Enteral Nutrition Protocol Research Articles

Clinical and Nutritional Effectiveness of a Nutritional Protocol with Oligomeric Enteral Nutrition in Patients with Oncology Treatment-Related Diarrhea.

(1) Background: Poor nutritional status and diarrhea are common complications in cancer patients. (2) Methods: This multicenter, observational, prospective study evaluated the effectiveness of an oligomeric enteral nutrition (OEN) protocol in the improvement of nutritional status and reduction of diarrhea symptoms. Nutritional status was assessed with the Subjective Global Assessment (SGA), Body Mass Index (BMI) and albumin levels. Diarrhea was evaluated by the frequency and consistency of stools (Bristol Stool form scale). (3) Results: After 8 weeks of OEN protocol, the nutritional status improved in 48.3% of patients, with an increased proportion of patients at risk of malnourishment (+27.3%) at the expense of a decrease of moderately (−19.9%) and severely (−7.3%) malnourished patients (p < 0.001). Serum albumin and BMI significantly increased after 8 weeks of OEN treatment (p < 0.005). OEN showed a 71.1% effectiveness in the improvement of stool consistency. The mean number of stools per day significantly decreased from baseline (4.17 stools/day) to week 8 (1.42 stools/day; p = 0.0041). The nutritional status significantly improved even in those patients with persistent diarrhea. (4) Conclusion: The proposed OEN protocol seemed to be effective in improving the nutritional status, frequency and consistency of stools in patients with oncology treatment-related diarrhea even in persistent cases.

Abstract No. 592 Early (

To report placement parameters, feeding protocols, and adverse events for inpatients undergoing initiation of early (<12 hours) enteral nutrition following primary percutaneous ≥16-French gastrostomy placements. Such practices have been reported in outpatient oncology patients and after endoscopic gastrostomy placements, but not regarding inpatient placements by interventional radiology. A total of 2573 encounters containing “gastrostomy placement” were screened between 2015 and 2019. 236 inpatients, including 148 (62.7%) males and 88 (37.3%) females with mean age 59.4 ± 17.4 years, underwent early (<12 hour) enteral nutrition via ≥16-French gastrostomy tubes. Indications for placement included: neurologic (n = 159; 67.4%), malignancy (n = 50; 21.2%), miscellaneous (n = 23; 9.7%), and malnutrition (n = 4; 1.7%). Tubes were cleared for use 4 hours after placement. Placement parameters, immediate (intraprocedural) adverse events, early nutrition protocols, 30-day adverse events, and mortality were recorded. Most interventions were performed using 3 gastropexy sutures (n = 231; 98.9%) and a 16-French gastrostomy tube (n = 180; 76.3%). Pigtail and balloon-type gastrostomy tubes were placed in 156 (66.1%) and 98 (41.5%) patients, respectively. Immediate adverse events occurred in 2 (0.8%) patients, including broken gastropexy sutures without (category A; minor) and with arterial injury requiring embolization (category D; major). Mean time to enteral nutrition initiation was 7.5 ± 3.0 hours with mean rate of 104 ± 150 mL/hour. There were 14 (5.9%) adverse events within 30 days, including 3 category A (minor), 7 category B (minor), 3 category D (major), and 1 category F (major) complications. There were no differences in gastrostomy size (P = 0.45), tube type (P = 0.93), mean time to enteral nutrition initiation (P = 0.58), or mean initial tube feed rate (P = 0.09) between those without and with 30-day adverse events. Early (<12 hours) enteral nutrition after percutaneous large-bore (≥16-French) gastrostomy placement is safe in inpatients with adverse events within previously reported standards (0.4-22.5%).

The effects of an enteral nutrition feeding protocol on critically ill patients: A prospective multi-center, before-after study

PurposeThe aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients. MethodsThis was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission. Results209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost. ConclusionThe implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate.Trial registrationClinicalTrials.gov, NCT02976155. Registered November 29, 2016- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02976155.

Inducing remission in paediatric Crohn's disease using nutritional therapies - A systematic review.

