Introduction
Enteral nutrition is important for all critically ill patients in intensive care units to support their metabolic processes. This type of feeding stimulates the immune system and guarantees the prevention of infections (Bahat et al. 2016). The purpose of this paper is to define early enteral nutrition, describe its benefits, present observations of early enteral feeding about the selected patient case, and analyze consequences associated with the discussed practice.
Definition of Early Enteral Nutrition
Early enteral nutrition can be defined as a process of feeding critically ill patients with the help of the jejunum or duodenum in cases when the oral intake is impossible. The timing of enteral feeding is also important for defining the practice as early, and it is associated with better patient outcomes in comparison to delayed enteral nutrition (Finoccchiaro & Hook 2015). Thus, enteral nutrition can be viewed as early when it is initiated within 24-48 hours after the patient’s admission or his or her hypermetabolic insult (Sun et al. 2013). When using early enteral nutrition, it is possible to expect certain benefits for patients.
Benefits of Early Enteral Nutrition
It is important to note that the benefits of early enteral nutrition are associated with the time during which feeding is received. If the nutrition is received early, it is possible to expect positive changes in gut permeability, decreases in systemic endotoxemia, changes in the activation and release of cytokines, and decreases in developing infections (Löfgren et al. 2015). Bowel, gall-bladder, and pancreatic functions also improve because of enteral feeding (Löfgren et al. 2015; Van Zanten et al. 2015; Yang et al. 2014). The observed acid-base balance becomes normal, and an early positive nitrogen balance can be expected (Boelens et al. 2014; Löfgren et al. 2015).
As a result, those patients who receive early enteral feeding are characterized by reduced lengths of their hospitality stay and increased tolerance to the further provided nutrition (Wereszczynska-Siemiatkowska et al. 2013). What is most important is that the level of mortality among critically ill patients who receive early enteral nutrition is lower in comparison to other patient groups (Boelens et al. 2014; Wereszczynska-Siemiatkowska et al. 2013). These benefits are taken into account when healthcare providers choose practices to use to improve outcomes for critically ill patients.
Observations Regarding Enteral Nutrition Feeding
Early enteral nutrition feeding was observed in Helen’s case. Healthcare providers identified that she had no abdominal problems, and her hemodynamic status was stable. Early enteral nutrition was proposed to be applied during the first 24 hours. The dietician and medical officer prescribed using a polymeric feeding solution in contrast to a semi-elemental enteral feeding product. It is possible to state that the selection of polymeric feeding was reasonable as its formulas contain complex carbohydrates, long-chain triglycerides, glutamine, arginine, nucleotides, and enough intact proteins (Seron-Arbeloa et al. 2013). Elemental and semi-elemental formulas contain glucose polymers and simple sugars, and this type of feeding is not appropriate in this patient’s case because of her type 2 diabetes.
A global fluid allowance was proposed to be 30-35 ml/kg, where this volume was divided between maintenance fluids and enteral nutrition solutions. Also, the consumption of enteral glutamine in 0.5 g/kg was also prescribed. The expected total energy target was 20–25 kcal/kg, and the consumption of 1.2-1.5 g protein/kg was prescribed. Although glutamine is important to improve the immune function, it can have some adverse effects on the patient’s state, and its use should be carefully monitored to avoid possible risks for the patient (Boelens et al. 2014; Löfgren et al. 2015).
Consequences of Enteral Nutrition Feeding
The enteral nutrition feeding pattern followed in Helen’s case had several consequences on the patient’s state. On Day 3, regurgitation associated with the altered gut motility was observed. In this case, there were no indicators of feeding intolerance (FI), such as the inability to absorb products of nutrition. When a patient suffers from FI, it is possible to observe abdominal pain, nausea, vomiting, distention, diarrhea, and constipation (Bahat et al. 2016; Weijs et al. 2015). In this case, it is possible to assume that about 90 per cents of nutrition were absorbed without observable symptoms of FI during the first 48 hours as regurgitation was caused by repositioning (Bahat et al. 2016; Seron-Arbeloa et al. 2013). The problem could also be in the technique and tubes used for enteral feeding (Bahat et al. 2016; Seron-Arbeloa et al. 2013; Van Zanten et al. 2015; Yang et al. 2014). To treat the condition, prokinetics were prescribed, and the feeding solution was decreased.
On Day 6, the patient had a loose stool. Her liver and renal functions were moderately impaired. Only nasogastric (NG) feeding was used. Furthermore, the energy intake decreased, and less than 50 per cents of the target achievement were observed. Thus, FI became observed, and it could be caused by changes in feeding associated with the regurgitation on Day 3, as well as by changes in the gut motility and gastroparesis (delayed gastric emptying) (Bahat et al. 2016; Finoccchiaro & Hook 2015). When such problems are observed, it is important to use the volume restricted formula, decrease the feeding rate, but promote calorie intake.
Polymeric feeding was initially selected for the patient, and the global fluid allowance of 30-35 ml/kg was prescribed. Thus, the associated a total energy target of 20-25 kcal/kg was recommended, as well as the protein intake in 1.2-1.5 g protein/kg (Bahat et al. 2016; Seron-Arbeloa et al. 2013). These recommendations can be discussed as being in line with guidelines on enteral feeding for patients with BMI < 30, but these volumes were reduced to address Helen’s state on Day 3, therefore, the amount of feed became insufficient. It is important to avoid the cumulative caloric deficit to prevent the development of complications (Seron-Arbeloa et al. 2013). As a result, Helen needed more protein intake when non-protein feed could be restricted. After Day 3, Helen was underfed, and her immune system did not function effectively, and the risk for infections increased. It was possible to reduce fat and glucose for Helen in her feed to contribute to feeding tolerance, but she lost energy.
On Day 10, Helen suffered from upper abdominal discomfort and reported nausea and vomiting. She was diagnosed with a retroperitoneal duodenal rupture. It was important to monitor enteral feeding tolerance with the focus on the patient’s complaints regarding abdominal pain, changes in gastric residual volumes, changes observed on radiographs (Boelens et al. 2014; Löfgren et al. 2015; Seron-Arbeloa et al. 2013). While being discharged, the patient was weak, and losses in the muscle mass were observed.
Conclusion
The paper has presented a discussion of the patient’s case concerning the benefits and consequences of early enteral nutrition. The patient had FI. Therefore, it is important to focus on monitoring the outcomes of early enteral nutrition during the first hours after suggesting the practice.
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