Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

Machado, Letiane de Souza; Rizzi, Paula; Silva, Flávia Moraes

doi:10.5935/0103-507X.20200019

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Revista Brasileira de Terapia Intensiva

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REVIEW ARTICLE • Rev. bras. ter. intensiva 32 (1) • Jan-Mar 2020 • https://doi.org/10.5935/0103-507X.20200019 copy

Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.

Keywords:
Nutrition therapy; Enteral nutrition; Prone position; Critical illness; Gastrointestinal contents; Pneumonia

Author, location	Design, follow-up	Sample	Interventions under study	Outcomes of interest
Saez de la Fuente et al.⁽⁹⁾9 Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, Garcia Gigorro R, Terceros Almanza LJ, Sanchez Izquierdo JA, et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr. 2016;40(2):250-5.	Prospective observational study Duration: 24.7 ± 12.3 days under ENT	n = 34 Adult patients on MV with prescription of ENT in prone position Age: 47.6 ± 18.4 years Men: 58% APACHE II: 33.3% of the sample between 10 and 14 points	Control: supine position, with interruption of enteral nutrition if GRV > 500 mL in 6 hours. Enteral feeding via infusion pump for 24 hours. Initial volume of 25% of the nutritional target achieved in 96 hours Intervention: prone position, if severe hypoxemia (PaO₂/FiO₂ < 150) in the presence of hemodynamic stability for 48 consecutive hours; neck/head were alternated to the right and left every 2 hours. Enteral feeding via infusion pump for 24 hours. Initial volume of 25% of the nutritional target was reached in 96 hours. Angle of elevation of the bed of 10º in reverse Trendelenburg	GRV (measured every 6 hours) Vomiting Regurgitation
Reignier et al.⁽¹⁹⁾19 Reignier J, Thenoz-Jost N, Fiancette M, Legendre E, Lebert C, Bontemps F, et al. Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med. 2004;32(1):94-9. França	Prospective observational study Duration: 5 days	n = 71 (37 control/34 intervention) Adult clinical patients on invasive and MV and sedated with the prediction of ENT for at least 5 days Age: 58 ± 16.5 years Men: 71.8% SAPS II: 52 ± 22 points	Control: semirecumbent supine position. Enteral feeding via infusion pump for 18 hours. Initial volume of 30 mL/hour; progression to nutritional target in 96 hours Intervention: prone position in cases of severe hypoxemia (PaO₂/FiO₂ < 150; FiO₂ = 0.6; PEEP = 10 cmH2O). Enteral feeding via infusion pump for 18 hours (6-hour rest in the supine or prone position, with position determined randomly). Initial volume of 30 mL/hour and progression to nutritional target in 96 hours. Elevated head of the bed	GRV (measured every 6 hours) Vomiting MV-associated pneumonia Mortality
Chen et al.⁽²⁰⁾20 Chen SS, Tzeng YL, Gau BS, Kuo PC, Chen JY. Effects of prone and supine positioning on gastric residuals in preterm infants: a time series with crossover study. Int J Nurs Stud. 2013;50(11):1459-67. Taiwan	Crossover randomized series Duration: 8.5 hours	n = 35 Convenience sample of preterm infants with Apgar score > 7 who were receiving ENT and were clinically stable Age: 29.75 ± 3.01 weeks Boys: 48.6%	Participants were allocated to two groups: in one group, the sequence of positions was supine-prone, and in the other group, the sequence was prone-supine. Subsequently, the order was inverted. In both groups, BM was administered via OGT by infusion pump. The initial volume was 20 mL/kg/day, with volume increases every 3 hours to 160 mL/kg/day of nutritional target. Two stages of BM administration: 50 mL/kg/day and 100 mL/kg/day	GRV (measured 30, 60, 90, 120 and 150 minutes after BM infusion)
Van der Voort et al.⁽²¹⁾21 van der Voort PH, Zandstra DF. Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients. Crit Care. 2001;5(4):216-20. Holanda	Prospective observational study Duration: 12 hours	n = 19 Adult patients on MV in the prone position with onset of ENT during the first 24 hours of ICU stay Age: 65.1 (41 - 82) years Men: 73.7% Apache II: 25.5 ± 8.9 points	Control: supine position for 6 hours, with head of the bed elevated at 30°. Enteral feeding 80 mL/hour as nutritional target Intervention: prone position if hypoxemia (PaO₂/FiO₂ < 100) or pneumonia with excessive production of bronchial secretion - maintained for 6 hours, after patient is placed in supine position. Head of the bed elevated at 30°. Enteral feeding 80 mL/hour as the nutritional target^* * Prokinetics were not administered during the study.	GRV (measured every 6 hours)
Lucchini et al.⁽²²⁾22 Lucchini A, Bonetti I, Borrelli G, Calabrese N, Volpe S, Gariboldi R, et al. [Enteral nutrition during prone positioning in mechanically ventilated patients]. Assist Inferm Ric. 2017;36(2):76-83. Italian. Itália	Retrospective observational study Information about follow-up period not provided	n = 25 patients with ARDS on MV and continuous ENT Age: 51.13 ± 15.93 years Men: not stated RASS: median of -5 in both groups (p = 0.165)	Control: supine position with head of the bed elevated to at least 15º Intervention: prone position with head of the bed elevated to at least 15º (pronation criteria were not described) Enteral nutrition interrupted if GRV > 300 mL, administration of metoclopramide and return to previous volume in both groups	GRV (measured every 3 hours)

