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Recommendations Summary

CI: Optimizing Enteral Nutrition Delivery 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Patient Positioning

    The Registered Dietitian (RD) should recommend that critically ill adult patients be positioned in a 30 to 45 degree head of bed elevation, if not contraindicated. Research shows that this practice decreases the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx.

    Rating: Strong
    Imperative

    CI: Gastric Residual Volume

    When gastric residual volumes (GRVs) are used as one of the indicators for tolerance, the Registered Dietitian (RD) should recommend against holding enteral nutrition (EN) when GRV is less than 500ml in the absence of signs of intolerance (e.g., abdominal distention, nausea, vomiting) in critically ill adult patients. Research indicates that holding EN when GRV is less than 500ml is associated with delivery of less EN. GRV does not correlate with risk for aspiration.

    Rating: Fair
    Conditional

    CI: Use of a Promotility Agent

    If the critically ill adult patient has gastroparesis or gastric residual volumes (GRVs) ranging from 200 to 500ml and there are no contraindications, then the Registered Dietitian (RD) should recommend the use of promotility agents. Research indicates that the use of a promotility agent has been associated with increased gastric emptying,  improved enteral nutrition (EN) delivery and possibly reduced risk of aspiration.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Patient Positioning

      • Raising the head of bed to 30 to 45 degrees may be contraindicated in specific medical conditions that require the patient to be supine (e.g., back and neck surgery, hypotension)
      • Long-term use of 45-degree head of bed elevation may be associated with increased pressure over the ischial tuberosities and may expose the patient to greater shearing forces due to gravity-related sliding in the bed (Wipke-Tevis et al, 2004). 

      Gastric Residual Volume

      • Potential for reduced EN delivery if formula is repeatedly stopped or held.

       Promotility Agents 

      • Metoclopramide may be contraindicated in specific medical conditions and should not be given (Pasricha et al, 2006)
      • Metoclopramide should not be used whenever stimulation of the gastrointestinal (GI) motility might be dangerous, (i.e., in the presence of GI hemorrhage, mechanical obstruction or perforation) (Metoclopramide Injection, USP. [package insert])
      • Metoclopramide is contraindicated in patients with pheochromocytoma (Metoclopramide Injection, USP. [package insert])
      • Metoclopramide is contraindicated in patients with known sensitivity or intolerance to the drug (Metoclopramide Injection, USP. [package insert])
      • Metoclopramide should not be used in epileptics or patients receiving other drugs which are likely to cause extrapyramidal reactions, since the frequency and severity of seizures or extrapyramidal reactions may be increased (Metoclopramide Injection, USP. [package insert])
      • Because erythromycin may impact antibiotic resistance in critically ill patients, metoclopramide may be a better choice in patients where use of the drug is not contraindicated.
      • Adverse reactions that have been documented in randomized controlled trials (RCTs) with the use of metaclopromide include: Depression, high blood pressure, headache, skin rash, fatigue, fever, insomnia, decrease of libido, nausea, sedation, tremor and agitation, dyslalia and dysphagia (Silva et al, 2002)
      • Chronic use of metoclopramide can cause tardive dyskinesia (TD), a syndrome characterized by persistent, potentially irreversible, abnormal, involuntary repetitive movements. While rare, TD is a serious, and potentially irreversible adverse effect of metoclopramide (Food and Drug Administration, 2009; and Shaffer et al, 2004).

    • Conditions of Application

      Patient Positioning and Promotility Agents

      • Patient clinical status may limit the application of this recommendation.

      Gastric Residual Volume

      • If GRV is used for monitoring,  then a policy should be in place to standardize GRV management. 

    • Potential Costs Associated with Application

      • No obvious costs are associated with the application of this recommendation for GRV or patient positioning
      • Additional cost may be incurred with use of promotility agents.

    • Recommendation Narrative

      After review of the recommendation, the expert work group determined that recent evidence would not affect this statement. Thus, the CIU: Patient Positioning and CIU: Use of a Promotility Agent recommendations are based on the original evidence analysis and the Canadian Clinical Practice Guidelines (Clinical Practice Guidelines, 2009). The CIU: GRV recommendation is based on the Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) (McClave et al, 2009). Please see the methodology for guideline revisions for more information.

