Critical Care Nutrition: Getting Involved as a Gastrointestinal Endoscopist

Abstract

The route, timing, and volume of enteral feeding delivered to a patient in the intensive care unit have a profound effect on clinical outcome. At the height of critical illness, problems with ileus, aspiration, and the systemic inflammatory response syndrome make the provision of enteral nutrients a difficult and somewhat risky endeavor. The gastrointestinal endoscopist has the technical skills to place feeding tubes deep within the jejunum and an underlying expertise in gut physiology to monitor patients effectively once feeds are initiated. Attention to detail in the techniques for attaining enteral access, early identification of potential problems, and quick institution of simple endoscopic strategies help improve delivery of nutrition support, minimize the likelihood for inhospital complications, and optimize patient outcome.

Nutrition Support in the Critically Ill: A Physician Survey

“…24 In patients with ileus, EN is encouraged by accessing the small bowel, decompressing the stomach, and initiating feeds to stimulate promotility agents. 19 Many of our respondents indicated that ileus is an absolute contraindication to enteral feeding.…”

“…33 Assessing and promoting tolerance may be the most important aspect of monitoring the patient on EN. 19 There was a large standard deviation in responses regarding an acceptable GRV in a tube-fed patient, indicating discordance in this area. Although GRVs have poor validity as a marker for risk of aspiration in critically ill patients, 34 they continue to be used in nutrition algorithms and are likely to be the practice of many ICUs.…”

“…10,16,17 The general goals of nutrition support are to provide nutrition support consistent with the patient's medical condition and nutrition status, to prevent or treat nutrient deficiencies, to avoid complications related to technique of dietary delivery, and to improve patient outcomes. 17 Our findings indicated that while physicians at all levels of training did believe that nutrition is important in the ICU, they did not feel confident in their knowledge of the role of nutrition support in the critically ill. Several factors may contribute to this lack of confidence, including (1) a deficiency in awareness and familiarity with current guidelines, 18 (2) availability of only poorly controlled, mostly retrospective data and expert opinion, 19 and (3) difficulty integrating previous dogma 19 with recent clinical practice guidelines. 20 In addition, given the long-standing exclusion of nutrition in the clinical management of patients, there may now be a lack of outcome expectancy (that if one performs the requested behavior, it will actually make a difference).…”

“…Furthermore, small bowel contractility may be assessed by examination for abdominal distension, bowel sounds, and air fluid levels on abdominal radiograph. 19 A very small percentage of responses included checking an abdominal radiograph or even performing a physical examination ( Table 1).…”

Critical care 24 × 7: But, why is critical nutrition interrupted?

“…[345] The value of EN is further supported by studies which have shown that nutritional deficit due to delayed initiation has an adverse effect, whereas institution of protocols to increase delivery often improves patient outcome. [6789] It has been noted that the value of EN is closely related to disease severity; greater the severity of the disease, higher the benefit of EN. [10111213] Optimal nutrition support during critical illness requires individualized assessment of timing, route and quantity of nutrients and protocolized feeding.…”