How can I prevent Hold Tube Feeds for 4 hours Prior harm in my - - PDF document

5/9/2015 1

Hold Tube Feeds for 4 hours Prior to Extubation?

Lindsey Huddleston, MD Anesthesia Critical Care Fellow Maria Amada Apacible, RN, NP Critical Care Nurse Practitioner

How can I prevent harm in my critically ill patients?

Pro: Hold TFs—Prevent complications

• f Aspiration
• ICU patients at high

risk of aspiration

• Peri-Extubation = high

risk period

• Content of aspirated

material matters

• Aspiration leads to

increased morbidity/mortality

Aspiration is Common in the ICU

• Epidemiology complicated b/o the lack of

specific and sensitive markers of aspiration

• Aspiration events are very unlikely to be overt
• Metheny, et al. found that ~88% of intubated

ICU patients receiving enteral nutrition had at least one aspiration episode (using pepsin assay)

5/9/2015 2

ICU Patients = High Aspiration Risk

• Altered Level of Consciousness

– Medications (sedatives, narcotics) – Encephalopathy – Primary CNS problem (eg., stroke, TBI) – Delirium

• Impaired gastric emptying

– Ileus – Recent surgery – SBO – narcotics

• GERD
• Impaired swallowing

– Especially within first 24h of extubation

Impaired Swallowing After Mechanical Ventilation

• Swallowing dysfunction has been demonstrated in

patients who have been intubated for as short as 48h

• Possible etiologies for swallowing dysfunction:

– Residual sedation – Decreased Cough reflex – Decreased airway reflexes and upper airway sensitivity – Mechanical problems (Laryngeal muscular dysfunction, glottic injury)

• Post-extubation dysphagia is common in ICU (up to

60% of pts w/o and 90% of patients with neurologic disorders)

High risk of Aspiration Peri-Extubation

• Leder, et al. Fiberoptic endoscopic documentation of

the high incidence of aspiration following extubation in critically ill trauma patients.

– Trauma patients intubated > 48h – Identified aspiration in 45% of pts w/in first 24h of extubation

• Barquist, et al. Postextubation fiberoptic endoscopic

evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial.

– Trauma patients intubated for > 48h – ~15% rate of aspiration in first 24h post-extubation – All patients who developed PNA had aspiration event

Decreased Cough Reflex Postextubation

• 86 pts undergoing CABG
• Baseline cough reflex

measured, then within 2hrs post-extubation and

• mult. subsequent time

points until reflex returned

• 60% of pts with NO reflex

at first measurement

5/9/2015 3 What/How much is Aspirated Matters

• Lower pH = higher risk of

chemical pneumonitis

• Higher

volume/particulate matter = higher risk of PNA

• Metheny, et al.--

Recurrent aspiration of acidic material increases r/o PNA

Aspiration Increase Risk of PNA and ALI/ARDS

• Aspiration is recognized

as a major cause of ALI/ARDS

– Studies show approximately 1/3 of patients with aspiration pneumonitis go on to develop ALI/ARDS

• Possible need for re-

intubation (mortality increase demonstrated in numerous studies)

Risk of Aspiration Too High, Hold TFs!

• Aspiration is common in the ICU
• Peri-extubation, ICU patients carry numerous

risk factors for aspiration

• Aspirated material content matters: oral

secretions ≠ gastric contents or particulate matter

• Aspiration increased r/o ALI/ARDS, re-

intubation  increased health care costs, morbidity and mortality

• How can I prevent harm

in my critically ill patients?

5/9/2015 4 Con: Continue tube feedings prevent Malnutrition/Underfeeding

• Malnutrition from underfeeding is common in

the ICU and increases morbidity and mortality.

• No data that continuing TF increases risk for

aspiration.

• There are preliminary data that continuing TF

in the peri-extubation period is safe and improves nutrition.

Importance of enteral tube feeding in critically ill patients

• Emerging data that nutritional support is

essential for recovery of critically ill patients.

• Optimal provision of calories and protein is

demonstrated to

– Reduce Morbidity and Mortality – Reduce Length of hospital and ICU stay – Improve function of the immune system – Mitigate weakness and deconditioning – Improve wound healing – Reduce Health care costs

Data supporting continuation of TFs

• While data is limited, there are some clinical trials in

pediatric population that continuing TFs peri-extubation is safe and results in more optimal nutrition

• Lyons et, al: RCT comparing continuous TFs to interrupted

feeds at time of extubation in pediatric patients

– No increase in adverse events in continuous TF group – Significant increase in calorie percentage in continuous TF group (55% greater)

• Multiple studies have shown that it is safe to continue TFs

in the perioperative period

– Patients with continuous TFs have fewer wound infections – Patients require less albumin supplementation – Overall better outcomes

A typical timeline for holding tube feedings for extubation

• NPO and hold TF at midnight (possibly 4 am) for morning

extubation.

