Role of Prokinetics in Enteral Feeding in Critically Ill Patients - Case Study Example

Role of Prokinetics in Enteral Feeding in Critically Ill Patients Introduction Patients admitted to critical care units are more often than not malnourished either because of their disease process or due to decreased intake of nutritious diet, or both. Malnourishment in these patients is dangerous and contributes to several complications which increase the mortality and morbidity rate (Binnekade et al, 2005). Hence, it is recommended that every effort be made to improve nutrition of the critically ill patient. There are several methods to enhance the nutrition status of intensive care patients, one of which is enteral feeding. There are different methods of enteral feeding and nasogastric tube feeding is the most commonly used method among them. The main disadvantage with nasogastric tube feeding is that it is associated with several complications, despite it being a simple procedure (Chapman et al, 2007). More often than not, the complications are related to delayed gastric emptying and feed intolerance. To enhance gastric emptying and improve feed intolerance, most critical care units use prokinetic drugs. While some institute only single therapy, some others administer a combination of drugs. The role of prokinetics in nasogastric tube feeding is yet unclear and many studies have been conducted in this regard. In this essay, administration of prokinetics in the management of gastric intolerance in enteral feeding patients admitted to critical care unit will be discussed with reference to suitable literature. Methodology and Search Strategy In order to retrieve articles for the review, electronic database PUBMED and internet search engine “Google Scholar” were used. The terms used for search were “enteral feeds” or “gastroenteral feeds” or “nasogastric feeds” and “prokinetics” with “critically ill patients” or “intensive care patients”. Several thousand articles were displayed. In PUBMED, the articles were displayed according to the date of publication and hierarchy of evidence. Only those articles beyond 1995 were included and also only English articles were chosen. The abstracts of the articles were quickly scanned and some of them which were useful for the review were selected. The full texts of the articles were retrieved and studied. Enteral feeding and role of prokinetics Severely ill patients admitted to critical care unit are in a hypercatabolic state and protein energy malnutrition is a major problem in them. Research has shown that early initiation of feeds enterally, is beneficial and has many advantages like decrease in complications due to sepsis and improved outcomes (DeB et al, 2001). This is because; enteral nutrition preserves the mass of the gut, prevents permeability of the gut to bacteria and their toxins, and preserves the lymphoid tissue of the gut (Binnekade, 2005). Enteral feeding has gained immense popularity because of lower rate of complications with the procedure and also lower cost involved (Binnekade, 2005). Early initiation of enteral feeding has been made a standard protocol in several intensive care units. Because of these protocols, the incidence of enteral feeding has increased dramatically. Malnutrition is not only a cause, but also a consequence of poor health. In the United Kingdom, it is common in those who are suffering for illness. Older patients and also individuals suffering from chronic diseases and psychosocial problems are underweight chronically and thus are vulnerable to acute illness. Malnutrition makes the individual vulnerable to infection, causes delay in wound healing, impairs the function of lungs and heart, causes depression and decreases the strength of the muscles. In general patients with malnutrition have higher mortality and morbidity rates. In surgical patients, those with malnutrition have 3 times increased risk of complication. They also have increased mortality rates, with risk being 4 times those without malnutrition. Persistence of poor eating and inability to properly feed for several weeks can cause death by itself (NICE, 2006). Often, when unwell, provision of drink and food along with some physical feeding help as required, will suffice. However, when such feeding is not practical or is not safe, other measures to provide proper nutritional support to the patient is indicated. They are either one or a combination of these: extra intake of nutrition in the form of high nutrition and protein powder, foods and drinks orally; feeding the patient nutritious food through a tube inserted into the gastrointestinal tract and feeding the patients appropriate amino acids, minerals, vitamins, glucose and lipids through intravenous route, known as total parenteral nutrition. Such nutritional support is essential in those who are not in a position to meet the nutrient needs of the body to a large extent and for longer periods of time (De, 2001). Decision making becomes complex when the period of insufficient nutrition intake is uncertain and is associated with some risk. Some of the complications of nutritional supports offered include pneumonia in patients with dysphagia when oral feeds are provided, and; infections, gastronintestinal problems, metabolic problems and trauma in those providing enteral feeds or parenteral nutrition (NICE, 2006). Enteral feeding must be initiated in patients who are either malnourished or at risk of malnourishment and are either unable to take sufficient nutrition or oral intake is unsafe. At the same time, the gastrointestinal tract must be accessible and functional. It should not be initiated in those who are not malnourished. According to NICE guidelines (2006), "surgical patients who are: malnourished and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract and are due to undergo major abdominal procedures, should be considered for pre-operative enteral tube feeding." NICE (2006) recommends that in general surgical patients, enteral feeds must not be initiated within 48 hours after surgery unless they suffer from malnourishment or are at definite risk of malnourishment. Several types of tubes have come up for establishing enteral tubes. The choice of tubes depends on the expected duration of feeding, condition of the patient and the anatomy of the gastrointestinal tract of the patient. The most frequently used tubes are nasogastric tubes. Other tubes include nasojejunal tubes and nasoduodenal tubes. In some patients, tubes may need to be inserted through gastrostomy or jejunostomy, either through radiological, endoscopic or surgical means and tubes for such purposes are different. Binnekade et al (2005) conducted a study to evaluate the feeding practice of patients in ICU who were fed enterally. They studied the impact of various preset factors in the attainment of predefined and optimal goals of nutrition. From their study, it was evident that the nutrition provided was inadequate in terms of protein and calorie requirement. This study proved that the current practice pertaining to enteral feeding in the intensive care units are inadequate in terms of nutrition provision. In the study by Binnekade et al (2005) factors which interfered with successful enteral feeding were location of tube and gastric retention. While successful feeding was greatest with duodenal or jejunal tubes, it was least with gastric tubes. With reference to gastric retention, those fed with duodemal tube had highest volume of gastric retention. Yet, gastric tubes are the first choice for initiation of enteral feeds because it is simple and easy to insert and start feeding. When gastric retention ensues, the tube can be changed to duodenal tube. Measurement of gastric retention is one of the important tools to guarantee safe enteral feeding. Though gastric tubes are associated with increased risk of development of gastric retention when compared to duodenal tubes, no such difference has been noted in terms of nosocomial pneumonia and aspiration. The study also showed that semi-elemental formula was atleast 3 times better than standard formula. According to a study by Dobson and Scott (2007), nurse led enteral feeding is not very effective and that only 60 percent of the patients receive correct regimen of feeds. Thus, it is important to stress the fact that proper regimens must be followed and if this really happens the burden on the ICU dietician to assess every ICU patient is likely to decrease. The researchers opined that nursing staff are in need of further support during enteral feeding management. Nasogastric tubes are mainly employed for feeding patients for a short duration of time and those who do not have problems like gastroesophageal reflux, vomiting, poor gastric emptying, intestinal obstruction and ileus. Use of these tubes for feeding is dangerous in patients who have unsafe swallow and in those who need to be nursed in the prone position. It is always advisable to use fine bore tubes of sizes between 5 – 8 FrG. Larger bore tubes must be used only when there is a need for gastric decompression due to large volumes of gastric aspiration (NICE, 2006). Nasogastric tubes can get misplaced or moved out of position easily and hence it is important to verify their position before administration of each feed. According to the National Patient Safety Agency guidelines, before administering each feed, the gastric contents must be aspirated and checked with pH indicator paper. If the pH is Read More