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Stopping Nasogastric feeds in ICU – Time for a CHANGE

Dr Swapnil Pawar July 14, 2021 1150


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    Stopping Nasogastric feeds in ICU – Time for a CHANGE
    Dr Swapnil Pawar

Malnutrition in critically ill patients in the intensive care unit (ICU) has been associated with increased infectious morbidity, increased length of ICU and hospital stay, increased rate of infections, increased number of ventilator days, and impaired wound healing.
EN supports gut integrity and decreases the risk of systemic infection from an immunologic standpoint. When gut integrity is compromised, intestinal permeability is increased, which can lead to systemic infections from normal gut bacteria.
And there is no argument about feeding ICU patients early or as soon as possible. Overall we as an intensive care community has got better with our feeding practices. And to be honest, we are very good at initiating Ng feeds. In fact, most of the ICUs will have additional services of dieticians to calculate target feed rates and we have adopted a multi-disciplinary approach towards nutrition in ICU.
However, the problem arises in attaining these goal rates as enteral nutrition is decreased or held for critically ill patients for numerous reasons, including for a prolonged period of time prior to general anaesthesia or procedures, thus leading to decreased caloric intake.1
American Society for Parenteral and Enteral  Nutrition (ASPEN), the Society of Critical Care  Medicine (SCCM) guidelines are considered to be the gold standard and both of them recommend minimising fasting times prior to surgery. however, none of them are very specific about it.
No standard protocol exists to decrease or eliminate preoperative fasting times for adult ICU patients with cuffed endotracheal tubes; however, multiple institutions in the United States and internationally have implemented their own protocols with adjusted times for the intubated patient.
Some institutions discontinue patients’ enteral feeds after midnight for surgery when it is possibly not warranted.  And that’s primarily because anaesthetics are worried about the risk of aspiration.
The ASA developed recommendations to guide preoperative fasting requirements; however, these recommendations do not include patients who have a cuffed endotracheal tube prior to surgery.
And discontinuing or postponing initiation of EN for a patient who requires surgery has been shown to greatly decrease caloric intake, possibly leading to malnutrition and worsened outcomes.
So the challenges are –
1. Our practices are not evidence-based or in fact, there is not enough evidence to support our current practices.
2 . We are risking our patients by stopping feeds frequently
 3. And importantly there is large variability in our practices  – practices differ between individuals, between ICUs and between countries.
Exploring fasting practices for critical care patients – A web-based survey of UK intensive care units Ella Segaran et al 2
A total of 167 ICU dieticians from 232 UK ICUs responded, representing 72% of all UK ICUs and 76% of ICUs with dietetic input. The presence of fasting guidelines was reported by 20% (34 of 167), while 78% (131 of 167) of the respondents had no guideline and another 1.8% (2 of 167) was unsure.
72% of all UK ICUs, has low bias and is representative of UK practice. The high response rate observed is likely a result of the robust methods used, which included the questionnaire being emailed to a named person, easy online access and follow-up emails and telephone calls made
Results are quite fascinating –
A significant trend was found for abdominal surgery (p < 0.002), non-abdominal surgery (p < 0.016) and radiology (p < 0.015). Before abdominal surgery, most patients were fasted for 6 h or less (87%) in the presence of a guideline compared to most being fasted 6 h or more (79%) without a guideline. A similar pattern was observed for non- abdominal surgery where 82% were fasted up to 6 h if there was a guideline compared to just over half (58%) for 6 h or more. Finally, for radiological procedures, 72% of patients in the guidelines group were fasted for less than 1 h, compared to 80% being fasted for up to 4 h in the non-guideline group. Fasting prior to extubation was predominately for 4 to 6 h irrespective of whether the ICU had a guideline or not, 72% in the guideline group versus 67% without. A similar trend was observed with a tracheostomy with 71% of fasting being within 4 to 6 h with a guideline versus 74% without.
The four main themes that emerged were ‘variation’, ‘unforeseen circumstances, ‘future strategies’ and ‘guideline issues’
Variation was the most commonly occurring theme with decision-makers frequently reported as the reason. This inconsistent approach caused frustration amongst staff. The patient’s clinical state, resources available and unpredictability of the ICU environment were also described as causes.
Unforeseen circumstances were reported since unplanned procedures frequently occurred and planned procedures did not always run to time. Extubation was commonly stated as being particularly unpredictable and consequently, the usual fasting practice was not always possible.
Future strategies were planned by respondents following the completion of the survey. Teams had high-lighted areas for improvement and the need for specific fasting guidelines. Units reported considering future strategies to help improve EN delivery and to decrease unnecessary long periods of fasting.
Guideline issues were observed in the units that had their own fasting guidelines, for example, problems with non-compliance and barriers to adoption.
Some of the useful quotes from this study –
“fasting times are dependent on patient condition and clinician in charge”
“Some consultants prefer no fasting, whereas others fast from midnight. Nurses tend to fast from midnight unless told otherwise”.
“We find that for many procedures consultant opinions differ; feeds will be turned off from midnight but with no known time for the procedure to take place”.
“inconsistency of approach by theatre staff drives me mad”
“Often multiple delays for procedures leading to patients being fasted from midnight but no intervention until late in the afternoon”
Another interesting issue – Gastric Residual volume –
the maximum GRVs their unit used as a measure of gastric emptying. The size of GRV varied between units ranging from 200 to 500ml. The most commonly reported volume was 400 ml, observed in 27%. When asked if the patients’ gastric emptying over the last 24 h influenced fasting practices, only 22 units (13%) affirmed, indicating that they would fast a patient with high GRVs for longer.
Evidence – whether stopping NG feeds lead to harm?
Uninterrupted enteral nutrition is an important facet of care of burns patients, who often need to undergo repeated, prolonged surgical procedures, during which significant nutritional deficits occur due to interruption of enteral feeding. In a retrospective study, Varon et al. evaluated the feasibility and safety of intraoperative feeding in burns patients. Thirty-three patients were included; 17 patients received intraoperative enteral feeds while 16 did not. Feeding was carried out through a post-pyloric tube and continued throughout the intraoperative period. No difference in mortality was observed between the two groups; besides, there was no intraoperative incidence of regurgitation or aspiration in either group. Patients who continued to be fed intraoperatively received 98% of the prescribed nutrition, compared to 70–73% among those who were not fed. The authors concluded that continued intraoperative enteral feeding in burns patients was feasible without an increase in the incidence of intraoperative regurgitation, aspiration, or increase in mortality while maintaining nutritional targets.10