• Patient placed on SBT & sedation weaned at 6 am. ABG sent.
• ICU team rounds start at 9 am.
• ICU team sees patient on rounds, but needs to confer with the

primary team prior to extubation.

• ICU finished rounds between 11 am and 12 pm.
• Patient may be extubated following ICU rounds provided the team

is not distracted by admissions, a procedure, a code blue, etc.

• Tube feeds are held for 2 to 4 hours following extubation to ensure

that the patient will not need reintubation.

• Result: Tube feedings are held for 8 to 16 hours which is too much

time to be made up with increased tube feeding rates and patient is malnourished that day.

5/9/2015 5 Continuing TF not necessarily increasing risk

• While the concern for aspiration exists, there

are no data that continuing TFs increases risk.

Incidence of Aspiration for Planned verses Unplanned Extubation

• Unplanned extubations may result in aspiration

and possible reintubation, leading to increased morbidity and mortality.

– The factors contributing to the higher reintubation risk in unplanned extubation are continuing sedation, decreased GCS, increased secretions, impaired ability to protect airway, severity of illness – not ready.

• However, patients who undergo planned

extubation do not carry the same risk, thus risk of aspiration and reintubation is likely small.

Continuing TF is right for most ICU patients

• The reintubation rate for planned extubations is

~17% while the reintubation rate for unplanned extubation is ~50%.

• The risks for aspiration and reintubation simply

are not present for most ICU patients who have planned extubations.

– Sedation has been weaned. – Awake and demonstrate neurological readiness for extubation. – Minimal secretions. – Able to protect airway – strong cough and gag.

Continuing TF is right for most ICU patients

• Patients who receive continuous TF meet 90%
• f nutritional requirements while those with

interrupted TF only meet 50%.

5/9/2015 6 Conclusions: Continuing TF is right for most patients!

• Continuing TF for extubation optimizes nutrition while

minimizing risks of underfeeding with relatively small risk

• r aspiration in most patients.
• Given the relatively small reintubation rate for planned

extubations, continuous TF would ensure that ~83% of patients would receive 90% of their nutritional requirements.

• Furthermore, there are data that those patients who

require reintubation would have required intubation regardless of whether TF are running on not.

• There is no diagnostic tool that measures whether those

intubations could be attributable to aspiration of TF verses many other risk factors around extubation such as LOC, etc.

References

• 1. Peev MP, Yeh DD, Quraishi SA, Osler P, Chang Y, Gillis E, Albano CE, Darak S, Velmahos GC. Causes and consequences
• f interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. JPEN J Parenter

Enteral Nutr. 2015 Jan;39(1):21-7.

• 2. Kallesen M, Psirides A, Huckabee ML. Recovery of cough after extubation after coronary artery bypass grafting: A

prospective study. J Crit Care. 2015 Mar 21.

• 3. McClave SA, Martindale RG, Rice TW, Heyland DK. Feeding the critically ill patient. Crit Care Med. 2014

Dec;42(12):2600-10

• 4. Elke G, Wang M, Weiler N, Day AG, Heyland DK. Close to recommended caloric and protein intake by enteral nutrition

is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Crit Care. 2014 Feb 10;18(1):R29.

• 5. Raghavendran K, Nemzek J, Napolitano LM, Knight PR. Aspiration-induced lung injury. Crit Care Med. 2011

Apr;39(4):818-26.

• 6. Barquist E, Brown M, Cohn S, Lundy D, Jackowski J. Postextubation fiberoptic endoscopic evaluation of swallowing

after prolonged endotracheal intubation: a randomized, prospective trial. Crit Care Med. 2001 Sep;29(9):1710-3.

• 7. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665-71.
• 8. Leder SB, Cohn SM, Moller BA. Fiberoptic endoscopic documentation of the high incidence of aspiration following

extubation in critically ill trauma patients. Dysphagia. 1998 Fall;13(4):208-12.

• 9. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH. Tracheobronchial aspiration of gastric contents

in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med. 2006 Apr;34(4):1007-15.

• 10. Lyons KA, Brilli RJ, Wieman RA, Jacobs BR. Continuation of transpyloric feeding during weaning of mechanical

ventilation and tracheal extubation in children: a randomized controlled trial. JPEN J Parenter Enteral Nutr. 2002 May- Jun;26(3):209-13.