ENTERAL NUTRITION AND ITS IMPACT ON
HOSPITAL LENGTH OF STAY
Scott Austin
Dietetic Intern
Sodexo Distance Dietetic Internship
1/27/2015
Learning Objectives
• Understand the differences involved with pre- and post
pyloric feeding routes
• Understand the effects of minimizing the duration of
postoperative fasting
• Understand the importance of glycemic specific formulas
Background
• Enteral Nutrition (EN) dates back 3500 years
• Einhorn – 1910
• Weighted rubber nasogastric tube
• Bolus feeding
• C.R. Jones – 1916
• Continuous feed
JADA, March 2002, Volume 102, Issue 3, Pages 399-404
Background
• Critical Patients
• Ebb Phase
• Typically 12-48 hours post-injury
• Characterized by
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 Cardiac output
 Respiratory rate
Tachycardia
Gut ileus
Flow Phase
 Acute Flow Phase
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Goals:
Identify highest risk patients
Estimate energy needs
Evaluate ability to tolerate
feedings
• Adaptive Flow Phase
 Goals:
 Repletion of body tissue
and micronutrient stores
 Maintain BW within 10% of
pre-injury weight if possible
Background
• Additional Immune Nutrients
• L-Arginine
• n-3’s
• L-glutamine
Debats IB, Wolfs TG, Gotoh T, Cleutjens JP, Peutz-Kootstra
CJ, van der Hulst RR. Role of arginine in superficial wound
healing in man. Nitric Oxide 2009;21:175–83.
The Research
• Optimal timing for the initiation of enteral and parenteral
nutrition in critical medical and surgical conditions
• A review paper
• Jose E. de Aguilar-Nascimento M.D., Ph.D., Alberto Bicudo-
Salomao M.D., M.S, Pedro E. Portari-Filho M.D., Ph.D.
Nutrition 28 (2012) 840–843
The Research – Optimal Timing
• Worldwide more than 90% of Physicians and Dietitians
strongly recommend the initiation of either EN or PN
within 24-48 hours after the patient is admitted to an ICU
• However in practice this is not the case
Cahill NE, Narasimhan S, Dhaliwal R, Heyland DK. Attitudes and beliefs related
to the Canadian critical care nutrition practice guidelines: an international
survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr
2010;34:685–96
The Research – Optimal Timing
• Modern guidelines endorse the initiation of EN regardless
of traditional parameters, such as the presence of bowel
sounds or flatus
• Underfeeding the critical or surgical patient is valid due to
gastrointestinal dismotility or hemodynamic conditions
The Research – Optimal Timing
• Withholding EN post GI resection
• Restart feeding once bowel movements appear
• Both elective and emergency surgeries
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•
•
Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal
surgery versus later commencement of feeding: a systematic review and metaanalysis. J Gastrointest Surg 2009;13:569–75.
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal
surgery versus later commencement of feeding for postoperative complications.
Cochrane Database Syst Rev; 2006 Oct 18:CD004080.
Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional post- operative
feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis.
JPEN J Parenter Enteral Nutr 2011;35:473–87.
The Research – Optimal Timing
• Post-operative EN is associated with a 45% reduction in
total complications when early feeding was prescribed.
• However….
The Research – Optimal Timing
• NGT reinsertion was more common
• No clear advantage of early EN with regard to:
• Mortality
• Length of Stay
Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional
post- operative feeding in patients undergoing resectional
gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral
Nutr 2011;35:473–87.
The Research – Optimal Timing
• Trauma patients:
• Meta-analysis of 3 RCT’s with n=126
• Early EN was associated with reduced mortality
Doig GS, Heighes PT, Simpson F, Sweetman EA. Early enteral nutrition
reduces mortality in trauma patients requiring intensive care: a meta- analysis
of randomised controlled trials. Injury 2011;42:50–6.
The Research
• Is duration of postoperative fasting associated
with infection and prolonged length of stay in
surgical patients?
• A prospective cohort study
Michelli Cristina Silva de Assis, Carla Rosane de Moraes Silveira, Mariur
Gomes Beghetto and Elza Daniel de Mello
Nutr Hosp. 2014;30(4):919-926 ISSN 0212-1611 • CODEN NUHOEQ
The Research – Duration of Postoperative
Fasting
• Methods:
• Included:
• Elective surgery patients
• Excluded:
• No nutritional assessment warranted
• <72 hour hospital stay

Results:
 n=521
 44.1% were fasted ≥1 day
 91% were fasted ≥ 3 days
 5.6% were fasted > 5 days
The Research – Duration of Postoperative
Fasting
• ≥ 1 day postoperative fasting
• Infection risk increased by 2.04
• ≥ 3 day postoperative fasting
• Infection risk increased by 2.81
• > 5 day postoperative fasting
• Infection risk increased by 2.88
 Prolonged
hospitalization risk:
• 2.4 times higher ≥ 1 day
• 4.44 times higher ≥ 3 day
• 4.43 times higher > 5 day
The Research – Duration of Postoperative
Fasting
• In summary,
• The longer the fasting period, the greater the risk for infection
• The longer the fasting period, the longer the length of stay
The Research
• Inadequate energy delivery during early critical illness
correlates with risk of mortality in patients who survive at
least seven days: A retrospective study
Jong-Rung Tsai, Wen-Tsan Chang, Chau-Chyun Sheu, Yu-Ju Wu, Yu-Heng
Sheu, Po-Len Liu, Chen-Guo Kerc, Meng-Chuan Huang
Clinical Nutrition 30 (2011) 209-214
The Research – Inadequate energy
delivery
• 295 patients retrospectively studied
• High and low energy delivery (ED)
• High and low protein delivery
• Mean daily intake ≥ 60% estimated needs or <60% estimated
needs
The Research – Inadequate energy
delivery
The Research – Inadequate energy
delivery
• In summary,
• No difference in Hospital or ICU LOS between the low and high
groups for either ED or PD.
Pichard C, Kreymann GK, Weimann A, Herrmann HJ, Schneider H. Early
energy supply decreases ICU and hospital mortality: a multicentre study in a
cohort of 1209 patients. Clin Nutr 2008;3(Suppl. 1):7.
The Research
• Severity of Illness Influences the Efficacy of Enteral
Feeding Route on Clinical Outcomes in Patients with
Critical Illness
Hsiu-Hua Huang, RD; Sue-Joan Chang, PhD; Chien-Wei Hsu, MD; Tzu-Ming
Chang, MD; Shiu-Ping Kang, RN; Ming-Yi Liu, RD
J Acad Nutr Diet. 2012;112:1138-1146.
The Research – Enteral Feeding Route
• GI motility and secretion are regulated by hormones such
as CCK
• Site of nutrient administration affects the magnitude of
gut-hormone secretion
Hypothesis – The magnitude of illness severity may
affect the efficacy of the enteral feeding route in
clinical outcomes
The Research – Enteral Feeding Route
• n = 101 (randomly assigned to NG or ND group)
• All patients administered Jevity 1.0 @ 20 increased by
20mL/hr q 4 hr to the patients specific goal rate.
• 25-30 kcal/kg IBW
• 1.2-1.5 g pro/kg IBW
The Research – Enteral Feeding Route
• Results
The Research – Enteral Feeding Route
The Research – Enteral Feeding Route
• In Summary,
• ND feeding route is more appropriate than NG feeding route in
reducing length of ICU stay among patients with high APACHE II
scores.
• No statistical difference in patients with lower APACHE II scores
The Research
• Differences in resource utilization between patients with
Diabetes receiving Glycemia-targeted specialized nutrition
vs. standard nutrition formulas in U.S. Hospitals
• An observational study – Financial support from Abbott Nutrition*
Osama Hamdy, MD, PhD; Frank R. Ernst, PharmD, MS;
Dorothy Baumer, MS; Vikkie Mustad, PhD; Jamie Partridge, PhD, MBA; and
Refaat Hegazi, MD, PhD, MPH, MS
Journal of Parenteral and Enteral Nutrition
Volume 38 Supplement 2 November 2014 86S–91S
The Research – Glycemic specific
formulas
• Diabetes Mellitus (DM)
• Substantial economic burden on patients and hospitals
• Longer hospital length of stay
• Higher hospital mortality
The Research – Glycemic specific
formulas
• Study Objective:
• To compare the LOS and resource cost of patients with DM
receiving Glycemia targeted specialized nutrition (GTSN), with
those receiving Standard Nutrition (STDN) during acute care
hospitalizations.
The Research – Glycemic specific
formulas
• Data Source
• Premier Research Database
• Patient Selection
• Adults and Children previously diagnosed T1DM or T2DM,
secondary DM, GDM, neonatal DM
• Received acute inpatient care
• Excludes transfer patients, and patients who left AMA.
The Research – Glycemic specific
formulas
• Results
The Research – Glycemic specific
formulas
• Limitations?
• Unable to establish causality
• Miscoded or missing data
• Strengths?
• Large number of patients
• Recording of specific data through the Premier Research Database
The Research – Glycemic specific
formulas
• In Summary,
• Feeding GTSN to patients with DM was associated with
significantly reduced LOS and lower costs than patients receiving
STDN
The Academy
• The AND Evidence Analysis Library (EAL)
suggests:
• In fluid-resuscitated, critically ill patients, EN started within
24-48 hours following injury or admission to the ICU may
reduce LOS.
• Actual delivery of intake of approximately 60-70% of EN
goal in the first week of ICU admission, is associated
with a shorter LOS in critically ill patients, particularly
when initiated within 48 hours of injury or admission
Questions?