Influence of gastric residual assessment in preterm neonates on time to achieve enteral feeding (the GRASS trial)-Multi-centre, assessor-blinded randomised clinical trial.

PURPOSE: Gastric residual measurement is routinely performed in premature infants prior to feeding despite a lack of evidence of benefit. We aimed to evaluate if the exclusion of routine gastric residual measurement and evaluation has an impact on the time taken to achieve full enteral feeding in preterm neonates. METHODS: International multi-centre randomised controlled trial. Clinically stable, appropriate for gestational age infants between 26+0 and 30+6 weeks of gestation and less than 1.5 kg birth weight were eligible. Infants were randomised to the intervention arm (no monitoring of gastric aspirates) or control arm (routine care). Primary outcome was the achievement of enteral feeds of 100 ml/kg/day by day 5 of life. RESULTS: Ninety-five infants were recruited with 88 included in an intention-to-treat analysis, 45 in the intervention arm and 43 in the control arm. There was no imbalance in baseline characteristics. Thirty-three (73.3%) infants in the intervention group and 32 infants (74.4%) in the control group reached full feeds by day 5 of life (p = 0.91) with no difference in median time to full feeds. There were no statistically significant differences in survival or the major morbidities of prematurity. CONCLUSION:  There was no difference in time to attainment of enteral feeds of 100 ml/kg/day in premature infants when gastric residuals were not monitored. In the absence of a clinical benefit to routine monitoring, it may be appropriate to discontinue this practice and only monitor residuals when clinical concern of feeding intolerance or gastrointestinal pathology arises in this group of patients. TRIAL REGISTRATION:  NCT03111329- https://clinicaltrials.gov/ . Registered 06/04/2017. WHAT IS KNOWN: • Previous randomized trials have shown little benefit to the performance of routine assessment of gastric residuals in preterm infants. Despite this, they continue to be performed due to concerns from observational data regarding development of NEC. Meta-analysis to date has failed to answer the question regarding NEC. WHAT IS NEW: • In very low birth weight infants who are fed using modern feeding practice of faster feed advancement, to minimize use of central access and parenteral nutrition, exclusion of routine checks of gastric residuals did not increase the proportion of infants reaching full enteral feeds by day 5. No harm was seen when residual checks were not performed. • In the absence of a clinical benefit to the routine performance of gastric residuals in very low birth weight infants, it may be appropriate to discontinue their use and instead check residuals when clinical concern of pathology arises.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients.

INTRODUCTION: Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States. METHODS: We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap. RESULTS: We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different. CONCLUSIONS: Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Assessment the knowledge, care, and experiences of neonatal nurses about enteral nutrition.

Enteral-feeding refers to any nutritional method throughout the gastrointestinal tract, including oral feeding. This qualitative study examined the information, experiences, and records of neonatal nurses of enterally fed patients. The study was conducted between 05.04.2018 and 05.05.2018 with 22 nurses (73.3%) working in the neonatal intensive care clinic of Çukurova University Balcali Hospital, Adana, Turkey. The data were collected by "Observation and Interview Form" developed based on the literature. Nurses were observed, and interviews were conducted depending on their appointments. Data were collected by observing each nurse on 2 different days. In all observations; it was determined that the nurses changed the feeding set daily, regularly checked the location of the feeding tube and amount of residue, and administered medication through the feeding tube. In 22.7% of the observations, nurses did not securely fix the feeding tube, 27.2% did not write a daily date on the injector with the residual volume measured, and 31.8% did not wash the injector. All the nurses recorded the amount of feed, residual amounts, and content. At the end of the interviews, 9% of the nurses stated that they had experienced aspiration among the complications encountered during enteral feeding. During the interview, they stated that all nurses were educated about enteral nutrition, had control of whether the probe was in place before feeding, performed residual control, washed their hands before the procedure, fixed the food injector to 1 place, and allowed the food injector to flow spontaneously with negative pressure. According to the results of the interviews and observations, nurses could not reflect on their nursing practices correctly. Nurses working in neonatal intensive care units should be regularly trained to share the results of evidence-based studies on enteral nutrition.

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room.

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Current practice of gastric residual volume measurements and related outcomes of critically ill patients: A secondary analysis of the intestinal-specific organ function assessment study.

