Administration of enteral nutrition to adult patients in the prone position

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Summary

Objective

To examine the safety and efficacy of administering enteral nutrition (EN) to patients in the prone position.

Study selection and data extraction

All English-language articles describing human studies identified from data sources were reviewed for inclusion. Included studies had to have at least two groups for comparison, one or all of which had to contain adult patients managed in the prone position.

Data synthesis

Four studies were identified that met our inclusion criteria. Only two of the included studies were specifically designed to compare outcomes associated with EN in the prone versus supine position. The remaining two studies did not specifically compare EN in the prone versus supine position, but did provide some insight on the tolerability of EN in the prone position. Overall, administration of EN to patients in the prone position results in gastric residual volumes similar to those seen in the supine position and does not appear to increase the risk of vomiting or ventilator associated pneumonia.

Conclusions

There is limited evidence proving the safety and tolerability of EN administered to patients in the prone position; however, it does not substantially increase the rate of complications when compared to EN administered in the supine positioning.

Section snippets

Background

Critical illness is associated with catabolic stress leading to a pro-inflammatory state and many physiologic derangements that may contribute to multi-organ dysfunction, infection and death. Historically, nutrition support in critically ill patients had been thought of as adjunctive therapy to maintain homeostasis and lean body mass. More recently, nutrition support is considered to be therapeutic, in that it decreases the metabolic response to stress, prevents cell injury and has favourable

Methods

A literature search of MEDLINE (1966–May 2013) and International Pharmaceutical Abstracts (IPA; 1977 to May 2013) was conducted using the search terms enteral nutrition, enteral feeding, tube feeding, prone position and rotational therapy. References of identified articles were reviewed for additional citations. All English-language articles describing human studies were screened. Included studies had to have at least two groups for comparison, one or all of which had to contain patients

Results

Of identified clinical studies conducted in adults, two were specifically designed to compare supine and prone position (Reignier et al., 2004, Van der Voort and Zandstra, 2001). A prospective crossover study of mechanically ventilated patients assessed EN tolerability in terms of gastric residual volumes recorded in the supine position versus the prone position (Van der Voort and Zandstra, 2001). Over the course of one year, mechanically ventilated ICU patients who were turned to the prone

Discussion

The ideal study to determine whether EN is tolerated in the prone position is a prospective cross-over study designed to assess the volume of EN received, gastric residual volume and incidence of adverse outcomes such as vomiting. It would be difficult to study the impact of EN on VAP incidence, due to limitations of cross-sectional design and low likelihood of further randomised controlled trials comparing prone and supine positions.

Most identified studies did not use a cross-over design (

Conclusion

In conclusion, there is limited evidence proving the safety and tolerability of EN administered to patients in the prone position; however, the minimal evidence available does not suggest a substantial increase in complications when compared to EN administered in the supine positioning. Close monitoring of tolerance to enteral nutrition is advised for patients in the prone position. Strategies to increase tolerance of EN for patients in the supine position, such as head-of-bed elevation,

Acknowledgement

At the time of writing, Dr. Foellinger was a pharmacy student at Purdue University College of Pharmacy, West Lafayette, IN.

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      Of note, when applied in the early phase of moderate to severe ARDS, prolonged (>16 hours) prone positioning sessions halved the 28-day mortality (Guerin et al., 2013). However, gastric emptying is delayed in up to 60% of critically ill patients; this is particularly true in patients during prone position, with increased risk for EN intolerance, regurgitation or vomiting (Linn et al., 2015). In this systematic review, only one study has reported an increased risk for EN intolerance and vomiting, deeming necessary to stop EN (Reignier et al., 2004).

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      Reignier et al13 later concluded that early EN is poorly tolerated in the prone position and use of a prokinetic agent should be considered. Subsequent meta-analyses have not suggested a substantial increase in complications when EN is administered in the prone compared with the supine position.14 We suggest that EN via NGT while prone should be used with caution and patients should be watched for signs of intolerance or vomiting.

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      Consequently, it was questioned whether it would be advisable to start or continue an enteral nutrition in these patients. The available evidence to support/contradict this hypothesis is low, but indicates that it is probably safe to provide patients treated in a prone position with enteral nutrients [194–198]. For clinical practice, we suggest to manage patients treated with a prone position as follows: if a patient requires an enteral nutrition, and if hemodynamics are sufficiently stable, the entire bed is brought to a Trendelenburg position.

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