Enteral nutrition is using the gastrointestinal tract to supply nutrients. This can be accomplished with feedings by mouth or through a feeding tube.
Advantages of enteral nutrition over parenteral nutrition include: safety, effective, decreased risk of infection, decreased cost, prevents gut atrophy, and preserving the barrier function of the gut.
Indications for Enteral Feeding
Enteral tube feeding is indicated in patients who cannot main adequate oral intake of food or nutrition to meet their metabolic demands. Healthcare professionals commonly use enteral feeding in patients with dysphagia. Patients with dysphagia sometimes cannot meet their daily nutritional needs even with modification of food texture and or consistency.
For enteral feeding to be successful, the GI tract should be accessible and functional. Inaccessible GI tracts, malabsorption, and severe GI losses might make enteral feeding a challenge. The alternative is parenteral feeding.
Enteral Nutrition in Critical Illness
In patients that are critically ill, there is overwhelming evidence that enteral feeding is the best approach for nutrition in critically ill patients. The GRADE system working group came up with the following recommendation based on the level of evidence 16.
Resting engery expenditure can be calculated using the indirect calorimetry. This method calculates the caloric requirements in patients requiring enteral feeding. When indirect calorimetry is not available, approximately 25 kcal/kg per day is the approximate energy requirement. Clinicians can calculate caloric intake for patients on mechanical ventilation by using the Penn State equation.
Carbohydrate intake should be approximately 4 gm/kg per day with a target glucose level below 180 mg/dl. Lipid intake should be between 0.7 to 1.5 gm/kg per day. Amino acid should be adjusted to 1 to 1.8 g/kg per day with an adequate supply of micronutrients.
Hypocaloric enteral intake is beneficial at the initial stage of critical illness as this can help to prevent hyperglycemia which is linked to a higher risk of mortality. Some authorities recommend around 80% of nutritional needs in the first 7 to 8 days of illness which can then be gradually increased during the phase of recovery.
Enteral nutrition is contraindicated in some special cases.
Acute Kidney Injury
In acute kidney injury (AKI), nutritional support is geared toward conserving the lean body mass, energy reserve, and preventing of malnutrition.
Patients with AKI and renal failure might be in a non-hypercatabolic or hypercatabolic state with excessive sodium, potassium, and phosphate load. In a non-hypercatabolic state, high-energy enteral nutrition with normal protein content and a low sodium, potassium and phosphate load is recommended. In AKI with a hypercatabolic phase, a low protein (2 to 2.5g/kg per day), a low electrolyte enteral nutrition is recommended. Apart from monitoring electrolytes like sodium, potassium, phosphorus, and calcium, clinicians should pay special attention to micronutrients like zinc, selenium, thiamin, folic acid, and vitamins A, C, and D.
Acute Liver Failure and Liver Transplantation
Liver failure is associated with loss of the synthetic function of the liver. Liver failure patients also have an impaired ability to synthesize clotting factors. Enteral feeding should be approached with caution in patients with liver failure because of the inherent risk gastrointestinal bleeding from varices and coagulopathy. In acute liver failure, parenteral nutrition might be better if the gut is not viable and or if the risk of hepatic encephalopathy is high. If enteral feeding is used, a balanced mixture of energy supply from carbohydrate and protein is recommended. Caloric intake should be around 25 kcal/kg per day. Enteral feeds should contain an adequate quantity of potassium, magnesium, and zinc. In liver transplant patient, early enteral feeding via a transpyloric approach is recommended.
Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS)
This is one of the most common reasons for admission into the intensive care unit (ICU). Daily protein intake should be around 1 to 1.8 g/kg per day. Use of high fat, low carbohydrate is not indicated. ALI and ARDS require an enteral diet rich in omega-3 fatty acid and antioxidants.
A patient who sustained multiple trauma should be started early enteral feeding. We recommend starting trauma patient should be started on a total caloric intake of about 25 to 30 kkal/kg per day. We also recommend arginine, omega in patients with multiple trauma.
