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Gastric Versus Duodenal Feeding in Patients With Neurological Disease: A Pilot Study.

Abstract: Both gastric and duodenal feeding tubes are used to provide enteral nutrition. Most studies comparing the two methods have focused primarily on rates of complications, rather than on nutritional outcomes, and show no difference in complications between the two methods. It is not clear which feeding route provides the best nutritional outcomes. The primary purpose of this randomized clinical pilot study was to compare the percentage of recommended calories and protein received by patients with neurological disease being fed enterally via gastric or duodenal feeding tubes. Secondary aims were to compare the following between groups: physiological effects of feeding, reasons for delay in feeding, volume of feeding residual, number of feeding tubes replaced, cost of feeding, and number and types of complications.

A convenience sample of 25 neuro intensive care unit patients was randomly assigned to gastric or duodenal feeding. Enteral feeding was ordered by using a standardized prescription formula and provided by the nursing staff. Serum albumin and prealbumin levels were measured at baseline, day 3, and day 10. Nitrogen balance was measured on day 10. Enteral feeding data were collected daily.

No significant differences were found between gastric and duodenal groups in nutritional outcomes, including percentage of recommended calories and protein received, physiological effects of feeding, reasons for delay in feeding, feeding residual, number of feeding tubes replaced, cost of feeding, and number and types of complications. Neither group achieved mean recommended caloric or protein intake during the 10 days of the study. Further research is needed to address how recommended nutrients can be provided enterally in a more timely and complete manner in critically ill NICU patients.

Nutritional support improves outcome and decreases morbidity and mortality in brain-injured patients.[21,30] Poor nutritional status impairs healing and immune competence and may increase the risk of nosocomial infections and multiple organ failure.[25,29] Enteral feeding is the preferred method for the delivery of nutrition to patients who are unable to sustain oral intake. Both gastric and duodenal routes have been used to provide enteral nutrition. Studies comparing these two modes of feeding have focused primarily on the rate of complications. Little work has addressed nutritional outcomes or factors that contribute to adequate or inadequate administration of prescribed enteral nutrition.

The primary aim of this pilot study was to determine which enteral feeding method, gastric or duodenal, produces the best nutritional outcomes in critically ill patients with neurological disease or injury. The main outcome variable was the percentage of recommended calories and protein received. The secondary aims of the study were to compare groups on physiological effects of feeding, reasons for delay in feeding, volume of feeding residual, number of feeding tubes replaced, cost of feeding, and number and types of complications.

Background

Metabolic responses to acute neurological disease or injury include hypermetabolism, hypercatabolism, and excessive nitrogen loss.[16,19] The metabolic changes observed during critical illness and injury result from a combination of cytokine- and hormone-mediated effects leading to the rapid breakdown of protein and lean body mass. Patients with neurologic injury often have significant increases in energy expenditure and nitrogen losses; increases in energy expenditure from 135% to 160% above predicted levels are not uncommon.[15,28] This hypermetabolic response may return to a normal range within the first week, but urinary nitrogen losses often persist for several days beyond resolution of hypermetabolism.[7] The provision of adequate nutrition reduces the loss of muscle protein and, once the acute illness resolves, improves nitrogen balance and restores muscle mass.[4]

Nutrition can be provided by parenteral or enteral routes. Parenteral nutrition allows for more rapid achievement of nutritional goals but is associated with significant complications compared to enteral nutrition.[1] Enteral administration is preferred in patients with a functional gastrointestinal tract who are unable to meet their protein and caloric requirements with oral intake.[15,21] The main benefits of enteral nutrition include physiological preservation of gut function and integrity, improved nutrient use, and safer administration.[3,16] Enteral nutrition promotes growth of intestinal mucosal cells and stimulates production of secretory immunoglobin A, which prevents bacteria from attaching to the intestinal lumen.[26] This process functions in part to protect against bacterial translocation and subsequent systemic infection. Enteral nutrition is also associated with fewer infections and costs less than parenteral nutrition.[15,21]