Exclusive enteral nutrition (EEN) is known to be a safe and effective treatment option for managing active Crohn's disease (CD) in children, although no uniform protocol exists. The aim of this systematic review was to evaluate and compare the clinical effectiveness of aspects of EEN protocols to ascertain whether an optimum regimen can be identified. A systematic search of the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL and AMED was conducted for studies published between 1998 and 2018 that examined paediatric patients being treated with an enteral nutrition protocol to induce remission. Studies that included patients receiving concurrent medication for active disease were excluded. Quality assessment was performed using separate tools for randomised controlled trials, cohort studies and for studies without a control group. Sixteen studies met the inclusion criteria. Of these, six found insufficient evidence to support use of a specific formula. One study examined the route of EEN, finding no difference between oral or nasogastric tube administration with respect to inducing remission. Three examined the use of partial enteral nutrition to induce remission, although conflicting results were seen. No studies explored the effect of length of treatment or energy prescription on remission rates CONCLUSIONS: An optimum enteral nutrition protocol for inducing remission cannot be identified. Further focused research is required by well designed, adequately powered prospective clinical trials to examine aspects of enteral feeding protocols that remain uncertain, including the use of partial enteral nutrition as a potential alternative to EEN.

Enteral nutrition in critically ill adults: Literature review of protocols.

Managing nutrition in critically ill patients is an important intervention to promote healing. It is unknown whether the implementation of a protocol that guides enteral nutrition (EN) support is effective in improving the outcomes of critically ill patients. Furthermore, it is unknown whether a nurse-driven protocol is more or less effective than a protocol not managed by nurses. The purpose of this literature review is to determine the current state of the science regarding evidence-based protocols for the administration and management of EN in critically ill patients. Studies were identified by searching the Cumulative Index to Nursing and Allied Health Literature Plus database for the terms "enteral nutrition AND nursing." Studies with EN protocols for adult, critically ill patients published since 2011 were included. Studies without a protocol and those pertaining to paediatric, disease-specific, medical-surgical, or community-based populations were excluded. A total of 10 studies meeting the inclusion criteria were identified. Defining and implementing both early initiation of EN and adequate titration to goal are important for achieving the maximum nutritional advantage. The highest benefit is also derived from identifying and delivering an individualized caloric and/or protein goal. A protocol increases standardization of practice in relation to these themes as well as the management of gastric residual volume, complications, and potentially for managing feeding interruptions. Because of the significant effects of nursing care on nearly all aspects of the management and delivery of EN, a nurse-driven protocol may yield higher compliance and greater effectiveness than a protocol that is not nurse driven. Nurses are at the forefront of EN administration, although interprofessional collaboration remains paramount. Current practice must align with the best practice in the development and implementation of an EN protocol.

Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease.

Background and AimExclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.MethodsA working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.ResultsAn optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.ConclusionEEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.

Enteral Feeding Intolerance in Patient Post Stem Cell Transplant (P12-050-19)

ObjectivesPatients undergoing stem cell transplant (SCT) often develop malnutrition as a result of disease state, pre-transplant regimen, and graft versus host disease. SCT patients are placed on nutrition support to prevent malnutrition and thus, higher mortality and morbidity. Enteral nutrition (EN) is preferred over parenteral nutrition (PN) support as it associated with decreased infection and inflammation, preserved gut function, and fewer complications overall. However, SCT patients often experience gastrointestinal intolerance (GI) (e.g., vomiting, abdominal distension, and diarrhea) as well as psychological stress with EN. MethodsThe patient was a 64-year old female who presented with complications of acute kidney injury and dysphagia with PEG placement after SCT two months prior. She experienced consistent, persistent EN intolerance. The nutrition diagnoses were a) inadequate EN infusion related to EN intolerance as evidenced by emesis, persistent nausea, and reaching only 48% of daily goal EN volume and b) severe chronic disease related malnutrition related to decreased energy intake secondary to disease state as evidenced by energy intake <75% of estimated energy requirements for >1 mo, unintentional weight loss >10% in 6 mo, and severe muscle mass loss in thighs, calves, shoulders, and clavicles. Nutrition interventions involved decreasing the EN rate, prescribing oral supplements, suggesting the addition of antiemetic/anti-anxiety medication, and encouraging intake by mouth per diet advancement. ResultsAlthough literature suggests choosing EN first for nutrition support in patients undergoing SCT, there are limited recommendations on how to effectively address GI and psychological stress that result from EN protocol. The patient was able to take in liquids/supplements by mouth and advanced to a regular diet. If she, however, would have continued to have severe EN intolerance and unable to take in nutrition by mouth, partial or total PN would have been indicated to prevent further malnutrition. ConclusionsAlthough EN improves patient outcomes for SCT patients, especially those with dysphagia, there is an opportunity to enhance care by establishing situation specific protocols/guidelines to prevent or reduce complications like GI and psychological distress. Funding SourcesNA.