The nutritional needs of patients with abdominal surgeryare similar to the needs of other critically ill patients. Surgery causes both inflammatory and metabolic changes in the body. A post-surgical patient with malnutrition might have delayed wound healing and dehiscence and a decrease in immunological functions placing the patient at risk for infectious and cardiopulmonary complications. This can prolong hospital stay and cause a higher rate of mortality.
Inflammation of the pancreas can provoke a systemic inflammatory response syndrome. This causes a hypermetabolic, hyperdynamic, and catabolic state. Classically acute pancreatitis is treated with bowel rest and parenteral nutrition. It has been shown that this approach is associated with high morbidity and mortality. In acute pancreatitis, there is intestinal barrier dysfunction which is associated with multiple organ failure, pancreatic necrosis, and mortality. Based on these facts, the current recommendation is to start early enteral feeding via the jejunum within 48 hours of hospitalization.
Types of Enteral Feeding Tubes
There are several types of enteral feeding tubes. They are usually made of polyurethane or silicone. Feeding tube diameters are measured in French units (Fr). Each French unit is equivalent to 0.33 millimeters. Feeding tubes are usually denoted or classified by the site of placement.
Tubes can be placed:
Nasogastric tube (NG) is mainly utilized for patients with no issues with vomiting, gastroesophageal reflux (GER), poor gastric emptying, and with no evidence of ileus, small or large bowel obstruction. NG tube is risky in patients with poor swallowing coordination or reflex. Fine bore 5 to 8 Fr NG is usually recommended. If there is a need for nasogastric decompression, a larger bore NG can be used. For patient’s safety, the recommendation is that a well-trained and qualified medical personnel places the feeding tube. After the placement, the position should be verified by auscultation or x-ray. Although not routinely recommended, an x-ray is used to confirm NG tube placement for high-risk patient population, specifically, intensive care and neonatal patients. The National Patient Safety Agency advocates for the analysis of gastric aspirate with pH graded paper to confirm proper position. The pH should be less than 5.5 before feeding is started.
Nasoduodenal and Nasojejunal Tube
These are enteral feeding tubes placed with the tip in the duodenum or jejunum. Placement can be done at the bedside or with fluoroscopy guidance
The feeding tube passes through the anterior abdominal wall into the gastric cavity. A gastrostomy tube is utilized for patients who require long-term feeding. It can be placed via endoscopy percutaneous endoscopic gastrostomy (PEG). PEG tubes are for patients who require long-term nutritional support. PEG tube with jejunal extension is associated with tube dislocation and dysfunction. Gastrostomy feeding tube can also be placed radiologically or surgically or via endoscopy.
This feeding tube passed through the anterior abdominal wall into the jejunum. It can be placed surgically or radiologically via extending through the pylorus into the jejunum. Endoscopically a percutaneous endoscopic gastrojejunostomy (PEGJ) can be placed. Placement of direct percutaneous endoscopic jejunostomy tubes is less commonly performed, but PEGJs are more robust and less likely to be dislocated.
Nutritional Support Team
An interprofessional approach is the best way to manage patients who require enteral feeding using the current protocol and guidelines. A nutrition support team is made up of the physician, nurse, clinical pharmacist, and the nutritionist. Provision of optimal enteral nutrition can be achieved by:
Services that the nutrition support team can offer include:
There are several modalities of delivery of enteral feeds. Traditionally, we usually start enteral feeding about 12 to 24 hours after placement of PEG. This is to allow for a better seal to develop at the site of insertion of the PEG tube. More recent studies have shown that enteral feeding can be initiated from 3 to 4 hours after the insertion of the PEG.
Bolus Intermittent Feeding with a Bulb or Syringe
Enteral feeding is delivered in volumes of about 100 to 400 ml over 5 to 10 minutes. It is mostly used in ambulatory settings. The risk of aspiration is high.
Cyclic Intermittent Feeding
This method is used for patients in a semi-recumbent position. Enteral feeding is delivered via a pump or gravity. Enteral feedings are delivered over an 8- to 16-hour period
This is popular for home enteral feeding. Approximately 1.5 to 2 liters of feeding can be delivered over an 8 to 16 hours period overnight. Feeding is delivered via gravity or pump.
