Nutritional Support: Timing (Early versus Delayed Enteral Feedings)

Published 2003
Citation: J Trauma. 57(3):660-679, September 2004.

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I. Statement of the Problem

Over the past two decades, the impact of nutrition support on critically injured patients has received significant attention with research focusing on the importance of route and type of nutrition, timing of nutrition, severity of injury, and clinical outcome. Comparative studies in laboratory animals have documented improved outcomes associated with early enteral feeding (2 hours post-injury) compared with feedings initiated at 72 hours post-injury. With the diverse patient populations of blunt and penetrating torso trauma, severe burns, and head injuries, the metabolic and clinical effects of nutritional support are significantly different. This document summarizes published data and makes recommendations regarding the relative advantages and disadvantages of early enteral feeding in these diverse populations.

II. Process

A. Identification of References

References were identified from a computerized search of the National Library of Medicine for English language citations between 1983 and 2000. We reviewed only articles that attempted to use specialized nutritional support as early as possible following injury and analyzed the data for clinical success with the therapies. The bibliographies of the selected references were reviewed for relevant articles not found in the computerized search. Literature reviews, case reports, and editorials were excluded. Twenty-five articles were identified.

B. Quality of the References

The quality assessment instrument applied to the references was developed by the Brain Trauma Foundation and subsequently adopted by the EAST Practice Management Guidelines Committee. Articles were classified as Class I, II, or III according to the following definitions:

Class I: A prospective, randomized clinical trial. Thirteen articles were chosen and analyzed.

Class II: A prospective, non-comparative clinical study or a retrospective analysis based on reliable data. Eight articles were chosen and analyzed.

Class III: A retrospective case series or database review. Two articles were chosen and analyzed.

III. Recommendations

A. Level I

In severely injured blunt/penetrating trauma patients, there appears to be no outcome advantage to initiating enteral feedings within 24 hours of admission as compared to 72 hours after admission.

B. Level II

  1. In burn patients, intragastric feedings should be started as soon after admission as possible, since delayed enteral feeding (>18 hours) results in a high rate of gastroparesis and need for intravenous nutrition.
  2. Patients with severe head injury who do not tolerate gastric feedings within 48 hours of injury should be switched to postpyloric feedings, ideally beyond the ligament of Treitz, if feasible and safe for the patient.

C. Level III

  1. Patients who are incompletely resuscitated should not have direct small bowel feedings instituted due to the risk of gastrointestinal intolerance and possible intestinal necrosis.
  2. In patients undergoing laparotomy for blunt and penetrating abdominal injuries, direct small bowel access should be obtained (via nasojejunal feeding tube, gastrojejunal feeding tube, or feeding jejunostomy) and enteral feedings begun as soon as is feasible following resuscitation from shock.

IV. Scientific Foundation

Several clinical trials have attempted to examine whether the benefit of “early” enteral feeding documented in the research laboratory extends into the clinical arena. Unfortunately, as is seen in the accompanying evidentiary tables, there is no consensus as to what is meant by “early”, ranging between 4 and 72 hours post-admission. In contrast, animal data demonstrating the superiority of an early enteral strategy initiated feeding within 2 hours of injury.[1]Furthermore, very few of the clinical trials actually compare “early” enteral with “late” enteral feeding, the majority comparing early enteral feeding and TPN. Because the impact of an early enteral strategy may vary depending on the specific injury type, three specific trauma patient subsets (blunt/penetrating torso, burn, head injury) are examined in this section.

Only one prospective randomized study in blunt/penetrating trauma patients has actually compared early and late enteral feeding, finding no metabolic or clinical advantage to early enteral feeding.[2]However, as the authors acknowledge, it may be that initiating enteral feeding at 39 hours post-injury was not early enough to demonstrate this advantage, or perhaps the metabolic advantages are not demonstrable until after the 10-day study period employed in this study. Regardless, the findings from this report are important for two reasons. First, it is unlikely, in this patient population, that enteral feeding can be consistently initiated much earlier than the 39 hours post-injury achieved by these authors, given their very aggressive approach to post-pyloric enteral access. Second, despite the small number of patients in this study, no clinical outcome advantage could be ascribed to initiating enteral feeding within 30 hours of admission compared with 80 hours from admission. Thus, in this particular patient population, there is no literature support for early enteral feeding, at least as defined by these authors.