BACKGROUND: Gastric residual volume (GRV) measurement to detect gastrointestinal (GI) dysfunction is a common diagnostic procedures in critical care, albeit still not well standardized being operator-, patient-, and tube-dependent. Our aim was to describe current practice of GRV measurements and its association with clinical outcomes in critically ill patients. METHODS: This was a secondary analysis of an international prospective observational cohort study (intestinal-specific organ function assessment). Eligibility criteria were defined as ≥1 GRV measurement during the 7-day study period. Data collection included GRV measurement practices, tube diameters and volumes, symptoms of GI dysfunction, and clinical outcomes. The primary aim was to describe current practices of GRV measurements, and the secondary aim was to test the association of high (>200 ml) vs. low GRV with symptoms of GI dysfunction and clinical outcomes using generalized linear regression and survival models. RESULTS: Two hundred fifty-eight patients with 2422 GRV measurements on 875 study days were analyzed. GRV was mainly measured via passive drainage twice daily using large diameter tubes. There was no significant association between tube size or measurement technique and high GRV. High GRV occurred in 34% of patients and was associated with other GI symptoms and with increased disease severity but not with 28-day or 90-day mortality, intensive care unit-free and ventilator-free days. CONCLUSION: There was substantial variability of GRV measurement techniques, but this had no impact on the amount of GRV. High GRV was not associated with mortality or ventilator-free days but may serve as a marker of GI dysfunction and disease severity.

Small-bore feeding tubes placed with an electromagnetic imaging device leads to cost avoidance and decreased time to initiation of enteral nutrition.

BACKGROUND: The Cortrak Enteral Access System (CEAS) was previously approved by the United States Food and Drug Administration (FDA) to be used in lieu of radiographic confirmation imaging for feeding tubes placed by trained clinicians. Following an institutional protocol change in 2016, our registered dietitians had the option to forgo radiographic confirmation imaging for tubes placed using the CEAS. Our research aimed to determine the difference in the number of radiographic confirmation images for feeding tubes placed using the CEAS between preprotocol and postprotocol environments and the associated cost avoidance after the institutional policy change. METHODS: We retrospectively reviewed data from 506 tube placements (n = 253 per protocol environment) in adult patients with diverse diagnoses admitted to various in-patient care units. RESULTS: There was a significant reduction in the mean number of radiographic images per tube placement (preprotocol = 1.10 [95% CI, 1.05-1.15]; postprotocol = 0.36 [95% CI, 0.30-0.41]; P < 0.001), leading to a cost avoidance of $67,282.80 for the 253 tube placements and a potential cost avoidance of $279,236 over the 5-year postprotocol environment. Additionally, the mean time to initiation of enteral nutrition was significantly reduced by 2.65 h in the postprotocol environment (P < 0.001). CONCLUSION: Our findings suggest that using the CEAS can reduce the number of radiographic images, provide cost avoidance, and improve nutrition outcomes. However, updated 2022 FDA regulatory changes to the use of the CEAS for tube confirmation lead to an uncertain future for this practice because of safety concerns.

Assessment of Oral Health in Long-Term Enteral and Parenteral Nutrition Patients: Significant Aspects of Nursing Care.

Oral health is an underestimated factor affecting overall human health and quality of life. Long-term enteral or parenteral nutritional treatment requires not only regular assessment of access routes, the patient's nutritional status, and tolerance to the selected method of nutrition but also of oral health. This article discusses the connections between the influence of chewing function, salivation, and xerostomia on the health of the oral cavity of patients on long-term enteral and parenteral nutrition. In addition, the role of nurses in assessing oral health is presented as well as crucial elements of a comprehensive oral assessment in a nursing care plan. Patients receiving long-term enteral and parenteral nutrition have an increased risk of developing oral diseases. Increasing knowledge about the factors affecting oral health among nurses is crucial to provide appropriate care for patients requiring long-term nutritional treatment with omission of the natural route of food intake. Regular assessment of oral health by nurses should be an important aspect in long-term nutritional treatment recommendations.

Systematic review of service improvements for home enteral tube feeding in adults.

