Factors influencing the implementation and adherence to volume-based enteral feeding protocols in the critical care setting: A scoping review

OBJECTIVE

Delivery of enteral nutrition is an essential component of care for patients in the intensive care unit (ICU); however, patients only receive approximately 60% of prescribed enteral nutrition. Volume-based feeding (VBF) has been demonstrated as a safe and effective strategy to catch up for missed delivery of enteral nutrition. The aim of this review was to investigate factors influencing the adherence and implementation of VBF in the adult critical care and high-dependency unit settings to inform future implementation of VBF protocols in the ICU.

METHODS

Systematic searches of databases (MEDLINE, EMBASE, and Emcare) and grey literature repositories (TROVE, TRIP, CPG Infobase, WorldCat, and Google) were conducted to identify original research studies including adults admitted to the ICU, where VBF or catch-up feeding protocols were in place. Studies reporting on barriers, enablers, and acceptability or adherence to VBF protocols were included.

RESULTS

A total of 28 studies involving 7057 participants were eligible for inclusion, of which 19 were conducted in the USA, seven in Canada, one in the UK, and one in Australia. Factors enabling the implementation of VBF included management support, multidisciplinary team engagement, a project team, multimodal education, and communication strategies. Embedding the protocol into current work systems increased success. Barriers included a culture of deprioritising nutrition, safety concerns, staff turnover, and failure to embed the changes into work systems including the electronic medical record. VBF was considered acceptable to ICU staff; however, adherence to VBF protocols was variable (between 32.1% and 90%).

CONCLUSION

Successful implementation of a VBF protocol is enabled by strong project leadership, staff education, team engagement, and embedding VBF into current work processes. VBF is acceptable to staff; however, continuous education is recommended to sustain change in practice. Implementation of VBF should be considered as part of an "enhanced" feeding strategy in the ICU setting.

REGISTRATION

The protocol was developed and registered a priori on Open Science Framework on 8th August 2023 (https://doi.org/10.17605/OSF.IO/8DJKY).

The effect of enteral nutrition strategy and non-invasive ventilation on diarrhea and nutritional goals in the critically ill: A protocol for a multicentre retrospective cohort study (ENND GOALS)

Enteral nutrition (EN) has become the standard of care for nutritional support among critically ill patients. However, little is known about whether continuous delivery (CEN) or intermittent delivery (IEN) is preferable or the consequences of either strategy. This is particularly true for diarrhea, which is understudied but consistently shown to be associated with increased morbidity among critically ill patients. This is a multicenter, retrospective cohort study including critically ill patients greater than 18 years of age, admitted to the Intensive Care Unit in Hamilton, Canada, and prescribed EN for greater than 48 hours. Patients will be divided into IEN and CEN groups based on the nutritional strategy they received during their stay. The primary outcome will be the proportion of patients in each group with diarrhea during their ICU stay, diarrhea will be defined according to WHO criteria. Multivariate logistic regression will be performed to identify the role of covariates in the risk of developing diarrhea. Secondary outcomes will include caloric intake, incidence of ICU-acquired infections, including Clostridioides difficile, length of stay, and mortality. This study protocol has been approved by the Hamilton Integrated Research Ethics Board (#16453). The study findings will be disseminated at academic conferences and published in peer-reviewed journals.

Volume-based enteral feeding for ward patients with acute neurological conditions: a pilot prospective cohort study

BACKGROUND

Patients requiring enteral nutrition (EN) after neurological insults experience feeding interruptions, contributing to inadequate nutrition delivery. This prospective cohort study investigated if volume-based enteral feeding (VBF) improved the delivery of prescribed EN volume in ward patients with acute neurological conditions.

METHODS

Over two sequential periods, the usual care group received standard continuous rate-based feeding, and the intervention group received VBF with bi-daily EN rate adjustments to achieve target daily volume. The primary outcome was percentage of prescribed daily EN formula volume delivered. Differences in energy and protein provision, weight, malnutrition and safety were explored. An evaluation survey captured nurse acceptability of the protocol.