In a study among surgical ICU patients, 14 received continued feeding through a postpyloric tube until the commencement of the procedure. The procedures included debridement of necrotizing fasciitis, bowel surgery, and orthopedic procedures. The mean duration of interruption of feeding per procedure was only 222.4 minutes; an additional 4.7 hours of feeding was provided through avoidance of the conventional period of NPO.

Critically ill trauma patients on invasive mechanical ventilation who underwent surgical or non-surgical procedures were the subjects of the study by Pousman et al. Enteral feeds administered through a gastric tube were continued for up to 45 min of the procedure; feeding through a small bowel feeding tube was continued until the time of commencement of the procedure. The investigators specifically evaluated the incidence of complications related to continued enteral feeding, including ventilated associated pneumonia, urinary infections, catheter-related bloodstream infections, wound infections, hypoglycemia, and intraoperative vomiting and regurgitation. There was no increase in the incidence of complications compared to a control group who underwent a conventional duration of fasting before the procedure. The authors concluded that continued feeding up until the commencement of the procedure was safe and allowed to meet nutritional targets better.11

Percutaneous tracheostomy  –

Yeh et al. compared ten patients who were continued on routine enteral feeding with 22 patients who were fasted according to American Society of Anesthesiology NPO guidelines.12 Patients who continued to be fed received higher median calories and had less calorie deficit on the day of the procedure compared to the control group. The overall incidence of complications was not different between groups, including airway-related, gastrointestinal and infectious complications.

Our recommendations –

based on the protocol from Queen Alexandra Hospital Portsmouth (NHS)

  1. A non-intubated patient going for any procedure or surgery, NBM for 6 hours prior to the procedure.
  2. Intubated patient with NG in situ going for any non-airway related surgery or surgery not involving GIT handling – stop feeds just prior to the procedure and aspirate NG feeds.
  3. Abdominal surgery or airway related procedure – stop NG feeds 4 -6 hours prior to surgery or procedure.
  4. Restart feeds immediately after the completion of the surgery unless contraindicated.
  5. 4-6 hours fasting prior to elective extubation ( assess the need on a case-by-case basis) and restart feeds  4 hours post-extubation.

References

1.         López Muñoz AC, Busto Aguirreurreta N, Tomás Braulio J. [Preoperative fasting guidelines: an update]. Rev Esp Anestesiol Reanim. 2015;62(3):145-156. doi:10.1016/j.redar.2014.09.006

2.         Segaran E, Lovejoy TD, Proctor C, et al. Exploring fasting practices for critical care patients – A web-based survey of UK intensive care units. J Intensive Care Soc. 2018;19(3):188-195. doi:10.1177/1751143717748555

3.         Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728-1737. doi:10.1007/s00134-009-1567-4

4.         Villet S, Chiolero RL, Bollmann MD, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24(4):502-509. doi:10.1016/j.clnu.2005.03.006

5.         Strack van Schijndel RJM, Weijs PJM, Koopmans RH, Sauerwein HP, Beishuizen A, Girbes ARJ. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care. 2009;13(4):R132. doi:10.1186/cc7993

6.         Alpers DH. Enteral feeding and gut atrophy. Curr Opin Clin Nutr Metab Care. 2002;5(6):679-683. doi:10.1097/00075197-200211000-00011

7.         McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27(7):1252-1256. doi:10.1097/00003246-199907000-00003

8.         Seron-Arbeloa C, Zamora-Elson M, Labarta-Monzon L, Mallor-Bonet T. Enteral nutrition in critical care. J Clin Med Res. 2013;5(1):1-11. doi:10.4021/jocmr1210w

9.         Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29(12):2264-2270. doi:10.1097/00003246-200112000-00005

10.       Varon DE, Freitas G, Goel N, et al. Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients. J Burn Care Res. 2017;38(5):299-303. doi:10.1097/BCR.0000000000000514

11.       Pousman RM, Pepper C, Pandharipande P, et al. Feasibility of implementing a reduced fasting protocol for critically ill trauma patients undergoing operative and nonoperative procedures. JPEN J Parenter Enteral Nutr. 2009;33(2):176-180. doi:10.1177/0148607108327527

12.       Yeh DD, Cropano C, Quraishi SA, et al. Periprocedural nutrition in the intensive care unit: a pilot study. J Surg Res. 2015;198(2):346-350. doi:10.1016/j.jss.2015.06.039

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