Early Enteral Nutrition: Benefits and Considerations

This assignment delves into the critical topic of early enteral nutrition for patients in a critical care setting. It examines various studies and clinical guidelines, highlighting the advantages of early enteral feeding in promoting recovery and reducing complications. Students are tasked with analyzing the research evidence, understanding the rationale behind early intervention, and considering the practical implications and potential challenges associated with its implementation.

1Running head: NURSING
Nursing
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Patients in critical conditions are at higher risk of malnutrition, occurring in almost
40% of all patient cases. The patient's body, in response to stress, suffers metabolic changes
that are the cause of the increase in protein catabolism. The ultimate outcome for such
patients is a significant loss of body mass and subsequent higher risks of health
complications. Such complications might be an infectious disease of increase in wound
dehiscence. In either case, the outcomes are unfavourable. The strategy under such condition
is to provide nutritional support for achieving optimal body functioning. Prevention of
malnutrition and the related complications is the chief aim. The aim is to provide appropriate
doses of micro and macro nutrients for meeting the body needs, avoid complications and
reduce nitrogen deficits (McClave et al. 2016). Enteral nutrition is defined as the provision of
a supply of nutrients through the gastrointestinal tract of the patient under conditions when
the patient is not able to ingest, chew or swallow food but is able to digest and absorb the
same. Early enteral nutrition is the process of enteral nutrition commenced within 24-48
hours after admission of the patient to the critical care unit (Yu et al. 2014).
The advantages presented by early nutritional support are continually being reported
in a vast pool of literature. According to Boelens et a. (2014), intensive care unit patients
presented with malnutrition during their hospital stay as well as those who are not supposed
to be on the full oral diet within three days are to receive specialised enteral nutritional
support. Malnutrition has been linked with morbidity, mortality and increased hospital stay
length. Evidence points out that patients admitted to the critical care unit and having the gut
in the functional state must be given nutrition through the enteral route. The rationale is that
administration of nutrition through other routes of feeding is associated with increased
chances of compilations due to infections. In case of early enteral nutritional support, the
feeding is to commence on the very first day after admission to the care unit for facilitation of
diet tolerance and reduction of risk of intestinal barrier dysfunction. The desirable outcomes

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are mechanical ventilation and reduced hospital stay length (Sun et al. 2013). As per the
authors, favourable impacts of early enteral nutrition include prevention of mucosal atrophy,
better substrate utilization, preservation of immunocompetence and preservation of the
integrity of gut flora. Early enteral feeding has also been linked to the amelioration of
oxidative stress after a patient has undergone surgery. The decrease in postoperative mortality
in patients is also a benefit of such nutritional support. In modern times, healthcare
professionals are focusing on feeding patients as soon as possible through such measures in
order to sustain stable patient conditions.
As highlighted by Blaser et al. (2017) early enteral nutrition is imperative is a crucial
element of the management plan for patients who are in critical condition. Nutrition is
important as it supplies antioxidants, vital cell substrates, minerals and vitamins that optimize
recovery from heath complications in a speedy process. Specialized immune-enhancing
nutritional formulations are into use at the present time that has been reported to decrease
inflammation, and augment cell-mediated immunity. Early enteral nutrition is elementary for
a decrease of organ failure, and in comparison to delayed enteral nutrition early enteral
nutrition improves wound healing, nitrogen balance and immunity. Augmenting the cellular
antioxidant systems is the mechanism of increasing the hypermetabolic response to tissue
injury and preserving the intestinal mucosal integrity. The decrease in bacterial translocation
and increase in mucosal permeability are the other possible mechanisms (Yang et al. 2014).
Shankar et al. (2015) reported that early enteral feeding protects the liver injury if there is
endotoxemia or haemorrhage, and kidney damage if there is rhabdomyolysis. They further
demonstrated that immediate enteral nutrition improves protein synthesis.
In the present patient case study, 55-year-old Helen had been shifter from thee
emergency department to the intensive care unit after suffering a high-speed motor vehicle
injury at 22:30. The patient had suffered several high rib fractures and major lung contusion/

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haemothorax. In addition, she had a fractured left humerus, left femur and a collapsed pelvis.
While in the ICU, she was commenced on maintenance fluid and saline. Vital signs were
observed for the next two days whose reports indicated that the patient was
haemodynamically stable. Enteral nutrition was after that commenced for the patient. In this
case, the patient was not given early enteral feeding since the definition for the same indicates
that the feeding is to be given one the very first day of admission to the clinical setting. The
observed feeding pattern was late enteral feeding as it was commenced after 48 hours of
patient admission to the unit.
Bakiner et al. (2013) have pointed out that late enteral feeding in case of patients who
have suffered tissue and organ injury are linked to intestinal inflammation and other adverse
outcomes. Under certain conditions, clinicians have the decision making process pertaining to
enteral feeding in favour of late enteral nutrition. Delay in advancing enteral nutrition has
been criticised widely. Compelling evidence indicates that there are certain drawbacks
associated with such practices. Studies have shown that prolonged period of lack of adequate
nutritional support delays mucosal atrophy, mucosal nutrition, and causes dysregulation of
secretion of trophic hormones. Late enteral nutrition in case of patients suffering trauma
augments the chances of mortality. Further, lack of early enteral feeding might lead to sepsis
and increased chances of a systematic inflammatory response. Enteral nutrition is to be
started soon after the injury to achieve haemodynamic stability and ensure that resuscitation
is complete (Jeejeebhoy 2016).
Post surgery, for fixing the pelvis and pinning the femur, the condition of the patient
deteriorated considerably. The patient suffered circulatory and ventilation problems,
demanding more detailed monitoring. She required blood products due to coagulation
disorders, as well as inotrope support for peripheral oedema. While the albumin was 26 g/L,
the blood glucose was 8.5 mmol/L. The normal range of albumin in adults is 35-55 g/L, while

