Feeding Interruptions Research Articles

New Protocol Avoiding Tube Feed Interruptions in Critically Ill Patients Requiring Tracheostomy

Current anesthesia guidelines require tube feed (TF) interruption for at least four hours before tracheostomy. We hypothesized that preprocedural TF interruption is not required before tracheostomy. We developed a protocol allowing continued feeding. Fifty-six patients undergoing tracheostomy with or without percutaneous endoscopic gastrostomy placement were included. Eleven patients underwent tracheostomy without TF interruption (TF group); the remaining 45 patients had TFs held per the existing anesthesia protocol (nil per os group). Data were collected by retrospective chart review. The groups were similar with regard to age, sex, race, risk of mortality, and preoperative albumin levels (3.2 vs 2.9 g/dL). There was no difference in pulmonary complications. No intraoperative aspiration occurred in either group, and there was no increase in mortality in the TF group (9.1 vs 22.2%, P = 0.43). The TF group had feeds held for 9.5 ± 6.3 vs 25.4 ± 19.0 hours (P = 0.0018). The TF group had a decreased missed caloric intake [761.5 ± 566.6 vs 1983.5 ± 1590.8 kcal (P = 0.0039)]. The TF group had a shorter time from consultation [40.4 vs 50.6 hours (P = 0.54)] and case booking [7.9 vs 12.8 hours (P = 0.40)] to the OR. The average length of stay for the TF group was 26.3 versus 31.1 days (P = 0.45). There was no increase in pulmonary complications or mortality in the fed patients, who experienced less procedural delays. Meanwhile, patients kept nil per os sustained a substantial caloric deficit. Tracheostomy without TF interruption is feasible and reduces malnutrition.

Gastric Residual Volume in Feeding Advancement in Preterm Infants (GRIP Study): A Randomized Trial

To evaluate the effect of not relying on prefeeding gastric residual volumes to guide feeding advancement on the time to reach full feeding volumes in preterm infants, compared with routine measurement of gastric residual volumes. We hypothesized that not measuring prefeeding gastric residual volumes can shorten the time to reach full feeds. In this single-center, randomized, controlled trial, we included gavage fed preterm infants with birth weights (BW) 1500-2000 g who were enrolled within 48 hours of birth. Exclusion criteria were major congenital malformations, asphyxia, and BW below the third percentile. In the study group, the gastric residual volume was measured only in the presence of bloody aspirates, vomiting, or an abnormal abdominal examination. In the control group, gastric residual volume was assessed routinely, and feeding advancement was based on the gastric residual volume. The primary outcome was the time to reach feeding volumes of 120 mL/kg per day. Secondary outcomes were time to regain BW, episodes of feeding interruptions, sepsis, and necrotizing enterocolitis. Eighty-seven infants were enrolled. There were no differences between the study and control groups with respect to time to reach full feeds (6 days [95% CI, 5.5-6.5] vs 5 days [95% CI, 4.5-5.5]; P = .82), time to regain BW, episodes of feeding interruptions, or sepsis. Two infants in the control group developed necrotizing enterocolitis. Avoiding routine assessment of gastric residual volume before feeding advancement did not shorten the time to reach full feeds in preterm infants with BW between 1500 and 2000 g. Clinicaltrials.gov: NCT01337622.

Nutrition is Critical.

Are they hungry?” is a frequent concern expressed by friends and family members in regard to patients receiving mechanical ventilation in the intensive care unit (ICU). Although the question seems to focus on patients’ comfort, we know that nutrition in critical illness plays a key role in patients’ outcomes. The 2016 clinical guidelines on nutrition support therapy from the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine (ASPEN-SCCM) include a recommendation for the early initiation of enteral feeding in critically ill adults who are unable to eat. Enteral feeding is a cost-effective strategy for preventing malnutrition, a common complication in acute care, and has the added benefits of maintaining the gastrointestinal tract’s integrity and promoting immune function. The study by Vest et al, showing that patients who had an order for enteral nutrition had a lower risk of death regardless of their body mass index, is further evidence of the value of enteral feeding.Although addressing nutrition is an intraprofessional responsibility, the implementation of enteral feeding relies on nursing expertise. Nurses assess patients’ tolerance of feedings, make decisions about feeding interruptions, and intervene to maintain feeding tube patency. By ensuring that these actions are aligned with current evidence, we deliver care that promotes the best possible outcomes for our patients and, might, at the same time, ease any concern about the discomfort of hunger.

