https://doi.org/10.33698/NRF0287-Anandika, Dhandapani M, Yaddanapudi N
ABSTRACT:
Background: Enteral nutrition is the best preferred method of providing nutrition in critical care settings to prevent malnourishment among patients. Bolus method of feeding is the most commonly used method in ICUs and that may also account for poor tolerability if provided in large boluses in small enteral feeding hence, increase the risk of aspiration, reux, abdominal distension, diarrohea and nausea. Objective: To assess the intolerance among patients on bolus method of intermittent enteral feeding admitted in ICU. Material and methods: A prospective study was conducted to observe the intolerance of enteral feeding with bolus method among 21 critically ill patients (18-75 Years) admitted in ICU of a tertiary care hospital in Chandigarh, India. Bolus feeding is the most commonly practiced method in ICU in which feed was given by using standardized protocol which include administration of feed under the ow of gravity after generating negative pressure in stomach. These patients were getting enteral feeding for atleast seven days during data collection period (July2018 to December 2018). Data was collected through clinical records, patient proforma and validated checklist. Data was entered in Excel 2013, coded then imported to IBM SPSS version 23 and were analyzed using descriptive statistics. Results: The mean age of patients was 46.62 ± 18.54 years, range (18-75years). More than half (57.1%), of the patients were females. Intolerance was developed among patients on enteral feeding in the form of diarrhea (67%), increased volume of aspirated gastric content (52%), aspiration pneumonia (33%), vomiting (24%) and abdominal distension (5%). Conclusion: Intolerance of feeding is a common problem among critically ill patients fed by bolus (siphon) method. Hence, there is a need to explore the other methods of enteral feeding for occurrence of gastric intolerance.
Keywords: Enteral nutrition, bolus feeding.
Address of correspondence:
Dr. Manju Dhandapani
Lecturer, Neurology and Neurosciences Nursing NINE, PGIMER, Chandigarh
Email id: manjuseban@gmail.com
Introduction
Malnourishment is an important and prominent issue among critically ill patients that may occur due to catabolic state of patients or disturbed gastric motility due to activation of sympathetic nervous system. It may further lead to various consequences with the longer duration that lasts for an hour as it restricts their range of activity. Noncompliance and impatience among long term percutaneous endoscopic gastrotomy patients on Pump assisted feed can be the reasons for higher use of large bolus infusions which results in abdominal like muscle wasting, infectious morbidity discomfort. 2 Bolus and intermittent and prolonged length of stay etc. To meet the challenges faced by the patients regarding nutritional intake in ICUs various methods of nutrition therapies are available. Choosing the best method of proving nutrition to critically ill patient is a challenge and it can be provided through either enteral or parenteral route.
Enteral nutrition is the most commonly used and preferred method as compared to parenteral feeding as it accompanies the lesser number of complications like sepsis, e l e c t r o l y t e i m b a l a n c e s a n d hyperglycaemia. Administration of enteral feeding to the patient does not depend upon the principles but individual factors like vulnerabilities in regards to ideal timing, ideal dose distinctive sort of feeding formula, mode and course of delivery also affect the nutritional intake. There are different strategies accessible for enteral feeding like continuous, cyclic, bolus and intermittent method and each of these strategies for Enteral Nutrition (EN) administration by means of syringe, directed trickle enteral feeding bag, or enteral feeding pump are favored in patients who have demonstrated tolerance with continuous enteral feeding and the individuals who will progress out of the intensive care settings with EN.3
For medically s table patients, intermittent and bolus feeding strategies are more physiological and favored because of practical issues, for example tolerant portability, convenience, cost and reduction in gastric intolerance so that appropriate and required amount of energy K/Cal can be provided to the patient.1,4 In spite of all these advantages, this bolus feeding method also serve for some disadvantages like poor tolerability if provided in large boluses in small enteral feeding, spares more nursing time as compared to pump method and increase the risk of aspiration, reux, abdominal distension, diarrhoea and methods may accompany some degree of nausea. 5 5-15 % of pneumonias incomplications.