Despite the many benefits of enteral nutrition, nasogastric feeding is not without risks, especially in critically ill or injured patients. Aspiration pneumonia is the most serious complication associated with enteral feeding and the most frequently studied outcome variable. Neurologically impaired and critically ill patients often experience slow gastric emptying, gastric paresis, and decreased lower esophageal sphincter tone.[1,18,20] These factors increase the risk of aspiration pneumonia. The risk of pulmonary aspiration has been reported to be as high as 80% in critically ill patients.[22] Norton et al. reported a 22% rate of aspiration in gastric fed patients with severe neurologic deficit. Additional factors that increase aspiration risk in neurologically injured patients are decreased level of consciousness, depressed cough reflex, and dsyphagia.[15]

Feeding beyond the stomach into the duodenum or jejunum has been suggested as one way to minimize the risk of aspiration and improve the adequacy of nutrient delivery.[10,11]

However, studies have demonstrated that the occurrence of aspiration is similar or equal with gastric and duodoenal feeding methods. The incidence of aspiration reported in the literature varies depending on the population studied, study design, and the criteria used to define pulmonary aspiration.[9] For example, Kiver et al. found a significantly higher rate of aspiration in patients fed into the stomach as compared to those fed into the duodenum (p = .005), whereas Grahm, Zadrozny, and Harrington, who studied head-injured patients, found no difference in the incidence of pneumonia with either feeding method.[10] Strong et al. randomized enterally fed patients into two groups, gastric and duodenal feeding, and found that clinical and radiographic evidence of aspiration was not statistically different between groups.[25] Marian et al. found a low incidence, 1 out of 42 patients, of aspiration pneumonia in gastric fed, critically ill, ventilated patients but made no statistical comparison to patients fed in the duodenum.[13] These authors claimed that strict adherence to aspiration precautions, such as checking residual volumes and elevating the head of the bed 30 to 40 degrees during feeding, may partially account for their results. They suggest that duodenal feedings are not safer than gastric feedings. Spain et al. found no difference in pulmonary complications, length of stay in the intensive care unit, or days on the ventilator in head-injured patients fed in the stomach compared to patients fed in the duodenum.[22]

In a prospective randomized trial duodenal versus gastric feeding was evaluated in 80 mechanically ventilated trauma patients,[12] the majority of whom ([is greater than] 75%) had head injury. Researchers found that patients randomized to duodenal feedings reached their nutritional goal rates sooner than those randomized to gastric feeding. They found no difference between groups in ventilator days or hospital length of stay. Although a trend toward a higher pneumonia rate was found in the gastric group, the power of the study was not sufficient to detect a statistical difference in aspiration pneumonia between groups.

Studies comparing methods of tube feeding in brain-injured patients have focused primarily on complication rates rather than on nutritional outcomes. Caloric deficits and negative nitrogen balance in critically ill patients result from the combination of increased resting energy expenditure, catabolism, immobilization, and inadequate nutritional delivery.[28] Gastric intolerance and feeding tube displacement have been identified as factors that limit the adequacy of enteral intake in critically ill patients.[2,24] The question of which feeding method provides the most adequate nutrition and the fewest complications remains to be clearly and specifically defined. Clevenger and Rodriquez stated that, "... prospective randomized clinical trials are needed to compare the efficacy of gastric to small-bowel feedings" (p. 112).[6] Research is needed to identify which feeding method, gastric or duodenal provides the best nutritional support with the fewest complications to the critically ill patient with neurologic injury.

This research study follows from a previous quality assurance project that examined delays in feeding related to feeding tube position in a neurological intensive care unit. The initial phase of the project established a standardized feeding tube insertion protocol.[27] The second phase documented delays in initiation of feeding and feeding interruptions. For this second project, patients were not randomized to treatment groups, nutritional outcomes were not measured, and complications were not described. The current pilot study was designed to increase control and compare outcomes of gastric and duodenal feedings using a prospective randomized design while also exploring factors that impede adequate administration of enteral nutrition.