RESULTS

The intervention group (n = 32) achieved greater median interquartile range (IQR) EN adequacy of prescribed volume at 92% (88-97) compared to 67% (54-78) for usual care (n = 35) (p < 0.001). VBF compared to rate-based feeding resulted in patients receiving more kilojoules (131 [121-138] kJ/kg vs. 84 [64-99] kJ/kg; p < 0.001) and protein (1.3 [1.2-1.5] g/kg vs. 0.9 [0.6-1.1] g/kg; p < 0.001). There were no differences in gastrointestinal intolerance between groups. Compliance to the VBF protocol was 90%, and 78% of staff reported high confidence using the protocol. The intervention group had less median weight loss at discharge (-1.4 [0.1 to -4.3] kg) than usual care (-3.6 [-1.3 to 8.4] kg; p < 0.011), but no differences in malnutrition status were observed.

CONCLUSION

A VBF protocol delivered greater EN volume, energy and protein following neurological injury. The VBF protocol was feasible with high acceptability from nursing staff.

Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit

BACKGROUND

Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

LOCAL PROBLEM

This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

METHODS

This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project.

RESULTS

During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

CONCLUSIONS

Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Gastric residual volume monitoring practices in UK intensive care units: A web-based survey

Background and aim

Monitoring of gastric residual volume (GRV) to assess for enteral feeding intolerance is common practice in the intensive care unit (ICU) setting; however, evidence to support the practice is lacking. The aim of this study was: (i) to gain a perspective of current practice in adult ICUs in the UK around enteral feeding and monitoring of GRV, (ii) to characterise the threshold value used for a high GRV in clinical practice, (iii) to describe the impact of GRV monitoring on enteral feeding provision and (iv) to inform future research into the clinical value of GRV measurement in the adult ICU population.

Methods

A web-based survey was sent to all UK adult ICUs. The survey consisted of questions pertaining to (i) nutritional assessment and enteral feeding practices, (ii) enteral feeding intolerance and GRV monitoring and (iii) management of raised GRV.

Results

Responses were received from 101 units. Ninety-eight percent of units reported routinely measuring GRV, with 86% of ICUs using GRV to define enteral feeding intolerance. Threshold values for a high GRV varied from 200 to 1000 ml with frequency of measurement also differing greatly from 2 to 12 hourly. Initiation of pro-kinetic medication was the most common treatment for a high GRV. Fifty-two percent of respondents stated that volume of GRV would influence their decision to stop enteral feeds a lot or very much. Only 28% of units stated that they had guidelines for the technique for monitoring GRV.

Conclusions

Measurement of GRV is the most common method of determining enteral feeding intolerance in adult ICUs in the UK. The practice continues despite evidence of poor validity and reproducibility of this measurement. Further research should be undertaken into the benefit of ongoing GRV measurements in the adult ICU population and alternative markers of enteral feeding intolerance.

Decision tree model for early use of semi-elemental formula versus standard polymeric formula in critically ill Malaysian patients: A cost-effectiveness study

BACKGROUND

Prevention of enteral feeding interruption (EFI) improves clinical outcomes of critically ill intensive care unit (ICU) patients. This leads to shorter ICU stays and thereby lowers healthcare costs. This study compared the cost of early use of semi-elemental formula (SEF) in ICU vs standard polymeric formula (SPF) under the Ministry of Health (MOH) system in Malaysia.

METHODS

A decision tree model was developed based on literature and expert inputs. An epidemiological projection model was then added to the decision tree to calculate the target population size. The budget impact of adapting the different enteral nutrition (EN) formulas was calculated by multiplying the population size with the costs of the formula and ICU length of stay (LOS). A one-way sensitivity analysis (OWSA) was conducted to examine the effect each input parameter has on the calculated output.

RESULTS

Replacing SPF with SEF would lower ICU cost by MYR 1059 (USD 216) per patient. The additional cost of increased LOS due to EFI was MYR 5460 (USD 1114) per patient. If the MOH replaces SPF with SEF for ICU patients with high EFI risk (estimated 7981 patients in 2022), an annual net cost reduction of MYR 8.4 million (USD 1.7 million) could potentially be realized in the MOH system. The cost-reduction finding of replacing SPF with SEF remained unchanged despite the input uncertainties assessed via OWSA.

CONCLUSION

Early use of SEF in ICU patients with high EFI risk could potentially lower the cost of ICU care for the MOH system in Malaysia.

