Monitoring Tolerance of Enteral Nutrition (EN) in Critically Ill Adults

96 Questions

What percentage of energy requirements do healthcare providers tend to prescribe for EN?

60%–80%

What is the primary method used by nurses to assess intolerance to EN?

Measuring GRVs

What percentage of patients reach their target goal energy intake during their ICU stay?

Less than half

What is the recommended frequency for monitoring tolerance of EN in adult critically ill patients?

Daily

What is the consequence of ordering a feeding status of NPO for the patient surrounding the time of diagnostic tests or procedures?

Propagation of ileus and inadequate nutrient delivery

What percentage of prescribed EN do patients typically receive?

80%

What is the average percentage of target goal energy intake that patients receive from one day to the next?

50%

What is a common definition of GI intolerance?

Vomiting, abdominal distention, and high NG output

What percentage of patients experience cessation of EN?

More than 85%

What is the main reason for cessation of EN?

Patient intolerance

What is the correlation between GRVs and gastric emptying?

Poor correlation

What is the sensitivity of GRVs in detecting aspiration?

1.5-4.1%

What is the result of raising the cutoff value for GRVs?

No change in incidence of regurgitation, aspiration, and pneumonia

What is the effect of eliminating the practice of using GRVs?

Improved delivery of EN without compromising patient safety

What is the main consequence of using GRVs?

Increased enteral access device clogging and inappropriate cessation of EN

What is the outcome of reducing the cutoff value for GRVs?

No change in incidence of aspiration and pneumonia

What is the result of continuing EN during frequent surgical procedures?

Decreased incidence of infections

What is the consequence of repeated and prolonged periods of NPO?

Ileus is propagated

What is a potential adverse effect of erythromycin that should be monitored?

Cardiac toxicity

What is a potential benefit of using naloxone infused through the enteral access device?

Reduction in GRVs

What is a recommended nursing directive to reduce the risk of aspiration and VAP?

Elevating the head of the bed 30°–45°

What is a potential complication of metoclopramide use, particularly in the elderly?

Tardive dyskinesia

What is a potential limitation of using blue food coloring as a marker for aspiration of EN?

It interferes with other colorimetric tests

What is a potential benefit of combination therapy with erythromycin and metoclopramide?

Improved GRVs with increased feeding success

What is a potential adverse effect of metoclopramide and erythromycin that should be monitored?

QT prolongation

What is a recommended step to decrease aspiration risk?

Reducing the level of sedation/analgesia when possible

What is a potential limitation of using glucose oxidase strips as surrogate markers for aspiration in the critical care setting?

They are not recommended by expert consensus

What is the main issue with using glucose oxidase as a monitor for aspiration in patients receiving EN?

It has poor sensitivity and specificity characteristics

What is a potential benefit of using peripherally acting mu-opioid receptor antagonists after surgery?

Facilitating recovery of GI function

Why should EN not be automatically interrupted for diarrhea in adult critically ill patients?

Because interrupting EN may lead to inadequate nutrition intake

What is a common definition of diarrhea in ICU patients receiving EN?

2-3 liquid stools per day or >250 g of liquid stool per day

What is a potential contributing factor to diarrhea in patients receiving EN, especially if they are also receiving antibiotics?

Formulas with a high content of FODMAPS

What should be included in the assessment of diarrhea in adult critically ill patients receiving EN?

Abdominal examination, quantification of stool, and review of medications

What type of formula is recommended for initiating EN in the critically ill patient?

Standard polymeric formula

Why should specialty formulas be avoided in critically ill patients?

They are not supported by evidence in the literature

What is a potential consequence of diarrhea in ICU patients receiving EN?

All of the above

What is a common cause of diarrhea in ICU patients receiving EN?

All of the above

What is the goal of assessing diarrhea in adult critically ill patients receiving EN?

To determine the etiology of diarrhea and initiate appropriate treatment

What is the primary reason for not recommending immune-modulating enteral formulations in the MICU setting?

