Options for Preventing Enteral Nutrition Intolerance in Mechanically Ventilated Patients in the ICU
Standards of care for critically ill patients recommend enteral nutrition for those on mechanical ventilation. A recently published study addressed the question of how to identify patients at risk of enteral nutrition intolerance (ENI) and how to subsequently prevent this intolerance, which may be associated with worse clinical outcomes.
Worldwide Prospective Survey
The aim of the study was to determine the incidence of ENI, factors associated with its onset, and the relationship between ENI and clinical outcomes in ICU patients on mechanical ventilation. It was an analysis of data from the prospective International Nutrition Survey, conducted between 2007 and 2014 across 785 ICUs worldwide.
Adult patients who were on mechanical ventilation for at least 72 hours during the first 12 days in the ICU and received enteral nutrition were included. ENI was defined as the interruption of enteral nutrition due to any of the following reasons: high gastric residual volume, increased abdominal circumference, abdominal distension, subjective nausea, vomiting, or diarrhea.
Incidence, Risk Factors, and Consequences of ENI
Out of 15,918 included patients, at least one episode of ENI was observed in 24%. It most frequently occurred on days 4 and 5, after which its incidence decreased. After adjusting for potential confounding factors, it was most common among patients admitted to the ICU for burns, gastrointestinal diseases, or sepsis. Compared to patients admitted for respiratory diseases, the relative risk of ENI was higher by 46%, 45%, and 34%, respectively.
Patients with ENI had 10% lower enteral intake than those without ENI, fewer ventilator-free days, longer ICU stays before discharge (among survivors), and higher daily mortality (all p < 0.0001). Worse outcomes were observed in patients with multiple episodes of ENI and those with ENI lasting at least 2 days. Patients with increased gastric residual volume had a higher risk of recurrent ENI compared to other ENI causes. The incidence of ENI decreased with higher thresholds for elevated gastric residual volume. A subgroup analysis of data from centers using a higher threshold for gastric residual volume (250 ml) showed similar results.
Identifying At-Risk Patients
ENI occurs in about a quarter of ICU patients on mechanical ventilation. Those most at risk are patients admitted for burns, gastrointestinal disease, and sepsis, with the peak incidence on days 4 and 5. Identifying at-risk individuals, preventing, and adequately treating ENI may increase the amount of enteral nutrition administered and thus improve clinical outcomes for critically ill patients.
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Source: Heyland D. K., Ortiz A., Stoppe C. et al. Incidence, risk factors, and clinical consequence of enteral feeding intolerance in the mechanically ventilated critically ill: an analysis of a multicenter, multiyear database. Crit Care Med 2021 Jan 1; 49 (1): 49−59, doi: 10.1097/CCM.0000000000004712.
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