One recent study[3] randomized multisystem trauma patients (ISS >25, GCS score =12) to early (< 6 hours after resuscitation from shock) or late (=24 hours after resuscitation from shock) gastric feeding using the same enteral diet for both groups. Parenteral feeding was provided to both groups to meet caloric demands. Within 4 days, the early fed group tolerated significantly more enteral feeding than the late-fed group, and by the end of 1 week, they were receiving 80% of their enteral feeding compared with 61% in the late-fed group (p <0.025). The early-fed group sustained significantly fewer incidents of late multiple organ dysfunction, but ICU length of stay, and duration of mechanical ventilation was similar between the two groups. The use of TPN in this study, and the use of shock resolution as a criterion for initiation of enteral feeding, makes the results of this trial difficult to compare to those of Eyer referred to above.[2] However, the two studies taken together would seem to raise serious questions regarding the significance of early enteral feeding, even if feedings are initiated as early as 6 hours following resuscitation.

The remainder of the prospective, randomized trials of blunt and penetrating trauma has been limited to patients with direct small bowel access obtained at the time of surgery. Moore et al.[4] randomized patients to either needle catheter jejunostomy feedings with a chemically defined diet started 18-24 hours postoperatively or to no early enteral nutrition and demonstrated a significant reduction in septic complications, primarily intra-abdominal abscesses. Patients were limited to an ATI between 15 and 40 because of previous work[5] [6] which demonstrated decreased gastrointestinal tolerance in patients with an ATI >40 or direct viscus injury. In this study, enteral feedings were administered to a goal rate within 72 hours, which limited successful advancement in the more severely injured. A second study of early enteral feeding versus TPN[7] confirmed a reduction in septic complications (primarily pneumonia with a trend toward reduced intra-abdominal abscesses) in a similar population with mild to moderately severe injuries. In another study recruiting patients with moderately severe injuries (i.e., ATI 18-40 or ISS 16-45),[8] diets were started within 24 hours and advanced to goal by 72 hours with gastrointestinal intolerance in approximately 26% of patients but interruption or discontinuation in only 13.5% of study patients.

A randomized, prospective study of enteral feeding via jejunostomy versus parenteral feeding demonstrated a significant reduction in intra-abdominal abscesses and pneumonia in moderate to very severely injured patients receiving enteral nutrition.[9] Four percent of enterally fed patients failed enteral feedings (defined as 50% of nutrient goal by 1 week) because of severity of injury. As a result, parenterally fed patients received more nutrition than the enterally fed population. Benefits of enteral feeding were only noted in patients sustaining an ATI >24 or an ISS >20. Feedings were successfully started within 24 hours in both groups. A subsequent study randomized severely injured patients with an ATI >24 or an ISS >20 to one of two enteral diets.[10] Diets were started 1.5 to 2 days following surgery due to early hemodynamic instability in many of the patients. Gastrointestinal symptoms were common and occurred in 88% of enterally fed patients, which required slowing the feedings in 45%. The more severe the blunt and penetrating trauma to the torso in patients requiring laparotomy, the greater the intolerance to feeding, the longer the delay before institution of feeding, and slower rate of progression necessary to improve tolerance.

Intragastric feedings have been studied most closely in burn patients. In a population of pediatric patients with > 40% total body surface area (TBSA) burns, early intragastric feeding started soon after admission was highly successful.[11] This was duplicated in a larger population of pediatric patients with burns greater than 10%[12] TBSA, and confirmed again in a group sustaining 25% to 60% TBSA burn.[13] Although diarrhea occurred in 40%, early intragastric feeding following burn was well tolerated. In a population of patients with burns of 40% to 70% TBSA[14], intraduodenal feeding was started within 48 hours and was well tolerated. Fifty-five intubated, ventilated patients with burns of approximately 45% were started on intragastric feedings with gastric stimulatory agents.[15] When diets were started within 15 hours, goals were reached in 82% of patients within 72 hours, but when feedings were delayed to 18 hours or greater, the majority of patients failed. A study in patients with 35% TBSA burn of intra-duodenal feeding started within 48 hours also was well tolerated with rare episodes of distension, reflux, or diarrhea.[16] In a retrospective study of 106 patients with burns of 20% or greater,[17] tolerance of intragastric feedings was >90% in patients started within 6 hours of burn.