Methods

This pilot study used a prospective randomized clinical design. It was funded through the Collaborative Clinical Research Initiative sponsored by the University of California San Francisco Medical Center and the School of Nursing.

Sample

The sample consisted of 25 patients admitted to the neurologic intensive care unit (NICU) of a Northern California university hospital between October 1998 and June 1999. Included were patients who had a primary neurologic diagnosis, were expected to require nasoenteral nutrition as their primary source of nutrition for at least 72 hours, and were approved for inclusion by their primary physician. Patients were excluded if they had documented gastroparesis, preexisting gastrointestinal bleeding, contraindication to head elevation of at least 30 degrees, or absence of a gag reflex.

Procedure

The study was approved by the Committee on Human Research. Nursing and medical staff members of the NICU were informed of the study purposes and procedures. The unit protocol for enteral nutrition was reviewed with the nurses and the importance of accurate documentation of enteral feeding was stressed.

Patients were screened; the study explained to those who met the inclusion criteria or to their next of kin; and informed consent was obtained. Patients enrolled in the study were randomly assigned to receive either gastric or duodenal feeding. Group assignment was performed by using a software-generated randomization schedule in which the numbers generated were placed into sealed envelopes that were opened after consent was completed. Patients remained in the assigned group throughout the study period.

All participants had a 10 French, 109-cm, 3-gm weighted tip, Corflow Ultra NG enteral feeding tube (Corpak Med Systems) placed in either their stomach or duodenum, followed by a kidney-ureter-bladder (KUB) X ray to confirm placement. Tube insertion followed the NICU Protocol for Feeding Tube Insertion.[27] If the tube was not properly placed after three attempts, the tube was placed under fluoroscopy as the NICU protocol dictates. The registered dietitian, blind to group assignment, calculated the total energy and protein requirement for each patient upon enrollment, using the Harris Benedict equation with activity and stress factors. This calculation became each participant's enteral nutrition prescription. Enteral nutrition was administered per unit protocol, starting as soon as the bedside nurse was notified of the results of the KUB. Two research assistants (RAs) collected daily nutritional data and demographic data from each participant's daily flow sheet and medical record.

Instruments and Measurement

Patients were weighed using Hillrom or Cardiosystems bedscales that were calibrated by the biomedical engineering department of the hospital. Serum albumin and prealbumin levels were drawn by the NICU nurse when the patient was enrolled in the study and on days 3 and 10 of their enrollment. A 24-hour urine sample for urine urea nitrogen (UUN) was collected by the NICU nurse on study days 9-10 for calculation of nitrogen balance by the dietitian. All laboratory tests were performed at the university hospital laboratory by using standard procedures.

Analysis

All data were entered into SPSS for Windows (SPSS, Inc., Chicago) for data management and analyses. A significance level of less than .05 was preset for statistical tests. A t test for independent samples was used to compare means between groups for each continuous variable. Chi-square and cross-tabs analyses were used to compare categorical data.

Results

Characteristics of the Sample

A total of 25 patients admitted to the NICU was enrolled. The mean age of the sample was 56.7 [+ or -] 15.3 years. Fourteen were men, and 11 were women. Patients were admitted with a variety of neurological insults including subarachnoid hemorrhage (44%), intracerebral and intraventricular hemorrhage (20%), acute stroke (12%), arteriovenous malformation or fistula (8%), Guillain-Barre syndrome (8%), and meningitis (4%). The mean Acute Physiology and Chronic Health Evaluation (APACHE III) score, used to evaluate severity of illness, was 47.8 [+ or -] 20.0, indicating severe illness with little likelihood of survival or recovery. Three patients died during the study period.