Bolus technique for enteral feeding is the most regularly used strategy for quick enteral feed administration. In bolus method the administration of enteral nutrition is done by a syringe/ gravity drip or siphon method over 4-10 min period.1 Patients are not comfortable to have feed hospitalized patients have been reported as aspiration pneumonia.6 Upto 60% of the patients having enteral nutrition admitted in ICU has reported gastric intolerance.7 The severity of disease, days on nil per oral, serum albumin levels, edema, and the utilization of prokinetic agents have noteworthy i m p a c t s o n t h e a d v a n c e m e n t o f gastrointestinal intolerance, as do the feeding methods, feeding speed and the osmolarity of feeding formula.8 But, how much intolerance patients developed with the commonly practiced method i.e, bolus (siphon) method in our setting needs to be reported. Hence, present study was conducted to assess the intolerance among patients on bolus method of intermittent enteral feeding admitted in ICU.
Material and methods
A prospective study was conducted to observe the intolerance with bolus method of enteral feeding received during the rst 7days of initiation of enteral feeding among 21 critically ill patients (18-75 Years) admitted in ICU of a tertiary care hospital in Chandigarh, India during the period of July 2018 to December 2018. During this period, total 40 patients were given enteral feeding. Patients receiving parenteral/ oral nutrition, extubated, transferred out or die within seven days, having gastrointestinal problems, high inotropic support, readmission, TEF and refuse to participate were excluded. Thus 21 patients were observed till the end of the study.
Protocol was developed to standardize the existing ICU feeding protocol i.e, bolus (siphon) method of feeding in which the feed was introduced to the patient under the ow of gravity with the help of negative pressure (siphoning technique). Using a syringe 5ml of feed was pushed through Ryle’s tube and Ryle’s tube was then dipped into the bowl to introduce feed under gravity over 5-10 min. Nursing ofcers w e r e g i v e n d e m o n s t r a t i o n a n d redemonstration was taken to observe the steps of procedure. Their prociency was checked by checklist. Written informed consent was obtained from all the patients or their legal representatives before enrolment into the study. Ethical clearance was taken from Institute Ethics Committee and permission from Head Department of Anesthesia and Intensive Care was taken.
Data was collected through patient proforma which was further divided into t w o p a r t s ; p a r t A i n c l u d e s t h e sociodemographic and clinical data of patients and part B includes data regarding treatment, enteral nutrition and variables related to feeding intolerance i.e, diarrhea, increased aspirated gastric content, abdominal distension vomiting and aspiration pneumonia.
The sociodemographic and clinical data was collected on the day of enrollment of the patient and then patients were followed up daily twice a day at an interval of 12 hours (9 am and 9pm) till discharge or death from the ICU. Clinical records and observation of the patients were also used for data collection regarding feeding intolerance. Data was entered in Excel 2013, coded, then imported to IBM SPSS (Statistical Package for Social Sciences) version 23.0 and were analyzed using descriptive statistics.
Results
Sociodemographic and clinical data of the patient has been shown in table 1. Of the twenty one patients ranging 18-75 years of age were included in the study, nearly half (47.6%) of the patients were in age group 18-38 years. More than half (57.1%) of the patients were females. Approximately half of the patients (57.2%) were having normal weight with BMI between 18.5 -24.9 kg/m2 on admission. Most of patients had a major diagnosis of renal (38%) and neurological (33%) problems. Length of stay of the patients in ICU vary from 7-140 days with 42.7 % of the patients having length of stay less than 15 days.
Table 1: Sociodemographic and clinical data of the patients on enteral feeding
|
N = 21
Table 2 depicts the enteral feeding associated characteristics of the patient on enteral feeding. Majority of the patients (71.4%) has been started on enteral feeding within 12 hours of admission. Most commonly used route for enteral feed administration was orogastric (86%) than nasogastric (14%) route. Majority of the patients were fed using small 14 F (91%) enteral feeding tube.