Optimizing enteral nutrition delivery by implementing volume-based feeding protocol for critically ill patients: an updated meta-analysis and systematic review

BACKGROUND

This study aims to provide an updated assessment of the efficacy of optimized enteral nutrition (EN) delivery by implementing the volume-based feeding (VBF) protocol in critically ill patients.

METHODS

We updated our previous literature retrieval with no language restrictions. The inclusion criteria were:1) Participants: Critically ill patients (Patients who was admitted in ICU; 2) Intervention: The VBF protocol was adopted for EN administration; 3) Comparison: The rate-based feeding (RBF) protocol was adopted for EN administration; 4) Major outcomes: EN nutrition delivery. The exclusion criteria included participants aged < 18 years, duplicated literature, animal and cellular experiments, and studies lacking any of the outcomes mentioned in the inclusion criteria. The databases included MEDLINE (through PubMed), Web of Science, Cochrane Library, Chinese Biomedical Literature Service System (SinoMed), Wanfang Data Knowledge Service Platform, and China National Knowledge Infrastructure.

RESULT

Sixteen studies involving a total of 2896 critically ill patients are included in the updated meta-analysis. Compared with the previous meta-analysis, nine new studies were added that included 2205 more patients. The VBF protocol significantly improved energy (MD = 15.41%, 95% CI: [10.68, 20.14], p < 0.00001) and protein (MD = 22.05%, 95% CI: [10.89, 33.22], p = 0.0001) delivery. The patients in the VBF group stayed in the ICU for a shorter time (MD = 0.78, 95% CI: [0.01, 1.56], p = 0.05). The VBF protocol did not increase the risk of death (RR = 1.03, 95% CI: [0.85, 1.24], p = 0.76) or prolong the mechanical ventilation duration (MD = 0.81, 95% CI: [-0.30,1.92], p = 0.15). In addition, the VBF protocol did not affect EN complications, such as diarrhea (RR = 0.91, 95% CI: [0.73, 1.15], p = 0.43), emesis (RR = 1.23, 95% CI: [0.76, 1.99], p = 0.41), feeding intolerance (RR = 1.14, 95% CI: [0.63, 2.09], p = 0.66), and gastric retention (RR = 0.45, 95% CI: [0.16, 1.30], p = 0.14).

CONCLUSION

Our study revealed that the VBF protocol significantly improved calorie and protein delivery in critically ill patients with no additional risk.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

Nutrition support for critically ill patients

Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.

Is the risk of refeeding syndrome a problem in reaching nutritional requirements? A cohort of patients on enteral nutrition support

BACKGROUND

refeeding syndrome (RS) is a metabolic complication associated with nutritional support. The lack of management protocols for patients on nutritional support may lead to the development of RS or undernourishment.

OBJECTIVE

to evaluate adherence to the algorithm for total enteral nutritional support (ASNET), and the efficacy of reaching nutrient requirements in patients at risk of RS.

METHODS

a cohort study: screening and nutritional evaluation of patients and risk of RS were performed. Adults admitted to hospital for noncritical illness who received exclusively enteral nutrition (EN) were eligible. Patients with RS, intestinal failure or chronic diarrhea were excluded. Adherence to ASNET was evaluated along with the efficacy of nutritional support to reach the optimal protein and energy requirement (OPER) and any associated complications. Patient follow-up ended when the feeding route was changed or upon discharge.

RESULTS

a total of 73 patients were included (mean age, 62 ± 16 yrs; BMI, 18.5 ± 4.2 kg/m2), and 55 % were men. All had nutritional risk of developing RS (57, low; 15, high; 1, very high); 34 % had adequate adherence to ASNET, and 33 % managed to cover the total requirement between 4 and 6 days. OPER was reached by 38 % by the fourth day of EN, and adequate adherence to ASNET increased the probability of achieving it (RR, 2.2; 95 % CI, 1.6-3.2, p < 0.0001) without increasing the associated complications. Nonetheless, 36 % developed complications, of whom 96 % did not adhere to ASNET.

CONCLUSION

adherence to ASNET in patients at risk of RS allowed the achievement of OPER safely by day four with fewer associated complications.

Nutrition in the Intensive Care Unit-A Narrative Review

Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.