This method is used for bedridden patients. Feeding is usually delivered via gravity or pump. The head is inclined at an angle of 45% to reduce aspiration or regurgitation.
Tube placement for enteral feeding might cause mechanical complications. Some mechanical complication form tube feeding are listed below.
Tube for enteral feeding can be inserted nasally, guided percutaneous application, or surgical technique.
Nasoenteral insertion is mostly done blindly by the bedside with about 0.5% to 16% mispositioning in the pleura, trachea or bronchial trees. This can cause the infusion of enteral feeds in the tracheobronchial tree causing a pulmonary abscess or pneumothorax. Instillation of air or auscultation is not an accurate method of determining proper tube placement. The best confirmation is with radiography. Failure of bedside nasoenteral tube placement is an indication for fluoroscopy or endoscopy-guided tube insertion.
Tube placement in enteral feeding is sometimes associated with infectious processes listed above. Aspiration pneumonia is reported in closed 89% of patients on enteral feeding with no clear benefit of nasoenteric feeding over nasogastric. Distal duodenal or jejunal feeding might prevent regurgitation of enteral feeds.
Complications from the enteral feeding tube also depend on:
Spark et al. critically reviewed pulmonary complications from nasoenteric tube placement. In 9931 cases of tube placement, there was 1.9% (187) malposition in the tracheobronchial tree. The 187 misplaced tubes resulted in 35 pneumothoraxes (18.7%) with at least 5 mortalities.
Enteral feeding is associated with several GI complications
Nausea and vomiting are common after the initiation of enteral feeding about 20% to 30% incidence. Non-occlusive bowel necrosis and aspiration can also occur. This is associated with high mortality.
This is the most gastrointestinal complication seen in enteral feeding. Diarrhea occurs in about 30% of patients admitted to the medical or surgical wards and in about 80% in patients in the ICU.
Diarrhea in enteral feeding is as a result of many factors. Using antibiotics and other medications in enteral feeding is a common cause of diarrhea. Medications like antacids, oral magnesium or phosphate, antacids, and prokinetic agents. Use of oral and intravenous antibiotics can also favor the growth of Clostridium difficile, Escherichia coli, and Klebsiella. The sorbitol-containing solution can also trigger profuse diarrhea in patients on enteral feeding. Use of fiber based on the result of meta-analysis has been found to be able to significantly reduce the incidence of enteral feeding associated diarrhea especially in high-risk patients both post-surgically and in the critically ill.
This is a less common complication that is associated with enteral feeding. Constipation is more common in patients on long-term enteral feeds. Some studies suggest that use of fiber supplementation might help reduce the percentage of patients reporting constipation in enteral feeding.
This is a potentially life-threatening complication from enteral feeding. It occurs because of aspiration of oral secretion and or gastric with enteric secretions. Aspiration is more common when patients are fed via a nasogastric tube in a supine position. The cause of aspiration pneumonia in enteral feeding are multifactorial.
Enteral feeding is associated with metabolic complications. A common complication seen in malnourished or undernourished patients is refeeding syndrome. This phenomenon was first described in Far East prisoners during the Second World War.
Patients with anorexia nervosa, hyperemesis, alcoholism, and malabsorption syndrome like short bowel syndrome who are started on enteral feeding are prone to develop the re-feeding syndrome.
The pathophysiology of the refeeding syndrome is still poorly understood. In a period of starvation, the cellular membrane system downregulates with loss of intracellular potassium, phosphorus, magnesium, and calcium. The total body content of these ions is depleted. Intake of sodium and water by the cell is also increased. The sudden reversal of malnutrition with enteral feeding is due to an uptake of potassium, phosphorus, magnesium, and calcium back by the cell with simultaneous movement of water and sodium out of the cells. The undernourished kidney is also impaired and cannot handle the sodium and water load.
Hypophosphataemia is the hallmark of re-feeding syndrome. Hypophosphatemia can cause rhabdomyolysis, cardiac failure, arrhythmia, muscular weakness, leukocyte dysfunction, seizure, coma, and sudden death.
The phenomenon is more common in enteral than parenteral feeding.