Author	Intolerance of ENT	Aspiration pneumonia	Other outcomes	Conclusion	Strengths and weaknesses
Saez de la Fuente et al.⁽⁹⁾9 Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, Garcia Gigorro R, Terceros Almanza LJ, Sanchez Izquierdo JA, et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr. 2016;40(2):250-5.	GRV/day (p = 0.054): Control: 126.6 ± 132.1 mL Intervention: 189.2 ± 203.2 mL Frequency of elevated GRV/day (p = 0.39): Control: 0.06 ± 0.01 Intervention: 0.09 ± 0.17 Frequency of vomiting/day (p = 0.53): Control: 0.016 ± 0.03 Intervention: 0.03 ± 0.09 Regurgitation/day (p =0.051): Control: 0 Intervention: 0.04 ± 0.13	Not evaluated	Not evaluated	ENT in critically ill patients with severe hypoxemia in prone position is viable and safe and is not associated with an increase in gastrointestinal complications	Weaknesses: Duration of ENT during supine position significantly longer than the prone position Sample size not calculated Enteral nutrition volume administered differed during prone and supine position. Strengths: Crossover design
Reignier et al.⁽¹⁹⁾19 Reignier J, Thenoz-Jost N, Fiancette M, Legendre E, Lebert C, Bontemps F, et al. Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med. 2004;32(1):94-9.	GRV (mean of 5 days): Control: 10.6 (0 - 58.6)mL Intervention: 27.6 (3.8 - 119.4)mL Significant difference at days 1, 2 and 4 (p <0.01) Interruption of EN (p < 0.01): Control: 49% Intervention: 82% Vomiting (p < 0.001): Control: 26 episodes Intervention: 30 episodes RR = 2.5 (1.5 - 4.0)	Associated with VM (NS): Control: 24% Intervention: 35%	Infused volume (mean of 5 days): Control: 1095 (876 - 1336) mL Intervention: 754 (552 - 929) mL Significant difference in the five days (p <0.05). Mortality (NS): Control: 24% Intervention: 35%	In severely hypoxemic patients on invasive MV, the administration of EN in the prone position is associated with a higher frequency of vomiting	Weaknesses: Allocation of the subjects to the groups according to the need for pronation Regular measurement of gastric residual volume and vomiting may underestimate changes in gastric emptying and esophageal reflux No sample size calculation was presented. Strengths: Similar groups regarding age, gender and SAPS (minimizes confounding bias)
Chen et al.⁽²⁰⁾20 Chen SS, Tzeng YL, Gau BS, Kuo PC, Chen JY. Effects of prone and supine positioning on gastric residuals in preterm infants: a time series with crossover study. Int J Nurs Stud. 2013;50(11):1459-67.	Redução % do VRG: 1º estágio - 50mL/kg/dia (p < 0,01): Controle: 23,26% Intervenção: 43,95% 2º estágio - 100mL/kg/dia (p < 0,01): Controle: 28,46% Intervenção: 48,07%	Not evaluated	Not evaluated	Preterm infants have lower GRV in the prone position compared to the supine position, when 50 mL/kg/day and 100 mL/kg/day are offered	Weaknesses: Short-term GRV assessment Breast milk may limit the generalization of results Fixed volumes of breast milk administered Strengths: Sample size calculated Random allocation Allocation Blinding
Van der Voort et al.⁽²¹⁾21 van der Voort PH, Zandstra DF. Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients. Crit Care. 2001;5(4):216-20.	VRG em 3 horas (p = 0,69): Controle: 59,5 (0 - 180) mL Intervenção: 59,7 (0 - 200) mL VRG em 6 horas (p = 0,85): Controle: 110 (0 - 325) mL Intervenção: 95 (10 - 340) mL	Not evaluated	Not evaluated	GRV did not differ significantly after 3 and 6 hours of enteral nutrition in the prone or supine position	Weaknesses: Sample size not calculated Order of interventions was not randomized Does not inform method of administration of the ENT and initial volume Short duration of interventions Strengths: Constant EN volume Crossover design
Lucchini et al.⁽²²⁾22 Lucchini A, Bonetti I, Borrelli G, Calabrese N, Volpe S, Gariboldi R, et al. [Enteral nutrition during prone positioning in mechanically ventilated patients]. Assist Inferm Ric. 2017;36(2):76-83. Italian.	VRG (p = 0,73): Controle: 20,62 ± 18,92mL I: 23,62 ± 50,02mL VRG > 300 ml (p = 0,65): Controle: 2 (0,4%) I: 2 (0,8%)	Not evaluated	Not evaluated	The administration of ENT in the prone position did not promote a significant increase in GRV compared to the supine position	Weaknesses: Sample size Criteria for pronation not described Strengths: Infused volume did not differ between groups

