Preventive Strategies for Feeding Intolerance in Patients with Severe Traumatic Brain Injury in China: An Online Cross-Sectional Survey

doi:10.21203/rs.3.rs-988912/v1

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Preventive Strategies for Feeding Intolerance in Patients with Severe Traumatic Brain Injury in China: An Online Cross-Sectional Survey

https://doi.org/10.21203/rs.3.rs-988912/v1

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Background

The application of preventive strategies for feeding intolerance in severe traumatic brain injury (STBI) patients is discrepant among different hospitals. We aim to investigate the application status of preventive measures of feeding intolerance in China.

Method

A cross-sectional study was carried out among 996 clinicians and nurses working in intensive care units of 89 hospitals in China (response rate of 89.81%). Data were collected by means of an online survey. Descriptive statistics were used to analyze respondents’ characteristics and questionnaire responses.

Results

Clinicians and nurses usually applied several methods simultaneously to assess gastrointestinal functions and risk of feeding intolerance among STBI patients, including assessment scales, gastrointestinal symptoms, etc. Furthermore, initiating enteral nutrition (EN) within 24-48 hours (61.45%), < 500 ml initial volume of EN solution (50.00%), using non-nutritional preparations as initial EN formula (65.56%), nasogastric tube EN (91.16%), continuous feeding by pump (72.89%), 30°-45° of head-of-bed elevation during EN (89.46%), monitoring gastric residual volume by syringe (93.67%), assessing gastric residual volume every 4 hours (51.51%), EN solution temperature of 38℃-40℃ (65.46%), prokinetic agents (73.29%), enema (73.59%), probiotics (79.01%), and antacid agents (84.13%), were mostly applied strategies in clinical practice for preventing feeding intolerance among STBI patients.

Conclusions

The data from the survey showed that medical staffs in China are closely concerned with the gastrointestinal functions of STBI patients and EN delivery protocol, and have a positive attitude towards preventive strategies for feeding intolerance. Meanwhile, there are still many points need to be paid attention to and solved, and researchers, clinicians, nurses and dietitians should strengthen the cooperation to explore more valuable preventive strategies for feeding intolerance in STBI patients.

Critical Care & Emergency Medicine

cross-sectional study

enteral nutrition

feeding intolerance

intensive care unit

prevention

severe traumatic brain injury

survey.

Severe traumatic brain injury (STBI) patients are susceptible to negative nitrogen balance, weight loss and malnutrition, which leads to poor prognosis [1]. It has been reported that early enteral nutrition (EN) could reduce the inflammatory responses, prevent bacterial translocation, improve nutritional status, and promote gastrointestinal functions [2–5]. However, due to the damage to the central nervous system (CNS), gut-brain axis dysfunction and secondary damage to gastrointestinal tract, it is difficult to deliver early EN in STBI patients, which is usually interrupted by feeding intolerance [6]. Moreover, the application of some conventional therapeutic measures such as analgesia and sedation might also aggravate the occurrence of feeding intolerance [7]. Studies have shown that the incidence of feeding intolerance can reach 60%-75% during EN among STBI patients [6, 8], which is a huge challenge for medical staff.

In the past two decades, with increasing understanding of the therapeutic role and significance of EN for critically ill patients, experts and researchers have conducted a series of explorations on how to improve gastrointestinal dysfunctions and reduce the incidence of feeding intolerance in STBI patients [9–11]. A variety of preventive and curative strategies for feeding intolerance have now been applied in clinical practice. However, the application of preventive strategies for feeding intolerance is discrepant among different hospitals, and even different departments in the same hospital.

To better apply the preventive strategies for feeding intolerance among STBI patients, the application status of these strategies needs to be known firstly. Thus, in this study we aimed to further understand the current application status of preventive measures for feeding intolerance in China by a cross-sectional survey, in order to provide a basis for medical staff to make more rational treatment decisions for STBI patients and reveal the research directions that need further exploration.