Success with enteral feeding of patients with severe head injuries is less encouraging. In two studies of patients with GCS scores between 4 and 10,[18] [19] patients randomized to intragastric feeding received <500-600 kcal/day over the first 2 days, < 800 cal/day on days 3-5, and <1,500 cal/day on days 6-8 due to gastroparesis. However, no attempts were made to feed patients until nasogastric drainage had dropped below 100 cc. Similar results were noted in 23 patients sustaining blunt and penetrating trauma to the head with GCS scores between 4 and 10.[20] Although feedings were not initiated unless nasogastric drainage was <200 cc per day and bowel sounds were present, only one-third of patients tolerated feedings within 7 days of injury, and 12 never tolerated feedings. Resolution of gastroparesis occurs on days 3 to 4 in many patients although it may occur sooner than the studies above since gastric emptying may occur despite higher nasogastric drainage and prior to return of bowel sounds.[21] In another study,[22] nasojejunal feedings approached nutrient needs within 3 days but did not approach nutrient goals until day 5 to day 7 in patients receiving intragastric feeding due to high gastric residuals. Similar delays were noted in a study of 48 evaluable head-injured patients.[23] Recently, 82 patients sustaining head injury were randomized to either intragastric feeding or to intestinal feeding using a pH sensor tube. All patients required mechanical ventilation on the first day of hospitalization, had a GCS score >3, and had at least one reactive pupil. Intestinal tube placement was confirmed by abdominal radiography. Patients receiving the small intestinal tube had a higher percentage of energy and nitrogen administration during the study. Within 3 days of injury, the intestinal-fed patients achieved 70% of their nutrient goal and by 6 days achieved 90% of their nutrient requirements. Intragastric-fed patients achieved 30% of nutrient goals by day 3 and 55% by day 6. The intestinally fed patients sustained fewer complications and had an associated reduction in acute-phase protein production.[24] The Cochrane Library has recently summarized the available data concerning the timing of nutritional support in head-injured patients.[25]

V. Summary

Direct small bowel access is necessary to successfully feed patients via the gastrointestinal tract who have sustained severe blunt and penetrating torso and abdominal injuries as well as severe head injuries. Intragastric feeding becomes successful in the majority of head-injured patients at approximately day 3 or 4, at the earliest, due to gastroparesis. Small bowel feedings are tolerated in this patient population with small bowel access. In patients with penetrating and blunt injuries to the abdomen who have small bowel access, enteral feeding can be instituted in most patients after resuscitation is complete and hemodynamic stability has been gained. Advancement to goal rate is slower in patients with higher ATI scores, in particular if ATI >40. In addition, gastrointestinal injury below the site of access may slow advancement of tube feedings but is not a contraindication to direct small bowel feedings. Intragastric feeding in patients with severe burns should be instituted as soon as possible during resuscitation to prevent or minimize the onset of gastroparesis that appears to occur with increasing incidence if feedings are delayed, particularly if delayed beyond 18 hours. In all patient populations, total parenteral nutrition can be instituted soon after injury, ideally after hemodynamic stability has been gained and resuscitation is complete.

