Artinian V, Krayem H, DiGiovine B. Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 129, 960-967

Henry Ford Hospital, Division of Pulmonary and Critical Care, 2799 W Grand Blvd, K-17, Detroit, MI 48202, USA.
Chest (Impact Factor: 7.48). 04/2006; 129(4):960-7. DOI: 10.1378/chest.129.4.960
Source: PubMed


To determine the impact of early enteral feeding on the outcome of critically ill medical patients.
Retrospective analysis of a prospectively collected large multi-institutional ICU database.
A total of 4,049 patients requiring mechanical ventilation for > 2 days.
Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing.
Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.

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    • "The value of EN is further supported by studies which have shown that nutritional deficit due to delayed initiation has an adverse effect, whereas institution of protocols to increase delivery often improves patient outcome.[6789] It has been noted that the value of EN is closely related to disease severity; greater the severity of the disease, higher the benefit of EN.[10111213] Optimal nutrition support during critical illness requires individualized assessment of timing, route and quantity of nutrients and protocolized feeding.[614] However, delivery of enteral feeding remains suboptimal due to interruptions for various reasons, some of which are avoidable.[1516] "
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    ABSTRACT: Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN. Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others. Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to "procedures inside CCU". Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.
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    • "Plusieurs méta-analyses confirment la réduction de la morbimortalité avec l'instauration d'une nutrition entérale précoce [34] [35] [36]. Une nutrition entérale instaurée précocement permet de limiter le déficit énergétique tout en protégeant la trophicité du tube digestif [22] [37]. La nutrition parentérale est associée à un risque infectieux plus élevé [26,38–43]. "

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    • "Early EN constitutes the first choice of nutritional support in the ICU when the gastrointestinal tract is functional [11]. This recommendation is supported by the presumed beneficial effects of EN on the intestinal trophicity and epithelial intestinal barrier, and clinical outcome [27], and by its lower material-related costs in comparison with parenteral nutrition [28]. The role of EN in the onset of diarrhoea has long been suspected [29], but a recent meta-analysis did not suggest an increased diarrhoea risk with EN as compared with parenteral nutrition [30]. "
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    ABSTRACT: Diarrhoea is frequently reported in the intensive care unit (ICU). Little is known about diarrhoea incidence and the role of the different risk factors alone or in combination. This prospective observational study aims at determining diarrhoea incidence and risk factors in the two first weeks of ICU, focusing on the respective contribution of feeding, antibiotics, and antifungal drugs. Out of 422 patients consecutively admitted into a mixed medical-surgical ICU during a 2-month period, 278 patients were included according to the following criteria: ICU stay > 24 h, no admission diagnosis of gastrointestinal bleeding, and absence of enterostomy or colostomy. Diarrhoea was defined as at least three liquid stools per day. Diarrhoea episodes occurring during the first day in the ICU, related to the use of laxative drugs or Clostridium difficile infection were not analysed. Multivariate and stratified analyses were performed to determine diarrhoea risk factors, and the impact of the combination of enteral nutrition (EN) with antibiotics or antifungal drugs. 1595 patient-days were analysed. Diarrhoea was observed in 38 patients (14%) and 83 patient-days (incidence rate: 5.2 per 100 patient-days). The median day of diarrhoea onset was the 6th day, and 89% of patients had <=4 diarrhoea days. The incidence of Clostridium difficile infection was 0.7%. Diarrhoea risk factors were EN covering >60% of energy target (relative risk (RR), 1.75 [1.02--3.01]), antibiotics (RR, 3.64 [1.26--10.51]) and antifungal drugs (RR, 2.79 [1.16--6.70]). EN delivery per se was not a diarrhoea risk factor. In patients receiving >60% of energy target by EN, diarrhoea risk was increased by the presence of antibiotics (RR, 4.8 [2.1--13.7]) or antifungal drugs (RR, 5.0 [2.8--8.7]). Diarrhoea incidence during the first two weeks in a mixed population of patients in a tertiary ICU is 14%. Diarrhoea risk factors are EN covering >60% of energy target, use of antibiotics and antifungal drugs. The combination of EN covering >60% of energy target with antibiotics or antifungal drugs increases the incidence of diarrhoea.
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