Evidence on nutritional therapy practice guidelines and implementation in adult critically ill patients: A systematic scoping review

BACKGROUND

The rapid increase in disease-related malnutrition makes it almost impossible for healthcare practitioners and policymakers to keep up with its negative consequences. Consequently, healthcare organisations and decision-makers have called for accelerated and double-duty actions to manage the double burden of malnutrition. Guidelines standardise nutritional practices, improve nutritional status and reduce hospitalisation duration and save costs.

OBJECTIVES

A systematic scoping review of the nutritional therapy practice guidelines and implementation in critically ill adults was undertaken to identify the breadth of literature on the topic, summarise findings and identify gaps.

METHODS

A comprehensive search strategy was designed and implemented to identify eligible studies from eight databases, websites of organisations, government departments and academic platforms. Reference lists of included studies were also searched for relevant studies. We assessed the quality of included studies, completed a descriptive numerical summary and analysed them.

RESULTS

In total, 1555 titles and 101 abstracts were screened, 65 underwent full text review and 19 were retained for data extraction. Studies scored average to high on quality assessment, and a summary of characteristics of included studies is presented. Nutritional therapy practice guidelines are considered a proactive strategy for enhanced, uniform and individualised nutritional practices and factors that influence implementation were identified.

CONCLUSIONS

A gap exists between research recommendations and actual practice despite the growing interest in implementation of nutritional therapy guidelines in critical care. There is a need for more research to evaluate the practicality of available guidelines.

Sarcopenia and Psychosocial Variables in Patients in Intensive Care Units: The Role of Nutrition and Rehabilitation in Prevention and Treatment

Critical illness leads to decline in muscle mass that promotes decline in physical function and psychological function and may lead to cognitive decline or dementia. Nurses are key to driving the multidisciplinary interventions that prevent protein loss and promote positive outcomes for critically ill patients.

Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Time' (PERFECT) protocol: a before-and-after study

BACKGROUND

Underfeeding in critical illness is common and associated with poor outcomes. According to large prospective hospital studies, volume-based feeding (VBF) safely and effectively improves energy and protein delivery to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after study was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit (ICU).

METHODS

The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The first cohort (n = 46) was fed using RBF, the second (n = 46) using VBF, and observed for 7 days, or until extubation or death. Statistical comparison of percentage feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation period, mortality, and length of ICU stay (LOICUS).

RESULTS

Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF group increased significantly by 11.2% (p ≤ 0.001), energy by 13.4% (p ≤ 0.001) and protein by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients meeting > 90% of energy requirements increased significantly from 47.8 to 84.8% (p ≤ 0.001); those meeting > 90% of protein requirements changed from 56.5 to 73.9% (p = 0.134). VBF did not increase symptoms of feed intolerance. Adjusted binomial logistic regression found each additional 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900-0.985], p = 0.010. No differences in mortality or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of protein requirements compared to those meeting < 80%, (p = 0.006). Adjusted Cox regression found the daily probability of being extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < 80%, hazard ratio 3.473, p = 0.021, 95% CI [1.205-10.014].

CONCLUSION

VBF safely and effectively increased the delivery of energy and protein to critically ill patients. Increased protein delivery may improve extubation rate which has positive patient-centred and financial implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced protein delivery to improve patient outcomes.

Enteral Nutrition in the Mechanically Ventilated Patient

Mechanically ventilated patients are unable to take food orally and therefore are dependent on enteral nutrition for provision of both energy and protein requirements. Enteral nutrition is supportive therapy and may impact patient outcomes in the intensive care unit. Early enteral nutrition has been shown to decrease complications and hospital length of stay and improve the prognosis at discharge. Nutrition support is unique for patients on mechanical ventilation and, as recently published literature shows, should be tailored to the individuals' underlying pathology. This review will discuss the most current literature and recommendations for enteral nutrition in patients receiving mechanical ventilation.

PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial

BACKGROUND

The Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP) has been shown to be feasible, safe, and effective in delivering significantly more energy/protein, though it has not been well studied in surgical/trauma patients. We hypothesized that PEP uP will effectively increase energy/protein delivery to critically ill surgical/trauma patients.

METHODS

This multicenter, prospective, randomized pilot study included adult patients admitted to surgical service who were expected to require mechanical ventilation for >24 hours and intensive care unit (ICU) care for >72 hours. Subjects were randomized to PEP uP or standard care. The PEP uP protocol includes initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24-hour volume-based goals, and modular protein supplementation. The primary outcome was nutrition adequacy over the first 12 ICU days.

