Combined Parenteral and Enteral Nutrition in Severe Trauma DAVID R. WAGNER,* MS; MICHAEL F. ELMORE,* MD, FACP, FACG, FACN; AND JOHN T. TATE,† MD, FACS *Indianapolis Gastroenterology Research Foundation, Beech Grove, IN, and † Upstate Surgical Associates, Spartanburg, SC
ABSTRACT: Early enteral feeding is increasingly advocated for the nutrition support of severely stressed patients. The successful use of this modality in critical illness is often limited by the patient’s condition, the availability of access for feeding, and the patient’s tolerance of the enteral formula. Factors such as abdominal injury or constraints on fluid volume also complicate nutrition support in this setting. Attention to a secure and well-maintained small bowel access tube and appropriate formula selection allow safe tube feeding in these patients. This case report describes the clinical course of a patient with severe chest and abdominal trauma who received enteral nutrition despite a large, open abdominal wound.
G.A., a 38-year-old man, sustained chest and abdominal trauma while driving on a rural western North Carolina road when a chain from an oncoming logging truck crashed through the windshield of his automobile and struck him in the chest. He was able to maintain control of his vehicle and drove several miles to a roadside convenience store. Local emergency medical services personnel stabilized him and transported him to Spartanburg Regional Medical Center. There was at least a 45-minute delay after his injury before he arrived at the medical center. Physical examination. At the time of his arrival at the emergency room, G.A. was minimally responsive and hypotensive. He had a large open wound in his left chest region and an open pneumothorax. Gastric contents appeared to be leaking from the wound. He had additional injuries that included a deep laceration of his left forearm with compound fractures of his radius and ulna, a large soft-tissue defect on the anterior portion of his left hand with fractures of the metacarpals, and multiple rib fractures.
Tube feeding has been increasingly advocated for the early nutrition support of critically ill and traumatized patients. Recent evidence suggests that the hypermetabolism of injury and the breakdown of the gut mucosal barrier can be attenuated by early intervention with tube feeding.I-3 The successful use of enteral feedings in the acute care setting, however, is often limited by unreliable enteral access tubes and intolerance to available formulas. Parenteral nutrition (PN) is still the first choice of many clinicians because it provides an early and reliable intake of nutrients. Recent advances in tube feeding formulations and concentrated intravenous amino acid solutions have provided the opportunity to integrate the two approaches to assure adequate nutrient intake and achieve the benefits of enteral nutrition.
Hospital course. He was taken to surgery immediately, and a ruptured left hemidiaphragm, laceration of the anterior gastric wall, and gross spillage of gastric contents throughout the chest and abdomen were revealed. The anterior gastric wall, left hemidiaphragm, and anterior chest defect were repaired. The left arm and metacarpal fractures were stabilized with external fixation. He arrived in the surgical intensive care unit in unstable condition and required support by mechanical ventilation. Although G.A.’s condition stabilized over the next 2 days, he remained mentally obtunded. PN was started on hospital day 3. His postoperative fluid and ventilator management were complicated by severe
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cardiac and pulmonary contusions. Over the next several days, a multisystem organ failure and progressive 113 Downloaded from ncp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
mediate improvement in his levels of uremia and
hypervolemia. Until this time, he had been maintained on a highly concentrated PN because of the fluids required for his pharmacotherapy and the limitations imposed by his renal and cardiopulmonary status. On hospital day 27, despite marked small bowel edema and an open abdominal cavity, G.A. had operative placement of an 8 French nasojejunal tube to allow for the initiation of a full-strength, peptide-based tube feeding (Reabilan’, O’Brien/KMI, Parsippany, NJ) at 20 mL/h (Fig 1). The tube feeding was tinted blue, and the administration rate was cautiously advanced over the next 7 days. When the rate reached 60 mL/ h, the formula was changed to one with higher protein and calorie content (Reabilan HN’, O’Brien/KMI). This infusion remained constant for the next 10 days. The combination of PN and tube feeding successfully met the patient’s estimated protein and calorie needs for the first time during his hospital course (Fig 2). The PN administration rate was steadily decreased during hospital days 37 through 50 and was then discontinued. At the same time, the tube feeding rate was slowly increased to a final rate of 100 mL/h, where it remained throughout the rest of his 79-day stay in the intensive care unit (ICU). The tube feeding was stopped during the abdominal explorations and dressing changes but was restarted within 1 hour of each procedure. No excessive stool output was noted,
Figure 1. G.A. on hospital day tube feeding at 20 mL/h.
