Fasting prior to extubation is a common practice in intensive care units, implemented with the intention of reducing the risk of aspiration in patients. However, this practice has not been thoroughly evaluated, and its potential consequences should be considered. Imposing fasting before extubation could lead to delayed extubation, which in turn may prolong a patient's stay in the ICU and increase the workload for healthcare professionals. Additionally, fasting may contribute to a reduction in the patient's caloric intake, which is crucial for their recovery and overall well-being.
The potential drawbacks of fasting prior to extubation highlight the importance of reevaluating current practices and examining evidence-based alternatives. As more research is conducted, healthcare providers may need to adjust their approach in order to optimize patient outcomes and ensure the most efficient use of resources within the ICU.
The Study: Comparing Continuous Enteral Feeding to Fasting and Gastric Suctioning before Extubation
A recent study conducted by French investigators compared the outcomes of continuous enteral feeding until extubation to fasting for 6 hours and gastric suctioning prior to extubation in 22 ICUs. Approximately 1000 patients, who were on mechanical ventilation for at least 48 hours and had enteral nutrition for at least one day, were included in the study. The assessment of readiness for extubation was based on local practice, and around one-third of the patients had risk factors for extubation failure [1].
Higher Reintubation Rates but Similar Long-Term Outcomes
During the first 72 hours after extubation, the study found that patients who continued to receive enteral feeding had a higher reintubation rate of 15%, as opposed to the 10% rate observed in the group that underwent 6 hours of fasting and gastric suctioning prior to extubation. This initial finding may raise concerns about the potential risks associated with continuous enteral feeding during the extubation process. However, it is important to note that this difference in reintubation rates was not sustained in the long term, as the reintubation rates at the 7-day mark were found to be similar for both groups, at around 17%. This suggests that the initial difference in reintubation rates may not be as clinically significant as it may seem at first glance.
No Significant Differences in Aspiration and Nosocomial Pneumonia Incidence
Additionally, the incidence of aspiration and nosocomial pneumonia, which are common concerns when it comes to enteral feeding during extubation, were low and did not differ significantly between the two groups. This indicates that continuous enteral feeding did not lead to an increased risk of these complications.
Benefits of Continuous Enteral Feeding: Shorter Time to Extubation and Quicker ICU Discharge
Furthermore, the patients in the continuous feeding group experienced a shorter median time to extubation after their first successful spontaneous breathing trial, by 15 hours, and were subsequently discharged from the ICU sooner than those who underwent fasting and gastric suctioning. This finding suggests that continuous enteral feeding may have benefits in terms of expediting the extubation process and reducing the overall length of stay in the ICU for these patients.
Would you continue tube feeding until the time of extubation and suction gastric content prior to extubation?
Yes, and this what I have been doing!
Yes, and this study changes my practice
No, I hold tube feeding 6 hours prior to extubation
I do not know!
Rethinking Enteral Feeding Practices: Moving Toward Continuous Feeding
As medical practices continuously evolve based on new evidence, it might be prudent for healthcare providers to reevaluate the standard protocols regarding enteral feeding during the extubation process. The study's findings highlight the need to move away from the practice of holding enteral feeding prior to extubation in favor of continuous enteral feeding. Implementing a continuous enteral feeding approach may lead to improved patient outcomes and a more efficient use of resources within the ICU. However, it is crucial to consider each patient's unique circumstances and risk factors before making any changes to established protocols. By incorporating evidence-based practices and individualized patient care, healthcare professionals can continue to optimize patient outcomes and overall ICU efficiency.
REFERENCE:
Landais M et al. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: An open-label, cluster-randomised, parallel-group, non-inferiority trial. Lancet Respir Med 2023 Apr; 11:319. Link