This study suggests that many pediatric patients receiving cardiovascular medications tolerate enteral nutrition without adverse events. Further prospective studies are needed to determine whether enteral nutrition can consistently benefit these critically ill pediatric patients.     

Sedative practice in intensive care units results of a Maghrebian survey

OBJECTIVES: sedation is central to the management of intensive care patients. The aim of this study was to establish the current sedation practice in Maghrebian intensive care units (ICUs). The use of sedation policies with or without a written protocol, the use of scoring systems, the influence of costs on drug choice, the most common drugs for sedation and the use of neuromuscular blocking agents. METHODS: a self-administered questionnaire composed of 20 items was sent to 138 intensivists in the Maghreb working in 25 teaching hospitals and 16 private clinics. RESULTS: 50 of 138 questionnaires were returned (response rate = 36.2%). Midazolam and Fentanyl were the main sedative agents used (respectively 98% and 87%) less than 14% of the ICUs used the Propofol mainly in the first 48 hours. A sedation policy was adopted in 63.6% with a written protocol in 20% of cases. Sedation scoring systems were noted in 14.3% of cases (RAMSAY scale in 100%). Economic aspect was important for 64.6% of ICUs. DISCUSSION: sedation may seem secondary in the initial management of intensive care patients, only 63% of our respondents had a sedation policy and 20% a written protocol though its use is thought to improve outcome and reduce costs. Economic aspect was important for the choice of the drug to use (64%), this may explain the preferential use of Midazolam 98% in association with an analgesic (Fentanyl: 85%) while Propofol is used only in 14% though pharmacoeconomic studies may be in fact in favor of the latter. Neuromuscular blocking agents are less frequently used (16%) mainly because of the risk of complications.     

Nosocomial infection and multidrug-resistant bacteria surveillance in intensive care units: a survey in France.

OBJECTIVES: To evaluate nosocomial infection (NI) surveillance strategies in French ICUs and to identify similar patterns defining subsets within which comparisons can be made. DESIGN: A questionnaire was sent to all French ICUs, and a random sample of nonresponders was interviewed. PARTICIPANTS: Three hundred ninety-five responder ICUs (69%) in France. RESULTS: In 282 ICUs (71%), a dedicated ICU staff member was responsible for infection control activities. The microbiology laboratory was usually in the hospital (90%) and computerized (94%) but issued regular hospital microbiology records in only 48% of cases. Patients receiving mechanical ventilation, central venous catheterization, and urinary catheterization were 90%, 79%, and 60%, respectively. Patients were screened for carriage of multidrug-resistant bacteria on admission and during the stay in 70% and 60% of ICUs, respectively, most often targeting MRSA. Quantitative cultures were used to diagnose ventilator-associated pneumonia (VAP) in 90% of ICUs, including distal specimens in 80% and bronchoscopy specimens in 60%. Quantitative central venous catheter (CVC)-segment cultures were used in 70% of ICUs. All CVCs were cultured routinely in 53% of the ICUs. Despite wide variations in infection control and surveillance strategies, multiple correspondence analysis identified 13 key points (4 structural variables and 9 variables concerning the diagnosis of VAP, the surveillance and diagnosis of catheter-related and urinary tract infections, and the mode of screening of MRSA carriers) that categorize the variability of French ICUs' approaches to NIs. CONCLUSION: This study revealed profound differences in NI surveillance strategies across ICUs, indicating a need for caution when using NI surveillance data for comparisons and benchmarking.     

重症监护病房环境病原菌流行病学调查

目的研究医院重症监护病房(ICU)环境中病原菌的种类及分布状况。方法对3个ICU的医护人员、患者及其周围环境中的病原菌进行流行病学调查。结果中心ICU、胸外ICU和神外ICU环境病原菌检出率分别为34.6%、58.8%、79.1%;中心ICU、胸外ICU病原菌主要为革兰阳性菌,神外ICU病原菌主要为真菌和革兰阴性菌;病原菌主要分布于患者手、鼻腔、办公用具及治疗仪器。结论有必要结合ICU环境病原菌情况,加强ICU环境清洁消毒工作,强化医护人员标准预防意识。     

Management and knowledge of enteral nutrition in intensive care units in a city in Belgium.

