Skip to main content
NCBI home page
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 1996 Jul;72(849):395–402. doi: 10.1136/pgmj.72.849.395

Enteral nutrition and the critically ill.

S A Shikora 1, A M Ogawa 1
PMCID: PMC2398520  PMID: 8935598

Abstract

Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.

Full text

PDF
395

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alberti K. G., Batstone G. F., Foster K. J., Johnston D. G. Relative role of various hormones in mediating the metabolic response to injury. JPEN J Parenter Enteral Nutr. 1980 Mar-Apr;4(2):141–146. doi: 10.1177/014860718000400214. [DOI] [PubMed] [Google Scholar]
  2. Alverdy J. C. Effects of glutamine-supplemented diets on immunology of the gut. JPEN J Parenter Enteral Nutr. 1990 Jul-Aug;14(4 Suppl):109S–113S. doi: 10.1177/014860719001400415. [DOI] [PubMed] [Google Scholar]
  3. Borlase B. C., Bell S. J., Lewis E. J., Swails W., Bistrian B. R., Forse R. A., Blackburn G. L. Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill, geriatric patients. Surg Gynecol Obstet. 1992 Mar;174(3):181–188. [PubMed] [Google Scholar]
  4. Bower R. H., Cerra F. B., Bershadsky B., Licari J. J., Hoyt D. B., Jensen G. L., Van Buren C. T., Rothkopf M. M., Daly J. M., Adelsberg B. R. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med. 1995 Mar;23(3):436–449. doi: 10.1097/00003246-199503000-00006. [DOI] [PubMed] [Google Scholar]
  5. Brinson R. R., Kolts B. E. Diarrhea associated with severe hypoalbuminemia: a comparison of a peptide-based chemically defined diet and standard enteral alimentation. Crit Care Med. 1988 Feb;16(2):130–136. [PubMed] [Google Scholar]
  6. Brinson R. R., Kolts B. E. Hypoalbuminemia as an indicator of diarrheal incidence in critically ill patients. Crit Care Med. 1987 May;15(5):506–509. doi: 10.1097/00003246-198705000-00011. [DOI] [PubMed] [Google Scholar]
  7. Burke D. J., Alverdy J. C., Aoys E., Moss G. S. Glutamine-supplemented total parenteral nutrition improves gut immune function. Arch Surg. 1989 Dec;124(12):1396–1399. doi: 10.1001/archsurg.1989.01410120042009. [DOI] [PubMed] [Google Scholar]
  8. Carmon M., Seror D., Udassin R., Feigin E., Szold A., Rimon B., Muggia-Sullam M., Freund H. R. Feeding jejunostomy for post-operative nutritional support. Clin Nutr. 1991 Oct;10(5):298–301. doi: 10.1016/0261-5614(91)90010-a. [DOI] [PubMed] [Google Scholar]
  9. Carrico C. J., Meakins J. L., Marshall J. C., Fry D., Maier R. V. Multiple-organ-failure syndrome. Arch Surg. 1986 Feb;121(2):196–208. doi: 10.1001/archsurg.1986.01400020082010. [DOI] [PubMed] [Google Scholar]
  10. Cerra F. B. Hypermetabolism, organ failure, and metabolic support. Surgery. 1987 Jan;101(1):1–14. [PubMed] [Google Scholar]
  11. Cerra F. B., Lehmann S., Konstantinides N., Dzik J., Fish J., Konstantinides F., LiCari J. J., Holman R. T. Improvement in immune function in ICU patients by enteral nutrition supplemented with arginine, RNA, and menhaden oil is independent of nitrogen balance. Nutrition. 1991 May-Jun;7(3):193–199. [PubMed] [Google Scholar]
  12. Cerra F. B., Upson D., Angelico R., Wiles C., 3rd, Lyons J., Faulkenbach L., Paysinger J. Branched chains support postoperative protein synthesis. Surgery. 1982 Aug;92(2):192–199. [PubMed] [Google Scholar]
  13. Cuthbertson D., Tilstone W. J. Metabolism during the postinjury period. Adv Clin Chem. 1969;12:1–55. doi: 10.1016/s0065-2423(08)60257-7. [DOI] [PubMed] [Google Scholar]
  14. Daly J. M., Lieberman M. D., Goldfine J., Shou J., Weintraub F., Rosato E. F., Lavin P. Enteral nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after operation: immunologic, metabolic, and clinical outcome. Surgery. 1992 Jul;112(1):56–67. [PubMed] [Google Scholar]
  15. Deitch E. A. Multiple organ failure. Pathophysiology and potential future therapy. Ann Surg. 1992 Aug;216(2):117–134. doi: 10.1097/00000658-199208000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Delany H. M., Carnevale N. J., Garvey J. W. Jejunostomy by a needle catheter technique. Surgery. 1973 May;73(5):786–790. [PubMed] [Google Scholar]