Anaerobic co-digestion of high-strength organic wastes pretreated by thermal hydrolysis

Thermal hydrolysis (TH) pretreatment was investigated for the anaerobic digestion (AD) of a mixture of high-strength organic wastes (i.e., dewatered human feces, dewatered sewage sludge, and food wastewater) at laboratory scale to simulate a full-scale plant and evaluate its feasibility. The reactors maintained efficient and stable performance at a hydraulic retention time of 20 days, which may be not sufficient for the mesophilic AD of high-suspended-solid wastes, despite the temporal variations in organic load. The addition of FeCl3 was effective in controlling H2S and resulted in significant changes in the microbial community structure, particularly the methanogens. The temporary interruption in feeding or temperature control led to immediate performance deterioration, but it recovered rapidly when normal operations were resumed. The overall results suggest that the AD process coupled with TH pretreatment can provide an efficient, robust, and resilient system to manage high-suspended-solid wastes, supporting the feasibility of its full-scale implementation.

Adequacy of nutrition support during extracorporeal membrane oxygenation

The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasing in adults with severe respiratory failure. Observational data suggest that there are significant challenges to providing adequate nutrition support for patients on vv-ECMO. We aimed to describe firstly the nutrition support practices in a large single-centre providing vv-ECMO to adults and secondly any association with clinical outcome. We conducted a retrospective review of patients receiving vv-ECMO on the Intensive Care Unit (ICU) of a large London teaching hospital. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and December 2015 were included. Daily energy and protein delivery were compared with estimated targets and reasons for feeding interruptions were collected from electronic medical records. Adequate feeding was defined as 80-110% of estimated targets. We analysed 203 eligible patients. Median duration of ICU stay was 21.0 (IQR, 15.0-33.0) days and vv-ECMO 10.0 (IQR, 7.0-16.0) days. Although median energy (89.8% (IQR, 80.5-96.0%)) and protein (84.7% (IQR, 74.0-96.7%)) delivery was adequate, underfeeding of either energy or protein occurred on nearly one third (28.3%) of nutrition support days. A higher admission severity of illness score was associated with inadequate protein delivery (p=0.040). Patients with more severe organ dysfunction on the first day of vv-ECMO received inadequate energy (p=0.026). The most common reasons for interrupted feeding were medical procedures (39.1%) followed by poor gastric motility (22.8%). Adequate energy and protein delivery during vv-ECMO is possible but underfeeding is still common, especially in those who are more severely ill or who have more severe organ dysfunction. Patients with inadequate energy or protein delivery did not differ in ICU and 6-month survival. Prospective studies investigating optimal feeding in this patient cohort are required.

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit.

Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.

The Effect of Different Enteral Feeding Protocols on Feeding Tolerance in Critically Ill Children

Objectives: To evaluate different enteral tube Feeding Protocols (FP) on feeding tolerance and achieving the goal feeds (GF) duration in pediatric intensive care unit (PICU) among 2 groups of patients with different risks of feeding intolerance. Design: Prospective randomized study. Settings & Patients: The study is conducted in 20 bed capacity medical/surgical PICU at king Fahad Medical City in Saudi Arabia over 1-year period. We included children from 1 month to 12 years old who are admitted to PICU >48 hours after obtaining informed consent signed by either parent or legal guardian. All patients with medical indication of admission were included except of gastroenterology related illness. Interventions: We categorize PICU patients into either low risk group or high-risk group because we think the severity of illness and medical management in the high-risk group, put them into a higher risk of early development of feeding intolerance. The patients were assigned into the high-risk group if they meet certain criteria that includes 1) need for inotropes/vasopressors >24 hours and/or 2) need for muscle relaxant infusion and/or 3) having severe metabolic acidosis with PH of less than 7.2, HCO3 serum level less than 10 mmol/L at the day of randomization to start the feeding. After assigning the patient into the risk group, then we blindly randomized each patient into one of the two feeding protocols, the continuous versus intermittent enteral NG/ OG tube feeding. Different variables were tracked to monitor the feeding tolerance of the feeding protocol like the frequency of vomiting and change in bowel motion. We determine the duration needed to reach the goal feeds recommended by a registered dietitian and we record any interruptions of the feeding protocol, duration of interruption and the reason. Measurements and Main Results: Total of eighty-five patients were recruited in our study. Sixty-two patients in the low risk group (35 patients fed continuously & 27 fed intermittently) and twenty-three patients in the high-risk group (11 patients fed continuously & 12 intermittently). All patients were fed regular formula for age with goal feeds decided by registered dietitians. No significant differences in patients’ characteristics. 65.7% of the low risk group who were continuously fed reached the goal feeds faster; within 2-3 days from feeding initiation vs 37% of the intermittent feeding group (P-value 0.025). 54.57% of the high-risk group who were continuously fed reached the goal feeds faster within 4-5 days vs 8.3% only of the intermittent feeding group (P-value 0.016). Both feeding protocols, continuous and intermittent feeding in both groups tolerate the feeds with no statistically differences. Feeding interruptions were not significantly different between both groups in each protocol with average interruption days of two days. Conclusion: Implementation of the proposed continuous enteral tube feeding protocol significantly improve the delivery of nutrition in critically ill children in shorter duration than the intermittent boluses feeding protocol with good tolerance of both in different patients’ risk groups. This is the first paper taking in consideration high risk factors because of the substantial risk of feeding intolerance that can affect early decision for feeding.

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?

The influence of implementing nurse-led enteral nutrition guidelines on care delivery in the critically ill: a cohort study

Aim: To identify how implementation of nurse-led enteral nutrition (EN) guidelines influenced nurses' care delivery in an intensive care unit. Methods: This multi-centre prospective observational study introduced an educational programme for 127 nurses on evidence-based ASPEN guidelines for enteral nutrition. Pre- and post-intervention observation assessed adherence to the guidelines through reporting of care delivered. Results: A total of 192 patients from 80 controls and 112 interventions were observed; gastric residual volume was evaluated in 67.9% of intervention patients compared with 26.3% of controls (p=0.001). The intervention group was more likely to maintain head-of-bed elevation, check tube placement and use continuous feeding and chlorhexidine mouthwash. Intervention patients received nutrition earlier than controls, and they had fewer feeding interruptions (median of 12.66 vs 32.18 hours, p<0.001) and higher caloric attainment (68.8% vs 50%, p=0.015). Conclusions: The guidelines improved nursing adherence to nutritional assessment measures.

The effects of light, darkness and intermittent feeding on the growth and survival of reared Atlantic bonito and Atlantic bluefin tuna larvae

In larval culture, long light photoperiod regimes are used to maximize ingestion rates by increasing the accessibility to prey and therefore enhancing larval growth. Intermittent feeding could provide a viable alternative to the commonly used continuous feeding regimes that aim to improve larval growth and survival. In this study, we investigate the effect of alternating light/darkness regimes with intermittent feeding on the growth and survival of piscivorous larvae of two Scombrid species: Atlantic bonito, Sarda sarda (Bloch, 1793) and Atlantic bluefin tuna Thunnus thynnus (Linnaeus, 1758). First we tested if the manipulation of a light regime generated intermittent feeding by analyzing the larval stomach content. Then, we conducted two laboratory experiments to identify the best alternating light regime that maximized larval growth and survival by comparing the results to those obtained using continuous light regimes. The manipulation of light was optimized to provide intermittent feeding opportunities for the larvae, since we discovered a clear interruption of feeding in darkness. An increase in specific ingestion throughout the day was observed in all experiments, reaching a maximum peak late in the day. Bluefin tuna larval growth rates were similar despite different alternating conditions whereas the bonito larvae grew best when provided with light at three hour intervals. In both species, growth under alternating light conditions was similar to the 15 hours continuous light treatment. No differences between the alternating and the continuous light treatments were observed in terms of their survival. Our results suggest that alternating light/feeding periods may have a beneficial effect on ingestion rates; possibly because feeding is less satiation-limited, metabolic costs are lower; or food digestion is more efficient under these conditions. Changes in the light regime, that result in pulse feeding, can thus be an optimal strategy to increase growth at no apparent survival cost in bonito or bluefin tuna larval cultures.

Estimating the scale of adverse animal welfare consequences of movement restriction and mitigation strategies in a classical swine fever outbreak

BackgroundThe study aim was to quantify the impact of movement restriction on the well-being of pigs and the associated mitigation responses during a classical swine fever (CSF) outbreak. We developed a stochastic risk assessment model and incorporated Indiana swine industry statistics to estimate the timing and number of swine premises that would encounter overcrowding or feed interruption resulting from movement restriction. Our model also quantified the amount of on-farm euthanasia and movement of pigs to slaughter plants required to alleviate those conditions. We simulated various single-site (i.e., an outbreak initiated from one location) and multiple-site (i.e., an outbreak initiated from more than one location) outbreak scenarios in Indiana to estimate outputs.ResultsThe study estimated that 14% of the swine premises in Indiana would encounter overcrowding or feed interruption due to movement restriction implemented during a CSF outbreak. The number of premises that would experience animal welfare conditions was about 2.5 fold of the number of infected premises. On-farm euthanasia needed to be performed on 33% of those swine premises to alleviate adverse animal welfare conditions, and more than 90% of on-farm euthanasia had to be carried out within 2 weeks after the implementation of movement restriction. Conversely, movement of pigs to slaughter plants could alleviate 67% of adverse animal welfare conditions due to movement restriction, and only less than 1% of movement of pigs to slaughter plants had to be initiated in the first 2 weeks of movement restrictions. The risk of secondary outbreaks due to movement of pigs from movement restriction areas to slaughter plants was low and only seven pigs from each shipment needed to be tested for CSF infection to prevent a secondary outbreak.ConclusionsWe found that the scale of adverse animal welfare consequences of movement restriction during a CSF outbreak in Indiana was substantial, and controlled movement of pigs to slaughter plants was an efficient and low-risk alternative mitigation response to on-farm euthanasia. The output estimates generated from this study provide empirical evidence for decision makers to properly incorporate required resources for mitigating adverse animal welfare conditions in CSF outbreak management strategic planning.

