الفهرس 
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Abstract
Summary
Critical patients are patients who experience instability of physiological conditions and changes in organ function that can cause organ damage and death. One that must be considered in critical patients is the fulfillment of nutritional needs. Early nutrition is very important to remove dependence on the ventilator, accelerate the healing process and shorten the length of treatment. Early enteral nutrition leads to reduced length of stay, death rates in ICU and in hospitals, decreased duration of mechanical ventilator use, and increased clinical outcomes compared with delayed enteral nutrition. Early delivery of nutrition (early enteral nutrition) is recommended in critical patients without contraindications. Therefor the aim of this study was to compare the effect of early versus late enteral feeding on the outcome of mechanically ventilated patients at Assiut university hospital. This study was conducted at General, trauma, coronary, anesthesia, and obstetric ICUs at Assiut university hospital. A quasi-experimental research design was adopted to conduct this study. A simple random sample of 80 adult critically ill patients who are mechanically ventilated and receiving enteral feeding assigned into two groups (40 in early enteral nutrition group and 40 in late enteral nutrition group.
Tools of the study:
Four tools were used in this study to investigate the effect of early versus late enteral feeding on critically ill patients’ outcome.
Tool one: ”patient’s assessment tool”
This tool was developed by the researcher after reviewing of literatures (Khalid. et al, 2010 & Hejazi. et al, 2016), to assess the patient conditions to form base line data to be compared with. This tool included four parts:
Part I: - Assessment of the socio-demographic patient’s profile and clinical data which included:
(Patient’s codes, sex, age, weight, height, BMI, Medical diagnosis, length of ICU stay and past medical history).
Part II: Assessment of the patient’s conscious level by Four Score.
Part III: MV parameters assessment which included:
(mode of ventilation, tidal volume(VT), fraction of inspired oxygen (FIO2), positive end expiratory pressure(PEEP), Minute ventilation, pressure support).
Part IV: Acute Physiology and chronic Health Evaluation (APACHE) II score. The APACHE-II scoring system was adopted to assess the severity of disease for adult patients admitted to intensive care units. The APACHE-II score consists of three components. The first component (largest component) of the APACHE-II score is derived from 12 clinical measurements that are obtained within 24 hours after admission to the ICU. The variables are: internal temperature, heart rate, mean arterial pressure, respiratory rate, oxygenation, arterial pH, serum sodium, serum potassium, serum creatinine, hematocrit, white blood cells count and Glasgow coma scale. Second component is age adjustment: from one to six points are added for patients older than 44 years of age. Third component of APACHE-II is chronic health evaluation. An additional adjustment is made for patients with severe and chronic organ failure involving the heart, lungs, kidneys, liver and immune system. (Khan. et al,2011).
Tool two: Nutritional status assessment tool:
This tool was developed by the researcher after reviewing of literatures (Fontes, et al, 2013 & Marcellous & Simadebrata, 2018), to assess the nutritional status of patient to form base line data to be compared with. This tool included three parts:
Part I: - Dietary history.
Part II: Anthropometric measurements were done at (1st and 7th day) of starting of enteral feeding which included:
(mid-arm circumference, arm muscle area and triceps skin fold).
Part III: Biochemical markers measurements were done at (1st and7th day) of starting of enteral feeding which included:
(Total lymphocyte count, S.total protein, Albumin, Phosphate, nitrogen balance, blood sugar and blood urea nitrogen).
Tool three: Nutritional Intervention Sheet:
This tool was developed by the researcher after reviewing of literatures (Daneshzada. et al, 2015 & Hejazi. et al, 2016), to deliver nutritional needs of the patient.
-This tool included three parts:
Part I: Calculation of 24 hrs energy requirements as following:
• Total energy expenditure (requirements)=basal metabolic rate (BMR)× (stress factor +activity factor + food thermic effect). -BMR was calculated by Harris -Benedict equation:
• Male (Kcal-D) =66.5+(13.75×weight kg) +(5×height cm) -(6.775×age y).
• Female (Kcal-D) = 655.1+(9.563× weight kg) +(1.85×height cm) -(4.67 ×age y).
• A stress factor and activity factor were estimated based on the patient’s condition and varied up, according to the published standardized factors.
Part II: Nutritional intake which included:
-Time of enteral feeding (early EN feeding within 24-48 hrs or late EN feeding after48hrs).
-Feeding formula and total duration of the formula intake (days).
-Fluid intake and output.
-Medication administered.
Part III: GIT function parameters which included:
A- Gastric Residual Volume (GRV).
B- Number and duration of GIT intolerance which included:
(constipation, diarrhea, and vomiting).
C- Causes of enteral feeding withholdings (interruption) as:
• Vomiting.
• High gastric residual volume.
• Abdominal distension.
Tool four: patient outcome assessment tool:
This tool was developed by the researcher after reviewing of literatures (Blaser, et al, 2017) to assess length of ICU stays, duration of mechanical ventilation and GIT complication.
The main results:
There was a significant decrease in length of ICU stay, duration of mechanical ventilation, and GIT complications in early enteral nutrition group than in late enteral nutrition group.