2.1. Survey development

We conducted a cross-sectional study by a self-completed questionnaire among clinicians and nurses working in intensive care units (ICU) of grade II level A to grade III level A hospitals in China. The survey tool was developed via a multi-step co-design process in collaboration with medical staff and experts. First, a literature review was conducted to identify initial questionnaire themes and items, including basic characteristics of participants (sex, age, educational background, department, job type, job title, work experience, hospital classification), and clinical treatments for preventing the occurrence of feeding intolerance among STBI patients (methods for assessment of gastrointestinal functions, methods for EN delivery, and preventive strategies of feeding intolerance in STBI patients). Twenty-five medical staff in ICU from 2 grade III level A hospitals were chosen to give advice of the prototype questionnaire. The questionnaire was refined according to the feedback and suggestions. Then, 7 experts in intensive care were invited to test the validity of the questionnaire. The questionnaire was further revised based on feedback and advice from experts. The final version of questionnaire was put into the Wenjuanxing website, an online crowdsourcing platform (https://www.wjx.cn/), for further large-scale investigation.

2.2 Participants and setting

The cross-sectional survey was performed among clinicians and nurses in general ICU or neurological ICU (NICU) beginning December 25th 2019 over a 2-week period in 89 hospitals of China. Inclusion criteria: registered clinicians and nurses; have worked in ICU or NICU at least for 1 year; willing and able to give informed consent.

2.3. Data collection

The survey distribution and data collection were completed between December 25th 2019 and January 7th 2020 by Wenjuanxing in 89 hospitals in China. The questionnaire took about 5 min to complete. Non-probability sampling methods (convenience sampling and snowball sampling) were used to select participants. According to the 7 geographic regions of China (including East China, South China, North China, Central China, Southwest China, Northwest China, Northeast China), 1 grade III level A hospital was selected in each region for survey. After obtaining consent and support from the surveyed hospitals, the link of questionnaire was sent to participants by WeChat. Meanwhile, we also distributed the questionnaire to the neighboring hospitals and through academic groups in a snowballing manner. A total of 1109 eligible participants were identified, and 996 returned a completed survey (response rate of 89.81%).

2.4. Statistical analysis

All the data collected in this study were analyzed using SPSSAU platform. Descriptive statistics were used to report respondents’ characteristics and questionnaire responses. Percent of responses and percent of cases are displayed. Percent of response is the percentage of each response out of total responses from the given data-set (sum total of percent of response is 100). Percent of cases is the percent of cases or respondents saying “yes” for the particular means of communication.

3.1. Participants

A complete overview of the basic characteristics of respondents was shown in Table 1. The majority of the respondents were female (84.84%), 18-35 years old (81.83%), and with Bachelor degree (68.47) (Table 1). Besides, 89.06% of the respondents were nurses and 72.49% of the respondents were from grade III level A hospitals in China (Table 1).

Table 1

Characteristics of participants (n=996).
Characteristics	Percent of cases, %
Sex
Male	151 (15.16)
Female	845 (84.84)
Age, year
18-35	815 (81.83)
36-55	174 (17.47)
≥56	7 (0.70)
Educational background
Technical and vocational education	2 (0.20)
Junior college education	278 (27.91)
Bachelor	682 (68.47)
Master/Doctor/Ph.D	34 (3.41)
Department
General ICU	657 (65.96)
Neurological ICU	339 (34.04)
Job type
Doctor	109 (10.94)
Nurse	887 (89.06)
Job title
Junior	659 (66.16)
Intermediate	294 (29.52)
Senior	43 (4.32)
Work experience, year
≤2	189 (18.98)
3-5	281 (28.21)
6-10	373 (37.45)
≥11	153 (15.36)
Hospital classification
Grade III level A	722 (72.49)
Grade III level B-Grade II level A	274 (27.51)

3.2. Methods of gastrointestinal function assessment

Our study found that the methods currently used to assess gastrointestinal functions in patients with STBI were: gastrointestinal symptoms (constipation, bowel distension, etc.) (85.04%), gastric residual volume (82.23%), bowel sounds (78.31%), acute gastrointestinal injury (AGI) grade (27.81%), motility of gastric antrum (15.66%), and other methods (1.31%) (Table 2). Other methods included relying on dietitians’ assessment and patients’ nutritional status.

Table 2

Gastrointestinal function assessment in STBI patients.
Characteristics	n	Percent of response, %	Percent of cases, %
Method for assessment of gastrointestinal function
Bowel sounds	780	26.97	78.31
Gastrointestinal symptom (constipation, bowel distension, etc.)	847	29.29	85.04
Gastric residual volume	819	28.32	82.23
Motility of gastric antrum	156	5.39	15.66
AGI grade	277	9.58	27.81
Others	13	0.45	1.31
Method for predicting feeding intolerance
Assessment scale	606	21.49	60.84
Injury severity (GCS, APACHE II, etc.)	711	25.21	71.39
AGI grade	485	17.20	48.69
Basic characteristics of patients (age, sex, etc.)	604	21.42	60.64
Personal experience	393	13.94	39.46
Others	21	0.74	2.11
AGI acute gastrointestinal injury grade, APACHE acute physiology and chronic health evaluation, GCS glasgow coma scale.

Injury severity (glasgow comma scale (GCS), acute physiology and chronic health evaluation (APACHE) II, etc.) (71.39%), assessment scales of feeding intolerance (60.84%), basic characteristics of patients (age, sex, etc.) (60.64%), AGI grade (48.69%), personal experience (39.46%) and other methods (including gastrointestinal symptoms) (2.11%) were commonly conducted to predict the risk of feeding intolerance in STBI patients (Table 2).

3.3. Methods of enteral nutrition delivery

The results showed that EN in STBI patients was usually initiated: within 24-48 hours (61.45%), within 48-72 hours (32.33%), within 24 hours (17.17%), within 72-120 hours (7.23%) and other time (according to patients’ conditions) (0.90%) (Table 3).

Table 3

Delivery of enteral nutrition among STBI patients.
Characteristics	n	Percent of response, %	Percent of cases, %
Initiation time of enteral nutrition
<24 hours	171	14.42	17.17
Within 24-48 hours	612	51.60	61.45
Within 48-72 hours	322	27.15	32.33
Within 72-120 hours	72	6.07	7.23
Others	9	0.76	0.90
Primary enteral nutrition catheterization method
Nasogastric tube	908	74.43	91.16
Nasointestinal tube	312	25.57	31.33
Others	0	0.00	0.00
Degree of head-of-bed elevation during enteral nutrition
<30°	76	7.04	7.63
30°-45°	891	82.58	89.46
>45°	108	10.01	10.84
Others	4	0.37	0.40
Infusion method during early enteral nutrition
Intermittent infusion (normal enteral nutrition solution)	475	32.31	47.69
Intermittent infusion (semi-solid enteral nutrition solution)	136	9.25	13.65
Continuous infusion by pump (normal enteral nutrition solution)	726	49.39	72.89
Continuous infusion by gravity (normal enteral nutrition solution)	133	9.05	13.35
Others	0	0.00	0.00
Temperature of enteral nutrition solution
Near room temperature (22 ℃-25 ℃)	382	36.94	38.35
Near body temperature (38 ℃-40 ℃)	652	63.06	65.46
Others	0	0.00	0.00
Initiation volume of enteral nutrition
<500 ml	498	44.95	50.00
500-1000 ml	456	41.16	45.78
1000-1500 ml	132	11.91	13.25
>1500 ml	19	1.71	1.91
Others	3	0.27	0.30
GRV measurement
By syringe	933	74.52	93.67
By vacuum drainager	220	17.57	22.09
Ultrasound	97	7.75	9.74
Others	2	0.16	0.20
Frequency for monitoring GRV
Every 2 hours	163	12.52	16.37
Every 4 hours	513	39.40	51.51
Every 6 hours	142	10.91	14.26
Each time before giving enteral nutrition solution	482	37.02	48.39
Others	2	0.15	0.20
Definition of gastric retention
GRV>500 ml every 6 hours	368	32.54	36.95
GRV>200 ml/time within 24 hours	575	50.84	57.73
GRV>400 ml/time within 24 hours	180	15.92	18.07
Others	8	0.70	0.80
GRV gastric residual volume.

Nasogastric tube (91.16%) and nasointestinal tube (31.33%) were commonly used to deliver EN among STBI patients (Table 3).

The degree of head-of-bed elevation during EN were: 30°-45° (89.46%), >45° (10.84%), <30° (7.63%) and other degrees (according to patients’ intracranial pressure) (0.40%) (Table 3).

Continuous infusion by pump with normal EN solution (72.89%), intermittent infusion with normal EN solution (47.69%), intermittent infusion with semi-solid EN solution (13.65%) and continuous infusion by gravity with normal EN solution (13.35%) were common infusion methods used among STBI patients during early EN (Table 3).

The EN solution was usually given with a temperature of 38-40℃ (near body temperature) (65.46%) or 22-25℃ (near room temperature) (38.35%) (Table 3).

Initial volume of EN was: <500 ml (50.00%), 500-1000 ml (45.78%), 1000-1500 ml (13.25%), >1500 ml (1.91%) and others (1000-2000 ml) (0.30%) (Table 3).

Extracting gastric content by syringe (93.67%) or vacuum drainager (22.09%) was mostly conducted to assess gastric residual volume (GRV) among STBI patients during EN. Ultrasound (9.74%) and other methods (do not monitor GRV) (0.20%) were also used.

Clinicians and nurses usually assessed GRV of STBI patients: every 4 hours (51.51%), each time before giving EN solution (48.39%), every 2 hours (16.37%), every 6 hours (14.26%), and others (during shift changes) (0.20%) (Table 3).

The definition of GRV was perceived as: GRV>200 ml/time within 24 hours (57.73%), GRV>500 ml every 6 hours (36.95%), GRV>400 ml/time within 24 hours (18.07%) and others (GRV>500 ml every 24 hours, GRV>100 ml every 4 hours, GRV>200 ml every 4 hours, GRV>500 ml/time every 4 hours or within 24 hours) (0.80%) (Table 3).

3.4. Preventive strategies for feeding intolerance in STBI patients

There were 81.22% of the respondents applied preventive strategies to promote gastrointestinal motility among STBI patients (Table 4). Prokinetic agents (73.29%), nursing strategy (58.63%), traditional Chinese medicine (22.59%) were commonly used (Table 4). Other measures (0.50%) included regulation of gut microbiota. Furthermore, 18.78% of the respondents chose not to take preventive measures, and the reasons were: unclear preventive effects (13.76%), no preventive effects (4.82%), side effects (3.82%), and other reasons (0.80%) (Table 4). Other reasons (0.80%) included: lack of awareness, health insurance restrictions, and no medical advice.

Table 4

Preventive strategies of feeding intolerance in STBI patients.
Characteristics	n	Percent of response, %	Percent of cases, %
Gastrointestinal motility promotion
Usage (n=809)
Traditional Chinese medicine (Dahuang, acupuncture, Dachengqi Tang, etc.)	225	12.68	22.59
Prokinetic agents (mosapride, metoclopramide, etc.)	730	41.13	73.29
Nursing strategy (abdominal massage, passive limb movement, etc.)	584	32.90	58.63
Others	5	0.28	0.50
Non-usage (n=187)
No preventive effects	48	2.70	4.82
Unclear preventive effects	137	7.72	13.76
Side effects	38	2.14	3.82
Others	8	0.45	0.80
Defection facilitation
Usage (n=838)
Enema (glycerol, paraffin oil, etc.)	733	41.58	73.59
Laxative (polyethylene glycol, lactulose, etc.)	548	31.08	55.02
Nursing strategy (rectal stimulation, acupoint massage, etc.)	283	16.05	28.41
Others	7	0.40	0.70
Non-usage (n=158)
No preventive effects	45	2.55	4.52
Unclear preventive effects	111	6.30	11.14
Side effects	25	1.42	2.51
Others	11	0.62	1.10
Gut microbiota modulation
Usage (n=806)
Probiotics (live combined Bifidobacterium, live combined Bacillus Subtilis and Enterococcus Faecium, etc.)	787	58.91	79.01
Prebiotics (inulin, polydextrose, etc.)	134	10.03	13.45
Synbiotics	189	14.15	18.98
Others	0	0.00	0.00
Non-usage (n=190)
No preventive effects	46	3.44	4.62
Unclear preventive effects	141	10.55	14.16
Side effects	26	1.95	2.61
Others	13	0.97	1.31
Gastrointestinal mucosa protection
Usage (n=933)
Gastric mucosa protective agent (sucralfate, bismuth potassium cirtrate, etc.)	529	29.44	53.11
Antacid (lansoprazole, omeprazole, etc.)	838	46.63	84.13
Immune-enhancing agent (glutamine, ω-3 polyunsaturated fatty acid, etc.)	352	19.59	35.34
Others	0	0.00	0.00
Non-usage (n=63)
No preventive effects	11	0.61	1.10
Unclear preventive effects	41	2.28	4.12
Side effects	16	0.89	1.61
Others	10	0.56	1.00
Initial enteral nutrition solution
Short peptide EN solution (Peptison Liquid, Peptisorb, etc.)	410	25.09	41.16
Intacted protein EN solution (Enteral Nutritional Emulsion, Pepti son, etc.)	553	33.85	55.52
Non-nutritional preparation (glucose, warm water, etc.)	653	39.96	65.56
Others	18	1.10	1.81
EN enteral nutrition.

There were 84.14% of the respondents applied strategies to facilitate defecation when patients had not defecated for less than 3 days, and the mostly used measure was enema (73.59%), followed by laxative (55.02%), nursing strategies (28.41%), and other measures (including herb) (0.70%) (Table 4). Besides, 15.86% of the respondents chose not to take preventive measures for the following reasons: unclear preventive effects (11.14%), poor preventive effects (4.52%), side effects (2.51%), and other reasons (no medical advice, no necessary to use) (1.10%) (Table 4).

Most respondents used measures to modulate gut microbiota in STBI patients, among which probiotics (79.01%), followed by synbiotics (18.98%) and prebiotics (13.45%) (Table 4). There were 19.08% of the respondents chose not to take preventive measures, and the reasons were: unclear preventive effects (14.16%), no preventive effects (4.62%), side effects (2.61%), and other reasons (health insurance restrictions) (1.31%).

There were 93.67% of the respondents took preventive measures to protect gastrointestinal mucosa, of which the main measure was antacid (84.13%), followed by gastric mucosa protective agent (53.11%) and immune-enhancing agent (35.34%) (Table 4). The reasons for not use were: unclear preventive effect (4.12%), side effects (1.61%), no preventive effect (1.10%), and other reasons (health insurance restrictions) (1.00%) (Table 4).

The types of initial EN formula were: non-nutritional preparations (65.56%), intacted protein EN solution (55.52%), short peptide EN solution (41.16%), and other types (1.18%) (Table 4). Other types included: rice broth, milk, rice flour, or dependent on the decision of nutrition department.

In the last 2 open-ended questions, 744 respondents (74.70%) filled in that combined use of preventive methods would reduce the occurrence of feeding intolerance in STBI patients. The answers from 5 respondents (0.50%) did not cover preventive measures.

4.1 Combined use of several methods were conducted to assess gastrointestinal functions and risk of feeding intolerance in STBI patients

The results of the survey showed that more than a half of respondents chose at least 3 options to assess patients’ gastrointestinal functions as well as predicting the risk of feeding intolerance, which indicated that most of the medical staff use multiple methods to evaluate gastrointestinal functions and tolerability of EN in patients with STBI. Further analysis of the collected data suggested that the current assessment methods of gastrointestinal functions are mainly based on clinical symptoms related to gastrointestinal dysfunction (85.04%), GRV (82.23%) and bowel sounds (78.31%). There were only 28.81% and 15.66% of the respondents took AGI grade and medical imaging methods (motility of gastric antrum), respectively, which showed that these 2 measures were not yet widely applied in clinical practice. In 2012, European Society of Intensive Care Medicine (ESICM) proposed AGI grade to assess the degree of acute gastrointestinal impairment in critically ill patients [12]. The low prevalence of AGI grade in evaluating gastrointestinal functions might due to 2 reasons: AGI grade lacks of objective evaluation indexes and is hard to quantify the severity; on the other hand, as most respondents involved in the survey were nurses (89.06%), we supposed that the use of AGI grade might have not been included in the scope of nurses’ responsibility. Using imaging measure to evaluate gastrointestinal functions is an emerging technique in the field of intensive care in recent years, and it can visually reflect the gastric antrum movement [13]. The low prevalence of this imaging measure may be due to that it’s a novel technique and has not yet been widely conducted among STBI patients. We suggest that timely comparative studies of emerging methods with traditional methods are urgently needed to confirm their effectiveness and feasibility in assessing gastrointestinal functions, in order to make these newest techniques timely applied in critically ill patients.

The present study found that 71.39% of respondents predict the risk of feeding intolerance in STBI patients based on injury severity (GCS, APACHE II, etc.), 60.84% of the respondents based on assessment scales, and 60.64% of the respondents based on the patients’ basic characteristics (age, sex, etc.). It is well known that disease severity is closely related to the occurrence of feeding intolerance [14]. GCS and APACHE II scores are applied in STBI patients within 24 hours after admission to assess the injury severity [15]. The risk of gastrointestinal dysfunctions is predicted on the basis of these assessments. As these 2 scores are the classic assessment methods for STBI patients, they have long been used in clinical practice and are therefore more widely applied. Studies have shown that basic characteristics of patients such as age and sex are risk factors for disease severity [16, 17]. For example, atrophy of intestinal mucosa can occur in the elderly, affecting the absorption and transportation of water and electrolytes [18]. Therefore, clinicians and nurses should pay attention to the basic characteristics of patients such as age and sex when considering EN delivery. Recent years, researchers in China have developed risk assessment scales to facilitate the assessment and prediction of the feeding intolerance in critically ill patients [19, 20]. These results of present survey showed that the assessment scales for feeding intolerance are used widely among STBI patients, indicating that clinical staff prone to use methods which are based on objective indexes and clear grading. However, considering the heavy workload and various assessment scales needed to complete in ICU, we suggest that it is necessary to further optimize the assessment scales and procedure, in order to improve the effectiveness in evaluation of feeding intolerance and reduce the workload of medical staff.

4.2 Evidence-based strategies for EN delivery have been widely used

We found the following feeding strategies were mostly applied in China: using nasogastric tube (91.16%), 30°-45° of head-of-bed elevation during EN (89.46%), continuous infusion method (72.89%), 38-40℃ of EN solution, and initiating EN within 24-48 hours after admission (61.45%) with <500ml EN solution (50%). Some of these strategies were in accordance with several guidelines and expert consensus on nutritional support for critically ill patients [21, 22], which indicating that most clinicians and nurses are able to apply evidence-based strategies during EN delivery. In recent years, it has been reported that administration of low-temperature EN solutions (22°C-25°C) [23] and intermittent infusion semi-solid solutions [24, 25] can reduce the risks of gastric ulcer and aspiration, while these 2 strategies were only used among 13.65% and 38.35% of the respondents, respectively. The low utility rates might due to the related researches were limited, causing insufficient popularization and application. Thus, for these effective methods found in clinical practice, we should summarize and spread them timely, and carry out multicenter and multidisciplinary studies to confirm their effectiveness.

The amount of GRV is positively correlated with the incidence of reflux and aspiration [26, 27]. Therefore, monitoring GRV is an important part during EN. The collected data in our survey presented that retraction of gastric content by syringe is still the main method for monitoring GRV (93.67%). However, it has been reported that the accuracy of use of syringe withdrawal would be influenced by various factors, such as patient’s position and gastric tube diameter [28]. Recent years, more accurate and feasible methods for monitoring GRV have been explored, including ultrasound. Some studies have shown that GRV could be calculated accurately using 3-dimensional morphology by ultrasound, which would not be affected by other factors [29, 30]. However, only 9.74% of the respondents chose to apply ultrasound to monitor GRV. The reason for this result may be related to the fact that use of ultrasound for EN is still in its early phase, and the ultrasound instrument is a highly specialized technique, which requires systematic learning and training. We suggest that we should focus on the timely training of new methods or techniques to make them applied in clinical practice better and faster.