There is a lack of evidence to support their use due to heterogeneity of studies

What is the concern with pulmonary formulas?

They have a high content of omega-6 fatty acid, which may drive inflammatory processes

In which patient population may immune-modulating enteral formulations be considered?

Patients with TBI and perioperative patients in the SICU

What is the concern with the studies on immune-modulating enteral formulations?

They had significant heterogeneity in patient populations and experimental formulations

What is the recommendation for the use of enteral formulations with an anti-inflammatory lipid profile in patients with ARDS and severe ALI?

They cannot be recommended due to conflicting data

What is the limitation of the studies on enteral formulations with an anti-inflammatory lipid profile?

They had significant heterogeneity based on the method of infusion

What is the concern with the placebo formula used in the large multicenter study by Rice et al?

It contained an extra 16 g of protein daily

What is the indication for using disease-specific and severe fluid-restricted formulas?

In a small percentage of patients on a case-by-case basis due to physiologic benefits

What is the conclusion about immune-modulating enteral formulations in the MICU setting?

They should not be used routinely due to lack of evidence

What is the main limitation of marketed immune-modulating enteral formulations?

They have significant heterogeneity in their makeup and dosage of individual components

What is the primary concern with using mixed-fiber formulas in critically ill patients?

Bowel obstruction

What type of formula may be beneficial for patients with persistent diarrhea and suspected malabsorption?

Small peptide semielemental formula

What is the proposed mechanism of action of fermentable soluble fiber additives?

Fermentation in the colon into short-chain fatty acids

What is the recommended daily dose of a fermentable soluble fiber supplement for adjunctive therapy in critically ill patients?

10-20 g in divided doses

What is the effect of short-chain fatty acids (SCFAs) on the colon?

Increased pancreatic secretions

What is the benefit of prebiotic fibers on the gut microbiota?

Stimulation of the growth of Bifidobacteria and Lactobacillus

What is the primary indication for using a commercial mixed fiber-containing formula in critically ill patients?

Persistent diarrhea

What is the concern with using insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility?

Bowel obstruction

What is the effect of fermentable soluble fiber additives on nutrient absorption?

Influential effects on absorption

What is the recommended population for routine use of a fermentable soluble fiber additive?

Hemodynamically stable MICU/SICU patients

What is the primary mechanism by which soluble fiber supplements reduce diarrhea in critically ill patients?

by stimulating the uptake of water and electrolytes through the trophic effect of SCFAs on colonocytes

What is the recommended dose of soluble fiber additive for ICU patients?

10-20 g/d divided over 24 hours

What is the main reason for considering the use of soluble fiber additives in ICU patients?

to promote bowel health and maintain commensal microbiota

What is the correlation between the use of probiotics and the incidence of VAP in ICU patients?

certain probiotic species decrease the incidence of VAP

What is the recommendation for the use of probiotics in ICU patients?

probiotics should be used only in select medical and surgical patient populations

What is the effect of using a soluble fiber additive on the risk of intestinal obstruction?

it theoretically poses a lower risk of intestinal obstruction

What is the outcome of patients with feeding intolerance who have higher amounts of Staphylococcus and lower amounts of anaerobes?

they have a higher rate of bacteremia and mortality

What is the benefit of using a prebiotic soluble fiber supplement in critically ill patients with diarrhea?

it has a more consistent benefit in reducing diarrhea compared to commercial mixed-fiber formulas

What is the mechanism of action of probiotic agents in the ICU?

they have species-specific mechanisms of action, including competitive inhibition of pathogenic bacterial growth

What is the recommendation for the provision of antioxidants and trace minerals in critically ill patients?

they should be provided to patients who require specialized nutrition therapy

What is the suggested approach to nutrition in ICU patients who are severely malnourished and EN is not feasible?

Initiating exclusive PN as soon as possible after ICU admission

What is the recommended time frame for considering supplemental PN in patients at low or high nutrition risk who are unable to meet energy and protein requirements through EN?

