Scott Austin Dietetic Intern Sodexo Distance Dietetic Internship 1272015 Learning Objectives Understand the differences involved with pre and post pyloric feeding routes Understand the effects of minimizing the duration of postoperative fasting ID: 780435
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Slide1
Enteral Nutrition and Its Impact on Hospital Length of Stay
Scott AustinDietetic InternSodexo Distance Dietetic Internship1/27/2015
Slide2Learning Objectives
Understand the differences involved with pre- and post pyloric feeding routesUnderstand the effects of minimizing the duration of postoperative fastingUnderstand the importance of glycemic specific formulas
Slide3Background
Enteral Nutrition (EN) dates back 3500 years Einhorn – 1910Weighted rubber nasogastric tubeBolus feeding
C.R. Jones – 1916
Continuous feed
JADA, March 2002, Volume 102, Issue 3, Pages 399-404
Slide4Background
Critical PatientsEbb PhaseTypically 12-48 hours post-injuryCharacterized by
Cardiac output
Respiratory rate
Tachycardia
Gut ileus
Acute Flow Phase
Goals:
Identify highest risk patientsEstimate energy needsEvaluate ability to tolerate feedings
Adaptive Flow PhaseGoals:Repletion of body tissue and micronutrient storesMaintain BW within 10% of pre-injury weight if possible
Flow Phase
Slide5Background
Additional Immune NutrientsL-Argininen-3’sL-glutamine
Debats
IB, Wolfs TG,
Gotoh
T,
Cleutjens
JP, Peutz-Kootstra CJ, van der Hulst RR. Role of arginine in superficial wound healing in man. Nitric Oxide 2009;21:175–83.
Slide6The Research
Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions A review paperJose E. de Aguilar-Nascimento M.D., Ph.D., Alberto
Bicudo-Salomao
M.D.,
M.S,
Pedro E.
Portari-Filho
M.D., Ph.D.
Nutrition 28 (2012) 840–843
Slide7The Research – Optimal Timing
Worldwide more than 90% of Physicians and Dietitians strongly recommend the initiation of either EN or PN within 24-48 hours after the patient is admitted to an ICUHowever in practice this is not the case
Cahill NE,
Narasimhan
S,
Dhaliwal
R,
Heyland DK. Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr
2010;34:685–96
Slide8The Research – Optimal Timing
Modern guidelines endorse the initiation of EN regardless of traditional parameters, such as the presence of bowel sounds or flatusUnderfeeding the critical or surgical patient is valid due to gastrointestinal dismotility or hemodynamic conditions
Slide9The Research – Optimal Timing
Withholding EN post GI resectionRestart feeding once bowel movements appearBoth elective and emergency surgeries
Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J
Gastrointest
Surg
2009;13:569–75.
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database
Syst
Rev; 2006 Oct 18:CD004080.
Osland
E, Yunus RM, Khan S, Memon MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr 2011;35:473–87.
Slide10The Research – Optimal Timing
Post-operative EN is associated with a 45% reduction in total complications when early feeding was prescribed.However….
Slide11The Research – Optimal Timing
NGT reinsertion was more commonNo clear advantage of early EN with regard to:MortalityLength of Stay
Osland
E,
Yunus
RM, Khan S,
Memon
MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr
2011;35:473–87.
Slide12The Research – Optimal Timing
Trauma patients:Meta-analysis of 3 RCT’s with n=126Early EN was associated with reduced mortalityDoig
GS,
Heighes
PT, Simpson F,
Sweetman
EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta- analysis of
randomised controlled trials. Injury 2011;42:50–6.
Slide13The Research
Is duration of postoperative fasting associated with infection and prolonged length of stay in surgical patients?A prospective cohort study
Michelli
Cristina Silva de
Assis
,
Carla
Rosane de Moraes Silveira, Mariur Gomes
Beghetto
and Elza Daniel de Mello Nutr Hosp. 2014;30(4):919-926 ISSN 0212-1611 • CODEN NUHOEQ
Slide14The Research – Duration of Postoperative Fasting
Methods:Included: Elective surgery patientsExcluded:No nutritional assessment warranted<72 hour hospital stay
Results:
n
=521
44.1% were fasted ≥1 day
91
% were fasted ≥ 3 days
5.6% were fasted > 5 days
Slide15Slide16The Research – Duration of Postoperative Fasting
≥ 1 day postoperative fastingInfection risk increased by 2.04≥ 3 day postoperative fastingInfection risk increased by 2.81> 5 day postoperative fasting Infection risk increased by 2.88
Prolonged hospitalization risk:
2.4 times higher ≥ 1 day
4.44 times higher ≥ 3 day
4.43 times higher > 5 day
Slide17The Research – Duration of Postoperative Fasting
In summary, The longer the fasting period, the greater the risk for infectionThe longer the fasting period, the longer the length of stay
Slide18The Research
Inadequate energy delivery during early critical illness correlates with risk of mortality in patients who survive at least seven days: A retrospective studyJong-Rung
Tsai,
Wen-
Tsan
Chang, Chau-Chyun
Sheu, Yu-Ju Wu, Yu-
Heng
Sheu, Po-Len Liu,
Chen-Guo Kerc, Meng-Chuan HuangClinical Nutrition 30 (2011) 209-214
Slide19The Research – Inadequate energy delivery
295 patients retrospectively studiedHigh and low energy delivery (ED)High and low protein deliveryMean daily intake ≥ 60% estimated needs or <60% estimated needs
Slide20The Research – Inadequate energy delivery
Slide21The Research – Inadequate energy delivery
In summary,No difference in Hospital or ICU LOS between the low and high groups for either ED or PD.
