The art and science.

Carol Parrish has provided an excellent review regarding enteral nutrition delivery. The article not only references key articles regarding enteral delivery but also incorporates the collected experience of the author. As a practicing gastroenterologist with an interest in nutrition support, I would agree with the comments made by the author in this paper. I think all of us have developed our own clinical instinct for the care of our patients as a result of our collected individualized clinical experiences over time. Having said that, I think we would all acknowledge that there is more than one best way to care for a patient. This is perhaps more true in nutrition support, given the lack of prospective, controlled studies in many instances. Also, as nutrition support providers, we have to interact daily with our medical/surgical colleagues, patients, and families. Each usually have their own ideas regarding nutrition, which is sometimes based on experience and sometimes not. As a consulting service, we have to be good listeners, understand the information presented to us, and most importantly, be good communicators. I believe it is our role as nutrition support providers to first guide all parties in the direction of what is safe for the patient, ie, first do no harm. I do not believe one should ever be criticized for erring on the side of safety for a patient. An example may be when tube feeds are held for 1 or 2 days because of reduced bowel sounds and mild abdominal distention, and you are not sure in which clinical direction the patient may turn. Although you may not agree with the decision to hold the feeding, it may ultimately be in the best interest of the patient. When to advance and when to hold enteral feeding is based on more than one piece of clinical information in my opinion. The decision first begins with accurate clinical information. It has been my observation that this is where most confusion begins. Examples may include incorrect charting of residual volumes, failure to discriminate stool incontinence from diarrhea, and failure to perform a careful abdominal examination. The clinical finding that concerns me the most is abdominal distention with abdominal pain on gentle palpation. Regardless of residual volumes or bowel sounds, I will usually suggest reduction or discontinuation of feedings. There are many variables (medications, postoperative ileus, diabetes) of hospitalized patients that can affect gastric function, and hence, residual volumes. Therefore, in my opinion, no set residual volume should be used because of patient variability. However, I do believe each specific institution needs to feel comfortable with a set number so the nursing staff can follow protocol. In terms of the art of enteral delivery, we should not forget our patient’s preference. We have recently published results showing that patients overwhelmingly prefer total parenteral nutrition (TPN) to nasal gastric feeding. 1 Perceived comfort was the primary reason for their answer. Gender, education level, physician’s recommendation, and cost did not influence patient’s preference. Although we advocate enteral nutrition in most circumstances, the results of this study have helped us become more aware of patients’ preferences, an important contribution to our efforts to provide the best care possible.