Post Pyloric Feeding (1)
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POST PYLO
RIC F
EEDIN
G
DR NAGESH JADAV
ICU REGISTRAR
INTRODUCTION
Adequate nutrition in critically ill is standards in medical and surgical care.
Enteral nutrition is preferred due to its relative simplicity, safety, cost as well its ability to maintain gut mucosal barrier function.
Improves nitrogen balance Wound balance Host immune functions Augments cellular anti-oxidant system Decrease hypermetabolic response and tissue injury Preserves interstial mucosal integrity
Malnourished patients have poorer outcomes, more infections and use more resources.
Nutri Clin Pract 2007
Clinic Nutrition 2006
Effect of Enteral and Parenteral Nutriton on Gut Mucosa
Am J Resp & Critical care med – 1995/152Burns Patient Studies on Host Defense – Early feeding Vs starvation
Critical care med – 1994 /22Influence of Early Post-operative Enteral Nutrition Vs Placebo on Cell Mediated Immunity
Sacd J GE 1999 – 34: 98-102
GOALS FOR NUTRITION
Enteral nutrition
All critically ill patient with functioning small bowel should be fed enterally
C/I to be excluded – Ileus , GI bleed, pending GI procedures, recent GI procedures with enterostomy or anastomosis
Targets:
Caloric intake25-30kcals/kg/day and protein of 1-1.5g/kg/day based on estimated ideal IBW
Jevity 1-1.5mls/kg/hr
Nepro 0.5-.75kcals/kg/hr
Special situation:
ARF – Standard feeding in acutely stressed patient
High dose RRT – Feeding to be augmented by 50%
Type 2 RF – 1.5Kcals of low carb and high fat with pulmocare and aim of 0.7-1ml/kg/hr
Poor Gastric Emptying – 1.5kcal/ml high cal jevity
WESTMEAD NUTRITION PROTOCOL
DiscussionPost Pyloric Feeding may be
an Important Alternative To
Parenteral Method
WHY DO I NEED TO KNOW THIS TOO?
Motility disorders in Critical Care
Motility disturbances remains unsolved is associated with morbidity &
mortality rate
Physiology
The motility regulation is a complex interaction of stimulation and feedback that
involves a large number of hormones and neuroendocrine peptides
Myentric plexus intrinsically collect information for the appropriate control of
digestion. Extrinsic innervations provide data of fluid and energy homeostasis
mediating immune, inflammatory response and pathological process
Mentec H (2001) Crit Care Med 29 : 1955-1961
Current Opinion in Clinical Nutrition Metabolic Care 2009, 12:161–167
MOTILITY DISORDERS IN CRITICAL CARE
MORTALITY
Pathophysiological
Antro-Pylorio-Duodenal Motor Dysfunction results in gastroparesis and has
led to a better knowledge of gut function
Humoral Mechanism with deranged feedback as a result of CCK
Disorganised MMC Phase: ↑Phase 1, ↓Phase 2, Retrograde Phase 3
Multifactorial cause and risk factor
Use of Sedation, Opiods, Vasopressors, Hyperglycaemia, Dyselectrolytemia
Abdominal Sx, Head and Spinal injuries, Sepsis & Fluid overload
Mentec H (2001) Crit Care Med 29 : 1955-1961
ICU
LOS
WHAT IS A BALANCE THEN
Early Commencing of Enteral Nutrition
Early Achievement of Optimum Caloric
NeedsFacing Problem of Upper GIT
intolerance & its related Sequels
HYPOTHETICALLY SB FEEDS
• Improved absorptive capacity
• Less impairment of motility
• Better respiratory function as it prevents gastric distension
• Greater distance between the delivery site and the pharynx & respiratory tree
EVID
ENCE SCRUTI
NY ?
A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis.Ho KM, Dobb GJ, Webb SA. ICM 2006
11 RCT’s of SB vs Gastric feeding2 Reviewers for the quality of studies and data collection
Med/Surg (4), Med (3), Trauma (2), Neuro (2) (N 667)
META-ANALYSIS OF POST PYLORIC FEEDINGClinical trails
Variable designs
• Most evident difference between the studies is the position of the tip of tube• 5 studies placed tube in duodenum while 3 in jejunum and 2 no mention
• Impotant consideration that is not equally controlled for in each study is the possible displacement of feeding tubes
• Decision to suction the gastric secretions in the small bowel feeding group. 3 studies placed a nasogastric tube for suction or free drainage other not
• Definition of pneumonia: 2 Studies used radiolabelled enteral feed to detect aspirations the other studies clinical methods and criteria
• Use of prokinetic during gastric feeding may negate any potential adv of SB feeds
• Perception of feed intolerance
STUDIES ON ASPIRATION RISK
2 RCT’s that have evaluated aspiration
33 patients, 1st - 3 days GE regurgitation 24.9% vs. 39.8% (P=0.04) Further into small bowel less aspiration
Heyland et al, CCM, 2001
54 patients, twice weekly Low rate of aspiration 7% vs 13% aspiration
Esparaza et al, Int Care Med, 2001
CONCLUSIONS OF THE META-ANALYSIS
Small bowel feeding compared with gastric feeding: *Associated with a reduction in pneumonia .
*Improves calorie and protein intake and is associated with less time taken to reach target rate of EN.
*No difference in mortality or MV days.
All studies are underpowered and a large heterogeneity exist between studies
Infection complication and Incidence of pneumonia
Definition of early feeding
Meta-analysis not possible Variable gastric feeding strategies Goals and success reported in different ways
INDICATION AND CONTRAINDICATIONBasis of 2 studies
Montegio et al – Critical care med 2002
Boulton- Jones et al – Clin nutrition 2004
American and European Guidelines recommend post pyloric feeding only in a subset of critically ill patients with the following indications
Gastroparesis
Recurrent aspiration
Severe hyperemesis
Acute pancreatitis
C/I
Obstruction in the different parts of GI tract at esophagus, gastric outlet, intestine from various causes
Absolute C/I being bowel obstruction and perforation
Migration of the tube
METHODS AVAILABLE
Non blind methods
Fluoroscopy
Endoscopically
US guided
EMG guided
Small bowel tubes
Tiger tube
Provides high insertion success rate
Cost effective
Self migrating
So it will be left in the stomach and it will migrate peristalsis to jejunum
DISADVANTAGES
Difficulty placement and ease of displacement
Frequent occlusion of small bore tube especially with viscid feeds and medications
Intestinal perforation
Feeding intolerance with dumping syndrome
SUMMARY
Feed Early Feed Enterally
Elevate The Head Of The Bed
Consider Small Bowel Feed If Feed Intolerant/Failed to Prokinetics
Remember that patients with high doses of caecholamines, muscle relaxants, opiates
and benzodiazepines will never tolerate naso-gastric feeds
NUTRIT
ION IN
HEA
LTHY
IS A
NEE
D
NUTRIT
ION IN
CRITIC
ALLY IL
L IS
NECES
SITY
Thank you