Changes of plasma acetylcholine and inflammatory markers in critically ill patients during early enteral nutrition: A prospective observational study

BackgroundAcetylcholine (Ach) is the key anti-inflammatory transmitter in the cholinergic anti-inflammatory pathway. In this study, critically ill patients treated with early enteral nutrition (EEN) were observed to explore whether EEN affected Ach levels and inflammation. MethodsOne hundred thirteen patients were included in this prospective observational study. All patients were provided the early enteral nutrition protocol 24–48 h after admission to the intensive care unit (ICU). Blood samples were collected, and the plasma levels of Ach, cholecystokinin (CCK), and inflammatory markers (tumour necrosis factor alpha (TNF-α), interleukin 1beta (IL1-β), and IL6) were measured on Days 0, 1, 3, 5, and 7. Nutritional intervention data were recorded within one week, including the number of patients receiving nutrition, the number of days nutrition was provided, the caloric intake and protein intake, feeding intolerance and prokinetic drug administration. Other collected data included the sequential organ failure assessment score (SOFA score), the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the use of mechanical ventilation (the number of patients and the duration), use of vasoactive drugs and the number of renal replacement treatments (RRT) received by each patient during their ICU stay. The primary outcome was 28-day mortality. Additionally, we analysed the correlation between plasma Ach levels and inflammation, as well as the correlation between plasma Ach and CCK levels. Moreover, a multivariate regression analysis was performed to examine the independent effects of different variables on 28-day mortality and Ach levels. ResultsThe overall 28-day mortality was 28.3% (32/113). Eighty-two patients tolerated enteral nutrition. Compared with Day 0 15.6 (2.8) nmol/l, the plasma Ach level was significantly increased on Day 3 18.6 (6.7) nmol/l, Day 5 19.3 (6.2) nmol/l and Day 7 19.7 (4.3) nmol/l (p < .001). Compared with Day 0176.2 (50.4) pg/ml, the plasma TNF-α level was significantly decreased on Day 3144.0 (77.4) pg/ml, Day 5127.3 (51.8) pg/ml and Day 7111.4 (42.5) pg/ml (p < .05). Compared with Day 0, the plasma IL1-β level was significantly decreased on Day 7 (p < .05). The plasma IL6 level was significantly decreased on Day 5 and Day 7 (p < .05) compared with Day 0. Compared with Day 0, the plasma CCK level was significantly increased on Day 3, 5 and 7 (p < .001). The correlation analysis revealed negative correlations between Ach levels and inflammation (p < .001), and a positive correlation between CCK and Ach levels (r = 0.775, p < .001). A comparison of patients who did or did not tolerate EEN revealed significant differences in the plasma levels of Ach, TNF-α, IL6 and CCK (p < .05). Significant differences in plasma levels of Ach, TNF-α, IL1-β, IL6 and CCK were observed between 28-day survivors and non-survivors (p < .05). The multivariate logistic regression analysis identified vasopressor support, RRT, the administration of EEN, SOFA score, APACHE II score at ICU admission and plasma Ach levels as independent determinants of 28-day mortality. Additionally, the multivariate linear regression analysis identified EEN, plasma lactate, mechanical ventilation, the SOFA score and plasma CCK levels as independent determinants of plasma Ach levels. ConclusionsThe administration of EEN to critically ill patients contributed to the increased plasma Ach levels and decreased inflammatory markers. The effect of EEN on Ach levels is partially attributed to the increase in CCK levels. Elevated plasma Ach levels indicate a better prognosis.Clinical trials identifier: NCT03612206.

