{"id":770,"date":"2011-06-01T09:59:13","date_gmt":"2011-06-01T13:59:13","guid":{"rendered":"https:\/\/med.virginia.edu\/ginutrition\/?p=770"},"modified":"2023-02-20T15:35:54","modified_gmt":"2023-02-20T20:35:54","slug":"june-2011-e-journal-club","status":"publish","type":"post","link":"https:\/\/med.virginia.edu\/ginutrition\/2011\/06\/01\/june-2011-e-journal-club\/","title":{"rendered":"June 2011 E-Journal Club"},"content":{"rendered":"

Greetings,<\/strong><\/p>\n

Traditionally, we do not plan traineeship programs for June because our teams generally take time for vacations, \u201cstaycations,\u201d and otherwise prepare the body, mind and spirit for the arrival of new resident physicians, fellows and dietetic interns in the near future.\u00a0 In view of the need to cover for staff that was away, we decided to postpone our June journal club.\u00a0 We reviewed two articles in July, but decided to post them separately so they will be easier to read and find.<\/p>\n

June Citation:<\/strong><\/p>\n

Metheny NA, Stewart BJ, McClave SA.\u00a0 Relationship between feeding tube site and respiratory outcomes.\u00a0 JPEN J Parenter Enteral Nutr. 2011 May;35(3):346-55.<\/p>\n

Summary:\u00a0<\/strong><\/p>\n

This was a retrospective analysis of 428 critically ill, mechanically ventilated patients from 2 prior studies that investigated the association between feeding site and by the simplified Clinical Pulmonary Infection Score (surrogate for pneumonia) and the presence of pepsin in tracheal secretions (proxy for aspiration). Feeding site was designated by physicians and initially confirmed by radiography. Each patient participated in the study for 3 consecutive days, and the simplified Clinical Pulmonary Infection Score was calculated on the fourth day.\u00a0 The investigators statistically controlled for 4 clinical variables: severity of illness, level of sedation, degree of backrest elevation and use of gastric suction.<\/p>\n

Inclusion and Exclusion Criteria were:<\/strong><\/p>\n

Inclusion criteria<\/em>:<\/p>\n

Age \u226518 years, admission to 1 of the 5 ICUs at the study site, continuous tube feedings, and mechanical ventilation.<\/p>\n

Exclusion criteria<\/em>:<\/p>\n

Pneumonia present before tube feeding started and use of a gastrostomy or jejunostomy tube.<\/p>\n

\u00a0<\/strong><\/p>\n

Major Results reported by authors:<\/strong><\/p>\n

The percentage of pepsin detected in tracheal secretions (aspiration proxy) was 11.6% lower than gastric feedings when feeding tubes were in the first portion of the duodenum, 13.2% lower when in the second\/third portions of the duodenum, and 18.0% lower when in the fourth portion of the duodenum and beyond (all significant at p<\/em> < 0.001). \u00a0The simplified CPIS score > 6 (possible pneumonia) was not significantly different between gastric and duodenal feeding, but a CPIS score > 6 occurred significantly less often when feedings were introduced at or beyond the second portion of the duodenum (p<\/em> = 0.02).\u00a0 Feeding beyond the second portion of the duodenum remained significantly associated with a CPIS > 6, even after statistical control for severity of illness, sedation, degree of backrest elevation and use of gastric suction.<\/p>\n

\u00a0<\/strong><\/p>\n

Author\u2019s Conclusions:<\/strong><\/p>\n

The authors concluded that their findings \u201csupport feeding critically ill patients with numerous risk factors for aspiration in the mid-duodenum and beyond to reduce the risk of aspiration and associated pneumonia.\u00a0 Diverting the level of feedings is one component of a multi-tiered strategy (including HOB elevation to at least 30 degrees when possible and using gastric suction during small bowel feedings), to decrease the risk of aspiration and ultimately to decrease the risk of pneumonia.\u201d<\/p>\n

\u00a0<\/strong><\/p>\n

Evaluation:<\/strong><\/p>\n

The major aspect that must be considered when evaluating the results is that it is a retrospective, observational study.\u00a0 Observational studies can only document associations, and should never be used to suggest cause and effect.\u00a0 There is no possible way to statistically control for the myriad of factors that influence outcomes in the ICU population, which is why the primary role of observational studies is to form theories that must then be tested in randomized studies.<\/p>\n

