Enteral Nutr Therapy for Surgical Pt
KBS
Canada Annual National Conference, and wondered if someone could
provide the answers to the case questions at the end of the
presentation. Very helpful presentation. Thanks!
Kathleen Standafer, MS, RD, CNSD
Columbia, MO
Rehab S.alyousif
Drover, Dr. John W.
questions pertain to. For those not want to review all of the
presentation it is posted on our website:
http://www.criticalcarenutrition.com/presentations/index.php
CASE #1
48 yo female with sigmoid cancer
Sigmoid resection
Healthy, uneventful OR
When will this patient be fed?
This was more a question to get the audience to reflect on the practice
at their own institution. There is evidence that it is safe and even
beneficial to start oral nutritional intake the day after the surgery.
What will the first diet be?
The evidence supports starting with a regular diet rather a progression
through fluids.
CASE #2
69 year old male, perforated DU
COPD on home oxygen
Post-operatively to ICU
No other organ failure
Predicted slow wean
When do you start enteral nutrition?
This depends on the access. I would pressure our surgeons to put in a SB
feeding tube or jejunostomy at the time of surgery and then I would
start EN at the time of admission and in our ICU the EN order set is
part of the admission order set.
If there is no small bowel access and only gastric access I would
usually wait for about 5 days to start feeding. Some surgeons may want a
contrast study done first to rule out an anastomotic leak before
proceeding with feeding.
How do you start enteral nutrition?
At our site we start feeds at 25ml/h and advance every 4 hours up to
target dose.
There are no bowel sounds audible - does that affect decision?
NO!!! This is not a clinical finding that is useful for decision making
in nutrition or surgery.
CASE #3
66yo male with obstructing colon cancer
POD #4 develops sepsis
return to OR, anastamotic leak
end ileostomy
Unstable in the OR
Post-op unstable transferred to our ICU
difficult to oxygenate and ventilate - ARDS
hypotensive on multiple vasopressors
Vasopressin 0.04u/h
Noradrenaline 12ug/min
Dobutamine 5ug/kg/min
When do you start feeds?
I would start feeds when resuscitation is complete. This is when volume
status is corrected and the patient is on stable doses of vasopressors.
This should generally be within 6-12h of admission to the ICU although
infrequently it might be 24 hours. I know there is controversy in the
literature and at meetings where this is discussed but early initiation
of feeding is consistent with the RCTs on early enteral feeding in which
feeds were started within 24-48 of admission to the ICU or completion of
resuscitation.
The guidelines and recommendations pertaining to early feeding can be
seen at:
http://www.criticalcarenutrition.com/docs/cpg/2.0early_FINAL.pdf
If there is concern or uncertainty in the state of resuscitation I would
start with low dose feeds for the first day or two. I would often use a
higher caloric density feed starting at 10ml/h.
What do you do with the Gastric Residual Volumes?
This question was meant to generate some discussion. One point to make
is there should be a standardized strategy in the ICU as to how GRVs are
handled. There is an example of this in our enteral feeding order set
posted on the Critical Care Nutrition web site under resources.
Feeding algorithm on this page:
http://www.criticalcarenutrition.com/index.php?option=com_content&view=c
ategory&layout=blog&id=18&Itemid=19#bedside
The evidence that is available to date suggests that it is safe to use
GRVs in the range of 250-500ml.
Feed early and feed better for better outcomes!
Cheers
John W. Drover, MD, FACS, FRCSC
Associate Professor
Chair and Program Medical Director
Critical Care Program
Queen's University
Kidd 2
Kingston General Hospital
76 Stuart Street
Kingston, Ontario
Canada
K7L 2V7
Phone 613-549-6666 ext 6335
Fax 613-548-2480
The information contained in this electronic message and any attachments
to this message are intended for the exclusive use of the addressee(s)
and may contain confidential or privileged information. If the reader
of this message is not the intended recipient, or the agent responsible
to deliver it to the intended recipient, you are hereby notified that
any review, retransmission, dissemination or other use of this
communication is prohibited. If you received this in error, please
contact the sender and destroy all copies of this e-mail.
--
You received this message because you are subscribed to the Google
Groups "Critical Care Nutrition" group.
To post to this group, send email to
criticalca...@googlegroups.com.
To unsubscribe from this group, send email to
criticalcarenutr...@googlegroups.com.
For more options, visit this group at
http://groups.google.com/group/criticalcarenutrition?hl=en.
Kathleen Standafer
Very helpful, thanks a lot. I'm presenting the cases to our chief of
surgery today for discussion, and it's great to provide information
from another surgeon!
