ASPEN Safe Practices for Enteral Nutrition Therapy

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process‐related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.     

Enteral Nutrition Overview

Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most commonly required for neurological conditions that impair swallow function, such as stroke, amytrophic lateral sclerosis, and Parkinson’s disease. An inability to swallow due to mechanical ventilation and altered mental status are also common conditions that necessitate the use of EN. EN can be short or long term and delivered gastrically or post-pylorically. The expected duration and site of feeding determine the type of feeding tube used. Many commercial EN formulas are available. In addition to standard formulations, disease specific, peptide-based, and blenderized formulas are also available. Several other factors should be considered when providing EN, including timing and rate of initiation, advancement regimen, feeding modality, and risk of complications. Careful and comprehensive assessment of the patient will help to ensure that nutritionally complete and clinically appropriate EN is delivered safely.     

Impact of Early Initiation of Enteral Nutrition on Survival During Pediatric Extracorporeal Membrane Oxygenation

Introduction: Pediatric data related to safety, tolerance, and outcomes of enteral nutrition (EN) for patients requiring extracorporeal membrane oxygenation (ECMO) are lacking. The objectives of this study were to evaluate early nutrition status and timing of EN initiation on survival during pediatric ECMO. Methods: A single center institutional review board–approved retrospective chart review was performed on all pediatric patients requiring ECMO from October 2008 through December 2013. Demographics, ECMO variables, laboratory values, vasoactive inotropic score (VIS), and nutrition data on day 5 (d5) were collected. Patients receiving parenteral nutrition (PN) were compared with those receiving any EN on d5. Analyses were conducted to identify factors influencing survival to completion of ECMO and to discharge. Results: Forty‐nine patients aged 53 ± 76 months met inclusion criteria. Kaplan‐Meier curves demonstrated greater survival to discharge in patients receiving any EN, compared with only receiving PN (P = .031). EN on d5 of ECMO support (P = .040) and a higher percentage of daily energy intake achieved (P = .013) were protective, whereas a higher VIS was associated with increased mortality (P = .010). Multivariable analysis demonstrated EN was no longer associated with survival to discharge (P = .139), whereas energy intake (P = .021) and VIS (P = .013) remained significant. Conclusions: Pediatric patients who received nutrition that was closer to goal energy intake, as well as those who received any EN early during ECMO, had improved survival to hospital discharge.     

Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step‐By‐Step Approach

This tutorial suggests a current strategy toward a multiprofessional therapy based upon a comprehensive step‐by‐step approach to the course of intensive care unit diarrhea episodes. Evidence published in the last 10 years, obtained through a database search (PubMed), shows that its prevalence is quite variable. Although multicausal, it is often erroneously associated with the supply of enteral nutrition. Several complications affect not only nutrition status but also the development of skin lesions, which can become the focus of infections, and the length of hospital stay. Here, we propose an early, objective, directed, and multimodal approach, aiming at optimizing care for these patients. In a dynamic walkthrough, the reader will find a guide for the general diagnosis and for colitis resulting from Clostridium difficile infections, as well as current instructions and recommendations for drug treatment and supportive therapy for these 2 modalities. We also bring together ways to prevent and treat associated skin lesions in this setting. Because it is neglected in the critical environment, diarrhea is still a poorly addressed disease, and its complications bring about a significant worsening in quality of life and hospital stay.     

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.     

A Comparison of Postoperative Early Enteral Nutrition with Delayed Enteral Nutrition in Patients with Esophageal Cancer

We examined esophageal cancer patients who received enteral nutrition (EN) to evaluate the validity of early EN compared to delayed EN, and to determine the appropriate time to start EN. A total of 208 esophagectomy patients who received EN postoperatively were divided into three groups (Group 1, 2 and 3) based on whether they received EN within 48 h, 48 h–72 h or more than 72 h, respectively. The postoperative complications, length of hospital stay (LOH), days for first fecal passage, cost of hospitalization, and the difference in serum albumin values between pre-operation and post-operation were all recorded. The statistical analyses were performed using the t-test, the Mann-Whitney U test and the chi square test. Statistical significance was defined as p < 0.05. Group 1 had the lowest thoracic drainage volume, the earliest first fecal passage, and the lowest LOH and hospitalization expenses of the three groups. The incidence of pneumonia was by far the highest in Group 3 (p = 0.019). Finally, all the postoperative outcomes of nutritional conditions were the worst by a significant margin in Group 3. It is therefore safe and valid to start early enteral nutrition within 48 h for postoperative esophageal cancer patients.     