Awareness of the syndrome is the key to treatment and prevention.
Patients at Risk for Re-feeding Syndrome
To manage refeeding syndrome, the cardiovascular status of the patient should be monitored closely preferably in the ICU. Judicious monitoring of electrolytes and micronutrients should also be implemented.
Goal caloric intake should target about 50% to 75% of daily requirements.
Sodium should be restricted, I mmol/kg of body weight per day or 1.5 g per day, but adequate amount of phosphorus, magnesium, and potassium should be given.
Magnesium (0.8 to 1.6mmol/L)
For hypomagnesemia, start 0.5 mmol/kg per day over 24 hours, then 0.25 mmol/kg of body weight per day for 5 days
Maintenance 0.2 mmol/kg per day intravenous or 0.5 mmol/kg per day oral
A normal range is 0.85 per 1.40mmol/L
For mild hypophosphatemia (0.6 to 0.85 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day
For moderate hypophosphatemia (0.3 to 0.6 mmol/L) start at 0.3 to 0.6 mmol/kg of body weight per day
Complications Associated with PEG Placement
Peristomal Wound Infection
Wound infection occurs after PEG placement with an incidence of about 3 to 70%. Wound site infection can be caused by the technique of placement, obesity, malnutrition, steroid, or immunosuppressive therapy. Prophylactic antimicrobial therapy has been shown to reduce the incidence of wound infection after placement of PEG. First-generation cephalosporins or penicillin gives adequate coverage.
Clogged Feeding Tube
The incidence of clogging of feeding tubes can be as high as 25%. Clogging occurs when very thick feeds and medications are delivered through a relatively thin feeding tube. Repeated gastric aspiration is discouraged since the low pH of gastric fluid can promote protein coagulation. Feeding tube should be flushed with about 40 to 50 mL of water after delivering thick feeds or medications. A clogged feeding tube can also be cleared mechanically using various endoscopic catheters, braided quid wires or plastic brushes.
This is also a complication of PEG tube placement for enteral feeding. Several factors can contribute to leakage. Excessive pulling and tugging, increased gastric secretion are factors that inhibit wound healing like malnutrition, diabetes, and immunodeficiency. This can be prevented by using antisecretory agents like proton pump inhibitors (PPI). Skin protectant and barrier creams can also be used.
The incidence of bleeding is about 2.5% after placement of PEG. This might be secondary to mucosal tear or damage to a local vessel. Risk factor for bleeding includes the use of antiplatelet or anticoagulation therapy. Based on current recommendation aspirin can be continued in a high-risk patient. Warfarin is recommended to be discontinued, and unfractionated heparin can be used as a bridge.
Misplacement of PEG for enteral feeding might lead to the formation of gastrocolic, colocutaneous and gastro colocutaneous fistulae. A gastrocolic fistula is a connection between the wall of the stomach and the colon. Gastro colocutaneous fistula is an epithelial connection between the wall of the stomach, colon and the skin that can occur because of iatrogenic puncture or direct erosion of the PEG into the wall of the colon and the skin.
To prevent colonic misplacement, the gastroscope should be transilluminated through the anterior abdominal wall, and the endoscopically visible imprint of a finger or needle on the is considered a “condition sine qua non” before introducing the needle through the stomach. Clinically the presence of a fistula is associated with watery diarrhea around the site of the PEG or the presence of stool around the site of insertion of the PEG. In rare instances, fistulae formation can cause peritonitis, infection or fasciitis.injection of contrast into the PEG can establish the diagnosis. Management can be conservative with the removal of PEG and awaiting the spontaneous closure of fistulae. For more severe cases, endoscopic intervention or invasive laparotomy with colonic exploration might be necessary.
Clinical significance cannot be overemphasized. Utilization of the gut to provide nutrients helps in the maintenance of the gut integrity, stimulation, and modulation of the immunological properties of the GI tract.
To improve the outcome in enteral feeding requires an interprofessional approach. Enteral feeding requires coordination amongst the nutritional support team.
