SUN-P023: Enteral Nutrition in Patients on Mechanical Ventilation and Prone Position

Aim To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS). Methods Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients’ demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded. Results Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position. Conclusion In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

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A Review of the Tolerance and Adequacy of Enteral Nutrition Administered in the Prone Position in Critically Ill Patients Receiving Mechanical Ventilation

Current Developments in Nutrition ◽

10.1093/cdn/nzab029_017 ◽

2021 ◽

Vol 5 (Supplement_2) ◽

pp. 216-216

Author(s):

Carolyn Ellis ◽

Miranda Brown ◽

Kristine Anne Del Rosario ◽

Paige Heiden ◽

Gabriella Salazar ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Critically Ill ◽

Prone Position ◽

Supine Position ◽

Dropout Rate ◽

Cochrane Library ◽

Prone Positioning ◽

Inclusion Criteria ◽

Mechanically Ventilated

Abstract Objectives During the coronavirus 2019 (COVID-19) pandemic, more patients require enteral nutrition (EN) while mechanically ventilated in the prone position (PP). Prone positioning may improve oxygenation in patients receiving mechanical ventilation; however, it is unclear how it affects EN adequacy and tolerance. This review explored how EN delivered in the PP impacts EN tolerance (vomiting, diarrhea, abdominal distention, or aspiration pneumonia) and adequacy (meeting estimated energy and protein requirements) in critically ill adults receiving mechanical ventilation. Methods A literature search was conducted in PubMed, CINAHL, Academic Search Premier, and Cochrane Library for English-language studies exploring EN administered in the PP published between 2000–2020. Studies that met inclusion criteria enrolled adult patients in intensive care units with acute respiratory distress syndrome or other respiratory conditions requiring mechanical ventilation, were cohort studies with ≥5 patients per study group, and had a dropout rate <20%. Studies were excluded if patients received only parenteral nutrition. Results Of 45 studies, 4 met inclusion criteria. Three were prospective cohorts and 1 was a before-after study. When comparing EN tolerance in the PP and supine positions, 1 study found no difference in diarrhea occurrence, 2 studies found no difference in the rate of vomiting, and 1 study found significantly higher rates of vomiting while in the PP. For feeding adequacy, 2 studies found no difference in the % of calories received when administered in prone or supine positions, while 1 study found patients in the PP received significantly less EN volume than patients in the supine position. One study concluded that prophylactic prokinetic agent use and head elevation while prone resulted in larger EN volumes delivered with reduced vomiting risk. Conclusions These results suggest the adequacy of EN delivered in the PP is comparable to the supine position and PP does not substantially increase vomiting or diarrhea risk. Prone positioning should not be considered an immediate contraindication to EN for adults receiving mechanical ventilation. These findings may apply to the nutritional management of critically ill mechanically ventilated adults with COVID-19. Funding Sources None

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Awake Prone Position in Hypoxemic Patients with Coronavirus Disease 19 (COVI-PRONE): A Study protocol and Statistical Analysis Plan for Randomized Clinical Trial

10.1101/2021.08.06.21261531 ◽

2021 ◽

Author(s):

Zainab Al Duhailib ◽

Yaseen Arabi ◽

Sarah Culgin ◽

Jason Weatherald ◽

Ken Kuljit S. Parhar ◽

...

Keyword(s):