The administration of enteral nutrition in intensive care unit (ICU) patients is largely managed by nurses. However, the degree of knowledge, interest, and training in this field can differ considerably among nurses and among ICUs. Such differences may lead to variations in the way in which enteral nutrition is used. To investigate these issues, a questionnaire survey was sent to the nursing staffs of 5 ICUs in Belgium. The response rate was 68%. Although theoretical knowledge of enteral nutrition was globally poor, its advantages over parenteral nutrition were usually known. Responses to questions related to practical issues associated with enteral feeding showed more institution-specific answers than interindividual differences.     

重症监护室医院感染目标性监测综合干预效果评价的Meta分析

目的 分析目标性监测综合干预在我国ICU医院感染防控中的效果.方法 文献检索中国知网、维普和万方数据库,将基于ICU医院感染目标性监测综合干预的前后对照研究纳入,并应用R 3.0.3软件进行Meta分析.结果 共纳入11篇文献.综合干预前后,各项感染率的合并相对危险度(RR)分别为:感染率0.70(95 ％CI:0.56～0.87),例次感染率0.70(95％ CI:0.58～0.84),千日感染率0.76(95％CI:0.60～0.95),千日例次感染率0.66(95％CI:0.54～0.80),干预前后差异均有统计学意义(P均＜0.05).干预前后各项器械使用率合并RR分别为:中心静脉插管0.96 (95％CI:0.82～1.12),呼吸机1.06(95％CI:0.97～1.15),导尿管0.93(95％CI:0.86～1.00),差异均无统计学意义(P均＞0.05);中心静脉插管、呼吸机相关感染率干预后合并RR分别为:0.75 (95％CI:0.53～0.88)、0.63(95％CI:0.56～0.72),差异均有统计学意义(P均＜0.05),但导尿管相关感染干预后仅有下降趋势0.85 (95％CI:0.68～1.06),差异并无统计学意义(P均＞0.05).结论 基于目标性监测的综合干预措施对医院感染防控效果显著,并且具有进一步挖掘空间,值得进一步临床推广应用.     

Parent-inclusive pediatric units: a survey of policies and practices.

A nation-wide survey of Parent-Inclusive Pediatric Units identified innovations and restrictions in policies and practices. Questionnaires mailed to Directors of Nursing Service at 84 general hospitals which encourage parental "living-in" indicated that parents are provided with a place to sleep but infrequently are offered additional facilities, services, and guidance necessary to optimize their presence on the Parent-Inclusive Pediatric Unit. Restrictions on parents remaining with their children are common during highly stressful procedures. Results indicate a gap between research on the importance of parental presence and current hospital practice.     

Enteral nutritional support in acute alcoholic pancreatitis.

The experience to date with total enteral nutritional (TEN) support in acute alcoholic pancreatitis patients admitted to the University of Kentucky affiliated hospitals was reviewed.

Standard enteral formulas sufficient to meet patient's needs were administered into the small bowel via endoscopically placed nasoenteric feeding tubes in five patients. Feedings were administered for a mean of 28.4 days. Pancreatitis was mild to moderate in severity by Ranson's criteria in four patients, and severe in one.

Four patients developed complications of pancreatitis before initiation of TEN, representing the most common indication for nutritional support. Nutritional status was maintained by TEN with no significant complications from this nutritional support identified. Diarrhea that did not limit tube feeding developed in a single patient.

This experience further supports the safety of TEN in acute pancreatitis and suggests that adequate nutritional support can be delivered by this route.     

Parenteral nutrition safe practices: results of the 2003American Society for Parenteral and Enteral Nutrition survey

BACKGROUND: The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its "Safe Practices for Parenteral Nutrition" guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines. METHODS: A web-based survey consisting of 45 questions was conducted (n = 651) June 1-30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN. RESULTS: There were 651 survey responses, 90% of which were from hospital-based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders, but dietitians and pharmacists had significant involvement. PN base components were most often ordered as percentage final concentration after admixture (eg, 20% dextrose), which is inconsistent with safe practice guidelines of ordering by total amount per day (eg, 200 g/day). There was no consistent method for ordering PN electrolytes. Approximately 45% of responders reported adverse events directly related to PN that required intervention. Of these events, 25% caused temporary or permanent harm, and 4.8% resulted in a near-death event or death. CONCLUSIONS: Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.