The results also showed that gastric retention in China is mainly defined by GRV > 200 ml/time within 24 hours (57.73%). However, GRV > 500 ml every 6 hours was recommended by ESICM in 2017 [31] and has been only used in 36.95% respondents. The definition of gastric retention can directly influence the EN delivery, as well as preventive and curative measures. If the definition is too conservative, it may lead to more feeding interruptions and clinical interventions during EN; if the threshold of the definition is too strict, it might increase the risk of feeding intolerance. Therefore, how to define the threshold of gastric retention still needs more further scientifically explorations.

4.3 The prevention of feeding intolerance has been paid more attention in clinical practice

Strategies for promoting gastrointestinal motility (81.22%) and defection (84.14%), protecting the mucosa (93.67%), and modulating gut microbiota (80.92%) have been widely used before the occurrence of feeding intolerance. We found that antacid agents (84.13%) are still important treatments for preventing stress-related gastrointestinal bleeding among STBI patients. The antacid is a double-edged sword. It can protect the gastrointestinal mucosa, while it will also increase the gastric pH and aggravate the risk of feeding intolerance. Expert consensus has stated that we should discontinue the application of proton pump inhibitors as soon as possible when TBI patients could take adequate energy by oral feeding [32]. Thus, how to use the antacid properly still needs further exploration.

The current survey also found that clinicians have paid attention to the effects of gut microbiota for STBI patients, and probiotics were mainly used in clinical practice (79.01%). With the increasing understanding of the interaction of gut microbiota-brain axis, it has been found that regulating the gut microbiota after TBI can not only improve gut dysbiosis, but also promote the recovery of neurological functions [33, 34].

For measures to improve gastrointestinal motility in STBI patients, most respondents chose prokinetic agents (73.29%) other than traditional Chinese medicine (22.59%). Although several studies in China have confirmed that measures such as Chinese medicine rhubarb [35], Da Cheng Qi Tang [36], and acupuncture [37] can significantly improve gastrointestinal motility in STBI. However, the applications of these effective methods of traditional Chinese medicine are still very limited. We suggest that the collaborative working model of Traditional Chinese Medicine department and physiotherapy department could be established to promote the applications of effective traditional Chinese medicine measures.

The results of survey indicated that enema is a commonly used strategy to assist defection in STBI patients. While enema can only alleviate the symptoms, but not treat primary cause of constipation. Studies suggested that nursing strategies such as rectal stimulation [38] and acupoint massage [39] are effective in stimulating gut motility and promoting defecation reflexes in patients. There were only 28.41% of the respondents chose nursing strategies, which might due to that these methods are mild and takes a longer time and shows slower progress. Moreover, it may also relate with the limited manpower of ICU nurses who are unable to perform tasks other than those prescribed by clinicians.

Most of the respondents gave STBI patients non-nutritional preparations (glucose, warm water, etc.) at the initiation of EN. Critically ill patients are commonly accompanied by gastrointestinal dysfunctions. Solutions such as glucose and water that can be easily digested and absorbed are given firstly in clinical practice, which will make the gastrointestinal tract to adapt the following EN solution. A research reported that giving non-nutritional preparations 1 day before giving EN solution could reduce the incidence of diarrhea in critically ill patients [40]. We also found that rice broth, milk or other solution were also used as the initial type of EN formula. This result suggests that there is a need to further explore and standardize what, how much and how long to give at the beginning of EN in STBI patients, so that EN can be delivered smoothly at the early stage.