After 7-10 days of ICU admission

What is the primary goal of early EN in critically ill patients?

To maintain gut integrity, reduce oxidative stress, and modulate systemic immunity

What is the effect of using PN in malnourished ICU patients compared to STD?

Reduced risk of mortality and infection

What is the consequence of initiating supplemental PN prior to 7-10 days in critically ill patients on some EN?

Minimal benefits and potentially detrimental effects

What is the recommended approach to nutrition in patients who are at high nutrition risk and EN is not available?

Initiating exclusive PN as soon as possible after ICU admission

What is the effect of STD on malnourished ICU patients compared to PN?

Increased risk of mortality and infection

What is the rationale for initiating exclusive PN in severely malnourished ICU patients when EN is not feasible?

To reverse the initial priorities and prioritize PN over STD

What is the recommended alternative to GRVs for monitoring critically ill patients receiving EN?

Careful daily physical examinations, review of abdominal radiologic films, and evaluation of clinical risk factors for aspiration.

What is the primary association of pneumonia and bacterial colonization of the upper respiratory tree?

Aspiration of contaminated oropharyngeal secretions.

What is the recommended strategy for patients deemed to be at high risk for aspiration?

Postpyloric enteral access device placement.

What is the benefit of switching to continuous infusion of EN in high-risk patients?

Reduced risk of aspiration pneumonia.

What is the effect of prokinetic agents on gastric emptying and tolerance of EN?

Improved gastric emptying and tolerance of EN.

What is the recommended dose of erythromycin for treating gastric enteral feeding intolerance?

3-7 mg/kg/d.

What is the effect of using prokinetic agents on GRVs?

Lower GRVs.

What is the primary concern with GRVs in the range of 200-500 mL?

Risk of aspiration pneumonia.

What is the benefit of using small bowel EN compared to gastric EN?

Reduced risk of regurgitation and aspiration.

What is the quality of evidence for using prokinetic agents in ICU patients?

Low.

What is the consequence of not standardizing the administration of antioxidant vitamins and trace minerals in critically ill patients?

Increased risk of mortality

What is the primary reason for not recommending enteral glutamine supplementation in critically ill patients?

It fails to generate a sufficient systemic antioxidant effect

When should parenteral nutrition (PN) be initiated in adult critically ill patients at low nutrition risk?

After 7 days of ICU admission if EN is not feasible

What is the primary consideration when deciding to initiate PN in critically ill patients?

Nutrition risk of the patient

What is the benefit of using antioxidant vitamins and trace minerals in critically ill patients?

Reduces overall mortality

Why should PN be considered in patients with a short bowel diagnosis?

Because they are PN dependent

What is the primary concern with using PN in critically ill patients?

It provides little benefit over EN

What is the recommendation for the use of enteral glutamine supplementation in critically ill patients?

It should not be used in critically ill patients

What is the primary consideration when deciding to use antioxidant vitamins and trace minerals in critically ill patients?

Renal function

What is the primary benefit of using antioxidant vitamins and trace minerals in critically ill patients with burns, trauma, and critical illness?

Reduces overall mortality

Study Notes

Monitoring Tolerance and Adequacy of EN

Patients should be monitored daily for tolerance of EN to avoid inadequate nutrient delivery.
Inappropriate cessation of EN should be avoided, especially around diagnostic tests or procedures to minimize ileus and propagation of nutrient deficiencies.
Tolerance can be determined by physical examination, passage of flatus and stool, radiologic evaluations, and absence of patient complaints.
GI intolerance is defined by vomiting, abdominal distention, discomfort, high NG output, high GRV, diarrhea, reduced passage of flatus and stool, or abnormal abdominal radiographs.