RESULTS

Thirty-six subjects were enrolled. Slow recruitment resulted in early trial termination by the sponsor. There were no baseline differences between groups. PEP uP patients received more protein (106.8 ± 37.0 vs 78.5 ± 30.3 g/d, P = 0.02). Energy delivery was not significantly different (1400.0 ± 409.5 vs 1237.9 ± 459.1 kcal, P = 0.25). Vomiting was more common in the PEP uP patients (32% vs 12%, P = 0.03). PEP uP protocol violations included 2 patients (15.4%) not receiving pro-motility medications, 3 (23.1%) not receiving volume-based feeds as ordered, and 4 (30.8%) not receiving supplemental protein.

CONCLUSIONS

In surgical/trauma patients, PEPuP seemed to improve protein delivery but was difficult to implement successfully and may increase vomiting rates.

Nutrition Care of Critically Ill Patients with Leukemia: A Retrospective Study

Adults with acute leukemia (AL) are at high risk of malnutrition due to their disease and treatment side effects and may be admitted to the intensive care unit (ICU), further increasing the risk of malnutrition. Although ICU care includes some form of nutrition, patients typically receive less than prescribed energy and protein. Our objective was to characterize the nutrition care for critically ill patients with AL. We completed a retrospective review of adults with AL admitted to the Medical/Surgical ICU >24 hours. Descriptive statistics were performed on collected data including: demographics, APACHE II and Nutric scores, nutrition therapy, reasons for withholding nutrition, and mortality status at discharge. Data were collected on 154 AL patients with an average APACHE II score of 27 and Nutric score of 5.96. ICU mortality was 36%. Enteral nutrition (EN) was most commonly prescribed. Patients on EN received 55% of energy and 51% of protein prescribed. EN was commonly withheld for airway management and gastrointestinal impairment. Patients with AL received low amounts of energy and protein in the ICU and had a high Nutric score. Strategies and barriers to improve protein intake in this population are identified.

Improvement of Nutritional Intake in Intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol

BACKGROUND

Enteral nutrition in intensive care unit patients has important prognostic clinical value. Feeding protocols are recommended by clinical practice guidelines as a key strategy to maximize the benefits and minimize the risks of enteral feedings.

OBJECTIVE

To examine whether enteral nutrition in critically ill patients could be improved by implementation of a nurse-led evidence-based feeding protocol.

METHODS

An interprofessional group of intensive care unit nurses, physicians, and a clinical dietitian designed a protocol to address and correct the shortcomings of enteral feeding. Data on feeding and clinical outcomes were collected retrospectively for patients for 12 months before (control group) and then for 12 months after (interventional group) implementation of the protocol.

RESULTS

Enteral feeding was started significantly earlier (P = .007) after admission to the intensive care unit in the intervention group (52.3 hours; SD, 42.6) than in the control group (70.3 hours; SD, 65.2). Use of the protocol resulted in a significant increase in nutritional intake; 90% of patients in the intervention group but only 34% in the traditional feeding group achieved their caloric target within 96 hours after admission (P < .001). After implementation of the protocol, cessation of feeding due to intolerance was significantly less (P = .03) in the intervention group (6%) than in the traditional feeding group (14 %), and no adverse events were detected.

CONCLUSIONS

Adherence to standardized guidelines with a written protocol for an early start and timely escalation of enteral feeding can improve nutritional intake among intensive care unit patients.

Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill

Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.

Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study

AIMS AND OBJECTIVES

To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. Our objectives are to provide tailored interventions for addressing identified barriers and propose an optimal enteral nutrition (EN) practice in intensive care unit (ICU).

BACKGROUND

Despite the availability of numerous verified clinical practice guidelines focusing on enteral feeding of critically ill patients, a wide gap remains between the guideline recommendations and actual nutrition performances. Underfeeding is also a global problem. Therefore, to further understand the reasons of the systemic iatrogenic underfeeding in ICUs, several potential issues are investigated.

DESIGN

This research is a cross-sectional descriptive study.

METHODS

A total of 808 nurses were recruited from 10 comprehensive hospitals from different districts in China. The nursing staff demographic, the unit's EN management information and the Chinese version of barriers to enteral feeding critically ill patients questionnaire were the parameters used to collect data via WeChat app. Moreover, the collected data were analysed by descriptive and correlative statistical analysis methods.