  17. Douglas R. G., Shaw J. H. Metabolic response to sepsis and trauma. Br J Surg. 1989 Feb;76(2):115–122. doi: 10.1002/bjs.1800760205. [DOI] [PubMed] [Google Scholar]
  18. Eyer S. D., Micon L. T., Konstantinides F. N., Edlund D. A., Rooney K. A., Luxenberg M. G., Cerra F. B. Early enteral feeding does not attenuate metabolic response after blunt trauma. J Trauma. 1993 May;34(5):639–644. doi: 10.1097/00005373-199305000-00005. [DOI] [PubMed] [Google Scholar]
  19. Gottschlich M. M., Warden G. D., Michel M., Havens P., Kopcha R., Jenkins M., Alexander J. W. Diarrhea in tube-fed burn patients: incidence, etiology, nutritional impact, and prevention. JPEN J Parenter Enteral Nutr. 1988 Jul-Aug;12(4):338–345. doi: 10.1177/0148607188012004338. [DOI] [PubMed] [Google Scholar]
  20. Grahm T. W., Zadrozny D. B., Harrington T. The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery. 1989 Nov;25(5):729–735. doi: 10.1097/00006123-198911000-00007. [DOI] [PubMed] [Google Scholar]
  21. Grant J. P., Snyder P. J. Use of L-glutamine in total parenteral nutrition. J Surg Res. 1988 May;44(5):506–513. doi: 10.1016/0022-4804(88)90155-2. [DOI] [PubMed] [Google Scholar]
  22. Guenter P. A., Settle R. G., Perlmutter S., Marino P. L., DeSimone G. A., Rolandelli R. H. Tube feeding-related diarrhea in acutely Ill patients. JPEN J Parenter Enteral Nutr. 1991 May-Jun;15(3):277–280. doi: 10.1177/0148607191015003277. [DOI] [PubMed] [Google Scholar]
  23. Hensle T. W., Askanazi J. Metabolism and nutrition in the perioperative period. J Urol. 1988 Feb;139(2):229–239. doi: 10.1016/s0022-5347(17)42373-1. [DOI] [PubMed] [Google Scholar]
  24. Hinsdale J. G., Lipkowitz G. S., Pollock T. W., Hoover E. L., Jaffe B. M. Prolonged enteral nutrition in malnourished patients with nonelemental feeding. Reappraisal of surgical technique, safety, and costs. Am J Surg. 1985 Mar;149(3):334–338. doi: 10.1016/s0002-9610(85)80102-1. [DOI] [PubMed] [Google Scholar]
  25. Kelly T. W., Patrick M. R., Hillman K. M. Study of diarrhea in critically ill patients. Crit Care Med. 1983 Jan;11(1):7–9. doi: 10.1097/00003246-198301000-00003. [DOI] [PubMed] [Google Scholar]
  26. Kemen M., Senkal M., Homann H. H., Mumme A., Dauphin A. K., Baier J., Windeler J., Neumann H., Zumtobel V. Early postoperative enteral nutrition with arginine-omega-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact. Crit Care Med. 1995 Apr;23(4):652–659. doi: 10.1097/00003246-199504000-00012. [DOI] [PubMed] [Google Scholar]
  27. Kudsk K. A., Croce M. A., Fabian T. C., Minard G., Tolley E. A., Poret H. A., Kuhl M. R., Brown R. O. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992 May;215(5):503–513. doi: 10.1097/00000658-199205000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Lord L. M., Weiser-Maimone A., Pulhamus M., Sax H. C. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN J Parenter Enteral Nutr. 1993 May-Jun;17(3):271–273. doi: 10.1177/0148607193017003271. [DOI] [PubMed] [Google Scholar]
  29. McClave S. A., Lowen C. C., Snider H. L. Immunonutrition and enteral hyperalimentation of critically ill patients. Dig Dis Sci. 1992 Aug;37(8):1153–1161. doi: 10.1007/BF01296554. [DOI] [PubMed] [Google Scholar]
  30. McClave S. A., Snider H. L., Lowen C. C., McLaughlin A. J., Greene L. M., McCombs R. J., Rodgers L., Wright R. A., Roy T. M., Schumer M. P. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enteral Nutr. 1992 Mar-Apr;16(2):99–105. doi: 10.1177/014860719201600299. [DOI] [PubMed] [Google Scholar]
  31. Meredith J. W., Ditesheim J. A., Zaloga G. P. Visceral protein levels in trauma patients are greater with peptide diet than with intact protein diet. J Trauma. 1990 Jul;30(7):825–829. doi: 10.1097/00005373-199007000-00011. [DOI] [PubMed] [Google Scholar]