Mechanical Ventilation ◽

Prone Position ◽

Controlled Trial ◽

Invasive Mechanical Ventilation ◽

Target Population ◽

Altered Mental Status ◽

Hemodynamic Instability ◽

Hospital Length Of Stay ◽

Prone Positioning ◽

Serious Adverse Events

Background Coronavirus disease 2019 (COVID-19), may progress to respiratory failure requiring invasive mechanical ventilation. Due to ventilator shortage and healthcare systems strain, affordable interventions such as awake prone positioning has been used to improve oxygenation, however, the effect of this intervention on patient-important outcomes is uncertain. The COVI-PRONE trial aims to determine if awake prone positioning in hypoxemic COVID-19 patients reduces the need for invasive mechanical ventilation. Study design A pragmatic, multicenter, international, parallel-group, and stratified randomized controlled trial, aiming to enrol 400 hospitalized adults with COVID-19. Participants The target population is hospitalized adults with confirmed or suspected COVID-19, hypoxemia that requires ≥40% oxygen or ≥ 5 L/min by nasal cannula, and abnormal chest x-ray. We will exclude patients with any of the following: immediate need for intubation; altered mental status; contraindication to prone positioning; hemodynamic instability; body mass index > 40 kg/m2; third trimester pregnancy; do not intubate status; previous enrolment or intubation within the same hospital admission; and prone positioning for more than one day prior to randomization. Study intervention and control Following informed a priori or deferred consent, eligible patients will be centrally randomized to either the intervention arm (prone positioning) or standard of care (no prone positioning). Patients randomized to the prone position will be required to either self-prone or assist-prone for a total of eight to ten hours per day until they meet pre-specified stopping criteria. Study outcomes The primary outcome is invasive mechanical ventilation at 30-days of randomization. Other outcomes include mortality at 60 days, invasive and non-invasive mechanical ventilation free days at 30 days, hospital length of stay at 60 days, days alive and outside of the hospital at 60 days, complications of proning, and serious adverse events.

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Invasive mechanical ventilation and prolonged prone position during the COVID-19 pandemic

Medicina Intensiva (English Edition) ◽

10.1016/j.medine.2021.12.002 ◽

2021 ◽

Author(s):

Pablo Concha ◽

Marina Treso-Geira ◽

Clara Esteve-Sala ◽

Cristina Prades-Berengué ◽

Joana Domingo-Marco ◽

...

Keyword(s):

Mechanical Ventilation ◽

Prone Position ◽

Invasive Mechanical Ventilation

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Evaluation of Delivery of Enteral Nutrition in Critically Ill Patients Receiving Mechanical Ventilation

American Journal of Critical Care ◽

10.4037/ajcc2008.17.1.53 ◽

2008 ◽

Vol 17 (1) ◽

pp. 53-61 ◽

Cited By ~ 71

Author(s):

Debra O’Meara ◽

Eduardo Mireles-Cabodevila ◽

Fran Frame ◽

A. Christine Hummell ◽

Jeffrey Hammel ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Critically Ill ◽

Critically Ill Patients ◽

Feeding Tube ◽

Feeding Tubes ◽

Academic Center ◽

Specific Step ◽

Feeding Process ◽

Medical Intensive Care

Background Published reports consistently describe incomplete delivery of prescribed enteral nutrition. Which specific step in the process delays or interferes with the administration of a full dose of nutrients is unclear. Objectives To assess factors associated with interruptions in enteral nutrition in critically ill patients receiving mechanical ventilation. Methods An observational prospective study of 59 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an 18-bed medical intensive care unit of an academic center. Data were collected prospectively on standardized forms. Steps involved in the feeding process from admission to discharge were recorded, each step was timed, and delivery of nutrition was quantified. Results Patients received approximately 50% (mean, 1106.3; SD, 885.9 Cal) of the prescribed caloric needs. Enteral nutrition was interrupted 27.3% of the available time. A mean of 1.13 interruptions occurred per patient per day; enteral nutrition was interrupted a mean of 6 (SD, 0.9) hours per patient each day. Prolonged interruptions were mainly associated with problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%), weaning (11.7%), and other reasons (22.8%). Placement and confirmation of placement of the small-bore feeding tube were significant causes of incomplete delivery of nutrients on the day of admission. Conclusions Delivery of enteral nutrition in critically ill patients receiving mechanical ventilation is interrupted by practices embedded in the care of these patients. Evaluation of the process reveals areas to improve the delivery of enteral nutrition.

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Intra-Abdominal Pressure as a Marker of Enteral Nutrition Intolerance in Critically Ill Patients. The PIANE Study

Nutrients ◽

10.3390/nu11112616 ◽

2019 ◽

Vol 11 (11) ◽

pp. 2616

Author(s):

M Bordejé ◽

Juan Montejo ◽

M Mateu ◽

Manuel Solera ◽

Jose Acosta ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Critically Ill ◽

