In my country some high E:N enteral formulas are fiber-enriched. Some colleagues have concerns in prescribing these kind of formula in critically ill patient, even if these patients achieve hemodynamic stability. I would like to know the experts practice.
Is the hemodynamic stability relevant? In unstable patients, any enteral nutrition is not going to be your first priority nor is it likely to be successful straightaway. I generally do not start feeding until the patient is stable. I am not aware of any precautions you need to take regarding use of fiber-enriched formulation, specifically related to circulatory status. Your colleagues may be worried about splanchnic perfusion, but if that is relevant I think it is for all enteral feeding. There is debate over whether there is any benefit in the fiber content. I stopped requesting fiber-enriched formulations more than 10 years ago. Sometimes dieticians suggest it to minimise diarrhoea and I might agree to it to keep them happy - and give patients anti-diarrhoeal therapy.
I agree with Dr. Kong about the stability issue but would add in the ICU setting we often err on the opposite side and neglect to get the gut involved in recovery early enough. In that context fiber is the great equalizer. It speeds that which is slow and makes matter out of liquid. I highly recommend it.
I agree about stability issue: if the patient is unstable enough to get soluble fibers in diet, he is unstable to receive diet at all. About fibers in the recovery phase, the argument is physiologically sound - I use very often fiber-enriched formulas - but I think that many times is more a question of following the principles than following a notion formed by empirical knowledge.
No concern to use fiber-enriched enteral nutrition even for patients hemodynamically unstable.
Most Evidence-Based Guide classified as type C recommendation that specialized nutritional support to be delayed until the hemodynamically unstable patient has been adequately resuscitated. Having achieved stability, if the gastrointestinal tract functions should be used early. Each case must be individualized, because although there are nutrients such as Glutamine discussed with more earnestness in different conferences to certain conditions, if the fiber is soluble or insoluble seems to have some influence on the intestinal microflora and homeostasis intestinal peristalsis. Therefore, use in patients with neurological pathology review (Brain Trauma, Stroke, etc.), coronary artery disease, post cardiac surgery, and may others have more indication once stabilized each case.
but if you ask all your colleagues what or when is a patient hemodynamically stable, you will have several definitions (is it when the patient has no lactates, when we don't increase of norepinephrine or when the patient is weaned from catecholamines…..)and it will be difficult to have the same management and till now we don't have any strong arguments to say when exactly starting nutrition.
I suggest you take a look at the EDEN trial published within the last year in the NEJM. It pertains to ARDS patients some of whom were in shock. The trial suggests that during the first week of critical illness trophic enteral feeding (10cc/hour) is better tolerated than full caloric support. My take is that trophic enteral feeding is tolerated even in unstable patients whereby one should admit that the benefit/risk of no feeding at all was not addressed in this study. The hypothesis remains that trophic feeing prevents bacterial translocation from the gut
NO, I DO NOT NEED ENTERAL NUTRITION WITH FIBER AT THE ICU. IT IS DIFFERENT IF WE ARE TALKING ABOUT PREBIOTICS, THE AIM IN THIS CASE IS DIFFERENT.
The debate about feeding and haemodynamic stability is totally superfluous. Most often when patients are unstable, we are concerned with resuscitating them and often the gut is forgotten! We only think about the gut as a 'secondary organ system' and when we have 'resuscitated' the patient and can step back, do we think of nutrition! But what is resuscitation? Is it a set haemodynamic end points? Is it normalisation of acid-base status, normal or near normal pulmonary gas exchange (i.e. a near normal PO2) or return of urine out put? So, in my view the debate should not take place at all. Sick patients (as we see them in ICU) are more often than not nutritionally challenged as they may not have eaten for a few days (at home) or not been fed on the hospital floor before ICU admission. Either way, feeding (high fibre or not) IS PART OF HOLISTIC RESUSCITATION of the patient!
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