and no antidiarrheal agents were required. Continuous nasogastric decompression was maintained, with no evidence of the enteral formula in the aspirate. Steady improvement occurred during the last 30 days of G.A.’s ICU stay with resolution of his acute renal failure, adult respiratory distress syndrome, septicemia, and systemic candidiasis. He was able to undergo a staged abdominal closure beginning on hos-
Gram-negative sepsis emerged. On hospital day 7, a second abdominal exploration was performed. Necrotic omentum and other debris were excised, multiple intra-abdominal abscesses were drained, and the peritoneal cavity was irrigated. Over the next few weeks, G.A. developed necrotizing pancreatitis, multiple intra-abdominal abscesses with marked small bowel edema, systemic candidiasis, adult respiratory distress syndrome, and nonoliguric acute renal failure. G.A. required a total of eight celiotomies between hospital days 9 and 21 for further debridement of necrotic omentum, removal of necrotic pancreatic tissue, drainage and irrigation of multiple intra-abdominal abscesses, and a splenectomy. During hospital days 22 through 45, 10 more explorations were performed for abscess drainage and irrigation. Between operations, irrigations of his abdominal cavity and dressing changes were performed every other day. Because of requirements for frequent exploration and drainage, the abdominal wound was managed with transparent dressings and a closed drainage system.’ Hemodialysis was begun on hospital day 27 for the
Figure 2. Protein and calorie intake, actual versus goal. TF, tube feeding; TPN, total parenteral nutrition; D/C, discon-
management of G.A.’s
failure, with im-
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pital day tion to
hospital day 70, he began the transiregular diet, and the tube feeding rate was
tapered over the next 6 days. The improvement in G.A.’s condition allowed him to be transferred to a regular surgical floor on hospital day 80. He was discharged home on hospital day 109. At this time, he was ambulatory and eating a regular diet. On long-term follow-up, he has done well, remained normoglycemic, and has had no trouble maintaining his weight. DISCUSSION
Practical considerations in the care of patients with catastrophic abdominal trauma often preclude attempts at enteral feeding. In such patients, tube feeding can be extremely hazardous unless adequate precautions are undertaken to assure appropriate placement of the tube in the small bowel, maintenance of the position and integrity of the tube, and protection against the aspiration of tube feeding. In this setting,
concentrated PN delivered as a total nutrient admixor standard formulation in one bag per day can offer significant advantages in the reduction of fluid volume and time management.’ Some reports suggest that early tube feeding in stressed patients can reduce the degree and extent of hypermetabolism.l,3,6 The advantages of enteral feeding may be unrelated to total nutrient intake, and any amount of enteral feeding may be better than no enteral feeding at all, even when PN supplies the majority of nutritional intake.’ This may be particularly true in the prevention of gut mucosal barrier breakdown.’ Historically, the provision of optimal substrate intake and the limitation of the degree of negative nitrogen balance have been considered of vital importance in the critically ill. Unfortunately, problems with several aspects of tube feeding delivery often make this level of intake difficult to achieve.9 Inadequate estimation of actual calorie needs, incomplete infusion of ordered volume, intolerance to feedings, and mechanical problems all reduce intake. In the critical care setting, central venous access is routinely available and the infusion of PN can usually meet a patient’s substrate requirements. In situations where the amount of substrate intake and the route of delivery are important in order to achieve an optimal response, a combination of modalities seems appropriate. Some may argue that the concurrent use of both intravenous and enteral feeding places the patient at risk for complications from both modalities and that these risks may outweigh the benefits. The infusion of PN in one bag per day, however, may not significantly increase the risk of infection over that of any other intravenous solution, provided that adequate control of serum glucose is maintained.lo°11 Rational tube feeding protocols and meticulous attention to detail can minimize the potential complications from this modality.
In this case report, clinical improvement occurred after the initiation of tube feeding, which allowed a progressive decrease in PN. No causal relationship can be drawn, however, because of the synchronous initiation of hemodialysis and the progressive clearing of intra-abdominal septic foci. Independent of these considerations, tube feeding was accomplished in a patient who had marked small bowel edema and an open abdominal cavity. The crucial aspects of providing enteral feedings in an ICU setting are strict attention to appropriate placement and maintenance of feeding tubes, protection from aspiration of formula, selection of appropriate formula, and rational schedules for the advancement of tube feeding administration rates. The ment of feeding tubes in the jejunum,
with simultaneous gastric suction, effectively reduces the risk of aspiration, should enterogastric reflux occur. The loss of enteral access from clogged tubes may increase with time, especially with small-diameter tubes. To prevent clogging, a regular schedule of flush-
ing the tube with water should be instituted. The volume and frequency of these flushes should be modified according to the patient’s fluid volume restrictions.