重度烧伤患者早期肠内营养支持的经济学评价

目的研究重度烧伤患者早期肠内营养支持的疗效及费用。方法采用随机临床分组试验,将41例烧伤面积超过30%的患者分为肠内营养组(enteral nutrition,EN,n=21)和肠外营养支持为主的常规治疗组(conventionaltherapy,CONT,n=20)。治疗7天后观察两组内脏蛋白水平和预后炎症营养指数(prognostic inflammatory and nutritionalindex,PINI)等的变化及不良反应。结果治疗7天后EN组的前白蛋白水平显著高于CONT组[(115.8±31.0)mg/Lvs.(69.4±17.3)mg/L,P<0.01];PINI显著低于CONT组(162.9±89.4vs.343±149,P<0.01);EN组治疗7天的费用比CONT组节约382.06元(P=0.00)。结论早期肠内营养支持改善营养状况的疗效优于常规治疗,且费用低,具有良好的成本效果比。     

Challenges to Optimal Enteral Nutrition in a Multidisciplinary Pediatric Intensive Care Unit

Objective: To describe nutrient intake in critically ill children, identify risk factors associated with avoidable interruptions to enteral nutrition (EN), and highlight opportunities to improve enteral nutrient delivery in a busy tertiary pediatric intensive care unit (PICU). Design, Setting, and Measurements: Daily nutrient intake and factors responsible for avoidable interruptions to EN were recorded in patients admitted to a 29‐bed medical and surgical PICU over 4 weeks. Clinical characteristics, time to reach caloric goal, and parenteral nutrition (PN) use were compared between patients with and without avoidable interruptions to EN. Results: Daily record of nutrient intake was obtained in 117 consecutive patients (median age, 7 years). Eighty (68%) patients received EN (20% postpyloric) for a total of 381 EN days (median, 2 days). Median time to EN initiation was less than 1 day. However, EN was subsequently interrupted in 24 (30%) patients at an average of 3.7 ± 3.1 times per patient (range, 1–13), for a total of 88 episodes accounting for 1,483 hours of EN deprivation in this cohort. Of the 88 episodes of EN interruption, 51 (58%) were deemed as avoidable. Mechanically ventilated subjects were at the highest risk of EN interruptions. Avoidable EN interruption was associated with increased reliance on PN and impaired ability to reach caloric goal. Conclusions: EN interruption is common and frequently avoidable in critically ill children. Knowledge of existing barriers to EN such as those identified in this study will allow appropriate interventions to optimize nutrition provision in the PICU.     

肠内外营养在妊娠剧吐治疗中的应用

妊娠剧吐不利于母亲和胎儿的健康,提供足够的营养支持是治疗的主要措施。本文简要介绍近年肠内外营养在妊娠剧吐治疗中的应用情况,旨在为正确选择何种营养途径提供新的思路。     

Development and Evaluation of a Home Enteral Nutrition Team

The organisation of services to support the increasing number of people receiving enteral tube feeding (ETF) at home varies across regions. There is evidence that multi-disciplinary primary care teams focussed on home enteral nutrition (HEN) can provide cost-effective care. This paper describes the development and evaluation of a HEN Team in one UK city. A HEN Team comprising dietetians, nurses and a speech and language therapist was developed with the aim of delivering a quality service for people with gastrostomy tubes living at home. Team objectives were set and an underpinning framework of organisation developed including a care pathway and a schedule of training. Impact on patient outcomes was assessed in a pre-post test evaluation design. Patients and carers reported improved support in managing their ETF. Cost savings were realised through: (1) prevention of hospital admission and related transport for ETF related issues; (2) effective management and reduction of waste of feed and thickener; (3) balloon gastrostomy tube replacement by the HEN Team in the patient’s home, and optimisation of nutritional status. This service evaluation demonstrated that the establishment of a dedicated multi-professional HEN Team focussed on achievement of key objectives improved patient experience and, although calculation of cost savings were estimates, provided evidence of cost-effectiveness.     

等热量不同糖成分营养制剂对急性脑卒中患者血糖影响的随机对照研究

目的探讨持续泵入等热量不同糖成分营养制剂对急性脑卒中患者血糖和血清蛋白的影响。方法60例急性脑卒中患者随机分为高蛋白肠内营养制剂组(30例,热氮比=100:1)和糖尿病专用型肠内营养制剂组(30例,热氮比=140:1),在相等非蛋白热量(104.6kJ.kg-1.d-1)摄入条件下,进行14天不同糖成分的肠内营养制剂对急性脑卒中患者血糖影响及蛋白支持效果的前瞻性随机对照研究。结果两组患者2周内每日平均血糖水平及每日平均胰岛素剂量比较差异无显著性(P>0.05)。两组第7天和第14天各营养相关指标及低蛋白发生率比较差异无显著性(P>0.05);但高蛋白制剂组第7天前白蛋白降低幅度小于糖尿病制剂组,第14天增高幅度高于糖尿病制剂组。3个月生存率和改良Rankin评分两组比较差异均无显著性(P>0.05)。结论持续肠内泵入高蛋白肠内营养制剂和糖尿病专用型肠内营养制剂对血糖影响差异不明显。高蛋白肠内营养制剂的血清蛋白支持作用更强,急性脑卒中并发高血糖和低蛋白血症患者可选择该制剂。     

