PRESENTED BY:

Steven Yip          Andy Tan
Maurice Wong      Melvin Kwan

Outline:

Introduction
Current Practice
“Burning Question”
Reasons For Change
Literature Review
Appraisal and Synthesis of Evidence
Recommendations for Best Practice
Integration of New Practice
Summary
References

Clinical Best Practice - NGT

Introduction

Critically ill patients are difficult to feed often resulting in MALNUTRITION!
Giner et al., Barr et al., 2004, found out that ICU patients, 43% to 88% are often malnourished.

Enteral nutrition is acknowledged as the preferred route of feeding (Heyland et al., 2003a).
However, underfeeding and intolerance are common problems (McClave et al., 1999).
Underfeeding and Overfeeding have been associated with undesirable outcomes.
Compromise the immune response, nutritional status, glycaemic control and diarrhea.

Besides under and over feeding, the delivery and tolerance of enteral nutrition is important.
Gut dysfunction, high gastric aspirates, vomitting, and abdominal distension are common problems.
This presentation attempts to investigate the best clinical practice in feeding a post stroke patient.
It is worthwhile to note that patient preferences are often neglected in the decision to use enteral feeding.
Current practice – Enteral Feeds

Indications for enteral nutrition:

Impaired swallowing or gag reflex
Cancer
Underlying condition may prevent eating
Ventilator-dependent or post operative patients
Stroke patients

Types of Nasogastric Tubes

Nasogastric tube (NG Tube) passes through the nose, down the throat and to the stomach;
Nasojejunal tube (NJ Tube) passes through the nose, down the throat, through the stomach and to the small intestine;
Gastrostomy Tube (G Tube) passes through a small cut in the skin directly into the stomach;
Gastroenteric or Transgastric jejunal tube (GJ Tube) passes through a cut in the skin directly into the stomach and extends into the small intestine;
Jejunostomy tube (J tube) passes through a cut in the skin directly into the small intestine;
Poor nutrition is common…

Silicone may cause slower flow and more frequent clogging…

But is anything being done to better the process??

“The Burning Question“

Reasons for Change
Improvements in delivery systems for enteral feeding, formulas and understanding of complications have made enteral feeding widely used, however,…Is there a better solution?

Literature Review
Bolus Feeding:

Also called intermittent feeding
Given over short periods of time several times throughout the day
Given by pump or gravity
Timing of feeds can be changed 2-3hrs between feeds to allow stomach to empty
Resembles normal pattern of eating-digestion

Continuous Feeding:

Given at a steady rate for as many hours as needed
A pump is used over the 24hr duration

Continous Feeding and Bolus Feeding Combined?

Sometimes bolus tube feeds are given during the day and continous feeds at night

Complications of Enteral Feeding

Aspiration Pneumonia
Cause serious local and systemic infections
Difficult to insert NGT
Risk of death (1%)
Uncomfortable and hence prone to being pulled out
Patient distress
Enteral Feeding

Klodell (2000) found that the preference for enteral nutrition, as opposed to parenteral, is universal.
Strict attention to patient positioning, as well as vigilant nursing care helps to minimize rates of complications with enteral access. 
However, controversy still remains regarding the route of administration.
Clinician driven decisions.
No strong evidence to support the preferential use of jejunal or gastric feeding tubes in Traumatic Brain Injury patients.

Enteral Feeding

Klodell et al (2000) also found that prokinetic agents such as metroclopramide in the initial 48hrs of enteral nutrition to  augment gastric emptying.
Klodell et al (2000) notes that gastric feeding in neurologically injured patients may be successful as early as 24hrs after the injury with the co-administration of drugs to facilitate gastric emptying.

Batson, S. (1997) found that gut dysfunction and elective stoppages for procedures were main reasons for preventing delivery of feeds.
Average daily gastric aspirate were compared over one month.
Average daily gastric aspirate were higher on the first few days of feeding.
The aspirate volumes then settled to a steady state at an average of +/-105mls.

Where a specific feeding protocol was employed, the average volume of feed delivered was 1418 +/- 505ml., the percentage of optimal feed delivered was 78 +/- 31%.
Where there was an absence of specific feeding protocol, the average volume of feed delivered was 1179 +/- 674ml, and the percentage of optimal feed delivered was 66 +/- 34%.
Discrepancies exist between the delivered and prescribed volume of feed. 
Causes suggested include the onset of diarrhea and nursing workload.

Diarrhea is invariably blamed on enteral feed.
Kandil et.al found that health volunteers did not show signs of diarrhea until they were fed more than 275ml/h.  This rate is far greater than any patient would receive, suggesting that feed is unlikely the cause.
Other causes have been identified:
Antibiotic, and other drug therapy, feed formula, contamination of feed
No clear cause but it seems likely that there are other more complex factors involved.

The percentage of prescribed feeds delivered depends on the volume of prescription. 
When smaller volumes are prescribed, the percentage delivered is higher.  1200ml over 24hrs versus 2000ml over 24hrs.
Rest periods are used to “catch-up” on feed schedules. 
Use of a rest period seems an effective way of ensuring the patients receive the prescribed amount of feed.
Delivery rate was 95-75% of prescribed feed with a rest period.
The researcher also notes that this aspect requires further investigation. 

