Symposium ProceedingsEarly enteral nutrition in surgical patients
Introduction
Although nutritional support has traditionally been administered to preserve lean body mass and avoid the complications of starvation-induced malnutrition, recent clinical and experimental work show that nutritional support can reduce the incidence of septic complications and improve clinical outcome after critical injury. By maintaining host defenses and preserving normal immunologic function, delivery of nutrients via the gastrointestinal (GI) tract provides significant benefits that are not gained when similar nutrients are delivered intravenously. An important objective in the management of critically injured patients, however, is to gain access beyond the ligament of Treitz during celiotomy, since failure to do so complicates the ability to deliver nutrients into the small intestine. If access is not obtained, the situation becomes even more complicated than in patients who do not require celiotomy because there may be significant reluctance in gaining postoperative access beyond the ligament of Treitz in patients with injuries to the stomach, duodenum, pancreas, and proximal small bowel. This article reviews the clinical and experimental data supporting the concept of early enteral nutrition in critically ill patients whenever possible.
Section snippets
Early experimental and clinical observations
In a study of the effect of progressive malnutrition on susceptibility to infectious peritonitis, Petersen et al.1 demonstrated that mortality increased after hemoglobin Escherichia coli peritonitis in malnourished animals compared with well-nourished animals. Surprisingly, animals fed intravenously with standard parenteral solutions sustained almost uniform mortality after the peritonitis.1 Subsequently, Kudsk et al.2, 3 demonstrated that well-nourished or previously malnourished rats
Recent clinical studies
During the last decade, there have been considerable developments in new enteral formulations designed to improve immune function. These diets contain various specialty nutrients that have been shown experimentally to have positive effects on immune function, wound healing, and the inflammatory response.
Arginine is a nonessential amino acid that appears to be a potent stimulant of growth hormone, prolactin, insulin, and glucagon release.10, 11, 12 As a precursor for nitrous oxide, arginine
Mechanism of improved complications after enteral feeding
Over the past 15 y, there has been increasing attention to the preservation of gut function in enterally fed animals compared with animals fed intravenously. The GI tract has many functions, including digestion, absorption, and immunologic defenses. It accounts for approximately 80% of the total immunoglobulin (Ig) produced by the body that is secreted across the mucosa from the gut-associated lymphoid tissue (GALT) to serve as a barrier, preventing attachment of bacteria, viruses, and other
Summary
The use of enteral nutrition had significant benefit in critically injured patients, reducing infectious complications and improving patient outcome. This is not an effect of avoiding malnutrition, because the majority of severely injured trauma patients are well-nourished at the time of their injury. An infection occurs within 4 to 7 d following injury, long before significant malnutrition could occur. It appears that feeding via the GI tract preserves normal epithelial defenses against the
References (49)
- et al.
Effect of enteral and parenteral feeding in malnourished rats with E. coli-hemoglobin adjuvant peritonitis
J Surg Res
(1981) - et al.
High arginine levels in intravenous hyperalimentation abrogate post-traumatic immune suppression
J Surg Res
(1984) - et al.
Stimulation of T cell immunity by arginine enhances survival in peritonitis
J Surg Res
(1988) - et al.
Uptake and metabolism of plasma glutamine by the small intestine
J Biol Chem
(1974) - et al.
The effect of glutamine-enriched TPN on gut immune cellularity
J Surg Res
(1992) - et al.
Role of oral intake in maintenance of gut mass and disaccharide activity
Gastroenterology
(1974) - et al.
The mucosal immune systemfrom fundamental concepts to vaccine development
Vaccine
(1992) - et al.
Effect of glutamine-enriched total parenteral nutrition on small intestinal gut-associated lymphoid tissue and upper respiratory tract immunity
Surgery
(1997) - et al.
Malnutrition and immunocompetenceincreased mortality following an infectious challenge during hyperalimentation
J Trauma
(1981) - et al.
Enteral and parenteral feeding influences mortality after hemoglobin-E. coli peritonitis in normal rats
J Trauma
(1983)
Beneficial effects of aggressive protein feeding in severely burned children
Ann Surg
Benefits of immediate jejunostomy feeding after major abdominal traumaa prospective randomized study
J Trauma
TEN vs. TPN following major abdominal traumareduced septic morbidity
J Trauma
Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal traumaa critical analysis
Crit Care Med
Early enteral feeding, compared with parenteral, reduces postoperative septic complicationsthe results of a meta-analysis
Ann Surg
Enteral vs. parenteral feedingeffects on septic morbidity following blunt and penetrating abdominal trauma
Ann Surg
Arginine and immune function
Nutrition
Metabolic and immune effects of arginine in postinjury hyperalimentation
J Trauma
Arginine enhances T-cell responses in athymic nude mice
JPEN
The guta central organ following surgical stress
Surgery
Glutaminea key substrate for the splanchnic bed
Ann Rev Nutr
A review of the effects of glutamine-enriched diets on experimentally induced enterocolitis
JPEN
Preservation of small bowel mucosa using glutamine-enriched parenteral nutrition
Surg Forum
Dietary omega-3 fatty acids decreases mortality and Kupffer cell prostaglandin E2 production in a rat model of chronic sepsis
J Trauma
Cited by (24)
Management of Traumatic Brain Injury
2017, Surgical Clinics of North AmericaCitation Excerpt :Early nutritional replacement (within 5 days) has been demonstrated to reduce 2-week mortality after sTBI59 and reduce the incidence of ventilator-associated pneumonias (VAPs).58 Certainly, the critical care and trauma literature on early nutritional replacement for the avoidance of the systemic inflammatory response60 and infectious complications61 also applies to patients with sTBI. Transpyloric feeding is favored over gastric feeding because of the decreased incidence of VAPs.62
Nutritional support in adult patients receiving extracorporeal membrane oxygenation
2010, Critical Care and ResuscitationEffect of Enteral Versus Parenteral Nutrition on LPS-Induced Sepsis in a Rat Model
2008, Journal of Surgical ResearchCitation Excerpt :Enteral nutrition is currently the preferred method of feeding critically ill patients unless obvious contraindications such as ileus or active gastrointestinal bleeding are present. In addition, a recent study on the use of TEN versus TPN for early initiation of enteral nutrition revealed that early use of enteral nutrition was associated with reduced infectious morbidity in critically ill patients [6, 13, 14]. Perioperative or postoperative enteral feeding has been shown to decrease morbidity in both postsurgical and trauma patients in comparison to TPN [12–14].
A review of the epidemiology, pathogenesis and management of tetanus
2004, International Journal of SurgeryIntravenous hydration versus naso-jejunal enteral feeding after esophagectomy: A randomised study
2002, European Journal of Cardio-thoracic Surgery