الفهرس 
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Abstract
Nutritional support is an important aspect of the care of critically ill patients and it is now widely accepted for the treatment and prevention of malnutrition, specific nutrient deficiencies, and improve patients’ outcome. Nutrition support can result in improving wound healing, decreasing catabolic response to injury, enhancing immune system function, improving gastrointestinal structure and function, and improving clinical outcomes.
However, many complications are associated with enteral feeding including gastrointestinal, mechanical, and metabolic complications, in addition, bacterial colonization of the stomach. Routine enteral feeding schedule is not allowing time to acidify the stomach with gastric pH. This may predispose the critically ill patients to acquired gastric colonization. Gastrointestinal complications are most commonly associated with complications derived from enteral feeding. Gastrointestinal complications include vomiting, diarrhea, constipation, and abdominal distension.
Gastric colonization becomes a serious problem facing the critical care team because its incidence increases with time. The gastric microbial growth is pH dependent; the higher the gastric pH, the greater the amount of bacterial growth, which may predispose to aspiration pneumonia. The nosocomial pneumonia is an important cause of morbidity, mortality, increasing the hospital stay, and costs of caring for critically ill patients. The intermittent enteral feeding schedule is proposed in order to lower the gastric pH, prevent bacterial gastric colonization, decrease the incidence of gastrointestinal complications and lastly decrease the length of the hospital stay.
So, this study aimed to investigate the effect of the intermittent enteral feeding schedule on the occurrence of gastrointestinal complications and the length of the hospital stay among critically ill patients at Assiut University Hospitals. The design of this study was a quasi-experimental design. This study was carried out in the trauma ICU at Assiut University Hospitals. Moreover, this study was conducted to test the research hypotheses that the gastrointestinal complications, gastric colonization, and length of hospital stay among patients who will receive the intermittent 4 hour interval feeding schedule (study group) will be lesser than that among patients who are receiving the intermittent 2 hour interval feeding schedule (control group), and to answer the research questions about what are aggravating and relieving factors of gastrointestinal complications among critically ill patients of trauma Intensive Care Unit, Assiut University Hospital?
The sample of this study consisted of a convenience sample of 80 adults, male and female critically ill patients on enteral feeding constituted the study sample. The subjects were assigned randomly into two equal groups (control group and study group, 40 patients each). Three tools were developed by the researcher based on reviewing the relevant literatures. Tool 1: Socio-demographic and clinical data sheet which consists of five parts, tool 2: Enteral nutrition assessment tool comprising two parts, and tool 3: Gastrointestinal complication assessment tool.
The tools were tested for content related validity by jury of 5 specialists in the field of critical care nursing and critical care medicine. A pilot study was conducted on 5 patients to test the feasibility and applicability of the tools and necessary modifications were done.
Both study and control patients were received the routine intermittent enteral feeding in the trauma ICU in relation the total amount and types of formula per day and same flow rate (14 drop/min). The only manipulation was in the rest period and time interval in which the study group subjects were rested 8hours at night as compared to 6hours for the control ones, as well study group subjects were having 4hours time interval between each two consecutive feeding as compared to 2hours for control group subjects. Feedings were started for study group subjects from 7am to 11pm as four hours between feedings. However, feedings for control group subjects were started from 7am to 1am of next day.
Gastrointestinal complications (vomiting, diarrhea, constipation, and abdominal distension) were assessed daily for frequency, aggravating conditions, and relieving factors. Gastric aspirates were implemented for the both groups to assess gastric pH and gastric colonization at the morning shift of 1st day, 3rd day, and 7th day before the beginning of the first feeding at 7am. Data collection of the study took approximately one year started from March 2010 till July 2011.
The main results:
Findings of the present study revealed that more than half (57.5%) of the control group subjects developed gastrointestinal complications as compared to 45% of the study group subjects with no significant statistical difference between the two groups. Diarrhea was prominent among 32.5% of the control group compared to 20% of the study group subjects. The least gastrointestinal complication among both groups was the abdominal distension in percentages of 12.5 as compared to 7.5 of the two groups respectively.
Results of the study also revealed that, the majority of control group subjects (90%) developed GC as compared to 40% of the study group subjects during the last assessment with a highly significant statistical difference between the both groups in this regard (p= 0.000, and p= 0.000). It was also found that 52.5 % of the study group subjects were hospitalized less than one month as compared to 35 % of the control group subjects were stayed between 30 to less than 45 days with a significant statistical difference between the two groups in this respect(p= 0.019).
Furthermore, significant statistical differences were existed between the gastric pH and colonization with gram positive and gram negative bacteria (p= 0.008 and p= 0.000) among the study group subjects respectively, indicating no-growth of gram positive and gram negative bacteria with lower gastric pH value (acidic stomach). A statistical significant difference was found between GC and gender among the control group subjects (p=0.025) indicating higher gastric colonization among male patients. In addition, statistical significant differences were found between GC and site of feeding tube, and formula preparation (p=0.028, p-=0.000) respectively among the study group subjects indicating higher gastric colonization among oral feeding tube and hospital prepared formulas.
It can be concluded that the intermittent enteral feeding schedule (IEFS) applied on the study group (feeding every 4 hours with fasting period 8 hours at night ) allowed to decease the gastric pH that inhibit gastric colonization. Also, the study group subjects had lower incidence of gastrointestinal complications (diarrhea, vomiting, constipation, and abdominal distention) and lesser length of the hospital stay than the control group ones.
Based on the study findings, the following recommendations are suggested:
• Developing strategies aiming at improving the quality of enteral nutrition practices.
• Establishing a standardized protocol for enteral nutrition support for critically ill patients.
• Gastric aspirate culture and sensitivity should be added to the routine investigations.
• Training nurses on enteral feeding procedure need to be pursued to minimize tube-fed associated complications.
• Studying the relationship between ventilator associated pneumonia and feeding methods (enteral versus parenteral), and feeding time (early versus late) and its effect on critically ill patients’ outcome.
• Reapplying this research on a larger probability sample acquired from different geographical areas in Egypt for generalization.<