  32. Minard G., Kudsk K. A. Is early feeding beneficial? How early is early? New Horiz. 1994 May;2(2):156–163. [PubMed] [Google Scholar]
  33. Moore F. A., Feliciano D. V., Andrassy R. J., McArdle A. H., Booth F. V., Morgenstein-Wagner T. B., Kellum J. M., Jr, Welling R. E., Moore E. E. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992 Aug;216(2):172–183. doi: 10.1097/00000658-199208000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Moore F. A., Moore E. E., Jones T. N., McCroskey B. L., Peterson V. M. TEN versus TPN following major abdominal trauma--reduced septic morbidity. J Trauma. 1989 Jul;29(7):916–923. doi: 10.1097/00005373-198907000-00003. [DOI] [PubMed] [Google Scholar]
  35. Mowatt-Larssen C. A., Brown R. O., Wojtysiak S. L., Kudsk K. A. Comparison of tolerance and nutritional outcome between a peptide and a standard enteral formula in critically ill, hypoalbuminemic patients. JPEN J Parenter Enteral Nutr. 1992 Jan-Feb;16(1):20–24. doi: 10.1177/014860719201600120. [DOI] [PubMed] [Google Scholar]
  36. Mullan H., Roubenoff R. A., Roubenoff R. Risk of pulmonary aspiration among patients receiving enteral nutrition support. JPEN J Parenter Enteral Nutr. 1992 Mar-Apr;16(2):160–164. doi: 10.1177/0148607192016002160. [DOI] [PubMed] [Google Scholar]
  37. O'Dwyer S. T., Smith R. J., Hwang T. L., Wilmore D. W. Maintenance of small bowel mucosa with glutamine-enriched parenteral nutrition. JPEN J Parenter Enteral Nutr. 1989 Nov-Dec;13(6):579–585. doi: 10.1177/0148607189013006579. [DOI] [PubMed] [Google Scholar]
  38. Page C. P. Edgar J. Poth lecture. The surgeon and gut maintenance. Am J Surg. 1989 Dec;158(6):485–490. doi: 10.1016/0002-9610(89)90176-1. [DOI] [PubMed] [Google Scholar]
  39. Petersen S. R., Sheldon G. F., Carpenter G. Failure of hyperalimentation to enhance survival in malnourished rats with E. coli-hemoglobin adjuvant peritonitis. Surg Forum. 1979;30:60–61. [PubMed] [Google Scholar]
  40. Rees R. G., Hare W. R., Grimble G. K., Frost P. G., Silk D. B. Do patients with moderately impaired gastrointestinal function requiring enteral nutrition need a predigested nitrogen source? A prospective crossover controlled clinical trial. Gut. 1992 Jul;33(7):877–881. doi: 10.1136/gut.33.7.877. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Rennie M. J., Harrison R. Effects of injury, disease, and malnutrition on protein metabolism in man. Unanswered questions. Lancet. 1984 Feb 11;1(8372):323–325. doi: 10.1016/s0140-6736(84)90369-6. [DOI] [PubMed] [Google Scholar]
  42. Shikora S. A., Blackburn G. L. Nutritional consequences of major gastrointestinal surgery. Patient outcome and starvation. Surg Clin North Am. 1991 Jun;71(3):509–521. doi: 10.1016/s0039-6109(16)45430-7. [DOI] [PubMed] [Google Scholar]
  43. Stern M. A., Wolf D. C. Erythromycin as a prokinetic agent: a prospective, randomized, controlled study of efficacy in nasoenteric tube placement. Am J Gastroenterol. 1994 Nov;89(11):2011–2013. [PubMed] [Google Scholar]
  44. Strong R. M., Condon S. C., Solinger M. R., Namihas B. N., Ito-Wong L. A., Leuty J. E. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. JPEN J Parenter Enteral Nutr. 1992 Jan-Feb;16(1):59–63. doi: 10.1177/014860719201600159. [DOI] [PubMed] [Google Scholar]
  45. Wan J. M., Teo T. C., Babayan V. K., Blackburn G. L. Invited comment: lipids and the development of immune dysfunction and infection. JPEN J Parenter Enteral Nutr. 1988 Nov-Dec;12(6 Suppl):43S–52S. doi: 10.1177/014860718801200603. [DOI] [PubMed] [Google Scholar]
  46. Wilmore D. W., Aulick L. H. Systemic responses to injury and the healing wound. JPEN J Parenter Enteral Nutr. 1980 Mar-Apr;4(2):147–151. doi: 10.1177/014860718000400215. [DOI] [PubMed] [Google Scholar]
  47. Wilmore D. W., Smith R. J., O'Dwyer S. T., Jacobs D. O., Ziegler T. R., Wang X. D. The gut: a central organ after surgical stress. Surgery. 1988 Nov;104(5):917–923. [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES