Different definitions of feeding intolerance and their associations with outcomes of critically ill adults receiving enteral nutrition: a systematic review and meta-analysis

Abstract

Background A unified clinical definition of feeding intolerance (FI) is urged for better management of enteral nutrition (EN) in critically ill patients. We aimed to identify optimum clinical FI definitions based on reported evidence. Methods We searched clinical studies comparing FI with non-FI with a clear definition, summarized the evidence by random-effect meta-analyses, and rated the certainty of evidence by the Grading of Recommendations Assessment, Development and Evaluation frameworks. Results Five thousand five hundred twenty-five records were identified, of which 26 eligible studies enrolled 25,189 adult patients. Most patient-centered outcomes were associated with FI overall. Low to very low certainty evidence established FI defined as large gastric residual volume (GRV) ≥ 250 ± 50 mL combined with any other gastrointestinal symptoms (GIS) had a significant association with high mortalities in particular all-cause hospital mortality (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.40–2.57), the incidence of pneumonia (OR 1.54, 95% CI 1.13–2.09) and prolonged length of hospital stay (mean difference 4.20, 95% CI 2.08–6.32), with a moderate hospital prevalence (41.49%, 95% CI 31.61–51.38%). 3-day enteral feeding (EF) delivered percentage < 80% had a moderate hospital prevalence (38.23%, 95% CI 24.88–51.58) but a marginally significant association with all-cause hospital mortality (OR 1.90, 95% CI 1.03–3.50). Conclusions In critically ill adult patients receiving EN, the large-GRV-centered GIS to define FI seemed to be superior to 3-day EF-insufficiency in terms of both close associations with all-cause hospital mortality and acceptable hospital prevalence (Registered PROSPERO: CRD42022326273). Trial registration: The protocol for this review and meta-analysis was registered with PROSPERO: CRD42022326273. Registered 10 May 2022.

Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study

“…It is necessary to enhance ICU nurses’ knowledge of enteral nutrition management to facilitate the development of standardized enteral nutrition protocols [ 30 , 31 ]. Currently, the threshold for GRV is not uniform in clinical settings, with 200–500 mL being the most common [ 32 , 33 ]. This is not conducive to ICU nurses’ judgment of GRV thresholds, which may lead to some degree to nurse-induced ENI.…”

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

“…Other common presentations encompass vomiting (18.68%), loss of bowel sounds (15.54%), abdominal distension (12.19%), and diarrhea (5.24%). [ 111 ] A systematic review conducted by Blaser et al [ 109 ] underscored the historical reliance on HGRV, either alone or in combination with vomiting, diarrhea, and abdominal distension, as a common symptom/method employed in studies assessing feeding intolerance. However, defining the threshold for HGRV has exhibited significant variation, ranging widely from 75 mL to 500 mL.…”

“…It's important to acknowledge the limitations of the 72-h diagnostic time window, alongside outcome risk assessment and incidence, while employing this diagnostic approach. [ 111 ] Given the higher prevalence of feeding intolerance diagnosed based on feeding amount in hospital settings and its association with overall mortality risk, a careful consideration between the two diagnostic methods or a combination thereof is recommended. This decision should weigh the practical and clinical nuances of each approach to better address the complexities in managing feeding intolerance among critically ill patients.…”

Best evidence summary for prevention and management of enteral feeding intolerance in critically ill patients

“…Intensive Care Association, 2021; Hua et al, 2023;McClave et al, 2020). However, some previous studies (Eveleens et al, 2020;Li et al, 2023;Preiser et al, 2021) have defined feeding intolerance only by gastrointestinal symptoms.…”

“…Enteral feeding intolerance refers to difficulties in enteral nutrition for various reasons, including high gastric residual volume, vomiting, abdominal distention, diarrhoea and other gastrointestinal adverse reactions, accompanied by a reduction in the ingested amount of enteral nutrition infusion and an inability of the patient to reach 20 kcal/(kg day) within 72 h (Chinese Abdominal Intensive Care Association, 2021; Hua et al., 2023; McClave et al., 2020). However, some previous studies (Eveleens et al., 2020; Li et al., 2023; Preiser et al., 2021) have defined feeding intolerance only by gastrointestinal symptoms.…”