BACKGROUND: Patients receiving home enteral tube feeding (HETF) have a high risk of complications and readmission to hospital. This study aims to evaluate effectiveness of staff- and/or patient-focused service-improvement strategies on clinical, patient-reported, and economic outcomes for patients receiving HETF across adult settings. METHODS: The search was conducted using MEDLINE, EMBASE, and CINAHL databases. Quality of studies were appraised using the Cochrane Collaboration Risk of Bias tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment. RESULTS: Eleven studies met the inclusion criteria. Pooled data found targeted HETF education with patients, carers, and staff significantly improved knowledge immediately after education and was sustained at 3-6 months. Multimodal interventions, including the formation of specialist HETF teams, significantly reduced complications such as infection, gastrostomy blockage, tube displacement, and feed intolerance but do not significantly reduce unplanned hospital encounters (outpatient clinic visits, hospitalizations, and emergency presentations). Owing to the high risk of bias in the included studies, there is low-quality evidence to support staff training, patient education, and dedicated HETF teams. CONCLUSION: This review highlights the need for further quality research to allow higher-level evidence for determining the usefulness of interventions aimed at improving outcomes for patients receiving HETF. Future research needs to include greater assessment of quality of life, quantification of the value of interventions in economic terms, and use of translational research frameworks. However, effective staff and patient education programs, along with comprehensive multidisciplinary care, should be considered standard care until a larger research base is developed.

Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE).

Parenteral nutrition (PN) is recommended in patients nutritionally at risk and unable to receive oral or enteral nutrition. A standardized electronic PN order format could enhance appropriate PN prescribing. We developed the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate PN using a Validated Electronic decision TREE), embedded in our electronic health record. We aimed to evaluate its validity and impact on physicians' prescribing behavior. A non-randomized before-after study was carried out in a tertiary care center. The OLIVE TREE comprises 120 individual items. A process validation was performed to determine interrater agreement between a pharmacist and the treating physician. To estimate the proportion of patients for whom the OLIVE TREE had an effective and potential impact on physicians' prescribing behavior, a proof of concept study was conducted. The proportion of patients for whom PN was averted and the proportion of decisions not in line with the recommendation were also calculated. The process validation in 20 patients resulted in an interrater agreement of 95.0%. The proof of concept in 73 patients resulted in an effective and potential impact on prescribing behavior in 50.7% and 79.5% of these patients, respectively. Initiation of PN was not averted and recommendations of the OLIVE TREE were overruled in 42.5% of the patients. Our newly developed OLIVE TREE has a good process validity. A substantial impact on prescribing behavior was observed, although initiation of PN was not avoided. In the next phase, the decision tree will be implemented hospital-wide.

Assessment of nutritional status of the cirrhotic patients on enteral and parenteral feeding.

BACKGROUND: Cirrhosis is an irreversible disease that replaces healthy tissues with scar tissues. According to the Pakistan Medical Research Council's national general population survey (2008-2014), the ratio of cirrhosis was 4.8% among the population. OBJECTIVES: To assess the nutritional status of cirrhotic patients on enteral and parenteral nutrition and to assess the degree of malnutrition among cirrhotic patients. METHODS: A cross-sectional study was conducted at Shalamar and Shiekh Zayed Hospitals of Lahore from January-April 2017. The convenient sampling technique was used. Inclusion criteria were the patients with decompensated liver cirrhosis, whereas compensated patients were excluded from the study. Data were collected through the patient's file, nurse's, and dietitian's notes. The nutritional status of participants was assessed based on socio-demographic characteristics, anthropometric measurements, biochemical assessment, clinical signs, and dietary recall. Variables were categorized and compared to observe the level of significance in enteral and parenteral nutrition. SPSS version 22 was used to analyze data. RESULTS: Patients on parenteral nutrition had a higher ratio of malnutrition with a significant Child-Pugh score-61.8% of patients belonged to Class C and 35.3% Class B, while in enteral support, 7.3% belonged to Class C and 43.9% patients belonged to Class B (p-value = 0.000). There was a definite relationship observed in the route of intake and malnutrition among cirrhotic patients. CONCLUSION: Enteral route of nutrition is an effective and the safest way to provide appropriate nutrients according to the patient's demands.