Critically Ill Patients ◽

Urinary Catheter ◽

Abdominal Pressure ◽

Icu Patients ◽

Group A ◽

Group B ◽

Low Sensitivity

To determine whether elevated intra-abdominal pressure (IAP) is associated with a higher rate of enteral nutrition-related gastrointestinal (GI) complications; to assess the value of IAP as a predictor of enteral nutrition (EN) intolerance. Intensive Care Unit (ICU) patients on mechanical ventilation requiring at least 5 days of EN were recruited for a prospective, observational, non-interventional, multicenter study. EN was performed and GI complications were managed with an established protocol. IAP was determined via a urinary catheter. Patients who developed any GI complications were considered as presenting EN intolerance. Variables related to EN, IAP and GI complications were monitored daily. Statistical analysis compared patients without GI complications (group A) vs. GI complications (group B). 247 patients were recruited from 28 participating ICUs (group A: 119, group B: 128). No differences between groups were recorded. Patients in group B (p < 0.001) spent more days on EN (8.1 ± 8.4 vs. 18.1 ± 13.7), on mechanical ventilation (8.0 ± 7.7 vs. 19.3 ± 14.9) and in the ICU (12.3 ± 11.4 vs. 24.8 ± 17.5). IAP prior to the GI complication was (14.3 ± 3.1 vs. 15.8 ± 4.8) (p < 0.003). The best IAP value identified for EN intolerance was 14 mmHg but it had low sensitivity and specificity. Although a higher IAP was associated with EN intolerance, IAP alone did not emerge as a good predictor of EN intolerance in critically ill patients.

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Emerging Problems in Mechanical Ventilation: the Prone Position

Mechanics of Breathing ◽

10.1007/978-88-470-2916-3_31 ◽

2002 ◽

pp. 359-368

Author(s):

L. Gattinoni ◽

D. Chiumello ◽

P. Pelosi ◽

M. L. Caspani

Keyword(s):

Mechanical Ventilation ◽

Prone Position

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Effects of prone and supine position on oxygenation and inflammatory mediator in a hydrochloric acid-induced lung dysfunction in rats

Acta Cirurgica Brasileira ◽

10.1590/s0102-86502008000500011 ◽

2008 ◽

Vol 23 (5) ◽

pp. 451-455 ◽

Cited By ~ 2

Author(s):

Wagner Rogério Souza de Oliveira ◽

Ivaldo da Silva ◽

Ricardo Santos Simões ◽

Luiz Fernando Portugal Fuchs ◽

Ricardo Martins Oliveira-Filho ◽

...

Keyword(s):

Mechanical Ventilation ◽

Hydrochloric Acid ◽

Prone Position ◽

Supine Position ◽

Inflammatory Mediator ◽

Partial Pressure Of Oxygen ◽

Total Proteins ◽

Partial Pressures ◽

Tnf Α ◽

Lung Dysfunction

PURPOSE: To compare the effectiveness of mechanical ventilation of supine versus prone position in hydrochloric acid (HCl)-induced lung dysfunction. METHODS: Twenty, adult, male, Wistar-EPM-1 rats were anesthetized and randomly grouped (n=5 animals per group) as follows: CS-MV (mechanical ventilation in supine position); CP-MV (mechanical ventilation in prone position); bilateral instillation of HCl and mechanical ventilation in supine position (HCl+S); and bilateral instillation of HCl and mechanical ventilation in prone position (HCl+P). All groups were ventilated for 180 minutes. The blood partial pressures of oxygen and carbon dioxide were measured in the time points 0 (zero; 10 minutes before lung injury for stabilization), and at the end of times acid injury, 60, 120 and 180 minutes of mechanical ventilation. At the end of experiment the animals were euthanized, and bronchoalveolar lavages (BALs) were taken to determine the contents of total proteins, inflammatory mediators, and lungs wet-to-dry ratios. RESULTS: In the HCl+P group the partial pressure of oxygen increased when compared with HCl+S (128.0±2.9 mmHg and 111.0±6.7 mmHg, respectively) within 60 minutes. TNF-α levels in BAL do not differ significantly in the HCl+P group (516.0±5.9 pg/mL), and the HCl+S (513.0±10.6 pg/mL). CONCLUSION: The use of prone position improved oxygenation, but did not reduce TNF-α in BAL upon lung dysfunction induced by HCl.

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Pression‐induced facial ulcers by prone position for COVID ‐19 mechanical ventilation

Dermatologic Therapy ◽

10.1111/dth.13748 ◽

2020 ◽

Vol 33 (4) ◽

Author(s):

Alice Ramondetta ◽

Simone Ribero ◽

Sonia Costi ◽

Paolo Dapavo

Keyword(s):

Mechanical Ventilation ◽

Prone Position

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