Patients were randomly assigned to the gastric feeding group (n = 11) and to the duodenal feeding group (n = 14). Demographic data by group are presented in Table 1. Statistical analysis showed the groups were homogeneous in terms of age, severity of illness, and recommended calorie and protein requirements.
Table 1. Demographic Data by Group

 Gastric Group

 Parameter Mean [+ or -] SD n

Gender
 Male 5
 Female 6 11
Age, years 60.6 [+ or -] 14.7 11
APACHE III score 51.7 (13.8) 11
Admission weight, kg 74.2 [+ or -] 15.4 11
Usual body weight, kg 83.4 [+ or -] 40.9 5
Height, cm 169.2 [+ or -] 11.7 9
Body mass index, kg/[m.sup.2] 25.5 [+ or -] 4.9 9
Caloric requirements, kcal 2,209 [+ or -] 495 10
Protein requirements, gm/dl 99 [+ or -] 27 10

 Duodenal Group

 Parameter Mean [+ or -] SD n

Gender
 Male 9
 Female 5 14
Age, years 53.6 [+ or -] 15.5 14
APACHE III score 44.5 [+ or -] 23.9 14
Admission weight, kg 78.6 [+ or -] 22.0 14
Usual body weight, kg 73.4 [+ or -] 12.9 7
Height, cm 171.8 [+ or -] 10.1 14
Body mass index, kg/[m.sup.2] 26.4 [+ or -] 6.7 14
Caloric requirements, kcal 2,459 [+ or -] 527 13
Protein requirements, gm/dl 105 [+ or -] 22 13

Note: p >.05 for all variables.


Nutritional Outcomes

Mean caloric intake by group by day and mean percentage of recommended calories received each day are reported in Table 2. The mean caloric requirement for the gastric group was 2,209 [+ or -] 495 kcal and for the duodenal group, 2,459 [+ or -] 527 kcal (p = .26). As indicated in Table 2, neither group's caloric requirements were fully met during the study period; however, the standard deviation for both groups was large and there were individual instances of participants receiving 100% of their prescribed calories on certain days. Analysis of percentage of daffy recommended calories revealed a statistically significant difference (p = .036) between groups only on day 2 (p = .036) and day 3 (p = .003).
Table 2. Mean Calories Received and Percentage of Recommended
Calories Received by Group by Day

 Gastric Group

 Percentage of
 Recommended
Day Mean kcal kcal

1 374 [+ or -] 380 19 [+ or -] 20
2 976 [+ or -] 561(*) 48 [+ or -] 31
3 1,672 [+ or -] 623(**) 79 [+ or -] 33
4 1,638 [+ or -] 647 77 [+ or -] 29
5 1,207 [+ or -] 728 61 [+ or -] 40
6 1,343 [+ or -] 477 69 [+ or -] 27
7 1,494 [+ or -] 760 72 [+ or -] 35
8 1,662 [+ or -] 584 82 [+ or -] 30
9 1,521 [+ or -] 642 75 [+ or -] 33
10 1,491 [+ or -] 768 76 [+ or -] 39

 Duodenal Group

 Percentage of
 Recommended
Day Mean kcal kcal

1 170 [+ or -] 234 8 [+ or -] 13
2 467 [+ or -] 473 22 [+ or -] 25
3 782 [+ or -] 518 35 [+ or -] 30
4 1,465 [+ or -] 851 61 [+ or -] 36
5 1,818 [+ or -] 945 75 [+ or -] 34
6 1,365 [+ or -] 975 57 [+ or -] 42
7 1,585 [+ or -] 1132 66 [+ or -] 42
8 2,169 [+ or -] 756 90 [+ or -] 17
9 1,473 [+ or -] 1071 64 [+ or -] 41
10 2,147 [+ or -] 625 86 [+ or -] 23

(*) p = .034;

(**) p = .001


Mean protein intake by group by day is reported in Table 3. The mean protein requirement for the gastric group was 99 [+ or -] 27 gm and for the duodenal group, 105 [+ or -] 22 gm (p = .591). Neither group's protein requirements were fully met during the study period; however, the standard deviation for both groups was large and there were individual instances of participants receiving 100% of their prescribed protein on certain days. The gastric group received significantly more protein than the duodenal group only on study days 2 (p = .045) and 3 (p = .004) (Table 3).
Table 3. Mean Protein Intake by Group by Day

