Incidence of aspiration and gastrointestinal complications in critically ill patients using continuous versus bolus infusion of enteral nutrition:

A pseudo-randomised controlled trial

Ibrahim Kadamani MS, Mustafa Itani MD, FCCP, Eman Zahran, Nadia Taha

Vincenza Zurlo, Dietetic Intern, Sage Graduate School

Introduction
Critically ill patient Multifaceted Hyper-catabolic Risk of malnutrition Enteral nutrition is optimal Maintain GI integrity Preserve immunity Decreased length of stay

Introduction
Complications of EN Pulmonary aspiration Risk factors Nausea Vomiting Diarrhea High gastric residual volume (HGRV) Constipation

Introduction
Complications act as barriers PURPOSE: Reveal the occurrence of GI complications and aspiration using bolus vs continuous EN infusion in critically ill patients

Design
Pseudo-randomized
Patients placed in groups based on type of EN

Descriptive testing At risk population

Critically ill

Patients chosen from ICU population Selection/ exclusion criteria

Design

Design
Dependent variable
Incidence of GI complications and aspiration

Independent variable:
Method of feeding (continuous or bolus EN)

Confounding variables:
Controlled: age, bed angle, critical illness status, calorie density of diet, type of nutrition support Uncontrolled: gender, admitting diagnosis, comorbidities, medications

Intervention

Equal groups 3 day study 30 patients Both groups:

Sterile, normo-caloric diet Based on estimated needs Blue food dye added Volume advanced
Day 1- 33% goal volume Day 2- 66% goal volume Day 3- 100% goal volume

Intervention
Bolus group
Gravity, Tommy syringe over 10-15 minutes every 4-6 hours Bed at 45-60 during/ 1 hour after 30 mL flush before and after

Continuous
24 hours via pump Bed 45-60 60 mL flush when changing EN formula/tubing (every 24 hours)

Data collection methods

Health characteristics Acute Physiology and Chronic Health Evaluation (daily) Glasgow Coma Score, cough reflex (every 4 hours)

Data collection methods

Pulmonary aspiration
Cyanosis, desaturation, tachycardia Tracheal secretions for blue color

GI complications
GRV: every 4 hours with Tommy syringe, HGRV reported if over 200 mL Vomiting: continuous for occurrence, color, amount Diarrhea: if passed 3 or more times per day Constipation: absent BM for 3 days or more

Results

Majority males Mean age 61-64 years Mean weight 63-64 kg Mean GCS 6.1 T 30 patients total APACHE II score averaged 16-20
15-19 = 24 % mortality 20-24 = 40 % mortatlity

Results
Most patients had positive cough Main medications: antibiotics, GI protectors No statistically significant differences found in overall health characteristics No difference between continuous/bolus in incidence of aspiration

Results
Incidence of constipation was greater in continuous Incidence of diarrhea was greater in bolus
66.7% 33.3%-not statistically significant 6.7%

Vomiting had the same incidence for both groups

HGRV incidence
Bolus-20% Continuous 13.3 % Not statically significant

Negative association between GCS and incidence of HGRV

lower GCS = higher occurrence of HGRV

Results

Results

Discussion
Results may be related to following protocol Strengths:
Pseudo-randomized control, specific to critically ill patients, specific measurements

Limitations:
Small sample size, small variety of patient types, blue coloration of tracheal secretions was not accurate, retrospective analysis from nurses for constipation instances, short length of study

Discussion
Consistency with other studies Not enough evidence to support change of practice Future research:
Larger sample size, greater array of patient presentations, how constipation may effect outcomes

References
Mahan, LK, Escott-Stump, S, Raymond, JL. Krauses Food and Nutrition Care Process. 13th ed. St. Louis, MO: Saunders; 2012. Kadamani I ,Itani M, Zahran E, Taha N. Incidence of aspiration and gastrointestinal complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: A pseudo-randomised controlled trial. Australian Critical Care. 2014; 27(1) doi: http://dx.doi.org/10.1016/j.aucc.2013.12.001