RESULTS

Results obtained by multiple linear regression showed that frequency of EN-related training, full-time ICU nutritionist, hospital level, specific protocols for enteral feeding and position were significantly influencing the enteral feeding of ICU patients.

CONCLUSIONS

Enteral feeding barriers of ICU patients are at a moderate level and are influenced by multiple aspects. Hence, hospital departments should strengthen standardisation and systematic EN training, provide ICU full-time nutritionists and distribute medical resources and personnel rationally. Moreover, construction of a localised feeding process and exerting subjective initiative of clinical nurses from an evidence-based guideline are important. Multifaceted tailored interventions should be implemented to address these barriers.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can be used to inform future intervention and guidelines aimed at addressing these barriers systematically and improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control

BACKGROUND

Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC).

METHODS

This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for ≥3 consecutive days during the first 12 ICU days.

RESULTS

Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P < .001) and protein (RBEN, 68.6%; VBEN, 79.3%; P < .001). Multiple linear regression analyses confirmed VBEN was significantly associated with an 8.9% increase in energy (P = .002) and 7.7% increase in protein (P = .004) received, after adjusting for age, Acute Physiology and Chronic Health Evaluation II score, duration of and initiation day for EN, and ICU admission location. Presence of hyperglycemia (P = .40) and glycemic variability (GV) (P = .99) were not different between the 2 groups. After adjusting for age, body mass index, diabetes history, primary diagnosis, and percent of days receiving corticosteroids, GC outcomes (presence of hyperglycemia, P = .27; GV, P = .67) remained unrelated to EN order type in multivariable regression models.

CONCLUSION

VBEN, compared with RBEN, was associated with increased energy and protein delivery without adversely affecting GC. These results suggest VBEN is an effective, safe strategy to enhance EN delivery in the ICU.

Nutrition support team activities can improve enteral nutrition administration in intensive care units

OBJECTIVES

The aim of this study was to evaluate the effect of the nutritional support team (NST) activities on the quality of enteral nutrition administration in intensive care units.

METHODS

An observational, analytical, and cross-sectional study was performed in nine hospitals in the Brazilian Federal District through the administration of two questionnaires. One questionnaire focused on the activities of the NST and the other on the quality of enteral nutrition administration in intensive care units.

RESULTS

There was a strong correlation between the scores of the two questionnaires, which was confirmed by a linear regression model (R² = 0.623; P = 0.007). The results suggest that high scores in the NST activities questionnaire predict a better performance in enteral nutrition administration. The sections of the NST activity questionnaire that most strongly affected enteral nutrition administration were the protocols (r = 0.895; P < 0.01), quality control (r = 0.779; P < 0.05), and continuing education (r = 0.753; P < 0.05).

CONCLUSIONS

The NST has the potential to positively influence enteral nutrition management in intensive care units and investments could be directed to the areas of continuing education, protocols, and quality control to maximize the effect of NST in intensive care units.

Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.

Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial

BACKGROUND

Unintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown.

OBJECTIVE

To evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting.

DESIGN

Randomized controlled clinical trial.

PARTICIPANTS AND SETTINGS

This trial was conducted from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of EN were excluded.

INTERVENTION

The intervention group received EN according to a protocol, whereas the control group was fed according to standard practice.

MAIN OUTCOME MEASURES

The proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation.

STATISTICAL ANALYSES PERFORMED

Student t test or Wilcoxon rank-sum test were used for continuous variables and the difference between the groups in the time to receipt of the optimal amount of nutrition was analyzed using Kaplan-Meier curves.

RESULTS

Forty-five patients were randomized to each group. At Day 4 after EN initiation, 61% of patients in the intervention arm had achieved the primary end point compared with 23% in the control group (P=0.001). In malnourished patients, 63% achieved the primary end point in the intervention group compared with 16% in the control group (P=0.003). The cumulative deficit on Day 4 was lower in the intervention arm compared with the control arm: 2,507 kcal (interquartile range [IQR]=1,262 to 2,908 kcal) vs 3,844 kcal (IQR=2,620 to 4,808 kcal) (P<0.001) and 116 g (IQR=69 to 151 g) vs 191 g (IQR=147 to 244 g) protein (P<0.001), respectively. The rates of gastrointestinal complications were not significantly different between groups.