4.4 Preventive measures for feeding intolerance need to be further explored

We provided an analysis of the reasons for not taking preventive measures. The survey found that the main reason why preventive measures are not used is “unclear preventive effects”. The results suggest that comparative studies of various measures for preventing feeding intolerance are urgently needed, which are important to confirm the effectiveness of these treatments and provide basis for clinical practice. Furthermore, medical staff should make an effort to learn the knowledge relevant to EN and the latest techniques, methods and theories, in order to reduce the risk of feeding intolerance as effective as possible.

As a nationwide survey, this survey is expected to provide a more realistic picture of the clinical conditions regarding feeding intolerance in STBI patients. In view of the diversity and complexity of clinical measures in practice, the survey was designed with the option “others” as the final option, in order to discover the points that the survey did not cover. We found that some nurses filled in “relying on dietitians’ assessment or suggestion” or “no medical advice”. This indicates that some nurses only act as a “implementer” during EN delivery period and lack initiative. A study has confirmed that nurse-led EN delivery protocols can help reduce feeding interruptions and improve the nutritional status of critically ill patients [41]. We suggest that it is important for nurses in ICU to improve their role awareness and skills in EN support for critically ill patients, which might significantly contribute to reducing the risk of feeding intolerance.

4.5 Limitations

This cross-sectional survey study provides a snapshot of medical staff’s views on preventive strategies for feeding intolerance in STBI patients. The demographic of the participants and the fact that participants were mostly recruited from grade II level A or above hospitals which may limit the generalizability. The non- probability sampling methods (convenience sampling and snowball sampling) used to approach hospitals or participants for inclusion in this study signifies that the findings are likely to not be generalizable to the wider medical staff in China.

Through the cross-sectional survey of medical staff of ICU in 89 grade II level A or above hospitals in China, we have gained the current application status of the preventive measures for feeding intolerance in patients with STBI. The results showed that clinicians and nurses in China are closely concerned with the gastrointestinal functions of STBI patients and EN delivery procedure, and have a positive attitude towards preventive strategies for feeding intolerance among STBI. Meanwhile, there are still some points need to be paid attention and solved. For example, the effectiveness of many clinical measures still needs to be further clarified, and some effective new technologies and methods are required to be timely applied in clinical practice. We suggest that researchers, clinicians, nurses and dietitians could strengthen cooperation to explore more valuable preventive strategies for feeding intolerance in STBI patients.

AGI: acute gastrointestinal injury; APACHE: acute physiology and chronic health evaluation; CNS: central nervous system; EN: enteral nutrition; ESICM: European Society of Intensive Care Medicine; GCS: glasgow comma scale; GRV: gastric residual volume; ICU: intensive care units; STBI: severe traumatic brain injury.

Conflicts of interest: The authors declare that they have no conflict of interests.

Acknowledgements

Not applicable.

Funding

No specific funding was received for this study.

Ethics approval and consent to participate

This study was approved by Human Ethics Committee of Daping Hospital.

Availability of data and materials

All data generated or analyzed are included in this published article.

Authors’ contributions

Author contributions: YF and JZ had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: YF and JZ. Acquisition of data: YF, TC. Analysis and interpretation of data: YM and HH. Drafting of the manuscript: YF, JZ, YM.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Preventive Strategies for Feeding Intolerance in Patients with Severe Traumatic Brain Injury in China: An Online Cross-Sectional Survey

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Abstract

Background

Method

Results

Conclusions

1. Introduction

2. Methods

2.1. Survey development

2.2 Participants and setting

2.3. Data collection

2.4. Statistical analysis

3. Results

3.1. Participants

3.2. Methods of gastrointestinal function assessment

3.3. Methods of enteral nutrition delivery

3.4. Preventive strategies for feeding intolerance in STBI patients

4. Discussion

4.1 Combined use of several methods were conducted to assess gastrointestinal functions and risk of feeding intolerance in STBI patients

4.2 Evidence-based strategies for EN delivery have been widely used

4.3 The prevention of feeding intolerance has been paid more attention in clinical practice

4.4 Preventive measures for feeding intolerance need to be further explored

4.5 Limitations

5. Conclusions

Abbreviations

Declarations

References

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