A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Hayden White, Kellie Sosnowski, Khoa Tran, Annelli Reeves, Mark Jones, Hayden White, Kellie Sosnowski, Khoa Tran, Annelli Reeves, Mark Jones

Abstract

Introduction: To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).

Methods: Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.

Results: A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.

Conclusions: Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications

Clinical trial: anzctr.org.au:ACTRN12606000367549.

References

    1. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27:355–373. doi: 10.1177/0148607103027005355.
    1. Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr. 2001;74:534–542.
    1. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, Berghe G van den, Wernerman J. DGEM (German Society for Nutritional Medicine); Ebner C, Hartl W, Heymann C, Spies C. ESPEN (European Society for Parenteral and Enteral Nutrition) ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr. 2006;25:210–223. doi: 10.1016/j.clnu.2006.01.021.
    1. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma--reduced septic morbidity. J Trauma. 1989;29:916–922. discussion 922-913.
    1. Adams S, Dellinger EP, Wertz MJ, Oreskovich MR, Simonowitz D, Johansen K. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. J Trauma. 1986;26:882–891. doi: 10.1097/00005373-198610000-00004.
    1. Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, Kellum JM Jr, Welling RE, Moore EE. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992;216:172–183. doi: 10.1097/00000658-199208000-00008.
    1. Zaloga GP. Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: assessment of outcomes. Lancet. 2006;367:1101–1111. doi: 10.1016/S0140-6736(06)68307-4.
    1. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–2270. doi: 10.1097/00003246-200112000-00005.
    1. Heyland DK, Tougas G, King D, Cook DJ. Impaired gastric emptying in mechanically ventilated, critically ill patients. Intensive Care Med. 1996;22:1339–1344. doi: 10.1007/BF01709548.
    1. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29:1495–1501. doi: 10.1097/00003246-200108000-00001.
    1. Montejo JC, Grau T, Acosta J, Ruiz-Santana S, Planas M, Garcia-De-Lorenzo A, Mesejo A, Cervera M, Sanchez-Alvarez C, Nunez-Ruiz R, Lopez-Martinez J. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med. 2002;30:796–800. doi: 10.1097/00003246-200204000-00013.
    1. Kaufman JP, Hughes WB, Kerstein MD. Pneumothorax after nasoenteral feeding tube placement. Am Surg. 2001;67:772–773.
    1. Kools AM, Snyder LS, Cass OW. Pneumothorax: complication of enteral feeding tube placement. Dig Dis Sci. 1987;32:1212–1213. doi: 10.1007/BF01300209.
    1. Wendell GD, Lenchner GS, Promisloff RA. Pneumothorax complicating small-bore feeding tube placement. Arch Intern Med. 1991;151:599–602. doi: 10.1001/archinte.151.3.599.
    1. Hernandez-Socorro CR, Marin J, Ruiz-Santana S, Santana L, Manzano JL. Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients. Crit Care Med. 1996;24:1690–1694. doi: 10.1097/00003246-199610000-00015.
    1. Hillard AE, Waddell JJ, Metzler MH, McAlpin D. Fluoroscopically guided nasoenteric feeding tube placement versus bedside placement. South Med J. 1995;88:425–428.
    1. Rives DA, LeRoy JL, Hawkins ML, Bowden TA Jr. Endoscopically assisted nasojejunal feeding tube placement. Am Surg. 1989;55:88–91.
    1. Shipps FC, Sayler CB, Egan JF, Green GS, Weinstein CJ, Jones JM. Fluoroscopic placement of intestinal tubes. Radiology. 1979;132:226–227.
    1. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. JPEN J Parenter Enteral Nutr. 1986;10:104–105. doi: 10.1177/0148607186010001104.
    1. Heyland DK, Dhaliwal R, Day A, Jain M, Drover J. Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study. Crit Care Med. 2004;32:2260–2266.
    1. Gatt M, Macfie J. Bedside postpyloric feeding tube placement: A pilot study to validate this novel technique. Crit Care Med. 2009;37:523–527. doi: 10.1097/CCM.0b013e3181959836.
    1. Salasidis R, Fleiszer T, Johnston R. Air insufflation technique of enteral tube insertion: a randomized, controlled trial. Crit Care Med. 1998;26:1036–1039. doi: 10.1097/00003246-199806000-00023.
    1. Slagt C, Innes R, Bihari D, Lawrence J, Shehabi Y. A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study. Intensive Care Med. 2004;30:103–107. doi: 10.1007/s00134-003-2071-x.
    1. Lee AJ, Eve R, Bennett MJ. Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus. Intensive Care Med. 2006;32:553–556. doi: 10.1007/s00134-006-0095-8.
    1. Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNM, Delarue J, Berger MM. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502–509. doi: 10.1016/j.clnu.2005.03.006.
