Authors (including presenting author) :
Lo WPJ(1)(2), Ho YS(1)(2), Wong KW (1)(2), Ip TJJ(1)(2), Lau PM(1)(2), Chun YK(1)(2), Chang LL (1)(2), Lee CH(1)(2), Kwan YF(1)(2), So HM (1)(2)(3), Yan WW(1)(2)
Affiliation :
(1)Department of Intensive Care, (2)Pamela Youde Nethersole Eastern Hospital, (3)Hong Kong East Cluster
Introduction :
According to the dedicated nutritional advisory organizations (APSEN / ESPEN), optimal nutritional support to critically ill patients during their stressful and hypermetabolic state is crucial to decrease patient’s mortality and prevent iatrogenic complications. Stringent calculation on both energy and protein requirements becomes the decisive factors to determine the goals of nutritional therapy. However, the delivery of enteral nutrition (EN) in the intensive care unit (ICU) is always reduced or withheld due to the accumulation of gastric residues. Furthermore, enteral feeding is sometimes interrupted by "fasting" for therapeutic interventions, but fasting time often takes too long than necessary.
Objectives :
Revise the current enteral nutrition (EN) protocol aimed at maximizing the provision of nutritional therapy to critically ill patients with minimal interruptions
Methodology :
A revised EN protocol was established in October 2019 with the following enhancements. Then a structured training was conducted to all ICU staff on the revised EN protocol.
1. No GRV monitoring
2. Initiate feeding within 48 hours since ICU admission unless contraindicated. Gradually increase the feeding rate 8 hourly until the target meets.
3. Shorten the fasting time to 2 hours before and after medical interventions unless contraindicated.
4. Detect any abnormal signs of intolerance like abdominal distension, tenderness or emesis throughout nutritional therapy and take appropriate actions promptly. Once problems resolved, continue with the contemporary EN protocol immediately.
Pre- and post-implementation observational surveys were conducted in October and early December. Thirty patients were recruited during each period.
Result & Outcome :
The result revealed that nurses compliance rate with the revised feeding protocol was 96.7%(29/30). Among the study group, 6(20%) patients presented with abnormal gastrointestinal signs, corrective strategies like administration of laxatives were taken shortly. Similar episodes were observed in the pre-implementation period. This result indicated that GRV monitoring is insensitive for the prediction and prevention of intolerance to feeding. Moreover, 19(63.3%) patients were able to have fasting time less than 2 hours before and after medical interventions. The remaining 11(33.7%) patients were not able to resume enteral feeding due to clinical decisions or preparation for endotracheal re-intubation. Conclusions: In conclusion, the revised EN guideline was easy to be followed and 96.7% compliance rate was observed. Early feeding, absence of GRV monitoring and shorten fasting time were effective in maximizing the provision of nutrition therapy to critically ill patients with a consistent workflow and minimal interruption. Besides, close monitoring of gastrointestinal complications ascertains tolerance to enteral feeding and provides reliable evidences to assure the patient’s safety.