Cost-effectiveness analysis of nasojejunal tube feeding for the prevention of pneumonia in adults who are critically ill.

BACKGROUND: Nasojejunal tube (NJT) feeding has demonstrated value in reducing pneumonia in adults who are critically ill who require enteral nutrition (EN) support. This study discusses whether EN support via NJT feeding is more cost-effective than nasogastric tube (NGT) feeding in reducing pneumonia. METHODS: A decision-tree model was created. The analysis was based on data from a health care provider in China. Model inputs were derived from published data. The end points included incremental cost per pneumonia infection avoided, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and incremental NMB (INMB) associated with prevention of pneumonia. The uncertainty was assessed through one-way and probabilistic sensitivity analysis. RESULTS: The base case analysis showed that EN support via NJT feeding resulted in 0.7453 quality-adjusted life years (QALYs) at a cost of $3018.83 compared with NGT feeding, which resulted in 0.7354 QALYs at a cost of $4788.76. NJT feeding was better than NGT feeding, providing an INMB of $2075.09 and an ICER of -$178,813.96 per QALY gained, and the cost per pneumonia infection prevented was $16,808.51. The probabilistic sensitivity analysis indicated that NJT feeding was more cost-effective in 83.4% of the cases, with a cost below the WTP threshold. The NMB and INMB estimation for different WTP thresholds also indicated that NJT feeding is the optimal strategy. CONCLUSIONS: EN support via NJT feeding was a more cost-effective strategy than NGT feeding in preventing pneumonia in adults who are critically ill.

Nurse-performed ultrasound assessment of gastric residual volume and enteral nasogastric tube placement in the general intensive care unit.

OBJECTIVE: Ultrasonography is an essential imaging modality in the critical care population and has been increasingly utilized to check gastric residual volume . Various studies have shown that intensive care unit nurses untrained in ultrasound can easily be trained in its accurate interpretation. We prospectively analyzed nurse-performed repeated measurements of gastric residual volume and nasogastric tube positioning via an ultrasound technique in the intensive care unit. DESIGN: This was a single-center, cross-sectional prospective study. Four intensive care unit nurses, evenly divided into two groups (teams A and B), underwent four hours of formal ultrasound training by three critical care staff physicians. The trained nurses provided bedside ultrasound assessments of gastric residual volume and nasogastric tube positioning which were compared to a standard protocol of syringe aspiration. RESULTS: Ninety patients were recruited to the study. Four measurements per patient were performed, for a total of 360 assessments. The ultrasound gastric residual volume assessments were correlated with the syringe aspiration protocol and demonstrated high Intraclass Correlation Coefficient rates of 0.814 (0.61-0.92) for team A and 0.85 (0.58-0.91) for team B. Nasogastric tube placement was successfully and independently verified by ultrasound in most of the critically ill patients (78% of team A and 70% of team B). The comparative ultrasound assessments of tube positioning demonstrated good correlation of 0.733 (0.51-0.88) between each team's two independent observers. CONCLUSION: Our study demonstrated a strong correlation between US utilization for assessment of gastric residual volume and nasogastric tube positioning and standard protocol methods, suggesting it is a safe, simple and effective practice for intensive care unit nurses.

Small bowel feeding: do you pay the price for bypassing the stomach?

PURPOSE OF REVIEW: Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians. RECENT FINDINGS: Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function. SUMMARY: The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.

Effect of enterally administered sleep-promoting medication on the intravenous sedative dose and its safety and cost profile in mechanically ventilated patients: A retrospective cohort study.

BACKGROUND: The clinical effect of enteral administration of sleep-promoting medication (SPM) in mechanically ventilated patients remains unclear. This study aimed to investigate the relationship between enteral SPM administration and the intravenous sedative dose and examine the safety and cost of enteral SPM administration. METHODS: This single-center retrospective cohort study was conducted in a Japanese tertiary hospital intensive care unit (ICU). The exposure was enteral SPM administration during mechanical ventilation. The outcome was the average daily propofol dose per body weight administered as a continuous sedative during mechanical ventilation. Patients were divided into three groups based on the timing of SPM administration at ICU admission: "administration within 48 hours (early administration [EA])," "administration after 48 hours (late administration [LA])," and "no administration (NA)." We used multiple linear regression models. RESULTS: Of 123 included patients, 37, 50, and 36 patients were assigned to the EA, LA, and NA groups, respectively. The average daily propofol dose per body weight was significantly lower in the EA group than in the LA and NA groups (ß -5.13 [95% confidence interval (CI) -8.93 to -1.33] and ß -4.51 [95% CI -8.59 to -0.43], respectively). Regarding safety, enteral SPM administration did not increase adverse events, including self-extubation. The total cost of neuroactive drugs tended to be lower in the EA group than in the LA and NA groups. CONCLUSIONS: Early enteral SPM administration reduced the average daily propofol dose per body weight without increasing adverse events.

