Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

Abstract

Background: Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support.Analysis of nutrition practices could improve nutrition management of this particular population. Methods:A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days.Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome. Results:A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections. Conclusion:EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.

Metabolic support for patients on extra-corporeal membrane oxygenation

“…GI intolerance is a common complication associated with EN which influences the decision on route of nutritional support. Gastrointestinal (GI) intolerance has been reported in 53% of ECMO patients receiving EN [49]. However, there is no significant difference in the incidence of total GI complications when comparing EN to non-EN groups of ECMO patients.…”

“…As ECMO patients typically present with severe critical illnesses or advanced chronic illnesses which require complex care plans, low prioritization of nutritional support may lead to delayed initiation [49]. Thus, randomized clinical trials corroborating the observed mortality benefit of early EN would raise the level of evidence supporting this practice and heighten prioritization of nutritional support earlier during the ECMO course.…”

Medical nutrition therapy in patients receiving ECMO: Evidence‐based guidance for clinical practice

“…Moreover, this MNT strategy might also be beneficial to attenuate muscle wasting and ICU‐acquired weakness 11,40,41 . On the contrary, early EN may be associated with an increased risk of feeding intolerance, which includes nausea and vomiting with pulmonary aspiration, pneumonia, and—in the context of high‐dose vasopressors—nonocclusive mesenteric ischemia and bowel necrosis 8,42,43 . Patients receiving ECMO may require frequent procedures leading to EN interruptions, 13 which may contribute to macronutrient and micronutrient deficiencies 7 …”

“…Illness‐associated metabolic changes and real or perceived barriers to initiating MNT in patients receiving ECMO may increase the risk for adverse clinical outcomes (Figure 1). The treatment of the underlying organ dysfunction is prioritized in clinical care and the implications of insufficient MNT often remains underrecognized 6–8 . Evidence derived from recent clinical studies and case reports indicate that adequate MNT, defined as achieving ≥80% of energy and protein goals, in patients receiving ECMO is possible 9 and associated with improvements in clinical outcomes 10–12 .…”

“…The treatment of the underlying organ dysfunction is prioritized in clinical care and the implications of insufficient MNT often remains underrecognized. [6][7][8] Evidence derived from recent clinical studies and case reports indicate that adequate MNT, defined as achieving ≥80% of energy and protein goals, in patients receiving ECMO is possible 9 and associated with improvements in clinical outcomes. [10][11][12] Due to the nascent use of ECMO and variance in MNT practices, 13,14 there are limited data to promulgate best practices for MNT in patients receiving ECMO and international critical care nutrition guidelines do not specifically address MNT in this specific patient cohort (Figure 1).…”