Background: Previous studies have shown that ICU patients receive only a fraction of their calculated nutritional goals, and that cumulative caloric deficit in the ICU has been correlated with poor outcome.One reason for this underfeeding is the frequent interruption of enteral nutrition.Many ICU patients receive enteral feeding formula via a nasogastric (NG) tube.Feeding is typically held for several hours prior to procedures due to the theoretical risk of aspiration.An alternative is to continue feeding up until the procedure begins, then stop the feeding and place the NG to suction.This evacuates the contents of the stomach and minimizes the risk of aspiration, while reducing the interruption of feeding that can result in malnutrition.Methods: This study is a review of prospectively gathered data including 55 sequential patients who underwent bedside percutaneous endoscopic gastrostomy (PEG) placement in a mixed ICU under a reduced fasting protocol.This was compared with a historical cohort of 33 critically ill trauma patients who fasted for at least 8 hours prior to the procedure.Under the reduced fasting protocol, enteral feeding via NG was continued up until the time of the procedure.The NG was then placed to suction, and sedation was given.The NG was left in place until the esophagus was cannulated, then it was removed.The PEG was placed in standard fashion, and feeding was resumed via the PEG immediately following the procedure.Results: We have documented no peri-procedural vomiting or aspiration.New diagnosis of pneumonia within 3 days occurred in 2/55 of the feeding group and 4/33 of the fasting group.Overall mortality was higher for the feeding group: 13/55 vs. 1/33, however when adjusted for baseline characteristics, the difference was no longer significant.Under our protocol, the interruption of feeding averaged approximately one hour, rather than the 8 or 9 hour interruption required by standard protocols.This saved an average of approximately 700 kilocalories per patient.Conclusion: We believe that continuing feeding via NG up until the time of bedside PEG is safe and advantageous for intubated patients in the ICU. Since there was minimal gastric content, it may also be safe for other procedures.
Cite this paper
C. Ho and J. Culhane, "Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients," International Journal of Clinical Medicine, Vol. 4 No. 8, 2013, pp. 369-373. doi: 10.4236/ijcm.2013.48066.
 M. E. Hise, K. Halterman, B. J. Gajewski, M. Parkhurst, M. Moncure and J. C. Brown, “Feeding Practices of Severely Ill Intensive Care Unit Patients: An Evaluation of Energy Sources and Clinical Outcomes,” Journal of the American Dietetic Association, Vol. 107, No. 3, 2007, pp. 458-465. doi:10.1016/j.jada.2006.12.012
 S. Villet, R. L. Chiolero, M. D. Bollmann, J. P. Revelly, R. N. Cayeus, J. Delarue and M. M. Berger, “Negative Impact of Hypocaloric Feeding and Energy Balance on Clinical Outcome in ICU Patients,” Clinical Nutrition, Vol. 24, No. 4, 2005, pp. 502-509.
 C. Faisy, M. Candela Llerena, M. Savalle, J. L. Mainardi and J. Y. Fagon, “Early ICU Energy Deficit is a Risk Factor for Staphylococcus Aureus Ventilator Associated Pneumonia,” Chest, Vol. 140, No. 5, 2011, pp. 1254-1260.
 American Society of Anesthesiologists Committee, “Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters,” Anesthesiology, Vol. 114, No. 3, 2011, pp. 495-511. doi:10.1097/ALN.0b013e3181fcbfd9
 R. Dhaliwal and D. K. Heyland, “Nutrition and Infection in the Intensive Care Unit: What Does the Evidence Show?” Current Opinion in Critical Care, Vol. 11, No. 5, 2005, pp. 461-467.
 C. S. Doig, P. T. Heighes, F. Simpson, Sweetman and E. A. R. Davis, “Early Enteral Nutrition, Provided within 24 h of Injury of Intensive Care Unit Admission, Significantly Reduces Mortality in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials,” Intensive Care Medicine, Vol. 35, No. 12, 2009, pp. 2018-2027. doi:10.1007/s00134-009-1664-4
 D. K. Heyland, R. Dhaliwal, J. W. Drover, L. Gramlich and P. Dodek, “Canadian Critical Care Clinical Practice Guidelines Committee. Canadian Clinical Practice Guidelines for Nutritional Support in Mechanically Ventilated Critically Ill Adult Patients,” Journal of Parenteral and Enteral Nutrition, Vol. 27, No. 5, 2003, pp. 355-373.
 J. A. Schneider, Y. J. Lee, W. R. Grubb, J. Denny and C. Hunter, “Institutional Practices of Withholding Enteral Feeding from Intubated Patients,” Critical Care Medicine, Vol. 37, No. 7, 2009, pp. 2299-2302.
 K. K. Kattelmann, M. Hise, M. Russell, P. Charney, M. Stokes and C. Compher, “Preliminary Evidence for a Medical Nutrition Therapy Protocol: Enteral Feedings for Critically Ill Patients,” Journal of the American Dietetic Association, Vol. 106, No. 8, 2006, pp. 1226-1241.
 A. Sorosky, J. Lorber, E. Klinowski, E. Illgayev, A. Mizrachi, A. Miller, T. M. B. Yehuda and Y. Leonov, “A Simplified Approach to the Management of Gastric Residual Volumes in Critical Ill Mechanically Ventilated patients: A Pilot Prospective Cohort Study,” Israel Medical Association Journal, Vol. 12, 2010, pp. 543-548.
 J. B. Ochoa and D. Caba, “Advances in Surgical Nutrition,” Surgical Clinics of North America, Vol. 86, No. 6, 2006, pp. 1483-1493.
 M. H. Delegge, “Managing Gastric Residual Volumes in the Critically Ill Patient: An Update,” Current Opinion in Clinical Nutrition & Metabolic Care, Vol. 14, No. 2, 2011, pp. 193-196. doi:10.1097/MCO.0b013e328341ede7
 M. E. Jenkins, M. M. Gottschlich and G. D. Warden, “Enteral Feeding during Operative Procedure in Thermal Injuries,” Journal of Burn Care & Research, Vol. 15, No. 2, 1994, pp. 199-205.
 R. M. Pousman, C. Pepper, P. Pandharipande, G. D. Ayers, B. Mills, J. Diaz, B. Collier, R. Miller and G. Jensen, “Feasibility of Implementing a Reduced Fasting Protocol for Critically Ill Trauma Patients Undergoing Operative and Nonoperative Procedures,” Journal of Parenteral and Enteral Nutrition, Vol. 33, No. 2, 2009, pp. 176-180. doi:10.1177/0148607108327527
 E. J. Huxley, J. Viroslav, W. R. Gray, et al., “Pharyngeal Aspiration in Normal Adults and Patients with Depressed Consciousness,” American Journal of Medicine, Vol. 64, No. 4, 1978, pp. 564-568.
 L. G. Thibodeau, V. P. Verdile and J. M. Bartfield, “Incidence of Aspiration after Urgent Intubation,” American Journal of Emergency Medicine, Vol. 15, No. 6, 1997, pp. 562-565. doi:10.1016/S0735-6757(97)90157-1
 J. B. A. MacLeod, J. Lefton, D. Houghton, C. Roland, J. Doherty, S. M. Cohn and E. S. Barquist, “Prospective Randomized Control Trial of Intermittent Versus Continuous Gastric Feeds for Critically Ill Trauma Patients,” Journal of Trauma, Vol. 63, No. 1, 2007, pp. 57-61.