Evidence-Based Project: Deliver the Best Evidence into the Gastro-intestinal Tract

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Authors (including presenting author) :
Yung SM(1), Leung HY(1), Cheung LS(1)
Affiliation :
(1)Intensive Care Unit, Yan Chai Hospital
Introduction :
Nutritional support assists patients to preserve lean body mass throughout stress response. In critically ill patients, frequency of motility disorders in gastrointestinal tract can be up to 80%. To monitor gastro-intestinal function, measurement of gastric residual volume (GRV) has been incorporated into specific guidelines. However, utilization and importance of GRV like whether enteral feeding should begin with trophic or full feeds, method of enteral feeding delivery (continuous or bolus) and frequency of GRV checking remain controversial.
Objectives :
1. To review and develop an evidence-based nutritional management protocol in intensive care unit (ICU). 2. To ensure safe and timely assessment of critically ill patients’ feeding tolerance.
Methodology :
Literature review of journals on enteral nutrition management for critically ill patients was conducted in October 2016 through keywords searching in electronic databases. Pre and post implementation of revised protocol surveys on nurses’ perception and practice on enteral feeding were conducted in October 2017 and January 2018 respectively.
Result & Outcome :
Literature review findings: Evidence suggested trophic feeds maybe enough to avoid mucosal atrophy and preserve gut integrity in low to moderate risk critically ill patients, while continuous feeding was associated with lower mortality, being more safe and practical when compared with bolus feeding. Meanwhile, literature suggested GRV showed no relationships with incidences of pneumonia, regurgitation or aspiration; Inappropriate use of GRV monitoring may however jeopardize adequacy of nutritional support. Monitor presence of clinical signs of feeding intolerance instead of solely GRV monitoring was recommended by latest international guidelines. Staff survey findings: Pre-implementation: Majority of respondents (79%) believed monitor GRVs in tube-fed patients can accurately reflect their feeding tolerance while 67% of nurses would feel hesitated if GRV is not being monitored. Although 75% of nurses agreed frequently withhold enteral feeding may altered nutrition absorption in critically ill patients, two-thirds of them have experienced not returning GRVs. 54% of respondents agreed routine GRV check consume their nursing time. Post implementation: 76% of respondents no longer trusted GRVs can exactly reflect ones’ feeding tolerance; 79% and 81% of them agreed new enteral feeding protocol reduced their workload while facilitated critically ill patients to achieve nutrition goal earlier respectively. Conclusion: A revised enteral feeding protocol was developed and implemented in Yan Chai Hospital and Princess Margaret Hospital ICU in October 2017. It has addressed the feeding should be in trophic feeds with continuous administration. Assessment should be based on daily review of clinical signs of feeding intolerance instead of routine GRV monitoring.

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