Elsevier

Clinical Nutrition

Volume 29, Issue 2, April 2010, Pages 210-216
Clinical Nutrition

Original Article
Before–after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position

https://doi.org/10.1016/j.clnu.2009.08.004Get rights and content

Summary

Backgrounds & aims

To evaluate an intervention for improving the delivery of early enteral nutrition (EN) in patients receiving mechanical ventilation with prone positioning (PP).

Methods

Eligible patients receiving EN and mechanical ventilation in PP were included within 48 h after intubation in a before–after study. Patients were semi-recumbent when supine. Intolerance to EN was defined as residual gastric volume greater than 250 ml/6 h or vomiting. In the before group (n = 34), the EN rate was increased by 500 ml every 24 h up to 2000 ml/24 h; patients were flat when prone and received erythromycin (250 mg IV/6 h) to treat intolerance. In the intervention group (n = 38), the EN rate was increased by 25 ml/h every 6 h to 85 ml/h, 25° head elevation was used in PP, and prophylactic erythromycin was started at the first turn.

Results

Compared to the before group, larger feeding volumes were delivered in the intervention group (median volume per day with PP, 774 ml [IQR 513–925] vs. 1170 ml [IQR 736–1417]; P < 0.001) without increases in residual gastric volume, vomiting, or ventilator-associated pneumonia.

Conclusion

An intervention including PP with 25° elevation, an increased acceleration to target rate of EN, and erythromycin improved EN delivery.

Introduction

Compared to parenteral nutrition, enteral nutrition (EN) in critically ill patients is associated with improvements in gut mucosa integrity, immune function and glycemic control, fewer infections, and lower costs of management.1, 2 Moreover, starting EN within 24–48 h of the onset of critical illness is associated with a higher energy intake, lower infection rates, shorter length of stay, and increased survival, compared to delayed EN.3, 4 However, many critically ill patients experience poor tolerance of early EN because of impaired gastric motility with delayed gastric emptying.5 The resulting high residual gastric volumes increase the risk of gastroesophageal reflux, vomiting, aspiration, and ventilator-associated pneumonia.6, 7 Intolerance can also lead to underfeeding with increased rates of muscular, respiratory, and infectious complications.7, 8, 9 Current guidelines emphasize the need to start EN within 48 h after admission to the intensive care unit (ICU) and to adopt strategies that optimize the delivery of EN while minimizing the risks associated with EN. Such strategies should include starting at the target rate, using prokinetic agents, and elevating the head of the bed.10, 11

Prone positioning is inexpensive, easy to perform, and associated with improved oxygenation and drainage of bronchial secretions, decreased ventilator-induced lung injury, and increased survival in patients with severe acute lung injury (PaO2/FiO2 ratios below 150).12, 13, 14 However, patients turned in the prone position are at increased risk for intolerance to EN.7 In a previous study of mechanically ventilated patients, we showed that patients turned in the prone position had larger residual gastric volumes, more vomiting, and lower daily volumes of EN, compared to patients who were left supine.15 With its associated increased risks of underfeeding and pneumonia, intolerance of EN may counterbalance the beneficial effects of both early EN and prone positioning. However, to our knowledge, current guidelines about feeding of critically ill patients fail to consider the potential specific problems raised by prone positioning, and no strategies for improving the delivery of early EN in patients managed with prone positioning have been reported.

In our ICU, we implemented a specific protocol for early use of EN in patients receiving mechanical ventilation with prone positioning. The aim was to improve EN delivery without increasing the residual gastric volume, vomiting, or ventilator-associated pneumonia, by increasing the acceleration to target feeding rate, using erythromycin as a prokinetic agent, and elevating the head of the bed. To assess the effects of our protocol, we designed a before–after study.

Section snippets

Setting and patients

This before–after study was performed in the 12-bed medical-surgical adult ICU of the District Hospital Center in La Roche-sur-Yon, France. A working group composed of ICU nurses and physicians studied means of improving EN delivery in patients receiving endotracheal mechanical ventilation. To this end, patient characteristics, EN variables, and patient outcomes recorded daily at the bedside were entered prospectively into a database. The working group showed that patients managed with prone

Results

Prone positioning was used in 64 patients during the control period and 69 during the intervention period. The overall population of patients screened for the study during the control phase and the intervention phase did not differ regarding age (64 ± 16 vs. 61 ± 14 years; P = 0.13), gender (43 male and 21 female vs. 48 male and 21 female, P = 0.85), McCabe score (no fatal underlying disease, 67.2% [43 of 64] vs. 65.2% [45 of 69]; P = 0.82), SAPSII (58 ± 18 vs. 55 ± 17; P = 0.40), medical diagnosis at

Discussion

In this prospective before–after study, we report an original approach for EN in patients turned in the prone position. We found an increase in the received daily volume of early EN without increases in residual gastric volumes, vomiting, or ventilator-associated pneumonia in patients receiving endotracheal mechanical ventilation with 25°-elevated prone positioning, an increased acceleration to target rate of EN, and prophylactic erythromycin, compared to standard nutrition practice in the

Conclusion

Studies in patients receiving endotracheal mechanical ventilation have shown that early EN and prone positioning each exerted beneficial effects on patient outcomes. These beneficial effects may be diminished by the high rate of intolerance to early EN leading to underfeeding in patients managed with prone positioning. Our study showed that a protocol including head elevation in the prone position, increased acceleration to target rate of EN and prophylactic erythromycin allowed the delivery of

Statement of authorship

All authors were involved in designing the study. JR collected the data and drafted the manuscript. JD was involved in the statistical analysis. All authors were involved in interpreting the data and revising the manuscript. All authors approved the final manuscript.

Acknowledgments

We are indebted to A. Wolfe, MD, for assistance in preparing and reviewing the manuscript.

References (34)

  • H. Mentec et al.

    Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications

    Crit Care Med

    (2001)
  • L. Rubinson et al.

    Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit

    Crit Care Med

    (2004)
  • D.K. Heyland et al.

    Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients

    J Parenter Enteral Nutr

    (2003)
  • L. Gattinoni et al.

    Effect of prone positioning on the survival of patients with acute respiratory failure

    N Engl J Med

    (2001)
  • J. Reignier et al.

    Short-term effects of prone position in chronic obstructive pulmonary disease patients with severe acute hypoxemic and hypercapnic respiratory failure

    Intensive Care Med

    (2005)
  • P. Pelosi et al.

    Prone position in acute respiratory distress syndrome

    Eur Respir J

    (2002)
  • J. Reignier et al.

    Early enteral nutrition in mechanically ventilated patients in the prone position

    Crit Care Med

    (2004)
  • Cited by (70)

    • Administration of enteral nutrition and gastrointestinal complications in Covid-19 critical patients in prone position

      2022, Clinical Nutrition Open Science
      Citation Excerpt :

      In our study, we also used the strategy with cushions at the pelvis and thorax region. Reignier J et al. (2010) reached a maximum infusion rate of 85 ml/h and administered erythromycin (250 mg intravenously every 6 hours) for all patients on PP, which did not provide an increase in GII or VAP [43]. In our study, PP was associated with the development of VAP, different from previous evidence where PP plays a role in preventing this condition [49].

    View all citing articles on Scopus

    This study was performed in the Medical-Surgical adult Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.

    View full text