ESPEN Congress Vienna 2009

Jejunal tubes - a missed opportunity?Warranted in all ICU patients?

J. Hallay (Hungary)

Warrented in all ICU patients?

Judit HallayDept. of Anesthesiology & Intensive Care;

University of Debrecen, HungaryESPEN 2009

„Critical illness“

Acute Stress Response

Trauma/Infection

Immunological

Response

Neuroendocrine Response

Metabolic Response

Iatrogenic Factors

Starvation

The Skeleton in the Hospital Closet:Hospitals try to hide

„ There are malnourished in America, not in the ghettos of the town, but in the

hospitals…”Patients starve, or will be malnourished

in the hospitalssimply for they are there…”

Butterworth Ch.E. Nutrition Today 9: 4-8 1974.

Malnutrition Subacut or chronic state Over or undernutrition Inflammatory activity Change of body composition Diminished function

Soeters P.B.Clin Nutr 27: 706-716 2008.

Aggressions Stress Trauma Burning New surgical technics More severely ill, or malnurished

patients despite of overnurishing and overweight

Immunologic response wound healing mobilises amino acids from lean tissues accelerated protein synthesis

ESPEN Guidelines on Enteral Nutrition: Intensive care It should have begun during the first 24h - standard high-

protein formula. Acute and initial phases: 20-25 kcal/kg /day should be

avoided. During recovery energy supply 25-30 kcal/kg /day. Supplementary PN to patients who do not reach their target

nutrient intake on EN alone. There is no general indication for immune-modulating

formulae. Glutamine should be supplemented in burns or trauma.

Kreymann K.G. Clin nutr 25: 01/05/2006.

Goal of aggressive, early EN

To maintain host defenses To preserve lean body mass Ease of administration Decreased cost Less infection No need for central vein Beneficial effect on gut mucosa on immunologic integrity on survival of septic peritonitis,

pneumonia, abscess formingOrlando R. Crit Care Med 27: 1659 1999.

Nutrition of critically ill Logical combination of EN (1970) and PN (1960) Early EN Demand of hypermetabolic patients in negative nitrogen

balance PN supplementation – target caloric intake Tight glycemic control Improve outcomes – EN on the intestinal lumen can preclude

the development of sepsis from bowel flora

Pichard C.Clin Nutr suppl 4: 3-7 2009.

Pathophysiology

Loss of body protein, fat, or abnormal protein, carbonhydrate metabolism results hepatic glyconeogenesis from amino acids, breakdown of muscle proteins.

Enteralism Is the first „ism” of the new millennium

Thomson A. Nutrition 20: 839-840 2004.

Who can be nourished enterally?

Stability in hemodynamics Who can absorb nutriment Who has bowel motility

Decision individually, according to the clinical condition

Postpyloric feeding

Should be reversed for those patients that do not tolerate gastric feeding -

gastroparesis - surgically modified gastric anatomy -Whipple procedure

effectiveness of EN protocols to reduce pneumonia indicated > 30 days

Regurgitation, reflux, emesis, penetration, aspiration

Lorenzo V. Clin Nutr 28: 355-356 2009. Krenitsky J. Practical Gastroenterology 42: 46-65 2006.

Postpyloric feeding Ileus Gastric reflux Pancreatitis Pancreatoduodenectomy Esophagectomy Head-neck surgery Head injury Stroke Ventilated, critically ill patients

Ileus - JN Intestinal obstruction, or functional inhibition of

bowel motility Causes: infection, sepsis, spinal cord trauma Tube placement involves the compressed

segment to gain access to the functional distal bowel - JN

Double-lumen, or 3-lumens catheter with enteral feeding tube simultaneous gastric decompression, slow JN

Gastric reflux - JN Cause: sepsis, trauma, drugs, body position,

gastroparesis, esophageal dysmotility, obesity Aspiration during GN can be problematic Postpyloric JN! Simultaneous gastric decompression (PEG-J) is

effective

Luttmann A. Gastrointestinal Endoscopy 61: 492-493 2005.

Acute pancreatitis severity

Severity: higher intestinal barrier dysfunction compared with patients with mild pancreatitis

Lactulose : Mannitol (L : M) ratio used to assess permeability

L : M ratio being .2 and .029 - window of opportunity for JN therapy

Nagpal K. Am J Surg 192: 24-28 2006.

