Early introduction of enteral feeding for patients with percutaneous cardiopulmonary support

Introduction

Early enteral nutrition has been shown to have a beneficial effect on intestinal integrity and motility, immunocompetence, and patient outcome. Generally, circulatory stability is needed for the introduction but, because there is no precise definition, we might miss the right time to begin. In the present study we attempted to establish early enteral nutrition for patients with cardiogenic shock with a ventricular assist device.

Methods

Ten postoperative patients with cardiogenic shock under percutaneous cardiopulmonary support were included. An enteral feeding tube was placed beyond the pylorus within 36 hours of operation under the observation of an upper gastrointestinal fiberscope. We estimated the mobility rate of the stomach by counting the number of vermiculation for 3 minutes at the pylorus. We assessed the movement of the intestine by observing the X-ray film to see whether the contrast medium we injected 3 hours before had moved or not. If the medium had moved rapidly to the colon, enteral formula was started at the rate of 20 ml/hour. The serum prealbumin concentration was measured every 7 days. Other laboratory data was compared with five control TPN patients retrospectively.

Results

The mobility rate of the stomach was decreased to 4.6 ± 3.2 times/3 minutes, but contrast media moved rapidly to the ascending colon in two patients, to the transverse colon in three patients, to the sigmoid colon in one patient, and to the rectum in three patients. One patient needed to stop enteral nutrition transiently because of reflux, but for the other nine patients enteral nutrition was well established. The prealbumin level also rose to 13 ± 3.5, 14.1 ± 4.9, 22 ± 2.8 weekly, but it was difficult to compare with control TPN patients because many of them died early. Serum ALP, total bilirubin, and direct bilirubin concentration 1 week after in survivors was lower in ED patients (ALP 437 ± 248 vs 566 ± 300, P = 0.57; total bilirubin 2.5 ± 2.5 vs 3.1 ± 1.0, P = 0.09; and direct bilirubin 1.5 ± 1.8 vs 2.1 ± 0.8, P = 0.09). Seven (70%) of the ED patients survived over 90 days (all five patients died in the TPN group).

Discussion

If mesenteric circulation were stable, enteral nutrition could not be contraindication. Even an improvement in patient outcome can be expected in the view of avoiding complications such as bacterial translocation.

Conclusion

Intestinal mobility is fairly maintained in patients with cardiopulmonary support, and early enteral nutrition can be established under close observation.