Original ArticleBefore–after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position☆
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.
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This study was performed in the Medical-Surgical adult Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.