CONCLUSIONS

Implementation of an EN protocol outside the ICU significantly improved the delivery of calories and protein when compared with current standard practice without increasing gastrointestinal complications.

What Is "Best Achievable" Practice in Implementing the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Intensive Care Units in the United States? Results of a Multicenter, Quality Improvement Collaborative

BACKGROUND

The purpose of this study was to determine what was "best achievable practice" with the implementation of a novel enteral feeding protocol (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol [PEP uP protocol]).

METHODS

This study was a multicenter quality improvement collaborative wherein we describe nutrition practices and outcomes within PEP uP sites. We report the minimum, average, and maximal site-level performance on aspects related to nutrition practices and outcomes.

RESULTS

In 2014, 7 intensive care units (ICUs) in the United States implemented the PEP uP protocol. On average, over the first 5 ICU days, patients received 35% (site range, 26%-53%) of their prescribed energy requirements and 42% (site range, 29%-66%) of their prescribed protein requirements from enteral nutrition. In PEP uP sites, 71% (site range, 58%-95%) of patients received a semidigested formula within 72 hours of admission to the ICU, 72% had a volume-based goal as the initial feeding strategy (site range, 47%-100%), 56% had prophylactic protein supplements (site range, 0%-100%), and 19% received prophylactic motility agents (site range, 0%-85%).

CONCLUSIONS

There was variable success with the implementation of the different components of the PEP uP protocol. Improving the implementation of the various components may further increase nutrition delivery.

The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review

The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.

Are Predictive Energy Expenditure Equations in Ventilated Surgery Patients Accurate?

BACKGROUND:

While indirect calorimetry (IC) is the gold standard used to calculate specific calorie needs in the critically ill, predictive equations are frequently utilized at many institutions for various reasons. Prior studies suggest these equations frequently misjudge actual resting energy expenditure (REE) in medical and mixed intensive care unit (ICU) patients; however, their utility for surgical ICU (SICU) patients has not been fully evaluated. Therefore, the objective of this study was to compare the REE measured by IC with REE calculated using specific calorie goals or predictive equations for nutritional support in ventilated adult SICU patients.

MATERIALS AND METHODS:

A retrospective review of prospectively collected data was performed on all adults (n = 419, 18-91 years) mechanically ventilated for >24 hours, with an Fio₂ ≤ 60%, who met IC screening criteria. Caloric needs were estimated using Harris-Benedict equations (HBEs), and 20, 25, and 30 kcal/kg/d with actual (ABW), adjusted (ADJ), and ideal body (IBW) weights. The REE was measured using IC.

RESULTS:

The estimated REE was considered accurate when within ±10% of the measured REE by IC. The HBE, 20, 25, and 30 kcal/kg/d estimates of REE were found to be inaccurate regardless of age, gender, or weight. The HBE and 20 kcal/kg/d underestimated REE, while 25 and 30 kcal/kg/d overestimated REE. Of the methods studied, those found to most often accurately estimate REE were the HBE using ABW, which was accurate 35% of the time, and 25 kcal/kg/d ADJ, which was accurate 34% of the time. This difference was not statistically significant.

CONCLUSION:

Using HBE, 20, 25, or 30 kcal/kg/d to estimate daily caloric requirements in critically ill surgical patients is inaccurate compared to REE measured by IC. In SICU patients with nutrition requirements essential to recovery, IC measurement should be performed to guide clinicians in determining goal caloric requirements.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Gastrointestinal dysmotility in the critically ill: a role for nutrition

PURPOSE OF REVIEW

The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial.

RECENT FINDINGS

The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring.

SUMMARY

To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.

Indirect calorimetry in nutritional therapy. A position paper by the ICALIC study group

BACKGROUND & AIMS

This review aims to clarify the use of indirect calorimetry (IC) in nutritional therapy for critically ill and other patient populations. It features a comprehensive overview of the technical concepts, the practical application and current developments of IC.

METHODS

Pubmed-referenced publications were analyzed to generate an overview about the basic knowledge of IC, to describe advantages and disadvantages of the current technology, to clarify technical issues and provide pragmatic solutions for clinical practice and metabolic research. The International Multicentric Study Group for Indirect Calorimetry (ICALIC) has generated this position paper.