The nutrition support team is made up of:
The clinician coordinates and directs the care related to enteral feeding. The clinician determines the optimal feeding regimen for the patient
A nutrition nurse specialist is primarily responsible for educating the patient on the use of the feeding tube. The nurse also supervises the care of the tube and notifies the clinician if there any complications that develop.
The dietician manages the evaluation of the nutritional requirements including the calculation of the daily caloric need and the optimal fluid requirements.
The pharmacist provides the enteral feed and can mix and compounds parenteral nutrition. The pharmacist advises on the compatibility of nutrients and interaction.
Other ancillary staff includes the social worker, physical, occupational and speech therapists, and a case manager to help arrange home supplies.
|||Mainous MR,Block EF,Deitch EA, Nutritional support of the gut: how and why. New horizons (Baltimore, Md.). 1994 May [PubMed PMID: 7922444]|
|||Volpe A,Malakounides G, Feeding tubes in children. Current opinion in pediatrics. 2018 Jul 12 [PubMed PMID: 30004947]|
|||Scott R,Bowling TE, Enteral tube feeding in adults. The journal of the Royal College of Physicians of Edinburgh. 2015 Mar [PubMed PMID: 25874832]|
|||Tuna M,Latifi R,El-Menyar A,Al Thani H, Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2013 Jun [PubMed PMID: 26815229]|
|||Holmes S, Enteral nutrition: an overview. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2012 May 30-Jun 5 [PubMed PMID: 22787992]|
|||Pennington CR,Powell-Tuck J,Shaffer J, Review article: artificial nutritional support for improved patient care. Alimentary pharmacology [PubMed PMID: 8580266]|
|||Payne-James J,Silk D, Enteral nutrition: background, indications and management. Bailliere's clinical gastroenterology. 1988 Oct [PubMed PMID: 3149904]|
|||Frankenfield D,Smith JS,Cooney RN, Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN. Journal of parenteral and enteral nutrition. 2004 Jul-Aug [PubMed PMID: 15291408]|
|||Bonet Saris A,Márquez Vácaro JA,Serón Arbeloa C, [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): macro-and micronutrient requirements]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309747]|
|||Fernández Ortega EJ,Ordóñez González FJ,Blesa Malpica AL, [Nutritional support in the critically ill patient: to whom, how, and when?]. Nutricion hospitalaria. 2005 Jun [PubMed PMID: 15981841]|
|||Singer P,Berger MM,Van den Berghe G,Biolo G,Calder P,Forbes A,Griffiths R,Kreyman G,Leverve X,Pichard C,ESPEN, ESPEN Guidelines on Parenteral Nutrition: intensive care. Clinical nutrition (Edinburgh, Scotland). 2009 Aug [PubMed PMID: 19505748]|
|||López Martínez J,Sánchez-Izquierdo Riera JA,Jiménez Jiménez FJ, [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): acute renal failure]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309748]|
|||Fiaccadori E,Cremaschi E, Nutritional assessment and support in acute kidney injury. Current opinion in critical care. 2009 Dec [PubMed PMID: 19812486]|
|||Montejo González JC,Mesejo A,Bonet Saris A, [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): liver failure and transplantation]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309749]|
|||Grau Carmona T,López Martínez J,Vila García B, Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: respiratory failure. Nutricion hospitalaria. 2011 Nov [PubMed PMID: 22411517]|
|||Blesa Malpica AL,García de Lorenzo y Mateos A,Robles González A, [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309757]|
|||Wernerman J, Glutamine and acute illness. Current opinion in critical care. 2003 Aug [PubMed PMID: 12883282]|
|||Marik PE,Zaloga GP, Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive care medicine. 2008 Nov [PubMed PMID: 18626628]|
|||Sánchez Álvarez C,Zabarte Martínez de Aguirre M,Bordejé Laguna L, [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): gastrointestinal surgery]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309752]|
|||Bordejé Laguna L,Lorencio Cárdenas C,Acosta Escribano J, [Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): severe acute pancreatitis]. Medicina intensiva. 2011 Nov [PubMed PMID: 22309750]|
|||Gopalan S,Khanna S, Enteral nutrition delivery technique. Current opinion in clinical nutrition and metabolic care. 2003 May [PubMed PMID: 12690265]|
|||Marks JM,Ponsky JL, Access routes for enteral nutrition. The Gastroenterologist. 1995 Jun [PubMed PMID: 7640944]|
|||Engelke M,Grund KE,Schilling D,Beilenhoff U,Kern-Waechter E,Engelke O,Stebner F,Kugler C, [Comparison of safety insertion techniques of percutaneous endoscopic gastrostomy in nurses and physicians - a non-randomized interventional pilot study on a simulation model]. Zeitschrift fur Gastroenterologie. 2018 Mar [PubMed PMID: 29113003]|
|||DiSario JA, Endoscopic approaches to enteral nutritional support. Best practice [PubMed PMID: 16782532]|
|||Byrne KR,Fang JC, Endoscopic placement of enteral feeding catheters. Current opinion in gastroenterology. 2006 Sep [PubMed PMID: 16891888]|
|||Bischoff SC,Kester L,Meier R,Radziwill R,Schwab D,Thul P, Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8. German medical science : GMS e-journal. 2009 Nov 18 [PubMed PMID: 20049081]|
|||Majid HA,Emery PW,Whelan K, Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2012 Apr [PubMed PMID: 22223668]|
|||Halloran O,Grecu B,Sinha A, Methods and complications of nasoenteral intubation. JPEN. Journal of parenteral and enteral nutrition. 2011 Jan [PubMed PMID: 20978245]|
|||Levy H, Nasogastric and nasoenteric feeding tubes. Gastrointestinal endoscopy clinics of North America. 1998 Jul [PubMed PMID: 9654567]|
|||Sparks DA,Chase DM,Coughlin LM,Perry E, Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN. Journal of parenteral and enteral nutrition. 2011 Sep [PubMed PMID: 21799186]|
|||Hull MA,Rawlings J,Murray FE,Field J,McIntyre AS,Mahida YR,Hawkey CJ,Allison SP, Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet (London, England). 1993 Apr 3 [PubMed PMID: 8096573]|
|||Marvin RG,McKinley BA,McQuiggan M,Cocanour CS,Moore FA, Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection. American journal of surgery. 2000 Jan [PubMed PMID: 10737569]|
|||Jack L,Coyer F,Courtney M,Venkatesh B, Diarrhoea risk factors in enterally tube fed critically ill patients: a retrospective audit. Intensive [PubMed PMID: 21087731]|
|||Ritz MA,Fraser R,Tam W,Dent J, Impacts and patterns of disturbed gastrointestinal function in critically ill patients. The American journal of gastroenterology. 2000 Nov [PubMed PMID: 11095317]|
|||NAGLER R,SPIRO HM, PERSISTENT GASTROESOPHAGEAL REFLUX INDUCED DURING PROLONGED GASTRIC INTUBATION. The New England journal of medicine. 1963 Sep 5 [PubMed PMID: 14043246]|
|||Gomes GF,Pisani JC,Macedo ED,Campos AC, The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Current opinion in clinical nutrition and metabolic care. 2003 May [PubMed PMID: 12690267]|
|||Ukleja A, Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2010 Feb [PubMed PMID: 20130154]|
|||Silk DB, The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN. Journal of parenteral and enteral nutrition. 2011 May [PubMed PMID: 21393640]|
|||White H,Sosnowski K,Tran K,Reeves A,Jones M, A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Critical care (London, England). 2009 [PubMed PMID: 19930728]|
|||SCHNITKER MA,MATTMAN PE,BLISS TL, A clinical study of malnutrition in Japanese prisoners of war. Annals of internal medicine. 1951 Jul [PubMed PMID: 14847450]|
|||KEYS A, The residues of malnutrition and starvation. Science (New York, N.Y.). 1950 Sep 29 [PubMed PMID: 14781769]|
