ENTERAL NUTRITION AND ITS IMPACT ON HOSPITAL LENGTH

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ENTERAL NUTRITION AND ITS IMPACT ON HOSPITAL LENGTH OF STAY Scott Austin Dietetic Intern

ENTERAL NUTRITION AND ITS IMPACT ON HOSPITAL LENGTH OF STAY Scott Austin Dietetic Intern Sodexo Distance Dietetic Internship 1/27/2015

Learning Objectives • Understand the differences involved with pre- and post pyloric feeding routes

Learning Objectives • Understand the differences involved with pre- and post pyloric feeding routes • Understand the effects of minimizing the duration of postoperative fasting • Understand the importance of glycemic specific formulas

Background • Enteral Nutrition (EN) dates back 3500 years • Einhorn – 1910 •

Background • Enteral Nutrition (EN) dates back 3500 years • Einhorn – 1910 • Weighted rubber nasogastric tube • Bolus feeding • C. R. Jones – 1916 • Continuous feed JADA, March 2002, Volume 102, Issue 3, Pages 399 -404

Background • Critical Patients • Ebb Phase • Typically 12 -48 hours post-injury •

Background • Critical Patients • Ebb Phase • Typically 12 -48 hours post-injury • Characterized by • • Cardiac output Respiratory rate Tachycardia Gut ileus Flow Phase �Acute Flow Phase �Goals: �Identify highest risk patients �Estimate energy needs �Evaluate ability to tolerate feedings • Adaptive Flow Phase �Goals: �Repletion of body tissue and micronutrient stores �Maintain BW within 10% of pre-injury weight if possible

Background • Additional Immune Nutrients • L-Arginine • n-3’s • L-glutamine Debats IB, Wolfs

Background • Additional Immune Nutrients • L-Arginine • n-3’s • L-glutamine Debats IB, Wolfs TG, Gotoh T, Cleutjens JP, Peutz-Kootstra CJ, van der Hulst RR. Role of arginine in superficial wound healing in man. Nitric Oxide 2009; 21: 175– 83.

The Research • Optimal timing for the initiation of enteral and parenteral nutrition in

The Research • Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions • A review paper • Jose E. de Aguilar-Nascimento M. D. , Ph. D. , Alberto Bicudo- Salomao M. D. , M. S, Pedro E. Portari-Filho M. D. , Ph. D. Nutrition 28 (2012) 840– 843

The Research – Optimal Timing • Worldwide more than 90% of Physicians and Dietitians

The Research – Optimal Timing • Worldwide more than 90% of Physicians and Dietitians strongly recommend the initiation of either EN or PN within 24 -48 hours after the patient is admitted to an ICU • However in practice this is not the case Cahill NE, Narasimhan S, Dhaliwal R, Heyland DK. Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr 2010; 34: 685– 96

The Research – Optimal Timing • Modern guidelines endorse the initiation of EN regardless

The Research – Optimal Timing • Modern guidelines endorse the initiation of EN regardless of traditional parameters, such as the presence of bowel sounds or flatus • Underfeeding the critical or surgical patient is valid due to gastrointestinal dismotility or hemodynamic conditions

The Research – Optimal Timing • Withholding EN post GI resection • Restart feeding

The Research – Optimal Timing • Withholding EN post GI resection • Restart feeding once bowel movements appear • Both elective and emergency surgeries • • • Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 2009; 13: 569– 75. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev; 2006 Oct 18: CD 004080. Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr 2011; 35: 473– 87.

The Research – Optimal Timing • Post-operative EN is associated with a 45% reduction

The Research – Optimal Timing • Post-operative EN is associated with a 45% reduction in total complications when early feeding was prescribed. • However….

The Research – Optimal Timing • NGT reinsertion was more common • No clear

The Research – Optimal Timing • NGT reinsertion was more common • No clear advantage of early EN with regard to: • Mortality • Length of Stay Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr 2011; 35: 473– 87.

The Research – Optimal Timing • Trauma patients: • Meta-analysis of 3 RCT’s with

The Research – Optimal Timing • Trauma patients: • Meta-analysis of 3 RCT’s with n=126 • Early EN was associated with reduced mortality Doig GS, Heighes PT, Simpson F, Sweetman EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta- analysis of randomised controlled trials. Injury 2011; 42: 50– 6.

The Research • Is duration of postoperative fasting associated with infection and prolonged length

The Research • Is duration of postoperative fasting associated with infection and prolonged length of stay in surgical patients? • A prospective cohort study Michelli Cristina Silva de Assis, Carla Rosane de Moraes Silveira, Mariur Gomes Beghetto and Elza Daniel de Mello Nutr Hosp. 2014; 30(4): 919 -926 ISSN 0212 -1611 • CODEN NUHOEQ

The Research – Duration of Postoperative Fasting • Methods: • Included: • Elective surgery

The Research – Duration of Postoperative Fasting • Methods: • Included: • Elective surgery patients • Excluded: • No nutritional assessment warranted • <72 hour hospital stay � Results: �n=521 � 44. 1% were fasted ≥ 1 day � 91% were fasted ≥ 3 days � 5. 6% were fasted > 5 days

The Research – Duration of Postoperative Fasting • ≥ 1 day postoperative fasting •

The Research – Duration of Postoperative Fasting • ≥ 1 day postoperative fasting • Infection risk increased by 2. 04 • ≥ 3 day postoperative fasting • Infection risk increased by 2. 81 • > 5 day postoperative fasting • Infection risk increased by 2. 88 � Prolonged hospitalization risk: • 2. 4 times higher ≥ 1 day • 4. 44 times higher ≥ 3 day • 4. 43 times higher > 5 day