 Protein Intake, gm (Mean [+ or -] SD)

Day Gastric Group Duodenal Group

 1 16.4 [+ or -] 17.37 7.5 [+ or -] 10.4
 2(*) 41.5 [+ or -] 25.7 20.1 [+ or -] 20.0
 3(**) 70.8 [+ or -] 27.0 33.8 [+ or -] 23.5
 4 69.7 [+ or -] 29.9 63.7 [+ or -] 37.8
 5 55.3 [+ or -] 34.1 79.4 [+ or -] 41.6
 6 60.8 [+ or -] 21.4 79.4 [+ or -] 41.6
 7 68.3 [+ or -] 34.9 67.3 [+ or -] 47.5
 8 76.2 [+ or -] 26.8 94.2 [+ or -] 31.1
 9 69.6 [+ or -] 29.2 63.9 [+ or -] 46.6
10 68.1 [+ or -] 34.2 93.5 [+ or -] 30.4

(*) p = .045;

(**) p = .002


Measures of serum albumin, prealbumin, and nitrogen balance were used collectively to determine the biochemical response to enteral feeding and are reported in Table 4. Baseline measures showed a significantly higher mean serum albumin in the gastric group (p = .05), but differences between groups on subsequent measures of albumin were not significant.
Table 4. Biochemical Nutritional Parameters by Group by Day

 Gastric Group

 Day and Measure Mean [+ or -] SD n

Baseline, Albumin(*) 3.42 [+ or -] 0.56 gm/dl 11
Day 3, Albumin 3.15 [+ or -] 0.61 gm/dl 10
Day 10, Albumin 2.98 [+ or -] 0.37 gm/dl 7
Baseline, Prealbumin 16.81 [+ or -] 8.49 mg/dl 11
Day 3, Prealbumin 14.40 [+ or -] 3.13 mg/dl 10
Day 10, Prealbumin 18.00 [+ or -] 6.90 mg/dl 7
Day 10, Nitrogen balance -2.6 [+ or -] 5.77 gm 6

 Duodenal Group

 Day and Measure Mean [+ or -] SD n

Baseline, Albumin(*) 2.96 [+ or -] 0.56 gm/dl 13
Day 3, Albumin 3.07 [+ or -] 0.53 gm/dl 13
Day 10, Albumin 3.75 [+ or -] 2.75 gm/dl 2
Baseline, Prealbumin 19.07 [+ or -] 8.81 mg/dl 13
Day 3, Prealbumin 13.38 [+ or -] 4.05 mg/dl 13
Day 10, Prealbumin 18.66 [+ or -] 6.11 mg/dl 3
Day 10, Nitrogen balance -4.4 [+ or -] 7.16 gm 4

(*) p = .05

Note: normal ranges: albumin = 3.5-5.5 gm/dl,
prealbumin = 20-44 mg/dl, nitrogen balance = 0.


Prealbumin at baseline was 14.4 [+ or -] 3.1 mg/dl in the gastric group and 13.4 [+ or -] 4.0 mg/dl in the duodenal group (p = .52; normal values, 20-44 mg/dl). There were no differences between groups in mean serum prealbumin at baseline, on day 3 or day 10. Mean nitrogen balance, a measure of whether ingested nitrogen is greater than metabolized nitrogen, was negative in both groups, but there were no differences between groups (Table 4).

There were no significant differences between groups in weight, usual body weight, or body mass index (BMI) at admission to the study (Table 1). There were no consistently significant differences in BMI (weight loss or weight gain) during the study, but the BMI for the gastric group decreased significantly more than that for the duodenal group on days 4 (p = .42) and 7 (p = .032). This difference in BMI fluctuation was not consistent between groups; it is possible that with the small number in each group, dropout of even a single participant during the study may account for these differences.

