Enteral Feeding in the Prone Position

The COVID-19 pandemic led to an exponential increase in patients placed in the prone position due to the virus's effect on their lungs. I have been a nurse for over 35 years, and we typically place our patients with ARDS in the prone position. However, with COVID-19 diagnoses, and the recognition that prone positioning is an effective treatment for these patients, the procedure has increased tremendously. Enteral nutrition has a positive effect on patient outcomes and should be started within 24-48 hours of ICU admission. This practice raises several important clinical questions.

• 1Can you feed patients while they are in the prone position?
  Most nurses are aware that the best practice is to ensure patients receive appropriate nutritional support in the ICU, but there is some confusion about feeding patients in the prone position. Seven research studies have compared gastric intolerance, increased gastric residual volume (GRV) or complications in the prone position with the supine position. One study by Reignier in 2004 showed some concern with gastric feeding and increased risk of aspiration and complications. Based on these results, the authors recommended use of prokinetic agents and/or diverting to post-pyloric feedings to overcome these risks. However, in a systematic review with six studies, all studies except the one by Reignier mentioned above reported no differences between supine and prone positions for GRVs. Another study published in 2021 by Savio also found no increase in complications for patients fed in the prone position. Based on the available research, we know it is safe and feasible to feed patients enterally in the prone position.

• 2What is the initial rate for enteral feeding, and how do we achieve goal rates when feeding patients in the prone position?
  When feeding into the stomach, it is often common to see trophic feeding starting at 10 mL/h. Rates can be increased if there are no signs of enteral feeding intolerance (EFI). Signs of EFI include complaints of nausea, vomiting, abdominal distention and diarrhea. High GRVs may also be noted if you are still measuring it. As you can imagine, signs of EFI are difficult to assess in a patient who is sedated, possibly paralyzed and lying in a prone position. Since patients with signs of EFI are at greater risk for complications from vomiting and potential aspiration, it is important to monitor for these signs. If there are concerns for EFI, it may be a good idea to start prokinetic agents or divert to post-pyloric feeding if feasible in your facility.

  Original recommendations for nutritional support for patients with COVID-19 from American Society of Parenteral and Enteral Nutrition (ASPEN) and Society of Critical Care Medicine (SCCM) state that gastric feedings were recommended to decrease undue exposure from post-pyloric feeding tube placements). However, a recent study by Suliman et al shows this strategy with gastric feeding may not adequately meet the needs of this patient population. In these situations, the authors recommend post-pyloric feeding or supplemental parenteral nutrition.

• 3What precautions should nurses take to prevent aspiration while a patient is in the prone position?
  In order to achieve safe and adequate feeding for patients in the prone position, nurses can implement the following strategies:

  • Ensure the tube is placed prior to the prone position, if possible, to avoid delays in starting feeding.
  • Consult with a dietitian for the appropriate start rate and goal.
  • Monitor for signs of EFI (abdominal distention, nausea, vomiting, high GRVs, diarrhea).
  • Place the patient in reverse trendelenburg as tolerated (up to 20-25 degrees if possible).
  • For EFI or increased risk of EFI, request the addition of prokinetic agents or divert to post-pyloric feeding.

• 4Do you need to stop feedings when turning the patient to the prone position and when returning supine?
  There is no need to stop feedings during the turning procedure or during prone positioning (other than you may want to get the tubing out of the way). There is no evidence related to stopping feedings when turning patients for prone positioning; however, evidence on repositioning patients while supine shows no increase in aspiration when feedings are left to infuse. This practice also is common sense if you consider the rate of feedings; for example 20 mL/h. During a 15-minute position change, only 5 mL will infuse, which will not increase aspiration.

Practice Change Is Needed

We must continue to ensure patients in our care receive high-quality, evidence-based care, which includes the provision of adequate and early enteral nutrition. Enteral nutrition is a critical need for ICU patients, which remains true even for patients in the prone position — maybe even more so due to their increased acuity. It is important to note that you can provide enteral nutrition for these patients — safely and efficiently.

What You Can Do

• Assess your procedures for feeding in the prone position. If you are not feeding your patients adequately — why not?
• Your unit may benefit from an enteral nutrition protocol to ensure feedings are started in a timely manner and delivered efficiently.
• Collaborate with your dietitian and physician colleagues to develop policies, protocols and practices to adequately meet your patients' nutritional needs. Provide education for your peers and other disciplines as well as your patients/families, as needed.
• Feed your patients early and adequately despite the need for prone positioning.

What practice changes have you implemented to successfully feed in the prone position?