Neng Huang, Cailing Huo, Yutong Zhu, Jing He, Cheng Huang, Lan Zheng
The refined enteral nutrition intervention was associated with improved short-term nutritional status and reduced incidence of feeding intolerance in critically ill stroke patients. However, due to the quasi-experimental design historical controls, the inclusion of adjunctive therapies with unproven efficacy, and the lack of long-term outcome data (including 30-day mortality and functional recovery), categorical claims about improved prognosis cannot be made. The observed benefits may be associated with the comprehensive nursing protocol rather than the refined EN intervention alone and our findings should be interpreted as demonstrating an association rather than a causal relationship. Large-scale, multicenter randomized controlled trials are needed to confirm these findings.
BACKGROUND: Critically ill stroke patients frequently experience dysphagia, posing challenges to adequate nutrient intake. Furthermore, these patients often remain in a prolonged state of high stress, hypermetabolism, and reduced immunity. While early enteral nutritional support is crucial, feeding intolerance remains a prevalent issue. This study evaluates the real-world impact of a refined enteral nutrition (EN) intervention on EN outcomes.
OBJECTIVE: To investigate the effect of a refined enteral nutrition intervention on nutritional status and feeding intolerance in critically ill stroke patients.
METHODS: This quasi-experimental study employed a pre-post design. The control group (n = 81; January-December 2022) was retrospectively enrolled, and the intervention group (n = 81; January-December 2023) was prospectively enrolled. The Control group received routine nutrition management, and the Intervention group received refined enteral nutrition management. Primary outcomes assessed included: (1) Nutritional markers: Serum albumin, hemoglobin, triceps skinfold thickness (non-paralyzed side), mid-upper arm circumference (non-paralyzed side); (2) EN intolerance incidence: Diarrhea (≥3 stools/day), vomiting, abdominal distension, elevated gastric residual volume (≥250 mL); (3) Disease severity: APACHE II score. Energy and protein targets were calculated individually (25-30 kcal/kg/day and 1.2-2.0 g/kg/day). Achievement of ≥70% of both targets was considered adequate. (4) Nutritional Risk Screening (NRS2002) and hospital length of stay were also recorded.
RESULTS: Post-intervention albumin levels were significantly higher in the Intervention group (40.69 ± 1.88 g/L) compared to the Control group (38.92 ± 1.21 g/L; t = -7.147, p < 0.001), mean difference 1.77 g/L [95% CI: 1.29-2.25], Cohen's d = 1.12, with comparable baseline values (36.97 ± 2.34 vs. 36.81 ± 1.67 g/L; p = 0.056). Post-intervention hemoglobin levels were also significantly higher in the Intervention group (114.40 ± 8.00 g/L vs. 110.57 ± 6.52 g/L; t = -3.337, p = 0.001), despite comparable baseline values (97.37 ± 9.89 vs. 99.77 ± 5.92 g/L; t = 1.870, p = 0.630). Post-intervention triceps skinfold thickness was significantly greater in the Intervention group (12.29 ± 2.08 mm vs. 11.20 ± 2.40 mm; t = -3.087, p = 0.002), with comparable baselines (9.97 ± 2.10 mm vs. 9.82 ± 2.21 mm; t = -0.448, p = 0.655). Similarly, post-intervention mid-upper arm circumference was significantly higher in the Intervention group (21.11 ± 1.47 cm vs. 19.86 ± 1.65 cm; t = -5.068, p < 0.001), with comparable baseline values (17.15 ± 1.22 cm vs. 16.99 ± 1.37 cm; t = -0.762, p = 0.447). Post-intervention NRS2002 scores were significantly lower in the Intervention group (4.56 ± 0.82 vs. 5.07 ± 0.83; p < 0.001). Moreover, the APACHE II score was significantly lower in the Intervention group (15.06 ± 2.89) than in the Control group (19.85 ± 3.36; t = 9.236, p = 0.000). In the Intervention group, 91.4% of patients achieved ≥70% of energy targets and 88.9% achieved ≥70% of protein targets, compared to 64.2% and 59.3% in the Control group, respectively (both p < 0.001). The Intervention group also had a significantly shorter hospital stay (42.22 ± 7.25 vs. 44.78 ± 5.21 days; p = 0.011).
CONCLUSION: The refined enteral nutrition intervention was associated with improved short-term nutritional status and reduced incidence of feeding intolerance in critically ill stroke patients. However, due to the quasi-experimental design historical controls, the inclusion of adjunctive therapies with unproven efficacy, and the lack of long-term outcome data (including 30-day mortality and functional recovery), categorical claims about improved prognosis cannot be made. The observed benefits may be associated with the comprehensive nursing protocol rather than the refined EN intervention alone and our findings should be interpreted as demonstrating an association rather than a causal relationship. Large-scale, multicenter randomized controlled trials are needed to confirm these findings.