MARNIAR C20911804 (GIZI KLINIK) PEMBIMBING : dr.

ABDUL WAHAB,SpAn

Critically ill patients

stress Malnourished hypermetabolism 40%

impaired immune function A recommended component and of adequate nutrition support is Impaired ventilatory drive early enteral nutrition (EEN)

prolonged ventilatory dependence and infectious morbidity and mortality

EN
preserved gut integrity reduction in infectious complications

FUNCTIONAL GASTROINTESTINAL (GI) TRACT

a prospective, observational study

November 2007 February 2008

medical ICU of Methodist University Hospital (MUH), University of Tennessee in Memphis

Inclusion criteria
EN was provided via a nasogastric tube 18 years
expected to be NPO for > 48 hours

candidates for oral intake

receiving PN within the first 48 hours of admission

Exclusion criteria
life expectancy < 48 hours ICU stay < 48 hours,

Contraindication to enteral feeding

severe nausea and vomiting

severe diarrhea

malabsorptive syndromes

significant small bowel resection

severe pancreatitis

bowel obstruction

perforation

peritonitis

IV dopamine infusion at a rate > 10 mcg/kg/min

IV norepinephrine infusion at a rate > 10mcg/min

CONTRAINDICATION TO ENTERAL FEEDING

EEN

Patients who received EN at a rate of at least 20 mL/h within 24 hours of admission to the ICU

primary objective

to evaluate the effect of EEN or delayed EN on length of stay in the medical ICU

secondary objectives

evaluation of the time to initiation of EN at the minimum rate (20 mL/h) determination of the effect of EEN or delayed EN on total hospital LOS, duration of mechanical ventilation, risk of pneumonia, risk of bloodstream infection, and hospital mortality

ADVERSE EFFECTS OF EN

gastric intolerance

diarrhea
multiple loose, watery stools noted by the nurse and/or the need for a C. difficile stool test

sinusitis

gastric residuals > 200 mL/4h

x-ray or CT scan

Single investigator Baseline information : date and time of admission, age, gender, BMI, comorbidities, and APACHE II score Presence of pneumonia at baseline

EN : time of initiation, formula, goal rate, % achieved, GRV, diarrhea, duration of ventilation, ICU/hospital LOS, insulin, mortality, prokinetic agents, vasopressors, discarge dx
Lab : WBC, Cr, alb, prealb, CRP, culture and X-ray results

Fishers exact/2 test

Wilcoxon rank sum test

P value <.05

MEDIAN TIME TO START

Early group :
23.9 h

Delayed group :
2.1 d

the occurrence of intolerance appeared similar between the 2 groups

there is no a significant increase in diarrhea in either group

the occurrence of sinusitis did not appear to be significantly increased in either group

initiation of EEN has been associated with benefits in surgical/trauma, burn, mechanically ventilated, and pancreatitis patients

decreased length of stay, decreased mortality, reduced risk of infection, shortened duration of mechanical ventilation, and an improved clinical course

concur with previously published literature

variability within our medical ICU in the initiation of nutrition, with only 50% of the eligible patients receiving EEN

EEN was associated with reduced inconsistency was identified Ilan et al (2007) found considerable variability in the in ICU LOS, time on the ventilator, initiation ofanutrition with < 50% application of the achieving goal rate, hospital mortality, and of each group reaching a goal (72.4% of eligible patients) rate occurrence of new pneumonia

Limitation
higher rate of vasopressor use in the delayed group compared with the EEN group small population size the difference in the number of ICU deaths did not reach statistical significance

ADVERSE EFFECTS OF EEN

gastric intolerance

diarrhea

sinusitis

NO SIGNIFICANT INCREASE

EEN
decreased incidence of pneumonia possible related to the decreased time on the ventilator

Kompan et al (2004) found similar results

improvement in patient outcomes associated with the use of EEN in a diverse population of critically ill patients < 50% of the patients in each group reached a goal rate of EN

EEN should be a priority in appropriate critically ill patients