      A total of 13 studies were included in the evidence analysis for this recommendation:

      • Two positive quality RCTs (Boivin and Levy, 2001; and Drakulovic et al, 1999)
      • One positive meta-analysis (Heyland et al, 2003)
      • One positive quality consensus statement (McClave et al, 2002)
      • Two positive quality systematic reviews (Booth et al, 2002; and Collard et al,  2003)
      • Four neutral quality RCTs (Esparza et al, 2001; Orozco-Levi et al, 1995; Torres et al, 1992; and Yavagal et al, 2000) 
      • Two negative quality RCTs (Ibanez et al, 1992; and Pinilla et al, 2001)
      • One negative quality medical opinion statement (Bowton, 1999).  

      Patient Positioning

      • Eight studies provide evidence that:
        • Critically ill patients placed in a 45-degree head of bed elevation during gastric EN had a decreased incidence of aspiration pneumonia
          Critically ill patients placed in a 45-degree head of bed elevation during gastric EN feeding had a decreased incidence of reflux of gastric contents into the pharynx and esophagus 
      • Evidence is based on the following studies: Bowton, 1999; Collard et al,  2003; Drakulovic et al, 1999; Heyland et al, 2003; Ibanez et al, 1992; McClave et al, 2002; Orozco-Levi et al, 1995; and Torres et al, 1992 
      • The following statements are included in Monitoring Tolerance and Adequacy of Enteral Nutrition (McClave et al, 2009) and support the recommendation:
        • The following measures have been shown to reduce risk of aspiration: In all intubated ICU patients receiving EN, the head of the bed should be elevated 30° to 45° (Grade: C)
          • Elevating the head of the bed 30° to 45° was shown in 1 study to reduce the incidence of pneumonia from 23% to 5%, comparing supine to semi-recumbent position, respectively (P=0.018)
        • Evidence is based on the following: One level I study and one level II study
      • The following statements are included in 5.4 Strategies to Optimize Delivery and Minimize Risks of Enteral Nutrition: Body position (Clinical Practice Guidelines, 2009) and support the recommendation:
        • Recommendation: Based on one level 1 and one level 2 study, we recommend that critically ill patients receiving EN have the head of the bed elevated to 45 degrees. Where this is not possible, attempts to raise the head of the bed as much as possible should be considered.
          • Discussion: On the basis of one level 1 and one level 2 trials, we conclude that semi-recumbent positioning is associated with a decreased incidence of ventilator-acquired pneumonia (VAP). The lack of treatment effect seen in the Nieuwenhoven study may be due to the inability to achieve the intended elevation of 45 degrees. This study raises concern about the feasibility of achieving 45 degrees of semi-recumbency and the long term safety concerns of this position are not known (especially skin care). Semi-recumbent positioning may also require resource utilization for implementation and maintenance Reports from observational data show that head of the bed elevation degrees less than 30 degrees was a significant risk factor for aspiration, therefore attempts to raise the head of the bed, even if not to 45 degrees may be worthwhile.

      Gastric Residual Volume 

      • The following statements are included in Monitoring Tolerance and Adequacy of Enteral Nutrition (McClave et al, 2009; and Montejo et al, 2010) and support the recommendation:
        • D.2. Holding EN for GRVs <500ml in the absence of other signs of intolerance should be avoided (Grade: B)
          • Gastric residual volumes do not correlate well to incidence of pneumonia, measures of gastric emptying, or to incidence of regurgitation and aspiration. Four level II studies indicate that raising the cutoff value for GRV (leading to automatic cessation of EN) from a lower number of 50 to 150ml to a higher number of 250 to 500ml does not increase risk for regurgitation, aspiration, or pneumonia. Decreasing the cutoff value for GRV does not protect the patient from these complications, often leads to inappropriate cessation, and may adversely affect outcome through reduced volume of EN infused. Gastric residual volumes in the range of 200 to 500ml should raise concern and lead to the implementation of measures to reduce risk of aspiration, but automatic cessation of feeding should not occur for GRV <500ml in the absence of other signs of intolerance. 
        • Evidence is based on the following: One level I study and three level II studies.