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that of blood glucose is 3.9–5.5 mmol/L (Pocock, Richards and Richards 2013). The
laboratory results indicated higher levels of creatinine and urea at 120 umol/L and 12 mmol/L
respectively. The reference range for the same is 50-110 umol/L and 1.5-7 mmol/L
respectively (Shier, Butler and Lewis 2015). The results indicated kidney damage and
increased protein catabolism due to stress and major illness. Normal levels of Haemoglobin
in adult females is 120-156 g/L while in the present case it was found to be low at 98 g/L.
Further, the patient reported lactic acidosis since the value of lactate was 2.6 mmol/L. The
common causes of lactic acidosis are ischemia, respiratory failure, renal dysfunction and
sepsis.
On the sixth day, and after a percutaneous tracheometry, there was a rise in the
patient’s body temperature with an increased count of WBC. This suggested that the patient
had incurred an infection for which antibiotics had to be administered. An early enteral
nutrition would have increased the immunity level of the patient and would have prevented
infection through bacterial translocation. Laboratory reports indicated renal and liver function
impairment. Further, a loose stool indicated complications in the digestive tract. On the tenth
day, the patient suffered a circulatory collapse after complaining of nausea, vomiting and
abdominal discomfort. Upon discharge, she was found to have lost body fat and reported of
weakness. As opined by White, Guenter and Jensen (2017) late enteral nutrition often is
unable to cope with the immediate nutritional requirements of a patient in case of severe
trauma and injury. For preventing secondary infection, it is pivotal to deliver nutritional
support the moment possible. An early enteral nutrition would have better supported the
patient in achieving optimal health outcomes.

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References
Bakiner, O., Bozkirli, E., Giray, S., Arlier, Z., Kozanoglu, I., Sezgin, N., Sariturk, C. and
Ertorer, E., 2013. Impact of early versus late enteral nutrition on cell mediated immunity and
its relationship with glucagon like peptide-1 in intensive care unit patients: a prospective
study. Critical Care, 17(3), p.R123.
Blaser, A.R., Starkopf, J., Alhazzani, W., Berger, M.M., Casaer, M.P., Deane, A.M.,
Fruhwald, S., Hiesmayr, M., Ichai, C., Jakob, S.M. and Loudet, C.I., 2017. Early enteral
nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care
Medicine, 43(3), pp.380-398.
Boelens, P.G., Heesakkers, F.F., Luyer, M.D., van Barneveld, K.W., de Hingh, I.H.,
Nieuwenhuijzen, G.A., Roos, A.N. and Rutten, H.J., 2014. Reduction of postoperative ileus
by early enteral nutrition in patients undergoing major rectal surgery: prospective,
randomized, controlled trial. Annals of surgery, 259(4), pp.649-655.
Jeejeebhoy, K.N., 2016. Nutrition Needs Should Be Modified to Consider Nutrition Status
and Acuity of Illness Lessons From the INTACT Trial. Journal of Parenteral and Enteral
Nutrition, 40(1), pp.10-11.
McClave, S.A., Taylor, B.E., Martindale, R.G., Warren, M.M., Johnson, D.R., Braunschweig,
C., McCarthy, M.S., Davanos, E., Rice, T.W., Cresci, G.A. and Gervasio, J.M., 2016.
Guidelines for the provision and assessment of nutrition support therapy in the adult critically
ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral
and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), pp.159-
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Pocock, G., Richards, C.D. and Richards, D., 2013. Human physiology. Oxford university
press.
Shankar, B., Daphnee, D.K., Ramakrishnan, N. and Venkataraman, R., 2015. Feasibility,
safety, and outcome of very early enteral nutrition in critically ill patients: Results of an
observational study. Journal of critical care, 30(3), pp.473-475.
Shier, D., Butler, J. and Lewis, R., 2015. Hole's essentials of human anatomy & physiology.
McGraw-Hill Education.
Sun, J.K., Mu, X.W., Li, W.Q., Tong, Z.H., Li, J. and Zheng, S.Y., 2013. Effects of early
enteral nutrition on immune function of severe acute pancreatitis patients. World journal of
gastroenterology: WJG, 19(6), p.917.
White, J., Guenter, P. and Jensen, G., 2017. Consensus statement: Academy of Nutrition and
Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics
recommended for the identification and documentation of adult malnutrition (undernutrition)
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Yang, S., Wu, X., Yu, W. and Li, J., 2014. Early enteral nutrition in critically ill patients with
hemodynamic instability: an evidence-based review and practical advice. Nutrition in
Clinical Practice, 29(1), pp.90-96.
Yu, J.H., Cha, W., Wang, H.J., Liu, X.L., Chen, X.F., Yin, Q.H., Ye, G.S., Wang, J., Fang,
Y. and Fu, S.N., 2014. The Effect of Tpf Enteral Nutrition on Nutritional Status and
Prognosis in Elderly Stroke Patients. Journal of the American Geriatrics Society, 62,
pp.S360-S361.