Tolerance Markers

Gastric residual volumes (GRVs) should not be used as a marker for aspiration in ICU patients receiving EN.
GRVs do not correlate with gastric emptying and have a low sensitivity for aspiration.
Eliminating GRVs does not jeopardize patient safety and may improve EN delivery.
Alternative strategies for monitoring critically ill patients receiving EN include:
- Careful daily physical examinations
- Review of abdominal radiologic films
- Evaluation of clinical risk factors for aspiration

Strategies to Reduce Aspiration Risk

Diverting the level of feeding by postpyloric enteral access device placement in patients deemed to be at high risk for aspiration.
Using continuous infusion of EN instead of bolus infusion to reduce risk of aspiration pneumonia.
Initiating agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), in patients at high risk of aspiration.
Elevating the head of the bed 30°–45° to reduce the incidence of pneumonia.
Using chlorhexidine mouthwash twice daily to reduce respiratory infection and nosocomial pneumonia.

Diarrhea Associated with EN

EN should not be automatically interrupted for diarrhea.
Diarrhea in ICU patients receiving EN is common, ranging from 2% to 95%.
Factors contributing to diarrhea include:
- Type and amount of fiber in formula
- Osmolality of formula
- Delivery mode
- EN contamination
- Medications
- Infectious etiologies
Assessment of diarrhea should include abdominal examination, quantification of stool, stool culture, serum electrolyte panel, and review of medications.

Selection of Appropriate Enteral Formulation

Standard polymeric formulas should be used when initiating EN in the ICU setting.
Specialty formulas, including disease-specific and immune-modulating formulas, should not be used routinely in ICUs.
Immune-modulating formulas may be considered for patients with TBI and perioperative patients in the SICU.### Enteral Formulations
There is no recommendation for the routine use of enteral formulations characterized by an anti-inflammatory lipid profile and antioxidants in patients with ARDS and severe ALI due to conflicting data.
Six RCTs have evaluated the use of additives or formulas with an anti-inflammatory lipid profile in patients with ARDS, ALI, and sepsis, but there is significant heterogeneity among the studies.

Fiber-Containing Formulations

Commercial mixed fiber formulas should not be used routinely in adult critically ill patients to promote bowel regularity or prevent diarrhea due to low-quality evidence.
However, mixed fiber-containing formulations may be beneficial in patients with persistent diarrhea, but not in those at high risk for bowel ischemia or severe dysmotility.
Small peptide formulations may be considered in patients with persistent diarrhea or suspected malabsorption.

Soluble Fiber Supplements

Soluble fiber supplements may be beneficial in reducing diarrhea in critically ill patients, particularly those on standard enteral formulas.
Fermentable soluble fiber additives (e.g., fructo-oligosaccharides, inulin) may be considered for routine use in hemodynamically stable ICU patients.
The supplement should be given in divided doses over 24 hours, with a recommended dose of 10-20 g/d.

Probiotics

Probiotics appear to be safe in general ICU patients, but their use should be limited to select medical and surgical patient populations for which RCTs have documented safety and outcome benefit.
Probiotics have species-specific mechanisms of action, including competitive inhibition of pathogenic bacterial growth and enhancement of intestinal epithelial barrier function.

Antioxidants and Trace Minerals

A combination of antioxidant vitamins and trace minerals in safe doses may be provided to critically ill patients who require specialized nutrition therapy.
Antioxidant vitamins and trace minerals may improve patient outcome, especially in burns, trauma, and critical illness requiring mechanical ventilation.

Glutamine

Enteral glutamine should not be added to an EN regimen routinely in critically ill patients, as it has not been shown to have a significant beneficial effect on mortality, infections, or hospital LOS.

Parenteral Nutrition

In patients at low nutrition risk, exclusive PN should be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible.
In patients at high nutrition risk or who are severely malnourished, PN may be initiated as soon as possible following ICU admission if EN is not feasible.
Supplemental PN may be considered after 7-10 days if unable to meet >60% of energy and protein requirements by the enteral route alone.

This quiz assesses understanding of monitoring tolerance of Enteral Nutrition (EN) in adult critically ill patients, including daily monitoring and minimizing unnecessary cessation of EN.

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