      Promotility Agents

      • Seven studies provide evidence that use of promotility agents (e.g., metoclopramide) or small bowel EN is associated with reduced GRV in critically ill patients
      • Evidence is based on the following studies: Boivin and Levy, 2001; Booth et al, 2002; Esparza et al, 2001; Heyland et al, 2003; McClave et al, 2002; Pinilla et al, 2001; and Yavagal et al, 2000 
      • The following statement is included in D.2. Monitoring Tolerance and Adequacy of Enteral Nutrition (McClave et al, 2009) and supports the GRV range of 200 to 500ml:
        • Gastric residual volumes in the range of 200 to 500ml should raise concern and lead to the implementation of measures to reduce risk of aspiration, but automatic cessation of feeding should not occur for GRVs <500ml in the absence of other signs of intolerance
      • The following statements are included in 5.2 Strategies to Optimize Delivery and Minimize Risks of EN: Motility agents (Clinical Practice Guidelines, 2009) and support the recommendation:
        • Recommendation: Based on one level 1 study and five level 2 studies, in critically ill patients who experience feeding intolerance (high gastric residuals, emesis), we recommend the use of a promotility agent. Given the safety concerns associated with erythromycin, the recommendation is made for metoclopramide. There are insufficient data to make a recommendation about the use of combined use of metoclopramide and erythromycin.
          • Discussion: Subsequent to an earlier systematic review that looked primarily at the effects of motility agents on gastric emptying and feed intolerance, additional randomized trials that report on clinical outcomes have been published. We have focused on those studies that report clinical outcomes (mortality, infection, LOS) as well as evaluate the impact of motility agents on measures of nutritional adequacy. Recent data from a non-randomized observational study showed that ICU patients with high GRV have delayed gastric emptying and that by initiating prokinetic therapy, this accelerates gastric emptying to resemble that of patients tolerating EN. The committee noted the lack of treatment effect on clinical outcomes from these trials, however the beneficial effects of motility agents on feed intolerance and nutritional adequacy were recognized and thought to be important. In five out of the six trials, motility agents were associated with a significant improvement in nutritional intake. Due to the concerns re: bacterial resistance, the potential for cardiac toxicity and tachyphylaxis with the use of erythromycin and the uncertainty around the safety and efficacy of naloxone as a motility agent, it was agreed that the recommendation be made for metoclopramide. Given the low probability of harm, the favourable feasibility and cost considerations and the benefits of motility agents in improving nutrient intake, particularly when initiating early EN, the committee decided that motility agents be considered as a strategy to optimize nutrient intake.

    • Recommendation Strength Rationale

      The Academy of Nutrition and Dietetics (A.N.D.) Critical Illness Expert Work Group concurs with the Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Canadian Clinical Practice Guidelines (Clinical Practice Guidelines, 2009). The Critical Illness Expert Work Group approved the following equivalency scale: 

      Grading System Used for SCCM/A.S.P.E.N. Guidelines, 2009 compared to The Academy's Evidence Analysis Library (EAL):

      • A: Supported by at least two level I investigations (EAL Rating Equivalent: Strong) 
      • B: Supported by one level I investigation (EAL Rating Equivalent: Fair) 
      • C: Supported by level II investigations only (EAL Rating Equivalent: Fair)
      • D: Supported by at least two level III investigations (EAL Rating Equivalent: Weak) 
      • E: Supported by level IV or level V evidence (EAL Rating Equivalent: Consensus).

      Grading System Used by Clinical Practice Guidelines, 2009 compared to The Academy's Evidence Analysis Library (EAL):

      • Strongly recommended: If there were no reservations about endorsing an intervention (EAL Rating Equivalent: Strong)
      • Recommended: If evidence was supportive but there were minor uncertainties about the safety, feasibility, or costs of the intervention (EAL Rating Equivalent: Fair)
      • Should be considered: If the supportive evidence was weak and/or there were major uncertainties about the safety, feasibility, or costs of an intervention (EAL Rating Equivalent: Weak)
      • No recommendation: If there was either inadequate or conflicting evidence (i.e., insufficient data) (EAL Rating Equivalent: Insufficient Evidence).

      Conclusion statements and grades are as follows:

      • Grade I evidence is available for the conclusion statement regarding the head elevation associated with decreased incidence of reflux in EN in critically ill adult patients
        • The data are consistent and congruent in regards to decrease incidence of both gastric reflux and aspiration pneumonia.
        • Clinical Practice Guidelines, 2009 support the recommendation with "recommended" rating (EAL Rating Equivalent: Fair). 
      • Grade II evidence is available for the conclusion statements regarding the relationship between the use of a promotility agent (e.g., metoclopramide) and EN tolerance in critically ill adult patients
        • Sub-therapeutic doses of erythromycin (prokinetic dose) may not be optimal in the ICU patient when considered with the emergence of antibiotic-resistant micro-organisms
          • Clinical Practice Guidelines, 2009 support the recommendation with "recommended" rating (EAL Rating Equivalent: Fair) 
      • The GRV statement is based on Grade B evidence (McClave et al, 2009) (EAL Rating Equivalent: Fair). 

    • Minority Opinions

      None.