Energy Expenditure, Protein Oxidation and Body Composition in a Cohort of Very Low Birth Weight Infants.

The nutritional management of preterm infants is a critical point of care, especially because of the increased risk of developing extrauterine growth restriction (EUGR), which is associated with worsened health outcomes. Energy requirements in preterm infants are simply estimated, so the measurement of resting energy expenditure (REE) should be a key point in the nutritional evaluation of preterm infants. Although predictive formulae are available, it is well known that they are imprecise. The aim of our study was the evaluation of REE and protein oxidation (Ox) in very low birth weight infants (VLBWI) and the association with the mode of feeding and with body composition at term corrected age. METHODS: Indirect calorimetry and body composition were performed at term corrected age in stable very low birth weight infants. Urinary nitrogen was measured in spot urine samples to calculate Ox. Infants were categorized as prevalent human milk (HMF) or prevalent formula diet (PFF). RESULTS: Fifty VLBWI (HMF: 23, PFF: 27) were evaluated at 36.48 ± 0.85 post-conceptional weeks. No significant differences were found in basic characteristics or nutritional intake in the groups at birth and at the assessment. No differences were found in the REE of HMF vs. PFF (59.69 ± 9.8 kcal/kg/day vs. 59.27 ± 13.15 kcal/kg/day, respectively). We found statistical differences in the protein-Ox of HMF vs. PFF (1.7 ± 0.92 g/kg/day vs. 2.8 ± 1.65 g/kg/day, respectively, p < 0.01), and HMF infants had a higher fat-free mass (kg) than PFF infants (2.05 ± 0.26 kg vs. 1.82 ± 0.35 kg, respectively, p < 0.01), measured with air displacement plethysmography. CONCLUSION: REE is similar in infants with a prevalent human milk diet and in infants fed with formula. The HMF infants showed a lower oxidation rate of proteins for energy purposes and a better quality of growth. A greater amount of protein in HMF is probably used for anabolism and fat-free mass deposition. Further studies are needed to confirm our hypothesis.

Sonda botton para gastrostomia em crianças e adolescentes / Botton probe for gastrostomy in children and teenagers