In another study by Serpa, et al (2003), it was found that it was acceptable practice that whenever 80% of the energy needs are supplied by 72hrs, the replenishment program should be considered adequate.
Undeniably there will be deficits of actual supplied and prescribed amounts, but according to the researcher, this shortcoming is small and justified in circumstances of critical disease.
(Note:  Two groups of 14 critically ill patients were randomly assigned to intermittent or continuous tube feeding.)

Chapman (1992) found that written protocols are a simple and effective method of increasing enteral feed delivery.
Delivery rate of >85% was achieved for patients with written protocols.
Delivery rate of >75% was achieved for patients without written protocols.
All researchers agree that more research is need to be done in this area for results to be more conculsive.

Appraisal and Synthesis of Evidence
Bolus versus Continuous Feeding
Bolus Feeding
Preferred by most clinicans
Promote the cyclical surges of gut hormones
However, delayed gastric emptying may hinder ability to handle bolus milk feeds
resulting in feeding intolerance – (Dumping Syndrome)
Causes diarrhea if given too fast and too much
Higher risk of aspiration if feeding intolerant.

Continuous Feeding
May be more efficient by increasing energy absorbed
Improved nutrient absorbtion
But may alter the cyclical pattern of gut hormones affecting metabolic homestasis
Should not be given overnight in patients who are at risk of aspiration

The Evidences speak for Themselves
The use of electronic pumps, slow administration even in cases of bolus prescription,
careful selection of diet and
positioning of tube,
prevention of abdominal distension or
high gastric residues and
constant monitoring of patients.

Recommendations – Best Practices
Health care professionals should aim to provide adequate nutrition to every patient.
It should be the hospital policy that results of an admission nutritional screening are recorded in the notes of all patients with serious illness or those needing major surgery.
Nutritional support is needed when oral take is absent or likely to be absent for a period of >5-7 days.  Earlier intervention may be needed in malnourished patients.
Choice of route in consultation with clinician and dietician.
Adoption of a written protocol for feed regimes in conjunction with the clinical care pathway,
The use of electronic pumps to administer feeds,
Proper positioning into semi-fowler position (if not contra-indicated) for feeding,
Use of prokinetics to encourage gastric emptying.
Constant monitoring of patient for abdominal distension.
Consultation with dietician and clinician if patient develops feeding intolerance or diarrhea.
Allowing breaks in feeding to let gastric PH fall will help prevent bacterial overgrowth during ETF.
Allows the gut to “rest’

Ethical Issues

Enteral feeding should not be started without consideration of all related ethical issues and must be in a patient’s best interests.
In cases where a patient cannot express a wish regarding Enteral feeding, consulting widely with all carers and family is essential.

Integration of New Practice

Presentation to the Medical Board and governing body, PTs, Dieticians
Propose changes to current hospital protocols and guidlines
Provide education, roadshows
Monitor for compliance, audits
Competency audits for nurses

Enteral feeding is the preferred modality of support for seriously ill patients
Who have acceptable gastrointestinal function but are unable to maintain oral diet.
Further future studies conducted should include longer periods and populations with different risk factors to advance the knowledge about these widely adopted therapeutic techniques.

REFERENCES

Axelsson, K., Asplund, K., Norberg, A., Eriksson, S. (1989) Eating problems and nutritional status during hospital stay of patients with severe stroke.  Journal of American Dietary Association. 8.1092

Giner, M., Lavino, A., Meguild, M.M. & Gleanson J.R. (1996)  In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists.  Nutrition 12, 23-29.

Heyland, D.K., Dhaliwal, R., Drover, J.W., Gramlich L. & Dodek, p. (2003)  Canadian Clinical practice guidelines for nutritonal support in mechanically ventilated, critically ill patients. JPEN 27, 355-373.

McClave, S.A. & Snider, H.L. (2002) Clinical use of gastric residue volumes as a monitor for patients on enteral tube feeding. JPEN 26, S43-S50.

Reid, C. (2006) Frequency of under and over feeding in mechanically ventilated ICU patients:  Causes and possible consequences.  The British Dietetic Association 19 pp 13-22.

Serpa L., Kimura, M., Faintuch, J., (2003).  Effects of continuous versus bolus infusion of enteral nutrition in critical patients.  Clinc. FAC, MED S. Paulo 58(1): 9-14, 2003.

Thomas, D. (2007)  Annals of Long-term Care, Clinical Care and Aging.  Retrieved from www.annalsoflongtermcare.com/article/857 on april 11, 2007.

Kandil HE, Oper FH, Switzer BR, Heitzer WD (1993) Marked resistance of normal subjects to tube-feeding induced diarrhea; the role of magnesium. Am J Clin Nutr 57:73-80.

Klodell, C., Carroll, M., Carrillo, E., Spain, D. (2000)  Routine intragastric feeding following traumatic brain injury is safe and well tolerated.  The American Journal of Surgery.  Vol 179, Issue 3, pp. 168-171.

Chapman G, Curtas S, Meguild M (1992) Standardized enteral orders attain caloric goals sooner:  a prospective study, JPEN J Parenter Enteral Nutr 16:  149-151.