Background: Postinjury enteral nutrition (EN) is beneficial. Unfortunately, severely injured patients who should benefit most are frequently intolerant. To assist in maximizing enteral tolerance in the critically injured, we first implemented a prospective analysis of the effectiveness of a standardized enteral protocol (EP) at a single institution followed by a prospective multi-institutional analysis of its implementation.
Methods: Tolerance parameters were prospectively collected on severely injured patients at a single (Phase I) and then multiple (Phase II) institutions. EN was begun at 15 cc/h and advanced every 12 h to a patient specific targeted goal. Intolerance symptoms (high nasogastric output/emesis, abdominal distention, and diarrhea) were assessed and graded every 12 h and managed using a standardized protocol. Tolerance was characterized as early (during initial advancement of feeds) or late (after standard goal) and classified as good (EN advanced per EP), moderate (rate decreased per EP), poor (EN held per EP), or EN discontinued (and TPN begun).
Results: In Phase I patients (ISS = 25 +/- 3) early tolerance was good in 82% (14/17) while late good tolerance decreased to 65% (11/17). In Phase II patients (ISS = 30 +/- 2), early tolerance was good in 85% (41/49) and late tolerance was good in 80% (39/49). Moderate intolerance was primarily seen in Phase II patients and due to high gastric output in patients fed proximal to the ligament of Treitz (13/16). Overall 88% (15/17) of Phase I and 100% (49/49) of Phase II patients were successfully maintained on EN.
Conclusions: Severely injured patients exhibited good tolerance to EN when managed using a standardized protocol at four Level I trauma centers. Moderate intolerance was associated with high gastric output and may be lessened by feeding distal to the ligament of Treitz.