Clinical Decision Support Tools and a Standardized Order Set Enhances Early Enteral Nutrition in Critically Ill Children.

Critically ill children in a pediatric intensive care unit (PICU) have unique nutrition needs that are challenging to achieve and thus are at high risk of malnutrition. There is increasing evidence that children who reach caloric goals early have improved outcomes. The purpose of this initiative was to implement an enteral nutrition (EN) algorithm in a tertiary care PICU utilizing clinical decision support tools (CDSTs) and a standardized order set within an electronic health record. A quality improvement initiative was undertaken to implement an EN feeding protocol using electronic CDSTs, including a new standardized order set. In a historical cohort of 376 patients, only 18% met goal EN in the first 48 hours of admission. The EN protocol was implemented in 272 patients who met 88% goal feed volume within 48 hours of intensive care unit admission. Median time to start EN (1.7 vs 1.3 days, P < 0.0001) and time to goal nutrition (2.8 vs 2.2 days, P < 0.001) improved after project implementation. Length of stay in the PICU was significantly reduced following protocol implementation (202 hours pre-implementation vs 156 hours post implementation, P < 0.0001). We used CDSTs and standardized order sets to implement a nutrition algorithm to facilitate and likely improve the nutrition care of critically ill children.

Effect of Evidence-Based Enteral NutritionProtocol on Complications Prevention among Trauma Patients

Trauma injury is the leading cause of mortality and hospitalization worldwide and the leading cause of potential years of productive life lost. Hypercatabolism after trauma may lead to acute protein malnutrition that ultimately results in multiple organ failure. Therefore, nutritional support is an essential component of the care of critical trauma patients for optimizing outcomes. Evidence-based practice improves the quality of care through patient-centered care, the utilization of patient resources, provider resources and experiences, current research and scientific information. The main objective; of this study was to assess and evaluate the effect of evidence-based enteral nutrition (EN) protocol on complications prevention among trauma patients. The research hypothesis; evidence-based enteral nutrition protocol will prevent complications among trauma patients. The study subjects consisted of 50 adult patients diagnosed with trauma and divided equally into two groups; control group who received the routine hospital nutrition and study group who received evidence-based enteral nutrition protocol at the Intensive Care Unit (ICU) El-Minia University Hospital. The tools of data collection were; 1) Assessment sheet, it includes two parts, 1st part included socio-demographic data of the patient. 2nd part included five items that cover medical data, 2) Evidence-based enteral nutrition protocol, and 3) Evaluation sheet, it includes two parts, 1st part included the laboratory investigations. 2nd part covers the vital signs. Results: This study revealed that the majority of the control group less than thirty years old compared to study group equal or more than forty years old. There are statistically significant differences regarding mouth condition, severe infection, and nutritional assessment, among study and control groups. The result also revealed that the highest percent regarding the time of start enteral feeding and body positioning were among the study group. Conclusion: Evidence-based enteral nutrition protocol had significantly prevention of complications among trauma patients. Recommendation: Hospital should be following evidence-based enteral nutrition protocol to prevent complications among trauma patients at intensive care unit.