Table 2: Enteral feeding associated characteristics among patients on enteral feeding
N = 21
| Characteristics | Frequency (%) |
| Time taken to initiate enteral feeding after admission in ICU*
≤ 12 hours 13- 24 hours ≥ 25 hours Route of enteral feeding Orogastric Nasogastric Size of enteral feeding tube 14 F 18 F |
15 (71.4) 04 (19.1) 02 (09.5)
18 (85.7) 03 (14.3)
19 (90.5) 02 (09.5) |
Mean ± S.D. (range) Age (yrs) 46.62 ± 18.54 (18-75); BMI (kg/m2) 23.69 ± 5.13 (12.3-33.5);GCS 10.8 ± 2.3 (3-15);
Length of ICU stay (days)30.43 ± 33.04 (7-140), ▲Others: Cholecystitis, AFI, Aplastic anemia, renal fungal pneumonia.
*Mean ± S.D. (Range) 9.95 ± 12.41 (1-53 hours)
Intolerance among patients on enteral feeding has been shown in gure 1. Intolerance was developed among patients on enteral feeding in the form of diarrhea (67%), increased aspirated gastric content (52%), aspiration pneumonia (33%), vomiting (24%) and abdominal distension (5%).
Enteral nutrition is the most preferable method of feeding. It is more practical, convenient and easy to administer method with lesser complications as compared to parenteral nutrition. Enteral nutrition (EN) can be directed by means of different strategies l ike continuous, cyclic, intermittent, and bolus techniques, either alone or in combination. Enteral feeding accounts for certain adverse effects in the form of gastrointestinal intolerance/ feeding intolerance which includes diarrhea, nausea, and vomiting, high gastric residual volume, gastroesophageal reux etc. Various studies have been conducted to Discussion nd out the different methods of feeding. Bolus method of feeding is the most commonly used method in critical care settings. It can be administered using syringe, trickled or gravity bag over 4-10 min. In our setting also the bolus method was commonly used but it was given through siphoning technique in which negative pressure was generated and then ryle’s tube was dipped into bowl to administer feed under the ow of gravity. Hence, the need was felt to conduct a prospective observational study to assess the intolerance of feed among patients on bolus (siphon) method of enteral feeding.
The feeding protocol was standardized because of availability of different methods and nursing ofcers can use either syringe or gravity bag to deliver feed. So, to maintain uniformity and standardization of the procedures, the demonstration was g i v e n t o n u r s i n g o f c e r s a n d redemonstration was taken and checklist was also used to assess the prociency. Majority of the patients (86%) were fed by orogastric route as orogastric feedings is the most successful method used to provide nutrition to patients with difculties in oral feeding and also helps to reduce the complications most commonly associated with nasogastric and other invasive bolus method. Hence, there is a need to explore the other methods of enteral feeding for occurrence of gastric methods of feeding.9 Enteral feeding in intolerance. A similar study can be majority of the patients 90.5% has been started within 24 hours of admission that may help in reduction of infectious conducted to compare the bolus (siphon) method with other methods of enteral feeding to see the effect on feeding morbidity10 and up gradation of tissue intolerance, nutrition indices and biologicalr e p a i r , s a f e g u a r d i n g o f i m m u n e competence, and protection of the integrity of gut vegetation. Hence, improve the well- being of the patients.11
In present study with bolus (siphon) feeding increased volume of aspirated gastric content has been reported among 52% of the patients, 67% of the patients developed diarrhea, 24 % of the patients developed vomiting, 33% of the patients developed aspiration pneumonia and only 5% of the patients developed abdominal distension. Bolus administration of enteral feeding in stomach leads to reduction in lower esophageal sphincter pressure to incompetent level hence may lead to parameters.
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