VI. Future Investigation

Several obstacles limit the successful use of early enteral nutrition. First, access to suitable sites in the gastrointestinal tract for the delivery of nutrition support requires clinical vigilance and planning. Although many patients can be successfully fed intragastrically, critical illness and critical injury often mandate placement of the tube beyond the ligament of Treitz. Unless access is obtained at the time of celiotomy, methods to successfully advance tubes beyond the ligament of Treitz are limited, and further research for solutions to this problem is warranted. Methods are needed to recognize dislodgment into the stomach and to keep the tube beyond the ligament of Treitz, particularly those advanced through the stomach. Second, protocols or markers which promote successful, safe advancement of feeding rate are needed, especially markers which identify patients who will be intolerant of enteral feeding due to distension, bloating, diarrhea, and the rare complication of intestinal necrosis. Third, development of pharmacologic or nonpharmacologic means to reverse or eliminate gastroparesis or ileus may minimize progressive calorie deficits and maximize the benefits of early enteral delivery of nutrients. Finally, authors do not agree about what constitutes “early” or “delayed” enteral feeding. In some studies, early is defined in hours, and in others, it is defined in terms of days. Until there is consensus regarding these definitions, it is impossible to determine whether the theoretic benefits ascribed to early enteral feeding truly outweigh the additional effort and potential complications associated with this approach to nutritional support. Well designed, prospective, randomized studies, employing a precise definition of early feeding, together with clinically relevant outcome parameters (morbidity, infectious morbidity, neurologic outcome, etc.) in a well-defined patient population (burns, head injury, or torso trauma) are needed to adequately resolve this important issue.

References

  1. Mochizuki H, Trocki O, Dominioni L, et al: Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann Surg 200:297, 1984.
  2. Eyer SD, Micon LT, Konstantinides FN, et al. Early enteral feeding does not attenuate metabolic response after blunt trauma. J Trauma. 1993;34:639-644.
  3. Kompan L, Kremzar B, Gadzijev E, Prosek M. Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury. Intensive Care Med 1999;25:157-161.
  4. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma: a prospective, randomized study. J Trauma. 1986;26:874-881.
  5. Moore EE, Dunn EL, Jones TN. Immediate jejunostomy feeding. Its use after major abdominal trauma. Arch Surg. 1981;116:681-684.
  6. Jones TN, Moore FA, Moore EE, McCloskey BL. Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal trauma: a critical analysis. Crit Care Med.1989;17:1146-1150.
  7. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma: reduced septic morbidity. J Trauma. 1989;29:916-923.
  8. Moore FA, Moore EE, Kudsk KA, et al. Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding. J Trauma. 1994;37:607-615.
  9. Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503-513.
  10. Kudsk KA, Minard G, Croce MA, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg.1996;224:531-543.
  11. Alexander JW, MacMillan BG, Stinnet JD, et al. Beneficial effects of aggressive protein feeding in severely burned children. Ann Surg. 1980;192:505-517.
  12. Gottschlich MM, Jenkins M, Warden GD, et al. Differential effects of three enteral dietary regimens on selected outcome variables in burn patients. J Parenter Enteral Nutr. 1990;14:225-236.
  13. Chiarelli A, Enzi G, Casadei A, Baggio B, Valerio A, Mazzoleni F. Very early nutrition supplementation in burned patients. Am J Clin Nutr. 1990;51:1035-1039.
  14. McArdle AH, Palmason C, Brown RA, Brown HC, Williams HB. Early enteral feeding of patients with major burns: prevention of catabolism. Ann Plastic Surg. 1984;13:396-401.
  15. Raff T, Hartmann B, Germann G. Early intragastric feeding of seriously burned and long-term ventilated patients: a review of 55 patients. Burns. 1997;23:19-25.
  16. Saffle JR, Wiebke G, Jennings K, Morris SE, Barton RG. A randomized trial of immune-enhancing enteral nutrition in burn patients. J Trauma. 1997;42:793-802.
  17. McDonald WS, Sharp CW Jr, Deitch EA: Immediate enteral feeding in burn patients is safe and effective. Ann Surg. 1991;213:177-183.
  18. Rapp RP, Young B, Twyman D, et al. The favorable effect of early parenteral feeding on survival in head injured patients. J Neurosurg. 1983;58:906-912.
  19. Young B, Ott L, Twyman D, et al. The effect of nutritional support on outcome from severe head injury. J Neurosurg. 1987;67:668-676.
  20. Norton JA, Ott LG, McClain C, et al. Intolerance to enteral feeding in the brain-injured patient. J Neurosurg. 1988;68:62-66.
  21. Hadley MN, Grahm TW, Harrington T, Schiller WR, McDermott MK, Posillico DB. Nutritional support in neurotrauma: A critical review of early nutrition in forty-five acute head injury patients.Neurosurgery. 1986;19:367-373.
  22. Grahm TW, Zadrozny DB, Harrington T. The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery. 1989;25:729-735.
  23. Borzotta AP, Pennings J, Papasadero B, et al. Enteral versus parenteral nutrition after severe closed head injury. J Trauma. 1994;37:459-468.
  24. Taylor, SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999; 27:2525-2531.
  25. Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. - Nutritional support for head-injured patients. [Review] Cochrane Database of Systematic Reviews [computer file] 2000;(2):CD001530.

Tables

Early versus Delayed Enteral Feedings Evidentiary Tables

Table 1. Blunt/Penetrating Trauma

First AuthorYearClassConclusions

Moore EE [4]

1986

I

63 patients with ATI >15 prospectively randomized to IV fluids (TPN added at day 5 if still NPO) or enteral feedings started at 12 to 18 hours postoperatively and advanced to goal by 72 hours. 12% of enteral patients switched to TPN versus 29% of controls. Postoperative infections: control 29% versus enteral 9%, p<0.05. Enteral failures: ATI >40. Conclusions: Enteral feeding feasible, reduces septic complications and costs, less well tolerated with ATI >40 if feeding rate advanced aggressively.

Moore FA [7]

1989

I

59 evaluable patients with ATI >15 and <40 prospectively randomized to TPN or jejunal feedings starting 12 hours postoperatively and advanced to goal rate by 72 hours. Major infectious complications 3% with enteral versus 20% with TPN, p<0.03. Conclusions: Enteral feedings are well tolerated and reduce serious infectious complications.

Kudsk [9]

1992

I

96 evaluable patients with ATI >15 prospectively randomized to enteral feeding started 24 hours postoperatively or TPN started 22.9 hours postoperatively and advanced as tolerated. Two patients failed enteral feeding; TPN patients received more nutrition over the hospital course. Significantly lower pneumonia and abscess rates with enteral feeding; most benefit in patients with more severe injuries (ATI >25, ISS >20). More diarrhea with enteral feeding. Conclusion: Nearly all patients received successful enteral feeding when advanced at slower rate as tolerated, even with high ATI, high ISS, and gut injury.

Eyer [2]

 

1993

 

I

 

38 blunt trauma victims randomized to early (target < 24 hours) or late (target > 72 hours) enteral feeding. No differences were noted between the groups at days 5 and 10 with regard to urinary nitrogen levels or serum levels of epinephrine, nor­epinephrine, dopamine, or cortisol. Furthermore, no outcome differences were noted with respect to ICU length of stay, ventilator days, organ system failure, specific infections or mortality. Despite attempt to initiate feedings within 24 hours of injury, mean time from injury to feeding (early group) was 39 hours, perhaps not early enough to demonstrate a beneficial effect. Overall infectious morbidity was higher in the early group

Moore FA [8]

1994

I

96 evaluable patients with ATI 18-40 or ISS 16-45 randomized to supplemented diet or standard diet started within 24 hours and advanced to goal by 72 hours. Gastrointestinal intolerance of 22% in supplemented diets versus 30% in standard (overall 26%) requiring interruption or discontinuation in 13.5%. Fewer intra-abdominal abscesses and less organ failure with supplemented diet. One bowel necrosis possibly related. Conclusion: Patients with moderate degree of injury tolerated gastrointestinal feedings started within 24 hours of injury with rapid advancement.

Kudsk [10]

1996

I

35 high-risk patients with ATI >25 or ISS >20 included. If enteral access obtained at laparotomy, patients randomized to supplemented diet or isonitrogenous diet starting 1.63 and 1.97 days after operation, respectively, and advanced as tolerated. Third group without enteral access followed prospectively. Gastrointestinal symptoms (distension, diarrhea, or cramps) in 88% of enterally fed patients, requiring slowing of feedings in 45% of patients. Major infection rate highest in unfed group and lowest with supplemented diet. Conclusions: Increased intolerance in most severely injured patients; however, septic morbidity reduced compared with unfed group. “Early” is later as severity of injury increases.

Kompan [3]

 

1999

 

I

 

28 patients were randomized to early (<6 hours after shock resuscitation) or late (‡24 hours following resuscitation) gastric feeding, and parenteral nutrition was used to supplement nutrient needs. The early-fed group tolerated significantly greater volumes of enteral feeding by day 4 and reached 80% of their calculated nutrient goals by the end of the first week. The late-fed group only achieved 61% of their enteral goal by 1 week. Early patients had lower late (days 4-14) MOF scores compared with late patients. Intestinal permeability measured by the lactulose/mannitol ratio was greater in the late group compared with the normal controls. On day 2, lactulose/mannitol ratios correlated with late MOF scores and with liver failure. Day 4 lactulose/mannitol ratios correlated with ISS from time of injury to initiation of enteral feeding. Conclusion: Multiply-injured patients started on early intrgastric feeding following resuscitation from shock are more rapidly advanced to nutrient goals than patients whose feedings are delayed for more than 24 hours. The early enteral feeding patients sustained much less late MOF and maintained normal gut integrity.

Moore EE [5]

1981

II

30 patients with two or more organs injured received jejunostomy feedings started 18 hours postoperatively. All patients advanced to 2.4 L/day at full strength within 72 hours but slowed in three patients. Conclusion: No evidence of pancreatic stimulation with pancreatic injuries.

Jones [6]

1989

II

123 patients (71 enterally fed with jejunostomy, 52 controls given TPN or IV fluids) followed for gastrointestinal symptoms. Feeding started 12 hours postoperatively. Gastrointestinal complaints in 50% of control patients and 83% of enterally-fed patients. Moderate to severe complaints in 12% of control versus 51% of enterally-fed. Risk factors for intolerance of enteral feedings: 1) ATI >40 (45% symptomatic), 2) gunshot wounds (73% symptomatic), 3) gut injury (82% symptomatic). Nine patients converted to TPN. Conclusion: Advance enteral feedings slower in high-risk patients.

ATI, abdominal trauma index; IV, intravenous; TPN, total parenteral nutrition, NPO, nothing by mouth; ISS, injury severity score, ICU, intensive care unit; MOF, multiple organ failure

 

Early versus Delayed Enteral Feedings Evidentiary Tables

Table 2. Burns

First AuthorYearData ClassSubject TypeConclusions

Alexander [11]

1980

I

Children

22 children with burns >40% (with four early deaths) randomized to an enteral high-protein or standard-protein diet with IV-TPN supplementation and diet. 60% to 70% of intake successful via the gastrointestinal tract. Standard-protein diet group received 14% of caloric intake as IV-TPN versus 6% in high-protein group. Conclusions: Fewer bacteremic days, better immunologic and serum protein values, and better survival in high-protein group. The gastrointestinal tract usable in severely burned patients.

Gottschlich [12]

1990

I

Human

50 patients with burns >10% randomized to intragastric feeding via tube with standard diet (n=14, 38.3% TBSA burn, age 15.1 years), supplemented diet (n=17, 45.0% TBSA burn, age 21.3 years), or stress diet (n=19, 38.6% TBSA burn, age 21.3 years). Feedings started soon after burn (Group 1: 2.3 days; Group 2: 1.1 days; Group 3: 1.9 days post-admission). 3, 5 and 2 patients needed TPN supplementation in Group 1, Group 2, and Group 3, respectively. Diarrhea occurred in 40% of patients overall. Significant reduction in LOS/percent body burn and wound infections in Group 2 with trend toward higher mortality in Group 3. Conclusion: Burned patients tolerated early intragastric feeding.

Saffle J[16]

1997

I

Human

50 patients (49 completed the study) randomized to enteral supplemented diet (n=25, age 35.0 years, TBSA burn 35.4%) or standard high protein diet (n=24, age 38 years, TBSA burn 34.7%) fed intraduodenally within 48 hours of burn and advanced by 25 mL every 4 hours to goal. Discontinuation or reduced rate rare due to distension, reflux, diarrhea. Conclusion: No differences in outcome but successful feeding rates high. Discussion – Majority of patients had feedings initiated within 12 hours of burn.

McArdle [14]

 

1984

 

II

 

Human

 

12 patients with TBSA burns of 40% to 70% (second and third degree) fed via intraduodenal tube with semi-elemental diet. 6/12 fed within 48

hours of burn. No distension or diarrhea and positive nitrogen balance at 9.8 days. Conclusion: Early enteral feeding well tolerated when started within 48 hours of burn.

Chiarelli [13]

1990

II

Human adult

20 patients with 25% to 60% TBSA burn started on intragastric feeding of blenderized diet 4.4 hours after burn (n=10, average burn 38 %) or 57.7 hours postburn (n=10, average burn 38.5%). Probability of survival 0.71 versus 0.74, respectively). Urinary catecholamine and glucagon levels lower in first 2 weeks in early fed group. Conclusion: Early intragastric feedings well tolerated after severe burn.

McDonald [17]

1991

III

Human

Retrospective study of 106 patients with >20% TBSA burn started on intragastric bolus feedings within 6 hours of burn. Tolerance of feeding by day: day 1: 82%; day 2: 90%, day 3: 92%, day 4: 95%. Vomiting occurred in 15 % of patients. Patients age <12 years exceeded goal by day 3 and patients >12 years by day 4. Conclusion: Immediate intragastric enteral feeding safe and effective after major burns.

Raff [15]

1997

III

Human

Retrospective review of 55 intubated, ventilated patients (>5 days) with TBSA burn of 44.2% (35.0 % third degree) and ABSI >7 (average 9.1) intragastrically fed with commercial, supplemented diet. Cisapride given via nasogastric tube TID and metoclopramide given IV TID. Diet started 15.3 hours post burn. 45 patients (81.8%) reached nutritional goal within 72 hours. Five (9.1%) tolerated but missed their goal, and five failed entirely. Only 4/48 patients who started feedings within 18 hours failed, while 6/7 who started after 18 hours failed with no significant difference in percent burn, ABSI, or age between success and failure groups. There was increased mortality with feeding failure. Conclusion: Early feeding is successful and should be started within 18 hours of burn.

IV, intravenous; TPN, total parenteral nutrition; TBSA, total body surface area; LOS, length of stay; ABSI, abbreviated burn severity index; TID, three times a day

 

Early versus Delayed Enteral Feedings Evidentiary Tables

Table 3. Head Injury

First AuthorYearClassConclusions

Rapp [18]

1983

I

38 patients with blunt/penetrating head injury randomized within 48 hours to TPN (n=20, age 29.2 years, GCS score 7.7) or intragastric feeding (n=18, age 34.9 years, GCS 7.2) with defined formula diet. Enteral caloric intake <400 cal/day for first day, <600 cal/day for first 10 days, and <900 cal/day for 14 days due to delayed gastric emptying. Eight of 18 gastrically fed patients died within 18 days compared with 0 TPN patients. Conclusion: Prolonged gastroparesis occurs with intragastric feeding post severe head injury.

Hadley [21]

1986

I

45 head-injured patients with GCS score <10 randomized to intragastric (n=21, GCS score 5.9) feeding with standard commercial diet or TPN (n=24, GCS score 5.8). Enteral patients achieved positive caloric balance (140% of BMR) in 5% on day 2, 45% on day 3, 70% on day 4, between 70% and 85% by day 11. TPN achieved >80% by day 5 and 100% by day 9. Complication and infectious rates were similar. Conclusion: Use TPN only when gastrointestinal tract fails to work. Editorial: Gastroparesis begins to resolve on day 3to 4. Don’t wait for nasogastric drainage to drop or bowel sounds to occur.