Knowledge of Intensive Care Nurses Regarding the Monitoring of Early Enteral Nutrition

Early initiated and uninterrupted enteral nutrition is associated with the reduction of disease severity, diminished complications, decreased hospital length of stay, and favourably affects the outcomes of critically ill patients. The aim of the study was to assess the knowledge of early enteral nutrition (EEN) monitoring among intensive care unit (ICU) nurses in selected facilities in the Eastern Cape, South Africa. A quantitative, descriptive and cross-sectional design was followed. A total of 115 questionnaires were distributed and 70 were returned giving a response rate of 61 per cent. Data were analysed using the Statistical Package for Social Sciences, version 21. The results showed that younger and less experienced nurses in private hospitals were more knowledgeable about EEN than the nurses in public hospitals. Regarding tolerance and adequacy monitoring, 60 per cent of the respondents reported the availability of enteral nutrition protocols while 40 per cent of the respondents disagreed that the protocols were available, which clearly stated a lack of efficient monitoring practices. Further, the varied knowledge reported by ICU nurses could be related to unclear protocols regarding procedures to be followed in monitoring tolerance and complications of EEN in the ICUs. Nurses, as primary care providers, should be equipped with the necessary knowledge to be able to advocate for EEN and to monitor the tolerance and adequacy of nutrient delivery.

Nutrition in head and neck cancer surgery: 15 years of enteral nutrition protocol

Nutrition in head and neck cancer surgery: 15 years of enteral nutrition protocol

Abstract P-298: TIMELINESS OF AN ACCELERATED CALORIE-BASED ENTERAL NUTRITION PROTOCOL IN THE PAEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: This study aimed to evaluate the timeliness of an accelerated calorie-based nursing-led enteral nutrition protocol in the paediatric intensive care unit (PICU). Methods A “before and after” study design was used. We compared the time taken to achieve targeted feeding goals and incidence of intolerance between patients on the previous protocol that was based on fluid requirement against a revised protocol based on both fluid and calorie requirement, together with faster feed escalation. Energy goals were calculated based on the Schofield equations and Dietary Reference Intakes. Comparison between continuous variables was performed using the Mann-Whitney U test. We used chi-2 tests to compare categorical variables. Statistical significance was taken as p < 0.05 for all tests. Results A total of 138 patients were included; 78 in the fluid-based protocol and 60 for the calorie-based protocol. The two groups did not differ in clinical characteristics. Patients were mostly aged <1 year (n=63, 45.7%) with a median weight of 9.5kg [Interquartile range (IQR) 5.3, 16.2]. Main cause for admission was respiratory (n=61, 44.2%). Time of initiation to target feeding goals was decreased from 18 (IQR 18, 20) to 12 (IQR 12, 16) hours (p<0.001) for 3hourly and 27 (IQR 24, 32) to 16 (IQR 15.3, 24) hours (p<0.01) for 4hourly feedings. There is no difference in gastrointestinal intolerance between both protocols.Conclusions The revised feeding protocol resulted in shorter duration of time to achieve goal feeds. The accelerated feeding schedule allowed most patients to achieve targeted feeding goals without significantly increasing incidence of gastrointestinal intolerance.

Comparison between the effects of two enteral nutrition support algorithms on nutrition care outcome in critically ill adult patients

Background The use of enteral nutrition (EN) algorithm optimizes nutrition by increasing the intake of calories in critically ill patients, but it does not compensate for loss of feeding time due to frequent interruptions as during fasting for operation or investigation.Aims were to compare implementation of enteral feeding support algorithm based on the SCCM/A.S.P.E.N guidelines and modifications to this algorithm (using a protocol that shifted from an hourly rate target goal to a twenty four hour volume goal). Settings and Design Case control study in the surgical ICU of zagazig university hospital. Methods and Material Patients of group1 were given caloric requirements as five bolus meals, patients of group 2 were given Fresubin by continuous infusion with hourly rate target goal and in Group 3 there was a Shift from hourly rate target goal to 24 hour volume goal and metoclopramide 10 mg I.V. q. 6 hours with the start of EN. Results There were statistically significant differences between groups regarding adequacy of caloric intake in 2nd, 3rd days and the overall adequacy of calories in all four days, where Group 2 provided more EN adequacy than Group 1 (P=0.02, 0.001, 0.01) respectively, and Group 3 provided more calories adequacy than Group1in 3rd day and overall adequacy (P=0.008 and 0.007) respectively. Also Patients in Group 2and 3 started accommodating EN earlier and had less episodes of vomiting than patients in group 1, (P value=0.043 and0.003 respectively). Conclusion The use of EN protocol provides more adequacy of calories and proteins from EN in comparison to bolus meals.