INTRODUÇÃO: A terapia nutricional enteral é uma possibilidade terapêutica indicada para os pacientes cujo sistema digestivo possui forma anatômica e funcionamento normais, mas que não conseguem ingerir alimentos por via oral. Essa terapia possibilita a redução do tempo de internação hospitalar, mortalidade e custos assistenciais. A viabilização da via gástrica depende de tecnologia em saúde, isto é, da implantação de dispositivo de alimentação via percutânea tipo sonda que possibilite a administração de nutrientes ao paciente na forma isolada ou combinada. TECNOLOGIA: Sonda Botton. PERGUNTA DE PESQUISA: O uso de sonda botton em crianças e adolescentes com gastrostomia quando comparado ao uso da sonda longa de silicone é eficaz, seguro e custo-efetivo? EVIDÊNCIAS CLÍNICAS: Foi realizada revisão sistemática da literatura a fim de identificar estudos que tenham comparado o uso da sonda botton e da sonda longa em pacientes com gastrostomia com idade até 18 anos. Não foram identificados ensaios clínicos comparando as tecnologias. Ao todo, 5 estudos observacionais comparativos foram selecionados. De acordo com as evidências disponíveis, a ocorrência de complicações como deslocamento da sonda, vazamento e formação de tecido de hipergranulação são menos frequentes em pacientes com sonda botton. A troca da sonda ocorreu em menor proporção entre pacientes com sonda botton. De maneira geral, os autores sugerem que a estrutura a nível de pele da sonda botton propicia melhor perfil estético e maior facilidade de manutenção, o que acarreta boa aceitabilidade por cuidadores e pacientes. AVALIAÇÃO ECONÔMICA: Foi realizada análise de custo-efetividade, sob a perspectiva do SUS, comparando a sonda botton com a sonda longa em pacientes com gastrostomia com idade até 18 anos. Utilizou-se um modelo de árvore de decisão que incluiu a ocorrência de complicações e troca da sonda. Foram considerados os custos médicos diretos relacionados aos dispositivos e manejo de eventos adversos. O horizonte temporal da análise foi de um ano, pelo que não foram aplicadas taxas de desconto. Obteve-se uma razão de custo-efetividade incremental com o uso da sonda botton igual a R$ 4.761,16 por paciente sem complicações. ANÁLISE DE IMPACTO ORÇAMENTÁRIO: O impacto orçamentário incremental gerado pela incorporação da sonda botton em um horizonte temporal de 5 anos totalizou R$ 13.989.486,00. MONITORAMENTO DO HORIZONTE TECNOLÓGICO: Foram encontrados uma patente concedida e um depósito patentário relacionados à tecnologia. A patente apresenta um sistema de alimentação por tubo gastrointestinal de baixo perfil (do tipo botton), composto por um dispositivo de fixação, conjunto de alimentação e tubo de gastrostomia. Já o depósito aborda um dispositivo de gastrostomia de baixo perfil de aplicação endoscópica que possui uma porção média tubular que se estende da extremidade intragástrica para o exterior por meio do estômago e das paredes abdominais, e uma extremidade externa de baixo perfil tendo um par de projeções em forma de asa que engatam a superfície externa ou pele da parede abdominal do paciente. CONSIDERAÇÕES FINAIS: A literatura científica comparando a eficácia e segurança da sonda botton com as sondas longas é escassa. No entanto, acredita-se que isso se deva ao fato de que esta não seja uma tecnologia nova, mas sim um dispositivo amplamente difundido em diferentes países e cuja efetividade e segurança são conhecidos. O aspecto estético favorável, a maior facilidade de manutenção e a menor incidência de complicações resultam na preferência por este tipo de sonda entre pacientes, cuidadores e comunidade médica. A sonda botton tem custo significativamente maior do que as sondas longas, o que pode ser determinante para a baixa difusão da tecnologia no Brasil. Supõe-se que análises levando em conta a qualidade de vida do paciente poderiam resultar ainda mais favoráveis à sonda botton, mas, no entanto, estudos adicionais seriam necessários. PERSPECTIVA DO PACIENTE: A chamada pública para a Perspectiva do Paciente nº 38/2021 sobre a sonda Botton para gastrostromia em crianças e adolescentes foi realizada entre os dias 15 e 20 de junho de 2021 e contou com a inscrição de 11 pessoas. A indicação dos representantes titular e suplente foi feita a partir de sorteio em plataforma on-line, gravado e enviado aos inscritos. A representante titular relatou que a sonda Botton apresentou os seguintes benefícios para a qualidade de vida dos pacientes: facilitação na mudança de posição do paciente, da troca de fralda, do banho no leito e da fisioterapia. Além disso, o uso da sonda Botton contribuiu para a inclusão social e engajamento nas atividades familiares, o que também se fez presente na experiência da representante suplente. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Diante do exposto, o Plenário da Conitec, em sua 100ª Reunião ordinária, no dia 05 de agosto de 2021, deliberou que a matéria fosse disponibilizada em Consulta Pública com recomendação preliminar favorável à incorporação no SUS da sonda de gastrostomia Botton para alimentação enteral exclusiva ou parcial de crianças e adolescentes. Justificou-se esta recomendação devido a tecnologia ser de uso difundido internacionalmente e se apresentar de forma segura e eficaz às tradicionais sondas longas, com a vantagem de proporcionar melhor qualidade de vida aos pacientes e cuidadores. Além disso, o valor de custo-efetividade incremental foi considerado razoável diante dos potenciais benefícios advindos de seu uso em crianças com gastrostomia. A matéria foi disponibilizada em consulta pública. CONSULTA PÚBLICA: Foram recebidas 425 contribuições, sendo 84 contribuições técnico-científicas e 341 de experiência e opinião. Todas as contribuições, exceto uma, concordaram com a recomendação preliminar da Conitec que é favorável à incorporação da sonda botton. Em sua maioria, os argumentos apresentados mencionam as vantagens da sonda botton quanto à menor ocorrência de eventos adversos e à maior qualidade de vida que proporciona ao paciente. Estes argumentos foram mencionados tanto por participantes profissionais de saúde quanto por pacientes, cuidadores ou familiares. DELIBERAÇÃO FINAL DA CONITEC: Pelo exposto, os membros do Plenário da Conitec, em sua 102ª Reunião Ordinária, no dia 06 de outubro de 2021, deliberou por unanimidade recomendar a incorporação da sonda de gastrostomia botton para alimentação enteral exclusiva ou parcial de crianças e adolescentes, no SUS. O Plenário considerou que as contribuições recebidas em Consulta Pública não modificaram o entendimento no qual se baseou a recomendação preliminar, acerca do custo incremental razoável diante dos potenciais benefícios clínicos em ganhos em qualidade de vida dos pacientes, para recomendar a incorporação desta tecnologia. Assim, foi assinado o Registro de Deliberação nº 667/2021. DECISÃO: Incorporar a sonda botton para gastrostomia em crianças e adolescentes, no âmbito do Sistema Único de Saúde ­ SUS,conforme a Portaria nº 70, publicada no Diário Oficial da União nº 211, seção 1, página 151, em 10 de novembro de 2021.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions.