The Research – Duration of Postoperative Fasting • In summary, • The longer the

The Research – Duration of Postoperative Fasting • In summary, • The longer the fasting period, the greater the risk for infection • The longer the fasting period, the longer the length of stay

The Research • Inadequate energy delivery during early critical illness correlates with risk of

The Research • Inadequate energy delivery during early critical illness correlates with risk of mortality in patients who survive at least seven days: A retrospective study Jong-Rung Tsai, Wen-Tsan Chang, Chau-Chyun Sheu, Yu-Ju Wu, Yu-Heng Sheu, Po-Len Liu, Chen-Guo Kerc, Meng-Chuan Huang Clinical Nutrition 30 (2011) 209 -214

The Research – Inadequate energy delivery • 295 patients retrospectively studied • High and

The Research – Inadequate energy delivery • 295 patients retrospectively studied • High and low energy delivery (ED) • High and low protein delivery • Mean daily intake ≥ 60% estimated needs or <60% estimated needs

The Research – Inadequate energy delivery

The Research – Inadequate energy delivery

The Research – Inadequate energy delivery • In summary, • No difference in Hospital

The Research – Inadequate energy delivery • In summary, • No difference in Hospital or ICU LOS between the low and high groups for either ED or PD. Pichard C, Kreymann GK, Weimann A, Herrmann HJ, Schneider H. Early energy supply decreases ICU and hospital mortality: a multicentre study in a cohort of 1209 patients. Clin Nutr 2008; 3(Suppl. 1): 7.

The Research • Severity of Illness Influences the Efficacy of Enteral Feeding Route on

The Research • Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical Illness Hsiu-Hua Huang, RD; Sue-Joan Chang, Ph. D; Chien-Wei Hsu, MD; Tzu-Ming Chang, MD; Shiu-Ping Kang, RN; Ming-Yi Liu, RD J Acad Nutr Diet. 2012; 112: 1138 -1146.

The Research – Enteral Feeding Route • GI motility and secretion are regulated by

The Research – Enteral Feeding Route • GI motility and secretion are regulated by hormones such as CCK • Site of nutrient administration affects the magnitude of gut -hormone secretion Hypothesis – The magnitude of illness severity may affect the efficacy of the enteral feeding route in clinical outcomes

The Research – Enteral Feeding Route • n = 101 (randomly assigned to NG

The Research – Enteral Feeding Route • n = 101 (randomly assigned to NG or ND group) • All patients administered Jevity 1. 0 @ 20 increased by 20 m. L/hr q 4 hr to the patients specific goal rate. • 25 -30 kcal/kg IBW • 1. 2 -1. 5 g pro/kg IBW

The Research – Enteral Feeding Route • Results

The Research – Enteral Feeding Route • Results

The Research – Enteral Feeding Route

The Research – Enteral Feeding Route

The Research – Enteral Feeding Route • In Summary, • ND feeding route is

The Research – Enteral Feeding Route • In Summary, • ND feeding route is more appropriate than NG feeding route in reducing length of ICU stay among patients with high APACHE II scores. • No statistical difference in patients with lower APACHE II scores

The Research • Differences in resource utilization between patients with Diabetes receiving Glycemia-targeted specialized

The Research • Differences in resource utilization between patients with Diabetes receiving Glycemia-targeted specialized nutrition vs. standard nutrition formulas in U. S. Hospitals • An observational study – Financial support from Abbott Nutrition* Osama Hamdy, MD, Ph. D; Frank R. Ernst, Pharm. D, MS; Dorothy Baumer, MS; Vikkie Mustad, Ph. D; Jamie Partridge, Ph. D, MBA; and Refaat Hegazi, MD, Ph. D, MPH, MS Journal of Parenteral and Enteral Nutrition Volume 38 Supplement 2 November 2014 86 S– 91 S

The Research – Glycemic specific formulas • Diabetes Mellitus (DM) • Substantial economic burden

The Research – Glycemic specific formulas • Diabetes Mellitus (DM) • Substantial economic burden on patients and hospitals • Longer hospital length of stay • Higher hospital mortality

The Research – Glycemic specific formulas • Study Objective: • To compare the LOS

The Research – Glycemic specific formulas • Study Objective: • To compare the LOS and resource cost of patients with DM receiving Glycemia targeted specialized nutrition (GTSN), with those receiving Standard Nutrition (STDN) during acute care hospitalizations.

The Research – Glycemic specific formulas • Data Source • Premier Research Database •

The Research – Glycemic specific formulas • Data Source • Premier Research Database • Patient Selection • Adults and Children previously diagnosed T 1 DM or T 2 DM, secondary DM, GDM, neonatal DM • Received acute inpatient care • Excludes transfer patients, and patients who left AMA.

The Research – Glycemic specific formulas • Results

The Research – Glycemic specific formulas • Results

The Research – Glycemic specific formulas • Limitations? • Unable to establish causality •

The Research – Glycemic specific formulas • Limitations? • Unable to establish causality • Miscoded or missing data • Strengths? • Large number of patients • Recording of specific data through the Premier Research Database

The Research – Glycemic specific formulas • In Summary, • Feeding GTSN to patients

The Research – Glycemic specific formulas • In Summary, • Feeding GTSN to patients with DM was associated with significantly reduced LOS and lower costs than patients receiving STDN

The Academy • The AND Evidence Analysis Library (EAL) suggests: • In fluid-resuscitated, critically

The Academy • The AND Evidence Analysis Library (EAL) suggests: • In fluid-resuscitated, critically ill patients, EN started within 24 -48 hours following injury or admission to the ICU may reduce LOS. • Actual delivery of intake of approximately 60 -70% of EN goal in the first week of ICU admission, is associated with a shorter LOS in critically ill patients, particularly when initiated within 48 hours of injury or admission

Questions?

Questions?