Enteral feeding: clinical applications and nutritional support

¶ … Feeding Guidelines

The importance of nutrition within a hospital situation is critical to a patient especially one in Intensive Care. When a critically ill patient reacts to treatment with complications due to inflammation, infection, or organs that refuse to function, nutrition must remain stable to ensure the patient has homeostasis. Nutritional support for this type of patient has been downplayed in significance and considered only necessary to normalize hydration or enough fuel to maintain energy when the body is stressed. However it has been discovered recently that nutrition therapy can provide more than just adjunct support but allow increased immune function, enable the body to maintain lean muscle, and improve metabolic response (ASPEN, 2009). The entrance of enteral nutrition is required in critical illnesses to stop cell oxidation and provide the body with the right nutrients at the macro and microcellular level. It is considered a proactive practice to use enteral nutrition therapy that can help the patient to fight infection, lessen the effects of disease, and reduce complications to the point of decreasing time in ICU.

ASPEN ENTERAL FEEDING GUIDELINES (ASPEN, 2009).

A1. Traditional nutrition assessment tools (albumin, prealbumin, and anthropometry) are not validated in critical care. Before initiation of feedings, assessment should include evaluation of weight loss and previous nutrient intake prior to admission, level of disease severity, comorbid conditions, and function of the gastrointestinal (GI) tract (ASPEN, 2009).

A2. Nutrition support therapy in the form of enteral nutrition (EN) should be initiated in the critically ill patient who is unable to maintain volitional intake (ASPEN, 2009).

A3. EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy.

A4. Enteral feeding should be started early within the first 24-48 hours following admission. The feedings should be advanced toward goal over the next

48-72 hours (ASPEN, 2009).

A5. In the setting of hemodynamic compromise

(patients requiring significant hemodynamic support including high dose catecholamine agents, alone or in combination with large volume fluid or blood product resuscitation to maintain cellular perfusion), EN

should be withheld until the patient is fully resuscitated and/or stable (ASPEN, 2009).

A6. In the ICU patient population, neither the presence nor absence of bowel sounds nor evidence of passage of flatus and stool is required for the initiation of enteral feeding (ASPEN, 2009).

A7. Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. Withholding of enteral feeding for repeated high gastric residual volumes alone may be sufficient reason to switch to small bowel feeding (the definition for high gastric residual volume is likely to vary from one hospital to the next, as determined by individual institutional protocol) (ASPEN, 2009).

Guidelines for Enteral Feeding are important because it maintains the strength and viability of gut associated lymphoid tissue called GALT. This is important as the structure of the cells in the GALT or lymphoid tissue must remain stable. In addition this supports the mucus associated lymph tissues or MALT in order for function of lungs, kidneys, and liver. The criticality of proper nutrition to these organs is very time sensitive. Therefore clear guidelines as to Enteral Feeding are essential to aiding the sustenance of the life and viability of the patient (ASPEN, 2009). With proper Enteral Feeding the risk associated with bacterial infection is increased. This may trigger MODS or multiple organ dysfunctions. When a disease increases in severity, EN can provide sustenance to the organs to trigger immune response. Standardized guidelines ensures the same treatment for similar cases of illness. This reduces the uncertainty of prescribed treatment and also allows for the best solutions to be adopted for treating all patients due to their positive response (ASPEN, 2009).

Complications of Enteral Feeding are time sensitive. It is necessary to provide feedings within the first 24 to 72 hours of a metabolic breakdown. This allows the GALT and MALT to be fortified with nutrition to reduce gut permeability and minimize inflammation due to tumors or necrosis. There are even instances of fewer infections that lead to morbidity (Aspen, 2009). The initiation of EN is possible when fluid are being used to resusitate and the blood flow is normalized.