肠内营养在克罗恩病治疗中的应用

目的探讨肠内营养在克罗恩病（CD）治疗中的作用。方法随机选取39例综合确诊的CD患者，依据是否行肠内营养治疗分为肠内营养组（n=31）和对照组（n=8），记录其临床表现、实验室检查结果和CD活动指数（CDAI）。结果（1）临床表现：肠内营养治疗2周和4周后，肠内营养组在发热、腹部包块、腹泻和肠外表现等临床症状方面，以及活动性病变人数和需肠外营养支持的人数方面，均较治疗前和对照组有明显好转（P〈0．05）；在肠梗阻、腹痛和便血等临床症状上也较治疗前明显好转（P〈0．05）；患者体重亦较治疗前明显增加（P〈0．05），而对照组却较治疗前显著下降（P〈0．05）。（2）实验室检查：肠内营养治疗2周和4周后，肠内营养组在γ球蛋白、α2球蛋白、CRP和ESR等方面均较治疗前显著下降（P〈0．05）；在H曲和血白蛋白方面较治疗前明显增加（P〈0．05），而对照组却较治疗前明显下降（P〈0．05）。（3）CDAI：肠内营养治疗2周和4周后，肠内营养组和对照组的CDAI均较治疗前明显下降（P〈0．05），但肠内营养组CDAI下降的幅度较对照组大。（4）皮质激素使用方面：肠内营养组和对照组无统计学上的显著差异（P均〉0．05），肠内营养组15例在观察期内均开始激素减量。结论肠内营养是CD患者充分有效的营养支持方式，有助于CD活动期病情的改善，可以作为激素的替代治疗选择。对于疾病的治疗具有重大意义。     

消化道恶性肿瘤术后早期肠内与肠外营养治疗的比较

目的探讨消化道恶性肿瘤术后早期肠内营养(EEN) 肠外营养(PN)可行性,并将其与完全胃肠外营养(TPN)对患者营养状况和免疫功能的影响进行比较。方法将2001年10月～2003年3月在本院普外科行择期消化道恶性肿瘤手术患者随机分为EEN PN组(22例)和TPN组(24例),于术后24h开始营养治疗,他们在获得能量与氮量方面差异无显著性。术前、术后第1、3、7天测定血前白蛋白(PA)、白蛋白(ALB)和血色素(Hb)水平;术前、术后第7天测定血IgA、IgG、IgM、T淋巴细胞亚群CD3、CD4、CD8及CD4/CD8水平;术后第1～7天每日测定氮平衡(NB)。比较两组上述指标在术后的差异。结果两组间在术前、术后第1、3、7天测定的血PA、ALB、Hb及术后第1～7天测定的NB比较,差异均无显著性(P>0.05)。术后第7天EEN PN组CD3、CD4水平明显高于TPN组(P<0.05熏P<0.01),而两组在CD8及CD4/CD8的差异无显著性(P>0.05)。术后第7天EEN PN组IgM明显高于TPN组(P<0.05),而两组在IgA、IgG的差异无显著性(P>0.05)。结论EEN PN是腹部术后安全有效的营养途径。由于EEN PN在改善免疫功能方面明显优于TPN,因此它应成为消化道肿瘤患者术后首选的营养方式。     

Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice

Background: Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. Methods: International prospective studies in 2007–2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. Results: There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60‐day mortality. Conclusion: Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.     

胰十二指肠切除术后患者临床营养的护理

目的总结胰十二指肠切除术后患者肠外营养（PN）和肠内营养（EN）的护理体会。方法回顾性分析了57例接受胰十二指肠切除术患者的临床资料，所有患者均于术前接受中心静脉置管，术中行空肠造瘘，术后给予PN和EN支持。结果PN中位时间为8天（5～24天），EN中位时间为21天（5～69天），平均术后肛门排气时间（72．5±19．8）小时，术后住院的中位时间为24天（17～74天）。57例患者中，1例于围手术期死亡，2例因严重腹胀、腹泻中止EN；41例出现腹胀，17例发生腹泻；中心静脉导管脱出和堵塞各2例，空肠造瘘未出现导管并发症；29例出现糖代谢严重异常，2例伤口裂开，19例次发生术后感染。结论胰十二指肠切除术后需要联合PN和EN，治疗中应坚持无菌配液、严格管路护理、注意血糖变化和加强心理治疗。