Although many drugs are available in liquid form for delivery through feeding tubes, we discourage indiscriminate pharmacotherapy via this route. Many liquid dosage forms are hypertonic and contain sorbitol, which can cause osmotic diarrhea.12,13 The potential for interactions that alter the bioavailability of drugs is often disregarded. The practice of crushing tablets for delivery through feeding tubes should also be discouraged, because blockage of the tube often results. There are reports that peptide-based feeding formulas may be better tolerated in patients with hypoalbuminemia and small bowel edema than are more traditional elemental or conventional long-chain protein hydrolysate formulas.14,15 In these reports, the extent of gut edema was only postulated on the basis of the degree of hypoproteinemia, malnutrition, and concurrent illness. We were able to see directly the markedly edematous bowel in this patient (Fig 1). Little, if any, motility was observed during the early stages of the enteral infusion. The peptide-based formula with 35% fat calories (60% long-chain triglycerides, 40% medium-chain triglycerides) was well tolerated and was not associated with increased stool output. In fact, within 24 hours of beginning the tube feeding, the patient passed a semiformed stool. He continued to have one or two semi-formed bowel movements daily for the duration of the tube feeding. We believe that the progression of feedings was as crucial to this patient’s tolerance as was the nature of the formula. Evidence suggests that dilution of nearly isotonic feedings is unnecessary. Our clinical experience tends to confirm that volume, rather than tonicity, is the most important factor in feeding tolerance.
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patient, full-strength feedings were started at low, constant infusion rate of 20 mL/h into the proximal jejunum. The infusion rate was advanced, conservatively, by 10 mL/h per day. The feedings were tinted blue so that any leakage or reflux into the stomach could be readily identified. Once a target rate had been achieved, the feeding was changed to a more concentrated peptide formula with higher nitrogen content. After establishing the patient’s tolerance of this new formula, conservative advancement of the In this a
feeding rate was This
report illustrates that enteral nutrition is
possible during even the most catastrophic abdominal trauma. Concentrated PN formulations delivered in one bag per day as dextrose and amino acids or as
total nutrient admixtures still have a significant role in supporting patients nutritionally until enteral feeding can be instituted. The key to safely incorporating enteral feeding into the care of the critically ill is an almost compulsive attention to detail. Feedings should be infused only into the small bowel, because gastric infusions are fraught with hazard. Drugs should not be indiscriminately infused through the feeding tube, especially if intravenous access if available. Any drug that is given by the enteral route should be carefully evaluated for compatibility with the enteral formula, adequate absorption, and appropriate therapeutic level. A defined flushing protocol should be followed to avoid clogging of the tube and loss of enteral access. Finally, attention to appropriate formula selection and rational infusion advancement schedules will minimize the potential for intolerance and complications.
secretion, and gut mucosal integrity after burn injury. JPEN 1987;11:1-7. 2. Inoue S, Epstein MD, Alexander JW, et al. Prevention of yeast translocation across the gut by a single enteral feeding after burn injury. JPEN 1989;13:565-71. 3. Chiarelli A, Giuliano E, Casadei A, et al. Very early nutritional supplementation in burned patients. Am J Clin Nutr mone
1990;51:1035-9. 4. Chariker M, Jeter KF, Tintle T, et al. Effective management of incisional and cutaneous fistulae with closed suction wound
drainage. Contemp Surg 1989;34:59-63. 5. Driscoll DF, Baptista RJ, Mitrano FP, et al. Parenteral nutrient admixtures as drug vehicles: theory and practice in the critical
setting. DICP 1991;25:276-83. H, Trocki O, Dominioni L, et al. Mechanism of prevention of post-burn hypermetabolism and catabolism by early enteral feeding. Ann Surg 1984;20:297-310. 7. Bower RH, Talamini MA, Sax HL, et al. Postoperative enteral vs parenteral nutrition. Arch Surg 1986;121:1040-5. 8. Alverdy JC, Aoys E, Moss GS. Total parenteral nutrition procare
bacterial translocation from the gut. Surgery 1988;104:185-90. 9. Abernathy GB, Heizer WD, Holcomb BJ, et al. Efficacy of tube motes
in supplying energy requirements of hospitalized patients. JPEN 1989;13:387-91. 10. Alpgren K. Answering the fat emulsion myth: 3-in-1 admixture vs conventional TPN in a clinical setting [Abstract]. JPEN
1987;11(suppl):19. M, Farraj M, Hwang L. The incidence and clinical significance of intravenous fat emulsion contamination during
infusion. JPEN 1987;11:42-5. 12. Edes TE, Walk BC, Austin JL. Diarrhea in tube fed patients: feeding formula not necessarily the cause. Am J Med
1990;88:91-3. DB, Henderson LM, McClain CJ. Osmotic diarrhea in-
by sugar-free theophylline solution in critically ill patients. JPEN 1991;15:332-6. 14. Brinson RR, Kolts BE. Hypoalbuminemia as an indicator of diarrheal incidence in critically ill patients. Crit Care Med 1988;15:506-9.
H, Trocki O, Alexander JW, et al. The effect of route of nutrient administration on the nutritional state, catabolic hor-
15. Hammaoui E, Lefkowitz R, Olender I, et al. Enteral nutrition in the early post-operative period: a new semi-elemental enteral formula versus total parenteral nutrition. JPEN 1990;14:5017.
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