This particular study statistically controlled for only 4 factors thought to have a possible influence on pneumonia.\u00a0 There was no control for other factors known to have an influence on pneumonia incidence, such as how often patients were turned, adequacy of oral care, subglottic secretion drainage, or need for transfusions, to name just a few.\u00a0 In an unblinded, non-randomized study there are any number of differences between patient groups that can occur which influence pneumonia.\u00a0 Although the authors reported that there was no significant difference in the degree of backrest elevation between the groups they report that the mean backrest elevation of the gastric group was 26.2 +\/- 13 while the mean backrest of the group fed into the 4th<\/sup> portion of the duodenum or beyond was 38.6 +\/- 11.\u00a0 This difference in backrest elevation is certainly a clinically significant difference, and illustrates not only that the gastric fed group did not have appropriate backrest elevation while the small bowel fed group did, but also indicates that these groups were not cared for in the same manner.\u00a0 An additional difference between the groups was that patients fed in the distal bowel had a significantly greater percentage of patients receiving gastric suction (28.4 fed in D1, 35.3 fed in D2-D3, and 46.9% fed in D4 or beyond).\u00a0 It would be reasonable to expect that there were other ways in which these groups were treated differently.<\/p>\n

The other major factor that limits conclusions drawn from this study is the use of CPIS score as a surrogate for pneumonia.\u00a0 CPIS score has been criticized as having low diagnostic accuracy when compared with quantitative cultures of bronchoalveolar lavage fluid (1-3).\u00a0<\/sup> Certainly, in this study, the CPIS would appear to be an over-sensitive marker of true clinical pneumonia incidence due to the very high pneumonia incidence suggested by the CPIS score.\u00a0 Considering that the investigators excluded patients with pre-existing pneumonia, and that the CPIS score was calculated on day 4, the 46.4% incidence of pneumonia in the gastric fed group and 40.2% in the D1 fed group is an extraordinarily high incidence of nosocomial pneumonia (especially within 4 days).<\/p>\n

Other limitations of this study include the use of nonvalidated measures to re-verify tube position (volume, appearance and pH of aspirates\u2014it was not stated how many patients were on PPIs in each group), only a small number of patients (n=32) were fed into the distal small bowel compared to those fed into the stomach (n=209) or D1 (n=102), and the fact that this study involved 2 cohorts of patients separated by 3-6 years allowing for potential changes in practice, protocols and medications in an ICU setting to influence outcomes (4,5).<\/p>\n

It is also interesting to note that 6% of patients experienced spontaneous tube migration from the small bowel back into the stomach and 3% of gastric tubes ended up in the small bowel.\u00a0 The displacement of feeding tubes was determined by an x-ray that was obtained for reasons other than for a tube check, and not all patients had routine radiographs of tube position, therefore it is highly probable that a higher percentage of tube migration occurred than was reported.<\/p>\n

Our Take Home messages:<\/strong><\/p>\n

1.\u00a0\u00a0\u00a0 Observational studies should not be used to make cause and effect or practice statements.<\/p>\n

2.\u00a0\u00a0\u00a0 There is a need for an adequately powered randomized study of the influence of small bowel feedings with or without gastric suction on the development of clinical pneumonia<\/em> incidence and overall outcomes.<\/p>\n

\u00a0<\/strong><\/p>\n

References:<\/strong><\/p>\n

    \n
  1. Schurink CA, van Nieuwenhoven CA, Jacobs JA, et al. Clinical Pulmonary Infection Score for ventilator-associated pneumonia: accuracy and interobserver variability. Intensive Care Med. 2004;30:217-224.<\/li>\n
  2. Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the Clinical Pulmonary Infection Score revisited. Am J Respir Crit Care Med. 2003;168:173-179.<\/li>\n
  3. Luyt CE, Chastre J, Fagon JY. Value of the Clinical Pulmonary Infection Score for the identification and management of ventilator-associated pneumonia. Intensive Care Med. 2004;30:844-852.<\/li>\n
  4. Metheny NA, Clouse RE, Chang YH, et al.\u00a0 Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors.\u00a0 Crit Care Med 2006;34(4):1007-1015.<\/li>\n
  5. Metheny NA, Davis-Jackson J, Stewart BJ.\u00a0 Effectiveness of an aspiration risk-reduction protocol.<\/a>\u00a0 Nurs Res. 2010;59(1):18-25.<\/li>\n<\/ol>\n

    Other News on the UVAHS GI Nutrition Website<\/u>:<\/strong><\/em><\/p>\n

    \u00a0–Check out our new, \u201cNutrition Support Blog\u201d and \u201c<\/strong> Resources for the Nutrition Support Clinician<\/strong><\/a>.\u201d<\/strong><\/p>\n

    –Fall webinar dates and topics now posted; registration to open soon<\/strong><\/p>\n

    —<\/strong>Latest Practical Gastroenterology article:<\/strong><\/p>\n

    Krenitsky J, Rosner M.\u00a0 Nutritional Support for Patients with Acute Kidney Injury: How Much Protein is Enough or Too Much?\u00a0 Practical Gastroenterology<\/em> 2011; XXXV(6): 28-42.<\/p>\n

     <\/p>\n

    Joe Krenitsky MS, RD<\/p>\n

    Carol Rees Parrish MS, RD<\/p>\n

    PS \u2013 Please feel free to forward on to friends and colleagues<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

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