Young [19]

1987

I

51 evaluable of 58 consented patients with GCS score 4-10 after blunt or penetrating head wounds randomized to TPN (n=23, age 30.3 years, GCS score 7.0) or intragastric feedings (n=38, age 34.0 years, GCS score 6.5) after bowel sounds return and nasogastric drainage dropped below 100 cc. Enteral patients received <500 cal/day for days 1-2 (versus 1221 kcal in TPN group), <800 cal/day for days 3-5 (versus 2367 kcal TPN group), <1500 cal/day for days 6-8 (versus 2350 kcal in TPN group) due to gastroparesis. Infectious complications were the same, and neurologic outcomes were similar at 1 year. Conclusion: Prolonged gastroparesis occurs after severe head injury.

Grahm [22]

 

1989

 

I

 

22 patients with blunt/penetrating wounds and GCS score <10 randomized (by admission day) to nasojejunal feeding started at goal rate by 36 hours (age 25.5 years, GCS score 5.1) or intragastric feedings after day 3 if gastrointestinal function returned (age 27.8 years, GCS score 7.1). Caloric intake matched measured needs by day 3 with jejunal tube and approached 75% of needs on day 5-7. With intragastric feedings, significantly fewer bacterial infections (bronchitis: 3-4 plus WBC in sputum with positive cultures) than with jejunal feedings. Conclusions: Goal rates achieved faster with small bowel access. Gastric residuals limit intragastric feeding rate. No change in metabolic rate by indirect calorimetry.

Borzotta [23]

1994

I

48 evaluable, head-injured patients (GCS score <8) randomized to TPN (n=21, age 28.9 years, ISS 33.4, GCS score 5.4) or enteral feeding via surgically placed jejunostomies (n=27, age 26.2 years, ISS 32.5, GCS score 5.2) and started within 72 hours of injury. All TPN patients had initial attempts with intragastric feeding (and presumably failed). TPN transition to intragastric feedings started on day 5. Diarrhea was more common in TPN patients. High rate of nasogastric tube dislodgement. Enteral delivered calories equaled 90.5% of measured resting expenditure by indirect calorimetry by day 3. Conclusion: With direct small bowel access, nearly achieved calculated goal by day 3 (and subsequently over) with little intolerance.

Norton [20]

1988

II

23 patients with blunt/penetrating head injury and GCS score 4-10 (average 6.6) followed for enteral tolerance. Feedings started when drainage <200 cc/day and bowel sounds present. Seven patients tolerated feedings within 7 days, 4 between 7 and10 days, and 12 never tolerated feeds with trend toward greater intolerance with lower GCS. Tolerance did not correlate with bowel sounds. Conclusion: Gastroparesis occurs in most patients with severe head injury.

Taylor [24]

1999

II

82 patients receiving the same tube feeding were randomized to either intestinal feeding using a pH-directed tube and started at goal rate or to intragastric feeding at 15 cc/hour with gradual advancement as tolerated. Patients receiving the intestinal feeding advanced to their goal rate significantly faster than patients fed intragastrically. By the fourth post-injury day, these patients received >70% of their nutrient requirements (compared with 40% in the intragastrically-fed group) and by day 6 received > 90% of their calculated requirements (compared with 55% in the intragastrically-fed group). Patients were similar with respect to GCS score, APACHE II score, CT scan results, and age. Their neurologic outcomes at 6 months were similar with a trend toward better 3-month outcomes in the group fed into the intestine. Infectious morbidity was significantly less in the intestinal-fed group.

Yanagawa [25]

 

2000

 

III

 

Review of 12 randomized, controlled trials with regard to timing or route of nutritional support following acute traumatic brain injury. Authors conclude that early feeding may be associated with fewer infections with a trend toward improved survival and long-term disability. There was a trend toward better outcomes with parenteral nutrition (compared with enteral), but this observation may be related, in part, to the delay in starting enteral feedings due to associated gastric ileus. Overall the quality of the trials was poor, and the authors recommend larger trials with more relevant clinical endpoints.

TPN, total parenteral nutrition; GCS, Glasgow Coma Scale; BMR, basal metabolic rate; WBC, white blood cell;

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