BACKGROUND: Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures. METHODS: A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. RESULTS: A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus. CONCLUSION: This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

Feeding during neonatal therapeutic hypothermia, assessed using routinely collected National Neonatal Research Database data: a retrospective, UK population-based cohort study.

BACKGROUND: Therapeutic hypothermia is standard of care in high-income countries for babies born with signs of hypoxic ischaemic encephalopathy, but optimal feeding during treatment is uncertain and practice is variable. This study aimed to assess the association between feeding during therapeutic hypothermia and clinically important outcomes. METHODS: We did a population-level retrospective cohort study using the UK National Neonatal Research Database. We included all babies admitted to National Health Service neonatal units in England, Scotland, and Wales between Jan 1, 2010, and Dec 31, 2017, who received therapeutic hypothermia for 72 h or died during this period. For analysis, we created matched groups using propensity scores and compared outcomes in babies who were fed versus unfed enterally during therapeutic hypothermia. The primary outcome was severe necrotising enterocolitis, either confirmed at surgery or causing death. Secondary outcomes include pragmatically defined necrotising enterocolitis (a recorded diagnosis of necrotising enterocolitis in babies who received at least 5 consecutive days of antibiotics while also nil by mouth during their neonatal unit stay), late-onset infection (pragmatically defined as 5 consecutive days of antibiotic treatment commencing after day 3), survival to discharge, measures of breastmilk feeding, and length of stay in neonatal unit. FINDINGS: 6030 babies received therapeutic hypothermia, of whom 1873 (31·1%) were fed during treatment. Seven (0·1%) babies were diagnosed with severe necrotising enterocolitis and the number was too small for further analyses. We selected 3236 (53·7%) babies for the matched feeding analysis (1618 pairs), achieving a good balance for all recorded background variables. Pragmatically defined necrotising enterocolitis was rare in both groups (incidence 0·5%, 95% CI 0·2-0·9] in the fed group vs 1·1% [0·7-1·4] in the unfed group). The enterally fed group had fewer pragmatically defined late-onset infections (difference -11·6% [95% CI -14·0 to -9·3]; p<0·0001), higher survival to discharge (5·2% [3·9-6·6]; p<0·0001), higher proportion of breastfeeding at discharge (8·0% [5·1-10·8]; p<0·0001), and shorter neonatal unit stays (-2·2 [-3·0 to -1·2] days; p<0·0001) compared with the unfed group. INTERPRETATION: Necrotising enterocolitis is rare in babies receiving therapeutic hypothermia. Enteral feeding during hypothermia is safe and associated with beneficial outcomes compared with not feeding, although residual confounding could not be completely ruled out. Our findings support starting milk feeds during therapeutic hypothermia. FUNDING: UK National Institute for Health Research Health Technology Assessment programme 16/79/13.