Acute pancreatitis I.Name Nutrition Severity Outcome - p

Eckerwall2007Sweden

fasting: early oral mild Early oral4:6 days0.05

Mcclave2006Kentucky

27 trialsrandomized

EN : PNIf PN only in 5 days

severe In 7 trials

EarlyJNInfect.morbidity p=0.001

HLOS p< 0.0001Organ failure less p=0.18

No effect on mortality p=0.72

Acute pancreatitis II.Name Nutrition Severity Outcome - p

Petrov2008

JN regardless Early JNMotility!Th. Window 2-3 days

Petrov2009Russia

TPNTPN+JN

regardless JN startIn 48 h0.05

Petrov2009

15 trialsrandomized

EN : no suppl. N

PN : no suppl. N

EN : PN

severe Inf. compl. – no diff. p=0.58Mortality – reduced p=0.01

Inf. compl – no diff. p=0.77Mortality – reduced p=0.04

Inf. compl. - less p<0.001Mortality - no effect p=0.12

Acute pancreatitis III.Name Nutrition Severity Outcome - p

Yunfei2008China

224RandomizedJN :TPN

severe Infection 0.001Compl. 0.021MOF 0.008

Ioannidis2008Greece

JN :TPN severe CheeperCompl. lessSurgery less

Abou-Assi2008

50 randomizedHypocaloricJN :TPN

severe Compl. 0.003Sepsis 0.01- CALORY !

Louie B2005Canada

28RandomizedJN :TPN

severe Only cost diff!JNcost 1375 PNcost 2608USD/day

Acute pancreatitis - postop.- JN : GN JN, even when instituted late, improves outcomes in 60 patients randomized after surgery due to secondary

peritonitis 30 JN, 30 PN Recovery of bowel transit took less time in the JN patients

54.6 h versus 76.8 h in PN patients p = 0.01 JF resulted in 3.3% mortality as opposed to 23.3% in the PN

group p = 0.05

Pupelis G. Nutrition 17: 91-94 2001.

Acute pancreatitis – probioticsDON’T! Small bowel necrosis may - in of patent vasculature of GI Hirota M.Pancreatology 3: 316-322 2003. Why? profound effect on uptake of food colonization of the gut bowel ischemia fiber + probiotics aggravated intestinal perfusion bypassing the normal predigestive and barrier formula „PROPATRIA” randomized study in Holland Severe pancreatitis - 80 patients Probiotic group - death 41% - 8 ischemic bowel Placebo group - death 5% - no ischemic bowel

Soeters P.B. Clin Nutr 27: 173-178 2008.

Acute pancreatitis - diet Effect of NJ perfusion of elemental and crushed food

homogenate on pancreatic enzyme - lipase, chymotrypsin - secretion in human subjects

Crushed food homogenate - greater stimulative effect on pancreatic enzyme secretion than elemental!

Vison N. Gut 19: 194-198 1978.

27 healthy voluntaries EN diets stimulated amylase, lipase, trypsin, bile acid

secretion and increase plasma gastrin, cholecystokinin Elemental formula reduced enzyme secretion by

50%O'Keefe S.J. Am J Physiol Gastrointest Liver Physiol 284: 27-36 2003.

Acute pancreatitis – diet normal diet OK in mild pancreatitis 62 randomized patients - reduced emotional and

financial costs Zoler M. L. Internal Medicine News May 1, 2008. - Philadelphia

EN + Supplements - arginine, glutamine, omega-3 polyunsaturated fatty acids, probiotics, may have positive impact on outcome

McClave JPEN J Parenter Enteral Nutr 30: 143-156 2006.- Kentucky

Role of NJ glutamine or ω-3 fatty acids are uncertainOláh A. Langenbeck's Arch Surg 3: 261-269 2008.

40 randomized patients - Stresson Multi Fibre (glutamine) JNfast recovery of IgG, IgM proteins

Hallay J. Hepatogastroenterology 48: 1488-1492 2001.

Pancreaticoduodenectomy JN+PN Comparison 17 patients - 8 - jejunostomy : 9 - JN + PN More, in the JN group dropped out of JN due to diarrhea,

abdominal distention No significant diff. in catheter-associated infections -

3/8 in the JN group vs. 2/9 in JN+PN No difference in immunological functions JN + PN is more adequate in energy supply Nagata S. Nutrition Journal 8: 24 2009. doi:10.1186/1475-2891-8-24

14 patients - JN continuously : JN in bolus Pancreatic juice was diverted from the Wirsungial duct by

nasopancreatic drainage JN bolus stimulated pancreatic enzyme secretion, JN

continuously did not!Harsányi L. Orv Hetil 48: 2659-2662 1991.

Pancreaticoduodenectomy Randomized controlled trials 34 articles for review -15 trials in Europe, 10 in North

America, 9 in Asia. Quality of every RCT was not satisfactory high-grade

evidence should be applied in clinical settings to improve surgical quality and quality of life for each patient

Kaido T. Pancreas 33: 228-232 2006.

Gut perforation - GN Early GN after surgery of gut perforations, peritonitis 100 randomized patients - GN 48 h p. op. Early positive nitrogen balance as compared to PN

regimen p < 0.001 Weight loss 3.10 kg vs. 5.1kg

Malhotra A.J. Postgrad Med 50: 102-106 2004. - India

Complication of postoperative JN Bowel necrosis associated with early JN - 9 studies - Chicago - enteral feedings responsible for

bowel ischemia Mesenteric ischemia may present in up to 3.5% of JN

surgical patients; associated mortality approaches 100%. Prompt bowel resection - for survival

Melis M. Arch Surg 141: 701-704 2006.