Reasons for Delay in Feedings

Feedings were held for several reasons and for variable lengths of time. The reasons for feeding interruption were categorized as procedural interruptions (surgical or diagnostic procedures, endotracheal intubation or extubation, or medications), mechanical dysfunction or tube displacement (tube clogging, removal, or failure to be placed in position), gastrointestinal (GI) dysfunction (vomiting, diarrhea, or abdominal distention), X-ray delay (confirmation of placement), and other or unknown. The most common reason feedings were held was in preparation for procedures; over the 10-day study period, feedings were held 52 times in the gastric group and 32 times in the duodenal group in order to prepare patients for procedures. While procedural interruptions were the most common, interruptions due to mechanical dysfunction accounted for the most feeding time lost with a mean of 555 minutes in the gastric group, 2,666 minutes in the duodenal group, and a total mean of 1,788 minutes for both groups combined.

Residual Volumes

Residual volumes, checked every 6 hr, ranged from 0 to 125 ml for the groups combined with daily means of 0-40 ml in the gastric group and 0-5 ml in the duodenal group (Table 5). There were no significant differences between the groups in the amount of residual volume obtained. In addition, the daily mean residual volumes obtained from each group were small and not clinically significant.
Table 5. Residual Volumes by Group by Day

 Residual Volumes, ml (Mean + SD)

Day Gastric Group Duodenal Group

1 2 [+ or -] 4 2 [+ or -] 2
2 22 [+ or -] 47 1 [+ or -] 4
3 12 [+ or -] 26 1 [+ or -] 2
4 10 [+ or -] 25 3 [+ or -] 9
5 20 [+ or -] 48 4 [+ or -] 9
6 40 [+ or -] 73 1 [+ or -] 2
7 22 [+ or -] 35 2 [+ or -] 3
8 6 [+ or -] 8 2 [+ or -] 4
9 6 [+ or -] 11 3 [+ or -] 6
10 0 5 [+ or -] 7


Number of Tubes Replaced

Feeding tubes were replaced a total of 25 times during the study, 9 times in the gastric group, and 16 times in the duodenal group. A total of 69 KUBs, 29 in the gastric group and 40 in the duodenal group, were required to establish feeding tube location. Data on the reasons feeding tubes required replacing were not collected for this study. No significant difference was demonstrated between the groups in the number of X rays related to feeding tube placement (p = .56). Although fluoroscopy was included as part of the protocol for difficult tube insertion, no participant required fluoroscopic placement of the feeding tube during the study.

Cost

Cost of feeding tube replacement was calculated by summing the patient cost for replacement feeding tubes, additional KUBs needed to determine tube placement, and the radiologist's fee for reading each KUB. Patient cost per feeding tube was $139; for KUB, $198; and for the radiologist's interpretation, $75. Multiplying the cost for the number of tubes, KUBs, and radiologist interpretations yielded a total cost for the gastric group of $9,168 (9 tubes times $139, plus 29 KUBs times $198, plus 29 radiologist interpretations times $75). In the duodenal group the total cost was $10,144 (16 tubes times $139, plus 40 KUBs times $198, plus 40 radiologist interpretations times $75). This is not a clinically significant difference.

Complications

Diarrhea, vomiting, incidence of aspiration pneumonia, and incidence of other documented infection are recognized as complications of enteral feeding. In the gastric group, five participants experienced diarrhea for a mean of 368 [+ or -] 641 ml. In the duodenal group, seven participants experienced diarrhea for a mean of 67 [+ or -] 132 mi. No significant difference was found between gastric and duodenal groups in the volume of diarrhea. No vomiting was recorded in either group. Aspiration pneumonia was noted in two participants in the gastric group and no participants in the duodenal group. Other infection was recorded four times for each group.