RESULTS

IC can be performed in in- and out-patients, including those in the intensive care unit, to measure energy expenditure (EE). Optimal nutritional therapy, defined as energy prescription based on measured EE by IC has been associated with better clinical outcome. Equations based on simple anthropometric measurements to predict EE are inaccurate when applied to individual patients. An ongoing international academic initiative to develop a new indirect calorimeter aims at providing innovative and affordable technical solutions for many of the current limitations of IC.

CONCLUSION

Indirect calorimetry is a tool of paramount importance, necessary to optimize the nutrition therapy of patients with various pathologies and conditions. Recent technical developments allow broader use of IC for in- and out-patients.

Peri-operative nutrition

Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.

Critical care: Meeting protein requirements without overfeeding energy

BACKGROUND AND AIMS

Relatively high protein input has been associated with improved clinical outcome in critical illness. However, until recently differences in clinical outcome have been examined in terms of the energy goal-versus under-feeding. Most studies failed to set the energy goal by an accurate measure or estimate of expenditure or independently set protein prescription. This leads to under-prescription of protein, possibly adversely affecting outcome. We determined whether an enteral nutrition prescription could meet local and international protein guidelines.

METHODS

Protein prescriptions of consecutive patients admitted to Southmead Hospital ICU and requiring full enteral nutrition were audited against local and international guidelines. Prescriptions were designed to not exceed energy expenditure based on a validated estimation equation, minus non-nutritional energy, and protein requirements were based on local or international guidelines of between 1.2 and 2.5 g protein/kg/d or 2-2.5/kg ideal body weight (Hamwi ideal body weight)/d.

RESULTS

From 15/1/15 to 12/4/15 139 ICU patients were prescribed full enteral nutrition. Protein prescriptions failed to meet local guidelines in 75% (p < 0.001) and international guidelines in 45-100%. Prescriptions meeting at least 90% of protein guidelines and 130 g of carbohydrate could be increased from between 0 and 55%, depending on the guideline, to between 53 and 94% using a protein supplement and 82 and 100% using a protein plus glucose supplement. Non-nutritional energy (NNE) proportionately reduces feed protein prescription and contributed 19% of energy expenditure in 10% of patients.

CONCLUSIONS

We need feeds with a lower non-protein energy: nitrogen (NPE:gN) ratio and/or protein supplementation if prescriptions are to meet protein guidelines for critical illness. NNE must be adjusted for in prescriptions to ensure protein needs are met.

Feeding the Postoperative Patient on Vasopressor Support: Feeding and Pressor Support

Initiating enteral nutrition in the postoperative patient can be challenging. Postoperative ileus and bowel edema, bowel anastomosis, and intra-abdominal pathology contribute to the reluctance and inability to achieve adequate nutrition in this patient population. The addition of vasopressors confounds the difficulties. Clinical data are sparse but suggest that most postoperative patients requiring vasopressor therapy can be safely initiated and advanced on enteral nutrition. Consideration of the vasopressor agent being utilized and its dose is imperative, as are individual patient characteristics. Temporal changes in the dosage should be closely monitored, as increasing doses may reflect worsening clinical status that can be due to intestinal ischemia. Well-designed prospective trials are clearly necessary to address this controversial topic.

Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP uP Protocol): A Review of Evidence

Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.

Optimal Nutrition for Acute Rehabilitation in the PICU

Achieving optimal nutrition for a child who is receiving acute rehabilitation in the pediatric intensive care unit requires an individualized approach. Nutrition screening and assessment is necessary to identify children at high risk for complications who require targeted interventions. Early enteral nutrition can improve outcomes, and is thus preferred over parenteral nutrition in the absence of gastrointestinal contraindications. Measurement of caloric requirements with indirect calorimetry is essential to accurately prescribe nutrition support, while monitoring body composition can determine efficacy of nutrition therapies employed. The complex care of critically ill children receiving acute rehabilitation is composed of treatments that compete with delivery of prescribed nutrition. Repeated feeding interruptions can lead to nutrition deficits and prolonged recovery. Nutrition bundles that incorporate evidenced-based nutrition algorithms, methods to overcome nutrition barriers, and nutrition monitoring parameters can direct and optimize nutrition care for critically ill children in need of acute rehabilitation.

Metabolic and nutritional support of critically ill patients: consensus and controversies

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.