Author	Precision	Measurement bias	Confounding bias/multivariate analysis
Saez de la Fuente et al.⁽⁹⁾9 Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, Garcia Gigorro R, Terceros Almanza LJ, Sanchez Izquierdo JA, et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr. 2016;40(2):250-5.	High risk Wide confidence interval for the result Sample size not calculated	Low risk Adequate measurement of the factors under study and outcomes	High risk Duration of supine position longer than that of the prone position and the volume of enteral feeding administered differed between groups Multivariate analysis not performed
Reignier et al.⁽¹⁹⁾19 Reignier J, Thenoz-Jost N, Fiancette M, Legendre E, Lebert C, Bontemps F, et al. Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med. 2004;32(1):94-9.	High risk Wide confidence interval for the result Sample size not calculated	Low risk Adequate measurement of the factors under study and outcomes	Uncertain risk Similar characteristics at baseline Multivariate analysis not performed
Chen et al.⁽²⁰⁾20 Chen SS, Tzeng YL, Gau BS, Kuo PC, Chen JY. Effects of prone and supine positioning on gastric residuals in preterm infants: a time series with crossover study. Int J Nurs Stud. 2013;50(11):1459-67.	Low risk Sample size calculated in a pilot study	Low risk Adequate measurement of the factors under study and outcomes	Low risk Random allocation of the order of interventions, crossover design Multivariate analysis not performed
Van der Voort et al.⁽²¹⁾21 van der Voort PH, Zandstra DF. Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients. Crit Care. 2001;5(4):216-20.	High risk Wide confidence interval for the result Sample size not calculated	Low risk Adequate measurement of the factors under study and outcomes	Uncertain risk Criteria for sample selection not clearly described Despite nonrandom allocation of the order of interventions, crossover design Multivariate analysis not performed
Lucchini et al.⁽²²⁾22 Lucchini A, Bonetti I, Borrelli G, Calabrese N, Volpe S, Gariboldi R, et al. [Enteral nutrition during prone positioning in mechanically ventilated patients]. Assist Inferm Ric. 2017;36(2):76-83. Italian.	High risk Wide confidence interval for the result Sample size not calculated	Uncertain risk Criteria for pronation were not described	Uncertain risk Unclear whether it was a crossover design or whether the allocation was random. Multivariate analysis not performed

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[1] Corresponding author: Flávia Moraes Silva, Departamento de Nutrição, Universidade Federal de Ciências de Saúde de Porto Alegre, Rua Sarmento Leite, 245 - Centro Histórico, Zip code: 90050-170 - Porto Alegre (RS), Brazil. E-mail: flaviams@ufcspa.edu.br