Discussion

The primary aim of this pilot study was to determine whether there was a difference in nutritional outcome in a sample of NICU patients fed enterally via gastric or duodenal routes. With 25 subjects, randomly assigned to treatment, there was no significant difference between the groups in the main outcomes of percentage of recommended calories and protein received. The groups did not differ in the physiologic measure of nutritional adequacy; albumin, prealbumin, nitrogen balance, and change in body mass index were similar over time in both groups.

Mean albumin levels were below normal range at baseline in both groups, indicating mild albumin depletion. By study day 10, albumin was within normal range in the duodenal group, but still mildly depleted in the gastric group; this may be attributable to the higher rate of participant attrition in the gastric group. Prealbumin levels, however, started out normal for both groups and came up further over time, but never reached normal range in either group. The prealbumin levels on day 10 indicate that the level of feeding provided allowed for minimal protein synthesis.

Mean nitrogen balance after 10 days of feeding was negative in both groups, and neither group consistently received the full amount of recommended calories. Nitrogen balance is a measure of protein breakdown in relation to protein intake and is calculated by comparing nitrogen intake with nitrogen excretion over a 24-hour period. Negative nitrogen balance shows that protein breakdown exceeds protein synthesis and is usually due to catabolism or starvation.[8]

Calories and protein received by the gastric group on days 2 and 3 were significantly greater than those received by the duodenal group, and overall, gastric feeding rates were higher in the first 4 days of feeding. However, beginning on day 5, the duodenal group on average received more calories and protein than did the gastric group; this is in contrast to Kortbeek et al., who found patients who received duodenal feedings were able to achieve nutritional goals sooner than patients who received gastric feedings.[12] These findings do, however, indicate a trend toward higher feeding rates in the duodenal group that may be shown to be statistically significant with a larger sample.

Few enteral feeding complications were observed in this study. While enterally fed patients with neurological disease are considered at high risk for aspiration pneumonia, only about 8% of the total sample developed aspiration pneumonia and 40% developed other infections; however, no difference between the groups in the rate of aspiration pneumonia or other infection was observed. This supports the findings of other studies in which the rate of enteral feeding complications was similar in gastric and postpyloric fed patients and supports the conclusion that duodenal feeding is not safer than gastric feeding.

Mechanical and procedural interruptions frequently caused delays in continuous feeding. These delays most likely contributed to the low percentage of recommended calories and protein received in each group. Feeding interruption is a common problem in enterally fed patients. Stechmiller et al. found interruptions in feeding attributed to phenytoin administration and tube displacement resulted in underfeeding in 80% of enterally fed NICU patients. Interestingly, physiologic reasons for holding feedings contributed very little to feeding interruption. Problems such as high residual volumes and diarrhea resulted in only about 5 hours of feeding time lost as compared to about 55 hours lost due to procedures.

Limitations and Recommendations

One limitation of this study was the small sample size that further decreased over the 10-day study period. Failure to reach statistical significance may have been a direct result of the limited sample size. Another limitation is the use of estimation to determine participants' energy requirements. It is generally recommended that nutrition support be provided according to measured rather than estimated requirements in critically ill patients. Measurement of energy expenditure by indirect calorimetry is the best way to determine the patient's metabolic rate and provides a more accurate assessment of nutritional requirements.[14] Nutritional adequacy in the critically ill patient with neurologic disease or injury is difficult to measure. Serum albumin and, to a lesser extent, prealbumin are lower in patients who are overhydrated, and overhydration is common in post-subarachnoid hemorrhage patients who are being treated with hypervolemia. The acute phase of injury alone may lower the serum albumin.[8] However, the acute stress response should have abated to some extent by the 10th study day. Calculation of nitrogen balance depends on the accurate measurement of protein intake over 24 hours; this can be difficult or impossible when tube feedings are turned off and on unpredictably throughout the day and night.

In this study, tube feedings were often held for prolonged periods because of procedures such as endotracheal extubation, central line placement, and CT scan. Despite some evidence that adherence to a specific infusion protocol can improve the delivery of enteral nutrition, it is not clear when enteral feedings should be held or whether the same standards ought to apply to duodenal and jejunal feedings as apply to gastric feedings.[23] Further research in this area is warranted.

