Nutritional support is an important component of care for the critically ill. There are numerous modalities to provide specialized nutrition support including oral dietary therapy, enteral nutrition, and parenteral nutrition. For patients with a functioning gastrointestinal (GI) tract, enteral nutrition is preferred to parenteral nutrition. It is safer, more physiologic, and economical. In the intensive care unit (ICU) setting, enteral nutrition is associated with a decreased likelihood of developing infections when compared to parenteral nutrition.1 In patients with acute pancreatitis, use of enteral nutrition is also associated with a reduction in hospital length of stay and a trend toward reduced organ failure when compared to parenteral nutrition.2 Patients who have a functioning GI tract but are unable to safely ingest oral intake are fed via enteral access. In patients in whom long-term enteral access is required, endoscopically placed enteral access is recommended. Percutaneous endoscopically placed gastrostomy (PEG) and jejunostomy (PEJ) tubes are utilized for long-term enteral nutrition.
A majority of patients have enteral feeding tubes (EFTs) inserted through the mouth (orogastric) or nares (nasogastric) at the bedside that terminate in the gastric antrum. EFTs allow noninvasive access to the intestinal tract in patients who are unable to eat or drink. Examples of patients requiring EFT include sedated or unconscious patients such as those who are mechanically ventilated or have head injury. Severe oropharyngeal dysfunction that occurs in stroke patients or patients unwilling to have oral intake such as severe depression or anorexia are also candidates for EFT. Use of EFT is short term, typically less than 30 days. If enteral access is required beyond 30 days, a PEG or PEJ tube should be inserted. Contraindications for the placement of EFT include bowel ischemia, intestinal obstruction, and ileus.
Endoscopy is not required for the insertion of most EFTs. Indications for endoscopy include the presence of an esophageal obstruction or to facilitate postpyloric EFT placement. For esophageal obstruction the gastroscope is passed to the stricture, the feeding tube guided through the stricture under direct vision and advanced to the desired depth. Alternatives include placement of a guidewire through the stricture using the gastroscope biopsy channel, exchanging the gastroscope and guidewire to leave the wire in place and then placing an EFT over the guidewire. Also, the stricture can be dilated endoscopically prior to bedside placement.
Postpyloric feeding should be considered in patients with delayed gastric emptying, those with a history of regurgitation3,4 as well as patients with acute severe pancreatitis. Jejunal feeds minimize pancreatic exocrine secretions by bypassing the upper GI tract and is a core aspect in treating acute severe pancreatitis. Comparisons between gastric and jejunal feedings have shown mixed results and a large prospective study is currently underway.5,6,7 Patients with acute severe pancreatitis should receive jejunal feeds until more evidence is available. There are ...