Esophagectomy

Name Patients Nutrition Onset of JNp.op.hour

Outcome - p

Mackenzie2004USA

12000/year/USA

TPN + JN 48-72

Shiraishi 2005Japan

16randomized

JN :TPNjejunostomy

48 recovery of PRA,RBP,compl. no difference

Gábor2005Austria

88randomized

JN : TPNdouble-lumen tube

48 Fist bowelmov.0.001ICU stay 0.01HLOS 0.001Mortality nodiff.

Esophagectomy - jejunostomy? During placement of the NJ catheter submucosal jejunal

metastasis of esophageal squamous cell carcinoma with small intestinal obstruction was detected

Yamada T. Surg Today 26: 800- 802 1996.

Head and neck surgery - JN Gastro-omental free flap reconstruction of the head

and neck Gastrojejunostomy tube Gastric mucosa - to reconstruct the hemiglossectomy

defect

Bayles S.V. Arch Facial Plast Surg 10: 255-259 2008.

Closed head injury GN, JN, PN

Beneficial effect of EN GN was successfully tolerated on the 3rd postinjury day 32 randomized patients - NJ tube Bronchitis, pneumonia, and ventriculitis appear to be lower in

EN patients It is unlikely that there is any benefit from advancing NJ tube

to bypass the temporary gastroparesis

Kudsk K.A.Gastrointest Endosc Clin N Am 17: 647–662 2007.

Epilepsy, neurological dysphagia - GN Epilepsy, drug resistant epilepsy predisposes to

malnutrition Lack of protein, energy, magnesium, social exclusions, food

taboos, antiepileptic drugs predispose malnutrition, induce epileptiform discharges.GN – possibility

Crepin S. Clin Nutr 28: 219-225 2009.

Neurological dysphagia.

Low iron, zinc, high copper serum concentration Malnutrition - GN Inflammation has to be treated. Monitoring!Hitoshi O. Clin Nutr 27: 587-593 2008.

Stroke patients GN : JN, NO PEG! 30 stroke patients. Esophageal manometry JN : GN? Lower esophageal sphincter dysfunction often

precludes safe gastric feeding in stroke patients. Lucas C. E. Archives of surgery 134: 55-58 1999.

Multicenter, randomized FOOD trial 859 dysphagic stroke patients early GN : no tube Reduction in risk of death - p=0.09, in death - p=0.7 321 patients PEG : GN Increase in risk of death - p=0.9, in death - p=0.05 Martin D. Lancet 365: 764-772 2005.

Critically ill, ventilated JN : GN? - l.Name Patients Nutrition Caloric intake - p Outome - p

Montecalvo1992

38randomized

JN : GN JN!0.05

PRA!0.05 pneumonia less 0.05

Meert2004 74 randomized

JN : GN JN!0.05

No diff.in aspiration

Holzinger2009Austria

42/62,8% of ventilated GI.compl. /

JN JN for ≥ 250 ml / day gastric volumes

Critically ill, ventilated NJ : GN? - ll.Name Patients Nutrition Caloric intake

pOutcome - p

Pupelis 2007

Based on 14 level, 2 studies

-early EN -24 -48 h-delayed EN -after 72 h

Bowel movement-JN, drugs,!In early phasePN doesn’thelp

No effect on mortality.

Montejo2002Spain

101 randomized

JN : GN GI compl. less in NJOutcome, mortality no diff.

Davies2006Australia

multicenter,randomized,46% - GIT intolerance

JN : GN More delivered nourishment!0.02

Reduced HLOS 0.003mortality0.058

Burn injuries – GN : JN Plus energy recquirement - maybe 2000 kcal/daySaffle J.Total burn care London: W.B. Saunders 271-287 2002.

Early EN - positive impact on the progress.Appropriate approach to nutrition - oral, GN, JN

Kripner J. Prague Acta 46: 2004

Early GN after serious burns - Germany 55 long-term ventilated (24.8 days) patients, in 45 patient initiation of

tube feeding was in 11h, could meet the caloric needs. EN decreased mortality

Raff T. Burns 23: 19-25 1997.

Home messageUse GN if possible!

JN vs. PN Pancreatitis - regardless of severity early start of JN - within

48h! Do not use prebiotics in pancreatitis - small bowel necrosis!

JN!(+PN) Oesophagectomy, pancreatoduodenectomy

GN or JN Ventilated patients - lower rate of pneumonia, GIT intolerance

may be in JN

Home message

„Man cannot live on bread alone…”

New Testament Luke 4. 4.