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MARNIAR C20911804 (GIZI KLINIK) PEMBIMBING : dr.ABDUL WAHAB,SpAn

MARNIAR C20911804 (GIZI KLINIK) PEMBIMBING : dr.ABDUL WAHAB,SpAn

Critically ill

patients

stress Malnourished ↑ hypermetabolism 40%
stress
Malnourished ↑
hypermetabolism
40%

impaired immune function

A recommended component

and

Impaired ventilatory drive

early enteral nutrition (EEN)

of adequate nutrition support

Critically ill patients stress Malnourished ↑ hypermetabolism 40% impaired immune function A recommended component and Impaired

is

prolonged ventilatory dependence and

↑ infectious morbidity and mortality

EN
EN

preserved gut integrity

reduction in

infectious

complications

FUNCTIONAL

GASTROINTESTINAL

(GI) TRACT

a prospective, observational study November 2007 - February 2008 medical ICU of Methodist University Hospital (MUH),

a prospective, observational study

November 2007 - February 2008

medical ICU of Methodist

University Hospital (MUH),

University of Tennessee in

Memphis

Inclusion criteria EN was provided via a nasogastric tube ≥ 18 years expected to be NPO

Inclusion criteria

EN was

provided via a nasogastric

tube

18 years

expected to

be NPO for >

48 hours

receiving PN within the first candidates for oral intake 48 hours of admission Exclusion criteria life
 

receiving PN within the first

candidates for oral intake

48 hours of admission

Exclusion

criteria

life expectancy < 48 hours

ICU stay < 48 hours,

Contraindication to enteral feeding

severe nausea and vomiting severe pancreatitis severe diarrhea bowel obstruction IV dopamine infusion at a rate

severe nausea and

vomiting

severe

pancreatitis

severe diarrhea

bowel obstruction

IV dopamine infusion at a rate > 10 mcg/kg/min

malabsorptive

syndromes

perforation

IV norepinephrine infusion at a rate >

10mcg/min

significant small

bowel resection

peritonitis

CONTRAINDICATION TO ENTERAL FEEDING

EEN • Patients who received EN at a rate of at least 20 mL/h within 24

EEN

Patients who received EN at a rate of at least

20 mL/h within 24 hours

of admission to the ICU

primary objective • to evaluate the effect of EEN or delayed EN on length of stay

primary

objective

to evaluate the effect of EEN or delayed EN on length of stay in the medical ICU

evaluation of the time to initiation of EN at the minimum rate (20 mL/h)

secondary

objectives

determination of the effect of EEN or delayed EN on total hospital LOS, duration of mechanical ventilation, risk of pneumonia, risk of bloodstream

infection, and hospital mortality

ADVERSE EFFECTS OF EN gastric intolerance gastric residuals > 200 mL/4h diarrhea multiple loose, watery stools

ADVERSE EFFECTS OF EN

gastric

intolerance

gastric residuals > 200 mL/4h
gastric residuals
> 200 mL/4h

diarrhea

multiple loose, watery stools noted by the nurse and/or the need for a C. difficile stool
multiple loose,
watery stools noted
by the nurse and/or
the need for a
C. difficile stool test

sinusitis

x-ray or CT scan
x-ray or CT scan
Single investigator Baseline information : date and time of admission, age, gender, BMI, comorbidities, and APACHE

Single investigator

Baseline information : date and time of admission, age,

gender, BMI, comorbidities, and APACHE II score

Presence of pneumonia at baseline

EN : time of initiation, formula, goal rate, % achieved, GRV,

diarrhea, duration of ventilation, ICU/hospital LOS, insulin, mortality, prokinetic agents, vasopressors, discarge dx

Lab : WBC, Cr, alb, prealb, CRP, culture and X-ray results

Fisher’s exact/χ2 test Wilcoxon rank sum test P value <.05

Fisher’s exact/χ2 test

Wilcoxon rank sum test

P value <.05

MEDIAN TIME TO START Early group : Delayed group : 23.9 h 2.1 d
MEDIAN TIME TO START Early group : Delayed group : 23.9 h 2.1 d
MEDIAN
TIME TO
START
Early group :
Delayed group :
23.9 h
2.1 d
the occurrence of intolerance appeared similar between the 2 groups there is no a significant increase

the occurrence of

intolerance appeared

similar between the 2 groups

there is no a significant

increase in diarrhea in

either group

the occurrence of sinusitis

did not appear to be

significantly increased in

either group

initiation of EEN has been associated with benefits in surgical/trauma, burn, mechanically ventilated, and pancreatitis patients

initiation of EEN has been associated with benefits in surgical/trauma, burn, mechanically ventilated, and pancreatitis patients

decreased length of stay, decreased mortality,

reduced risk of infection, shortened duration of mechanical

ventilation, and an improved clinical course

variability within our medical concur with previously published literature ICU in the initiation of nutrition, with
variability within our medical concur with previously published literature ICU in the initiation of nutrition, with
variability within our medical
concur with previously published
literature
ICU in the initiation of nutrition,
with only 50% of the eligible
patients receiving EEN
EEN was associated with reduced
Ilan et al (2007) found considerable variability in the
inconsistency was identified in
ICU LOS, time on the ventilator,
achieving a goal rate, with < 50%
application of the initiation of nutrition
hospital mortality, and
of each group reaching a goal
(72.4% of eligible patients)
occurrence of new pneumonia
rate
Limitation higher rate of vasopressor use in the delayed group compared with the EEN group small

Limitation

higher rate of vasopressor use in the delayed group compared with the EEN group small population
higher rate of vasopressor use in the delayed
group compared with the EEN group
small population size → the difference in the
number of ICU deaths did not reach statistical
significance
ADVERSE EFFECTS OF EEN gastric intolerance diarrhea sinusitis NO SIGNIFICANT INCREASE

ADVERSE EFFECTS OF EEN

gastric

intolerance

diarrhea

sinusitis

NO SIGNIFICANT INCREASE

EEN
EEN
EEN decreased incidence of pneumonia possible related to the decreased time on the ventilator Kompan et

decreased incidence

of pneumonia

possible related to

the decreased time on the ventilator

Kompan et al (2004)

found similar results

improvement in patient outcomes associated with the use of EEN in a diverse population of critically

improvement in patient outcomes associated with the use of EEN in a diverse population of critically ill patients

< 50% of the patients in each group reached a goal rate of EN

EEN should be a priority in appropriate

critically ill patients