Kathleen
--
*Kathleen Standafer MS RD CNSD*
*Clinical Nutrition Support Specialist*
*Denver, CO*
Kathleen Standafer
48M pod30 hartman's + colostomy due to perf'd sigmoid diverticula. Severe sepsis due to abdominal fecal contamination. Trach, NGT/TF. ARF. PMH: DM, HTN, hyperchol, DM neuropathy. BMI 40. Ht 5'9" wt 120kg. Insulin drip at 1u/hr. Abd remains open, wound healing very slowly. ALT high, other LFTs normal. No TG level. Glucose <180mg/dl. CO2 24. WBC 10.2. Ostomy output looks good ~500ml/day. MVI ordered. Wt trend not accurate. No metabolic cart available.
Current TF: Nepro at 45ml/hr + protein shot = 1900 cal/d (16 cal/kg)
110g protein/d (1.5g/kg IBW)
Should we be giving more calories? More protein?
What if we feed 21-22 cal/kg ABW and give 2g protein/kg IBW? overfeeding?
Thanks,
Kathleen Standafer, MS, RD, CNSD
Sent from my iPhone
Verger, Judy
thanks,
judy
________________________________________
From: criticalca...@googlegroups.com [criticalca...@googlegroups.com] On Behalf Of Drover, Dr. John W. [dro...@KGH.KARI.NET]
Sent: Tuesday, November 29, 2011 11:40 PM
To: criticalca...@googlegroups.com
Subject: RE: [Critical Care Nutrition] Enteral Nutr Therapy for Surgical Pt
margaret hersman-myslinsky
I am wondering if you experts would consider this an appropriate practice if fluid balance is monitored.
In reviewing the total TF volumes given per day--we noticed when we used the 1.0 cal/ml products-many patients did not meet their goal rates until day 4-5. In Dr Drover's comments below, I notice that he gave smaller volume of a higher calorically dense feeding in some of the critical care patients.
> Date: Tue, 29 Nov 2011 23:40:15 -0500
> From: dro...@KGH.KARI.NET
> To: criticalca...@googlegroups.com
Drover, Dr. John W.
Recommendation C5. For all classes of obesity where BMI is >30, the goal of the EN (enteral nutrition) regimen should not exceed 60%-70% of target energy requirements or 11-14 kcal/kg actual body weight per day (or 22-25 kcal/kg ideal body weight per day). Protein should be provided in a range of ≥2.0 g/kg ideal body weight per day for class I and II patients (BMI 30-40), ≥2.5 g/kg ideal body weight for class III (BMI ≥40). (Grade D).
The reference is:
Kushner RF, Drover JW. Current Strategies of Critical Care Assessment and Therapy of the Obese Patient. (Hypocaloric Feeding): What are we doing and what do we need to do? Journal of Parenteral and Enteral Nutrition, 2011; 35: 36S-43S.
The evidence for this is not any large RCTs. The rationale is outlined in the article. I hope this helps.
Cheers
John W. Drover, MD, FACS, FRCSC
Associate Professor
Chair and Program Medical Director
Critical Care Program
Queen's University
Davies 2
Andrea Maudsley
I personally wouldn't permissive underfeed as I don't think he'd tolerate
the protein load unless he's on CRRT for ARF. If on CRRT then can increase
up to 2-2.5 g protein/kg/ d based on IBW range.
His insulin needs don't seem that high and appears to be having glucose
controlled if consistently less than 180 mg/dl so this would give you a clue
that you're probably not overfeeding.
Is he actually getting what you've recommended or has he been on and off
feeds a lot so not getting at least 80 % of recommended goal. Can you do a
tube feed calorie count from nursing flow sheets and see what he's actually
received in the last 5 days to get a sense of if he's getting what's
prescribed. It looks to me like you've got everything covered. He's likely
getting at least 50 mg elemental zinc in tube feed and multivite if it has
minerals and checking his zinc level probably won't tell you much about zinc
stores.
If you think he needs more protein as there can be huge losses if he has a
VAC dressing I would increase slowly and see trends in urea level.
All the best, these cases are very challenging but unfortunately not
uncommon.
Andrea Maudsley,RD
Surrey Memorial hospital
BC, Canada
-----Original Message-----
From: criticalca...@googlegroups.com
[mailto:criticalca...@googlegroups.com] On Behalf Of Kathleen
Standafer
Sent: Thursday, December 01, 2011 12:23 PM
To: criticalca...@googlegroups.com
Subject: [Critical Care Nutrition] Obese surgical patient
Thoughts? (see below)
Sent from my iPhone
-----
No virus found in this message.
Checked by AVG - www.avg.com
Version: 2012.0.1890 / Virus Database: 2108/4689 - Release Date: 12/18/11
Kathleen Standafer
Kathleen Standafer
Sent from my iPhone