Pediatric Acute Pancreatitis: Changes in Management and Disease Outcomes Over 16 Years.

OBJECTIVE: To examine the changes over time of pediatric acute pancreatitis (AP) severity, management, and disease outcomes at our academic tertiary center. METHODS: We reviewed 223 pediatric AP admissions (2002-2018) and used a time-to-event regression model to study changes over time. Disease outcomes were analyzed using a subgroup of 89 patients in whom only the AP event determined length of hospital stay and duration of opioid use. RESULTS: There was an increase in mild, but not severe, AP episodes over the examined period. June 2014 was identified as a single cutoff point for change in AP management and disease outcomes independent of each other and of disease severity. Timing of initiating enteral nutrition decreased from 5 to 1.6 days (P < 0.0001) in the entire cohort and from 4.1 to 1.8 days in the subgroup (P = 0.0001) after June 2014. Length of hospitalization decreased from 6 to 3.3 days (P = 0.0008) and days of opioid use from 4.1 to 1.3 (P = 0.002) after June 2014. CONCLUSIONS: Timing of initiating enteral nutrition has significantly reduced at our center after June 2014. In parallel, we observed a significant improvement in disease outcomes.

Gastrostomía endoscópica percutánea / Percutaneous endoscopic gastrostomy

ANTECEDENTES: Solicitud presentada por la Dirección General de la Dirección de Medicina, en relación a la opinión técnica sobre la adquisición de insumos médicos para el Equipo Funcional de Gastroenterología: Sistema de Gastrostomía Endoscópica para pacientes adultos y pediátricos. Pregunta Clínica: ¿Es la Gastrostomía endoscópica percutánea un procedimiento efectivo y seguro en pacientes con indicación de nutrición enteral por gastrostomía, en comparación a otras técnicas? Recolecciòn de los Manuscritos a Revisar: Tipos de estudios: La estrategia de búsqueda sistemática de información científica para el desarrollo del presente informe se realizó siguiendo las recomendaciones de la Pirámide jerárquica de la evidencia propuesta por Haynes y se consideró los siguientes estudios: Sumarios y guías de práctica clínica. Revisiones sistemáticas y/o meta-análisis. Ensayos Controlados Aleatorizados (ECA). Estudios Observacionales (cohortes, caso y control, descriptivos). Fuentes de información: De acceso libre o Bases de datos: Pubmed Fecha de búsqueda: La búsqueda sistemática se limitó a estudios publicados en los últimos 10 años. DISCUSIÓN: Tomando los criterios para un marco de valor de la Health Technology Assessment International (2018)17 para la toma de decisiones y formulación de la recomendación, se describe: La calidad de evidencia es alta. Se cuenta con recomendaciones de dos Guías de Prácticas Clínicas (GPC) internacionales, de alta calidad, las cuales emiten recomendaciones de uso de GEP, catalogado como un método eficaz para el soporte nutricional en pacientes a los que se les ha indicado nutrición enteral para un periodo mayor de 4 semanas y que tienen una expectativa de vida mayor a 2 meses. Así mismo, en comparación a otras técnicas de gastrostomía, muestran ser igual de efectivas, sin embargo; se prefiere este método por ser más segura y menos costoso. CONCLUSIONES: La nutrición enteral por gastrostomía está indicada en pacientes con una expectativa de vida mayor a 2 meses y necesidad de tratamiento por más de 4 semanas. Según la evidencia, la GEP es un método igual de seguro y más económico, comparado a otras técnicas de gastrostomía. El Set de GEP, es comercializado a nivel nacional. Cuenta con Código SIGAMEF y Registro Sanitario. Además ya hemos contado con esta tecnología en nuestra institución. El costo del Set es de S/ 560, lo cual es más económico que los set de las otras técnicas de inserción de sondas de gastrostomías. Por lo expuesto, la UFETS en consenso con el panel, emite opinión favorable para el uso de la tecnología Set de Gastrostomía endoscópica percutánea (GEP).