Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study

Abstract

BackgroundEarly enteral nutrition is recommended in cases of critical illness. It is unclear whether this recommendation is of most benefit to extremely ill patients. We aim to determine the association between illness severity and commencement of enteral feeding.MethodsOne hundred and eight critically ill patients were grouped as “less severe” and “more severe” for this cross-sectional, retrospective observational study. The cut off value was based on Acute Physiology and Chronic Health Evaluation II score 20. Patients who received enteral feeding within 48 h of medical intensive care unit (ICU) admission were considered early feeding cases otherwise they were assessed as late feeding cases. Feeding complications (gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, length of hospital stay, ventilator-associated pneumonia, hospital mortality, nutritional intake, serum albumin, serum prealbumin, nitrogen balance (NB), and 24-h urinary urea nitrogen data were collected over 21 days.ResultsThere were no differences in measured outcomes between early and late feedings for less severely ill patients. Among more severely ill patients, however, the early feeding group showed improved serum albumin (p = 0.036) and prealbumin (p = 0.014) but worsened NB (p = 0.01), more feeding complications (p = 0.005), and prolonged ICU stays (p = 0.005) compared to their late feeding counterparts.ConclusionsThere is a significant association between severity of illness and timing of enteral feeding initiation. In more severe illness, early feeding was associated with improved nutritional outcomes, while late feeding was associated with reduced feeding complications and length of ICU stay. However, the feeding complications of more severely ill early feeders can be handled without significantly affecting nutritional intake and there is no eventual difference in length of hospital stay or mortality between groups. Consequently, early feeding shows to be a more beneficial nutritional intervention option than late feeding in patients with more severe illness.

QTc prolongation during erythromycin used as prokinetic agent in ICU patients

“…Ideally, we should have included a positive control, but we found giving for instance moxifloxacin for this reason not ethically justified in this vulnerable study population. A placebo controlled trial was not feasible due to lack of alternatives for erythromycin as prokinetic therapy and early timing of enteral feeding is equally associated with better outcomes 16. Some of the patients used CYP3A4 inhibitors (such as voriconazol or amiodarone), which might have increased the blood concentration of erythromycin and contributed to the QTc prolongation.…”

Temporal Trends in the Use of Parenteral Nutrition in Critically Ill Patients

“…40 The data from the original studies (the majority of which were published before 2005) may be driving the increased use of enteral nutrition we observed. However, a more recent study called into question early, aggressive use of enteral nutrition, 41 and results of randomized controlled trials of early, full nutritional support are equivocal. 14,42,43 The majority of these studies postdate the time period we investigated, precluding a direct examination of these studies on usage trends.…”

Enteral Nutrition for Adults in the Hospital Setting

“…Clostridium difficile infection is the most frequently identified cause of nosocomial diarrhea 107 . The incidence and duration of diarrhea has also been associated with severity of illness, hypermetabolic stress, serum albumin level, decreased immunity, glucose control, white blood cell count, and peripheral oxygen saturation 108 – 110 …”

“…107 The incidence and duration of diarrhea has also been associated with severity of illness, hypermetabolic stress, serum albumin level, decreased immunity, glucose control, white blood cell count, and peripheral oxygen saturation. [108][109][110] Medication administration also has the potential to contribute to diarrhea. Liquid medication solutions, for example, can contain a number of poorly absorbed sweeteners (eg, sorbitol) and stabilizers, which increase the osmolality of the medication and, therefore, the potential to cause diarrhea.…”