fain

T Campbell,

Leonie

Randal

Shapiro,

P Morton,

Ian

A Macdonald,

Shirley

Judd,

and Philip M Stell

ABSTRACT The effects of two different feeding patterns on oxygen consumption, nitrogen balance, blood biochemistry, and urinary catecholamine excretion were investigated over 5 d in patients after major head and neck surgery. Both groups of nine patients each were fed a regimen that provided

and

4.7

MJ

tube

with

the effects

by

continuous

One

Night

feeding

on day

1 and

10 MJ

infusion

on days

with

an

2-5

via a nasogastric

enteral

feeding

pump.

was fed continuously for 24 h, the other was fed only at ie, from 1700 to 0900 the next morning. Oxygen consumption was significantly higher (P < 0.01), nitrogen balance better (P < 0.05), and urinary catecholamine excretion higher (P < 0.05) in the 24-h-fed patients than in the night-fed pafeeding

at night

efficient than is feeding continuously with poorer nitrogen balance. These

ated by sympathoadrenal 1990;52:1 107-12. KEY WORDS erative study, cholamines

only

is more

Am

J C/in

Eighteen

Nutr

gery.

feeding, postopbalance, cate-

a conventional

practice

This

enables

the

abdominal

adequate

when

quantities

discomfort

offood

and

to be ingested

distension

associated

feeding

ad

libitum,

and

even

at lower

intakes

they

gain

applies

in humans

an earlier

In

study

head

and

ministration oxygen feeding

the

neck

every

surgery,

patients

were

2 h during

nasogastric

fed for 5 d after

the

day

feeding only

resulted

by bolus

ad-

Am J C/in Nutr

patients 1990;52:

complained 1 107-12.

Printed

of abdominal in USA.

underwent

only.

the abdomi-

major

surgery

for

malig-

and larynx consented weighed the day before (biceps,

to sur-

triceps,

and

hand

and

(16).

nutrient

from

grip

intakes

food tables(l

Liverpool

strength

A dietary

Hospital

were

sub-

measured

history

for

the

was

week

Ethical

on

taken

before

7). The project

and

surgery

was approved

Committee.

regimen were given Clinifeed-iso UK) via a conventional

serted

during

the

pump

(Clinifeeding

operation

Pump

and

by

2, Watson

(Roussell Laboratories nasogastric tube inuse

of an

Marlow

enteral

Ltd.

feeding

Falmouth,

I

From

the University

Departments

ofAnaesthesia,

Otolaryngology,

and Dietetics, Royal Liverpool Hospital, Liverpool; the Department of Physiology and Pharmacology, University of Nottingham; and the Department of Clinical Chemistry, St lames’s University Hospital, Leeds 9, UK.

Supported

by Roussel

Laboratories,

Uxbridge,

UK.

Address reprint requests to IT Campbell, University of Anaesthesia, University Hospital of South Manchester, Withington, Manchester, M20 8LR, UK. ReceivedAugust 11, 1989. Accepted for publication January 17, 1990.

in a lower

discomfort

© 1990 American

at night

in that

measurements

arm

3

consumption and better nitrogen balance than did the same quantity continuously for 24 h (I 3). However,

bolus-fed

consumption

infusion

advantages

All patients Ltd, Uxbridge,

2

major

oxygen

urinary catecholamine for 24 h were compared

the

(7-12).

in which

Royal

Feeding

fed ad libitum. This is usually associated with a higher rate of urinary nitrogen excretion and a smaller lean body mass (3-6). There is some evidence that the same

energy

by the

in-

as animals

weight

who

circumference

were estimated

serting intermittent boluses down a wide-bore feeding tube (1, 2). Feeding patterns, however, are known to affect metabolism, and in animals it is well established that an intermittent feeding pattern is metabolically more efficient than is feeding ad libitum. Animals tube fed or fed intermittently have a greater increase in body fat for a given energy intake than do animals same

patients

nondominant

daily

without with

on

by continuous

has potential

Skinfold-thickness

the

feeding patients engravity or a pump.

by use ofeither

to do so continuously

offeeding only

effects

balance, and enteral feeding

scapular, and suprailiac) were made with Harpenden skinfold calipers (British Indicators, Ltd, Luton, UK) (14). Total body fat was calculated from the equations of Durnin and Womersley (I 5), appropriate to the patients’ age and sex. Midarm

It is now

the

disease of the buccopharnynx part in the study. They were

nant

Introduction

terally

study

of being

pump.

Subjects

take

Continuous feeding, night oxygen consumption, nitrogen

present

for 24 h complained

by the enteral

Methods

energy

for 24 h, but is associated differences may be mcdi-

mechanisms.

the

bedside

nal discomfort associated with bolus feeding is avoided; an intermittent pattern is used, which may be more energy efficient; and the patient is free to be up and about during the day.

night,

Postoperatively,

In

.

fed continuously

to their

(VO2), urinary nitrogen excretion ofcontinuous

group

tients.

the patients

“tethered”

Society

for Clinical

Nutrition

Department Nell Lane,

1 107

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/6/1107/4651155 by University of Glasgow user on 09 September 2018

Comparison of the metabolic effects of continuous postoperative enteral feeding and feeding at night on1y13

1 108

CAMPBELL

TABLE

I

ET

AL

TABLE

Anthropometric

details

of24-h-fed

and night-fed

groups5

24-hfed 57±4 173.2 ± 2. 1 60.3 ± 4.2 47.2 ± 2.9 12.5±1.8 26.9 ± I .0 36.9 ± 3.2

(cm) (kg)

fed

60±2 169.9 ± 3.4 60.8 ± 6.5 46.6 ± 3.8 13.6±1.7 27.3 ± 1.6 36.67 ± 3.1

5i±SEM.