Pichard
C,
Kreymann
GK,
Weimann
A, Herrmann HJ, Schneider H. Early energy supply decreases ICU and hospital mortality: a multicentre study in a cohort of 1209 patients. Clin
Nutr
2008;3(Suppl. 1):7.
Slide22The Research
Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical IllnessHsiu-Hua Huang, RD; Sue-Joan Chang, PhD;
Chien
-Wei Hsu, MD; Tzu-Ming Chang, MD;
Shiu
-Ping Kang, RN; Ming-Yi Liu, RD
J
Acad Nutr Diet. 2012;112:1138-1146.
Slide23The Research – Enteral Feeding Route
GI motility and secretion are regulated by hormones such as CCKSite of nutrient administration affects the magnitude of gut-hormone secretion
Hypothesis – The magnitude of illness severity may affect the efficacy of the enteral feeding route in clinical outcomes
Slide24The Research – Enteral Feeding Route
n = 101 (randomly assigned to NG or ND group)All patients administered Jevity 1.0 @ 20 increased by 20mL/hr q 4 hr to the patients specific goal rate.
25-30 kcal/kg IBW
1.2-1.5 g pro/kg IBW
Slide25The Research – Enteral Feeding Route
Results
Slide26The Research – Enteral Feeding Route
Slide27The Research – Enteral Feeding Route
In Summary,ND feeding route is more appropriate than NG feeding route in reducing length of ICU stay among patients with high APACHE II scores.No statistical difference in patients with lower APACHE II scores
Slide28The Research
Differences in resource utilization between patients with Diabetes receiving Glycemia-targeted specialized nutrition vs. standard nutrition formulas in U.S. HospitalsAn observational study – Financial support from Abbott Nutrition*
Osama
Hamdy
, MD,
PhD;
Frank R. Ernst,
PharmD, MS;Dorothy
Baumer
,
MS; Vikkie Mustad
, PhD; Jamie Partridge, PhD, MBA; and Refaat Hegazi, MD, PhD, MPH, MS Journal of Parenteral and Enteral NutritionVolume 38 Supplement 2 November 2014 86S–91S
Slide29The Research – Glycemic specific formulas
Diabetes Mellitus (DM) Substantial economic burden on patients and hospitalsLonger hospital length of stayHigher hospital mortality
Slide30The Research – Glycemic specific formulas
Study Objective:To compare the LOS and resource cost of patients with DM receiving Glycemia targeted specialized nutrition (GTSN), with those receiving Standard Nutrition (STDN) during acute care hospitalizations.
Slide31The Research – Glycemic specific formulas
Data SourcePremier Research DatabasePatient SelectionAdults and Children previously diagnosed T1DM or T2DM, secondary DM, GDM, neonatal DMReceived acute inpatient careExcludes transfer patients, and patients who left AMA.
Slide32The Research – Glycemic specific formulas
Results
Slide33The Research – Glycemic specific formulas
Limitations?Unable to establish causalityMiscoded or missing dataStrengths?Large number of patientsRecording of specific data through the Premier Research Database
Slide34The Research – Glycemic specific formulas
In Summary,Feeding GTSN to patients with DM was associated with significantly reduced LOS and lower costs than patients receiving STDN
Slide35The Academy
The AND Evidence Analysis Library (EAL) suggests:In fluid-resuscitated, critically ill patients, EN started within 24-48 hours following injury or admission to the ICU may reduce LOS.Actual delivery of intake of approximately 60-70% of EN goal in the first week of ICU admission, is associated with a shorter LOS in critically ill patients, particularly when initiated within 48 hours of injury or admission
Slide36Questions?