Post Pyloric Feeding (1)

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POST PYL O RIC FEEDING DR NAGESH JADAV ICU REGISTRAR

Transcript of Post Pyloric Feeding (1)

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POST PYLO

RIC F

EEDIN

G

DR NAGESH JADAV

ICU REGISTRAR

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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

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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

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DiscussionPost Pyloric Feeding may be

an Important Alternative To

Parenteral Method

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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

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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

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WHAT IS A BALANCE THEN

Early Commencing of Enteral Nutrition

Early Achievement of Optimum Caloric

NeedsFacing Problem of Upper GIT

intolerance & its related Sequels

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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

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EVID

ENCE SCRUTI

NY ?

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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)

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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

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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

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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

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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

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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

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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

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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

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NUTRIT

ION IN

HEA

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IS A

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NUTRIT

ION IN

CRITIC

ALLY IL

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NECES

SITY

Thank you