|||Marinella MA, The refeeding syndrome and hypophosphatemia. Nutrition reviews. 2003 Sep [PubMed PMID: 14552069]|
|||Terlevich A,Hearing SD,Woltersdorf WW,Smyth C,Reid D,McCullagh E,Day A,Probert CS, Refeeding syndrome: effective and safe treatment with Phosphates Polyfusor. Alimentary pharmacology [PubMed PMID: 12755846]|
|||Zeki S,Culkin A,Gabe SM,Nightingale JM, Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients. Clinical nutrition (Edinburgh, Scotland). 2011 Jun [PubMed PMID: 21256638]|
|||Mehanna HM,Moledina J,Travis J, Refeeding syndrome: what it is, and how to prevent and treat it. BMJ (Clinical research ed.). 2008 Jun 28 [PubMed PMID: 18583681]|
|||Marinella MA, Refeeding syndrome in cancer patients. International journal of clinical practice. 2008 Mar [PubMed PMID: 18218007]|
|||Crook MA,Hally V,Panteli JV, The importance of the refeeding syndrome. Nutrition (Burbank, Los Angeles County, Calif.). 2001 Jul-Aug [PubMed PMID: 11448586]|
|||Safadi BY,Marks JM,Ponsky JL, Percutaneous endoscopic gastrostomy. Gastrointestinal endoscopy clinics of North America. 1998 Jul [PubMed PMID: 9654568]|
|||Lipp A,Lusardi G, Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. The Cochrane database of systematic reviews. 2006 Oct 18 [PubMed PMID: 17054265]|
|||Jafri NS,Mahid SS,Minor KS,Idstein SR,Hornung CA,Galandiuk S, Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Alimentary pharmacology [PubMed PMID: 17311597]|
|||Powell KS,Marcuard SP,Farrior ES,Gallagher ML, Aspirating gastric residuals causes occlusion of small-bore feeding tubes. JPEN. Journal of parenteral and enteral nutrition. 1993 May-Jun [PubMed PMID: 8505829]|
|||Amann W,Mischinger HJ,Berger A,Rosanelli G,Schweiger W,Werkgartner G,Fruhwirth J,Hauser H, Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients. Surgical endoscopy. 1997 Jul [PubMed PMID: 9214323]|
|||Anderson MA,Ben-Menachem T,Gan SI,Appalaneni V,Banerjee S,Cash BD,Fisher L,Harrison ME,Fanelli RD,Fukami N,Ikenberry SO,Jain R,Khan K,Krinsky ML,Lichtenstein DR,Maple JT,Shen B,Strohmeyer L,Baron T,Dominitz JA, Management of antithrombotic agents for endoscopic procedures. Gastrointestinal endoscopy. 2009 Dec [PubMed PMID: 19889407]|
|||Larson DE,Burton DD,Schroeder KW,DiMagno EP, Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987 Jul [PubMed PMID: 3108063]|
|||Berger SA,Zarling EJ, Colocutaneous fistula following migration of PEG tube. Gastrointestinal endoscopy. 1991 Jan-Feb [PubMed PMID: 1900799]|
|||Guloglu R,Taviloglu K,Alimoglu O, Colon injury following percutaneous endoscopic gastrostomy tube insertion. Journal of laparoendoscopic [PubMed PMID: 12676027]|
|||Friedmann R,Feldman H,Sonnenblick M, Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature. JPEN. Journal of parenteral and enteral nutrition. 2007 Nov-Dec [PubMed PMID: 17947601]|
|||Ponsky JL,Gauderer MW, Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. World journal of surgery. 1989 Mar-Apr [PubMed PMID: 2499128]|
|||Wiesen AJ,Sideridis K,Fernandes A,Hines J,Indaram A,Weinstein L,Davidoff S,Bank S, True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study. Gastrointestinal endoscopy. 2006 Dec [PubMed PMID: 17140892]|
|||Nazarian A,Cross W,Kowdley GC, Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. The American surgeon. 2012 May [PubMed PMID: 22546133]|
|||Blum CA,Selander C,Ruddy JM,Leon S, The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. The American surgeon. 2009 Jan [PubMed PMID: 19213395]|
|||Kudsk KA, Beneficial effect of enteral feeding. Gastrointestinal endoscopy clinics of North America. 2007 Oct [PubMed PMID: 17967372]|
|||Nightingale J, Nutrition support teams: how they work, are set up and maintained. Frontline gastroenterology. 2010 Oct [PubMed PMID: 28839571]|