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

BackgroundUnintentional 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. ObjectiveTo evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting. DesignRandomized controlled clinical trial. Participants and settingsThis 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. InterventionThe intervention group received EN according to a protocol, whereas the control group was fed according to standard practice. Main outcome measuresThe proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation. Statistical analyses performedStudent 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. ResultsForty-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. ConclusionsImplementation 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.

Volume-Based Feeding in Enteral Nutrition: What About Diabetes?

Q At my hospital, we have a volume-based tube feeding practice. If a patient's tube feeding rate is adjusted up and down to ensure delivery of the 24-hour volume, how do you control blood glucose level? This would be especially important in a patient receiving an insulin infusion with hourly checks of blood glucose level. Is the blood glucose level significantly affected by changes in the tube feeding rate? If so, do you find that the standard ordered insulin scales are adequate?

Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes.

Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.

Reduction in necrotising enterocolitis after implementing an evidence-based enteral nutrition protocol in very low birth weight newborns

Introduction An unexpected increase in the incidence of necrotising enterocolitis (NEC) cases was observed in our hospital. Just in case, our feeding policy could be responsible, it was decided to conduct a systematic review and develop a clinical guideline regarding enteral nutrition of very low birth weight infants (VLBW). Objective To assess the impact of the new feeding protocol in the incidence of NEC. Method A “before” (2011) and “after” (May 2012–April 2013) study was performed on the new feeding protocol. This included initiation of enteral feeding in the absence of haemodynamic problems, a trophic feeding period of 5–7 days, and subsequent increments of 20–30 mL/kg/day, of breast milk/donor human milk from the beginning. Probiotics were not administered. Primary outcome: incidence of NEC II 2 Bell's stage. Secondary outcomes: focal intestinal perforation, overall mortality and mortality due to NEC, nosocomial sepsis; weight at 28 days and 36 weeks; % of infants with weight p < 10 at discharge; and length of stay. Results Of the 270 VLBW infants, 155 were included in the “before” group, and 115 in the “after” group. NEC significantly decreased (12/155 vs 1/115, p = .008). A decrease in mortality rate was also observed (17.4% vs 7.8%, p = .02). In four cases NEC was part of the sequence of events that led to death in the first cohort, with none in the second. There was no difference in the incidence of focal intestinal perforation or of the other secondary variables analysed. Conclusions Implementation of an evidence-based enteral feeding protocol leads to a decrease in incidence of NEC, without increasing hospital stay or the incidence of sepsis.

Comparison of Two Different Enteral Nutrition Protocol in Critically Ill Patients

In this study, two enteral nutrition protocols with different gastric residual volumes (GRVs) and different monitoring intervals were compared with respect to gastrointestinal intolerance findings in intensive care unit (ICU) patients. The study was carried out prospectively in 60 patients in the anaesthesiology and reanimation ICU under mechanical ventilation support, who were scheduled to take enteral feeding. Patients were sequentially divided into two groups: Group 1, GRV threshold of 100 mL, and monitoring interval of 4 hours, and Group 2, GRV threshold of 200 mL, monitoring interval of 8 hours. To test the significant difference between the groups, Student's t test, chi-square text and Fisher exact test were used. In Group 1, 3.3% vomiting, 6.6% diarrhoea was observed; in Group 2, 16.6% vomiting, 10% diarrhoea. In terms of total intolerance (vomiting and/or diarrhoea) of the two groups, the incidence was significantly higher in Group 2 (33.3%) than in Group 1 (10%) (p=0.02). According to the results of the study, a lower gastrointestinal intolerance rate was detected in the GRV threshold 100 mL, monitoring interval for 4 hours protocol (Group 1) than in GRV threshold 200 mL, monitoring interval for 8 hours protocol (Group 2); Group 1 may be preferred renovation.

Gastrointestinal dysmotility in the critically ill: a role for nutrition.

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