The proposed benefits of enteral nutrition in critically ill patients are to prevent malnutrition, to provide enough nutrition to meet metabolic needs, to avoid associated complications, and to improve outcomes.[5] Efforts to improve the delivery of enteral nutrition have the potential to improve patient outcomes. Additional research is needed to address the adequacy of nutritional intake and its effect on outcomes in critically ill patients with neurological disease and should include a more thorough examination of factors that limit the adequate delivery of enteral nutrition.

Summary

This pilot study showed neurologically injured patients fed by gastric and duodenal routes did not differ in nutritional outcomes or complications. This means that one route is no more effective or safe than the other. However, this study also points out the overall inadequacy of enteral nutrition in NICU patients. Barriers to the delivery of adequate enteral nutrition include inaccurate measurement of caloric requirements, inaccurate measurement of feeding received, and interruption of feedings.

Acknowledgments

This study was funded by the Collaborative Clinical Research Initiative sponsored by the University of California San Francisco Medical Center and the School of Nursing.

We thank Wade Smith, MD PhD, Daryl Cress, MD, and the nurses in the Neurologic Intensive Care Unit at University of California San Francisco Medical Center for their help and support in this study.

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[22.] Spain DA, McClave SA, Sexton LK, et al: Infusion protocol improves delivery of enteral tube feeding in the critical care unit. J Parenter Enteral Nutr 1999; 23(5): 288-292.

[23.] Spain DA, DeWeese RC, Reynolds MA, et al: Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications. J Trauma 1995; 39(6): 1100-1102.

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[25.] Strong RM, Condon SC, Solinger MR, et al: Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: A randomized, prospective study. J Parenter Enteral Nutr 1992; 16(1): 59--63.

[26.] Takahashi I, Kiyono H: Gut as the largest immunologic tissue. J ParenterEnteral Nutr 1999; 23(5 Suppl): S7-S12.

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[28.] Weekes E, Elia M: Observations on the patterns of 24-hour energy expenditure changes in body composition and gastric emptying in head-injured patients receiving nasogastric tube feeding. J Parenter Entral Nutr 1996; 20(1): 31-37.

[29.] Wilson RF, Tyburski JG: Metabolic responses and nutritional therapy in patients with severe head injuries. J Head Trauma Rehabil 1998; 13(1): 11-27.

[30.] Young B, Ott L, Twyman D, et al: The effect of nutritional support on outcome from severe head injury. J Neurosurg 1987; 67(5): 668-676.

Questions or comments about this article may be directed to: Lisa Day, PhD RN, University of California San Francisco School of Nursing, 2 Kirkham, Box 0610, Room N631, San Francisco, CA 94143-0610. Dr. Day is an assistant clinical professor at the University of California San Francisco School of Nursing.

Nancy A. Stotts, EdD RN, is a professor at the University of California San Francisco School of Nursing.

Anna Frankfurt, BS RN, is an assistant patient care manager in the neurologic intensive care unit, University of California San Francisco Medical Center.

Annette Stralovich-Romani, RD CNSD, is an adult critical care nutritionist in the department of nutrition and dietetics, University of California San Francisco Medical Center.

Monica Volz, MS RN, is an assistant patient care manager in the neurologic intensive care unit, University of California San Francisco Medical Center.

Marylou Muwaswes, MS RN, is a clinical nurse specialist in neurological surgery, University of California San Francisco Medical Center.

Yoshimi Fukuoka, MS RN, is a doctoral student at the University of California San Francisco School of Nursing.

Colleen O'Leary-Kelley, MS RN, is a doctoral student at the University of California San Francisco School of Nursing.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Day, Lisa; Stotts, Nancy A.; Frankfurt, Anna; Stralovich-Romani, Annette; Volz, Monica; Muwaswes, Ma
Publication:Journal of Neuroscience Nursing
Geographic Code:1USA
Date:Jun 1, 2001
Words:5993
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