UK). Patients were randomly assigned into two groups of nine patients each. One group was fed continuously for 24 h (24-hfed group), the other was fed by continuous infusion at night only

(night-fed

group),

ic, from

1700

to 0900

the

next

day.

Feeding was started the morning after surgery when the presence of bowel sounds had been confirmed. All patients were given a total of 1 125 mL (three cans) of enteral feed (4. 18 kJ/ mL) for a total of 4.7 MJ on day 1 and on days 2-5 were fed 2400 mL ( 10 MJ)/d. Feeding

was

started

at 0900

in the

1700 in the night-fed group. menced at a rate of 25 mL/h.

In both

gradually

increments

increased

The

by 25-mL

always

completed

Oxygen

consumption

within

group feeding

rate

or 16 h, respectively. From the morning group was given enteral feed at a rate fed group was fed at a rate of 150 mL/h the next morning. The night-fed group fluids during the day. The enteral pumps were accurate to nal rate ofadministration when tested ing was

24-h-fed instances

and

of administration over

at

com-

was

the ensuing

24

of day 2 the 24-h-fed of 100 mL/h; the nightbetween 1700 and 0900 was allowed only clear

oftumor burden by the method ofthe Center Cancer(UICC)(20) in patients

24-h fed

Night fed

T1 T2 T3 T4 T

1 1 1 2 2

1 0 3 3 2

N0 N1 N2 N3 N1

1 2

1 3

3 0 1

3 0 2

One patient noma;

1 h ofthe

stated

nomiFeed-

times.

Urinary

tients into

were the

spirometer

cheostomy ments

still

they

cheostomy

being

fed.

via a face

done

during

were

attached

measured with a Benedict PK Morgan, Chatham, 0800 and 0900 and every ( I 600- 1700) for 5 d after was measured in the afterthe morning while the pa-

Preoperatively, mask.

surgery

and

to the

All the

patients patients

for postoperative

spirometer

via their

breathed had

measurecuffed

tra-

tube.

2

Average

daily energy

and nutrient

intakes

for 1 wk before

24-h fed Energy(MJ)

5i±SEM.

adenocystic

carci-

and cat echolamines

Biochemical

monitoring

Venous

blood

was taken with

daily

routine

between

practice,

0800

and 0900,

a number

and

of biochemical

indices (eg, alanine amino transferase, -y-glutamyl transferase, alkaline phosphatase, and inorganic phosphate) were monitored by use of a multichannel analyzer (Technicon, SMAC, UK).

Venous

blood

was

also

analyzed

for cortisol

by use of a solid-phase radioimmunoassay (Becton Dickinson Immuno Diagnostics, Oxford, UK), insulin by use of a radioimmunoassay (Amersham International, Amersham, UK), and glucose by use ofa glucose oxidase technique. St atistical

analysis

Statistical

comparisons analysis

between of variance

the two groups (ANOVA)

(19).

were

made

When

AN-

OVA showed a significant difference between the groups, Student’s t test was used to determine differences at specific times. Student’s t test was used to determine differences at specific times within groups.

Results

TABLE

Fat (%) Carbohydrate Protein(%) Alcohol (%)

and another

not be classified.

Twenty-four-hour urine collection was started at 0900 the day after surgery and was continued for 5 d. Urine was collected into sulphuric acid and analyzed for nitrogen concentration by the micro Kjeldahl technique and for epinephrine, norepinephrine, and dopamine concentrations by high-performance liquid chromatography with electrochemical detection (18).

by two-way

a tra-

they could

nitrogen

Basingstoke,

Resting oxygen consumption was Roth Spirometer (Mark II Spirometer, UK) on the day of surgery between morning (0800-0900) and afternoon surgery. In the night-fed group VO2 noon before feeding started and in

had adenocarcinoma

therefore,

in accordance

within 10% ofthe in the laboratory.

Union with squamous

9.3±

(%)

1.0

36. 1 ± 2.4 42.0 ± 1.6 14.4±0.7 7.3 ± 3. 1

study5

Subjects

Night

fed

8.6±

35.5 42.0 14.1± 9.5

1.2 ± ±

±

2.7 2.9 1.3 5.0

Personal details of the two groups of patients are given in Table 1; antecedent nutrient and energy intakes are given in Table 2. There were no differences between the groups in height, weight, body fat, arm circumference, hand grip, or previous

energy

All patients

and

nutrient

except

intakes.

for two

mous cell carcinoma. For classified by the International

in the

these

24-h-fed

group

had

squa-

patients, tumor burden was Union Against Cancer (UICC)

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/6/1107/4651155 by University of Glasgow user on 09 September 2018

Age(y) Height (cm) Weight (kg) Fat-free mass (kg) Totalbodyfat(kg) Midarm circumference Hand-grip dynamometry

Night

3

Classification International cell carcinoma

24-H

AND -

250-

.-.-

NIGHT FED

24hr NTD

FEEDING

1 109

POSTOPERATIVELY

n-8 n-6

12

I z

8 200-

8

1 C,

6-’ --..

S

4AM PM DAY I

PREOP

AM PP.1 DAY 2

MI PM DAY 3

AM PM DAY 4

AM PM DAY 5

5*

FED

NIGHT p