    1. Fouque D, Guebre-Egziabher F. An update on nutrition in chronic kidney disease. Int Urol Nephrol. 2007;39:239–246. doi: 10.1007/s11255-006-9108-3.
    1. Heyman JK, Whitfield CJ, Brock KE, McCaughan GW, Donaghy AJ. Dietary protein intakes in patients with hepatic encephalopathy and cirrhosis: current practice in NSW and ACT. Med J Aust. 2006;185:542–543.
    1. Meduri GU. Diagnosis and differential diagnosis of ventilator-associated pneumonia. Clin Chest Med. 1995;16:61–93.
    1. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000;162:505–511.
    1. Ho KM, Dobb GJ, Webb SA. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med. 2006;32:639–649. doi: 10.1007/s00134-006-0128-3.
    1. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003;7:R46–51. doi: 10.1186/cc2190.
    1. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28:1742–1746. doi: 10.1097/00003246-200006000-00007.
    1. Neumann DA, DeLegge MH. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med. 2002;30:1436–1438. doi: 10.1097/00003246-200207000-00006.
    1. Fruhwald S, Holzer P, Metzler H. Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Intensive Care Med. 2007;33:36–44. doi: 10.1007/s00134-006-0452-7.
    1. Tarling MM, Toner CC, Withington PS, Baxter MK, Whelpton R, Goldhill DR. A model of gastric emptying using paracetamol absorption in intensive care patients. Intensive Care Med. 1997;23:256–260. doi: 10.1007/s001340050325.
    1. Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med. 2001;29:1916–1919. doi: 10.1097/00003246-200110000-00011.
    1. Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma. 1999;46:992–996. doi: 10.1097/00005373-199906000-00002. discussion 996-998.
    1. Montecalvo MA, Steger KA, Farber HW, Smith BF, Dennis RC, Fitzpatrick GF, Pollack SD, Korsberg TZ, Birkett DH, Hirsch EF. et al.Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med. 1992;20:1377–1387. doi: 10.1097/00003246-199210000-00004.
    1. Nguyen NQ, Ng MP, Chapman M, Fraser RJ, Holloway RH. The impact of admission diagnosis on gastric emptying in critically ill patients. Crit Care. 2007;11:R16. doi: 10.1186/cc5685.
    1. Kao CH, ChangLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998;93:1108–1112. doi: 10.1111/j.1572-0241.1998.00338.x.
    1. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29:1955–1961. doi: 10.1097/00003246-200110000-00018.
    1. Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. doi: 10.1378/chest.119.4.1222.
    1. Ritz MA, Fraser R, Edwards N, Di Matteo AC, Chapman M, Butler R, Cmielewski P, Tournadre JP, Davidson G, Dent J. Delayed gastric emptying in ventilated critically ill patients: measurement by 13 C-octanoic acid breath test. Crit Care Med. 2001;29:1744–1749. doi: 10.1097/00003246-200109000-00015.
    1. Zaloga GP. The myth of the gastric residual volume. Crit Care Med. 2005;33:449–450. doi: 10.1097/01.CCM.0000148086.12949.2F.
    1. Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007;13:3909–3917.
    1. Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med. 2001;27:660–664. doi: 10.1007/s001340100880.
    1. Davies AR, Froomes PR, French CJ, Bellomo R, Gutteridge GA, Nyulasi I, Walker R, Sewell RB. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med. 2002;30:586–590. doi: 10.1097/00003246-200203000-00016.
    1. Griffith DP, McNally AT, Battey CH, Forte SS, Cacciatore AM, Szeszycki EE, Bergman GF, Furr CE, Murphy FB, Galloway JR, Ziegler TR. Intravenous erythromycin facilitates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study. Crit Care Med. 2003;31:39–44. doi: 10.1097/00003246-200301000-00006.
    1. Ugo PJ, Mohler PA, Wilson GL. Bedside postpyloric placement of weighted feeding tubes. Nutr Clin Pract. 1992;7:284–287. doi: 10.1177/0115426592007006284.
    1. Gabriel SA, Ackermann RJ. Placement of nasoenteral feeding tubes using external magnetic guidance. JPEN J Parenter Enteral Nutr. 2004;28:119–122. doi: 10.1177/0148607104028002119.
    1. Gray R, Tynan C, Reed L, Hasse J, Kramlich M, Roberts S, Suneson J, Thompson J, Neylon J. Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique? Nutr Clin Pract. 2007;22:436–444. doi: 10.1177/0115426507022004436.
    1. Levy H, Hayes J, Boivin M, Tomba T. Transpyloric feeding tube placement in critically ill patients using electromyogram and erythromycin infusion. Chest. 2004;125:587–591. doi: 10.1378/chest.125.2.587.
    1. Young RJ, Chapman MJ, Fraser R, Vozzo R, Chorley DP, Creed S. A novel technique for post-pyloric feeding tube placement in critically ill patients: a pilot study. Anaesth Intensive Care. 2005;33:229–234.

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