Evaluation of Movement Restriction Zone Sizes in Controlling Classical Swine Fever Outbreaks.

The objective of this study was to compare the impacts of movement restriction zone sizes of 3, 5, 9, and 11 km with that of 7 km (the recommended zone size in the United States) in controlling a classical swine fever (CSF) outbreak. In addition to zone size, different compliance assumptions and outbreak types (single site and multiple site) were incorporated in the study. Three assumptions of compliance level were simulated: baseline, baseline ± 10%, and baseline ± 15%. The compliance level was held constant across all zone sizes in the baseline simulation. In the baseline ± 10% and baseline ± 15% simulations, the compliance level was increased for 3 and 5 km and decreased for 9 and 11 km from the baseline by the indicated percentages. The compliance level remained constant in all simulations for the 7-km zone size. Four single-site (i.e., with one index premises at the onset of outbreak) and four multiple-site (i.e., with more than one index premises at the onset of outbreak) CSF outbreak scenarios in Indiana were simulated incorporating various zone sizes and compliance assumptions using a stochastic between-premises disease spread model to estimate epidemic duration, percentage of infected, and preemptively culled swine premises. Furthermore, a risk assessment model that incorporated the results from the disease spread model was developed to estimate the number of swine premises under movement restrictions that would experience animal welfare outcomes of overcrowding or feed interruption during a CSF outbreak in Indiana. Compared with the 7-km zone size, the 3-km zone size resulted in a longer median epidemic duration, larger percentages of infected premises, and preemptively culled premises (P’s < 0.001) across all compliance assumptions and outbreak types. With the assumption of a higher compliance level, the 5-km zone size significantly (P < 0.001) reduced the epidemic duration and percentage of swine premises that would experience animal welfare outcomes in both outbreak types, whereas assumption of a lower compliance level for 9- and 11-km zone sizes significantly (P < 0.001) increased the epidemic duration and percentage of swine premises with animal welfare outcomes compared with the 7-km zone size. The magnitude of impact due to a zone size varied across the outbreak types (single site and multiple site). Overall, the 7-km zone size was found to be most effective in controlling CSF outbreaks, whereas the 5-km zone size was comparable to the 7-km zone size in some circumstances.

Modelling the time at which overcrowding and feed interruption emerge on the swine premises under movement restrictions during a classical swine fever outbreak

A stochastic risk model was developed to estimate the time elapsed before overcrowding (TOC) or feed interruption (TFI) emerged on the swine premises under movement restrictions during a classical swine fever (CSF) outbreak in Indiana, USA. Nursery (19 to 65 days of age) and grow-to-finish (40 to 165 days of age) pork production operations were modelled separately. Overcrowding was defined as the total weight of pigs on premises exceeding 100% to 115% of the maximum capacity of the premises, which was computed as the total weight of the pigs at harvest/transition age. Algorithms were developed to estimate age-specific weight of the pigs on premises and to compare the daily total weight of the pigs with the threshold weight defining overcrowding to flag the time when the total weight exceeded the threshold (i.e. when overcrowding occurred). To estimate TFI, an algorithm was constructed to model a swine producer’s decision to discontinue feed supply by incorporating the assumptions that a longer estimated epidemic duration, a longer time interval between the age of pigs at the onset of the outbreak and the harvest/transition age, or a longer progression of an ongoing outbreak would increase the probability of a producer’s decision to discontinue the feed supply. Adverse animal welfare conditions were modelled to emerge shortly after an interruption of feed supply. Simulations were run with 100 000 iterations each for a 365-day period. Overcrowding occurred in all simulated iterations, and feed interruption occurred in 30% of the iterations. The median (5th and 95th percentiles) TOC was 24 days (10, 43) in nursery operations and 78 days (26, 134) in grow-to-finish operations. Most feed interruptions, if they emerged, occurred within 15 days of an outbreak. The median (5th and 95th percentiles) time at which either overcrowding or feed interruption emerged was 19 days (4, 42) in nursery and 57 days (4, 130) in grow-to-finish operations. The study findings suggest that overcrowding and feed interruption could emerge early during a CSF outbreak among swine premises under movement restrictions. The outputs derived from the risk model could be used to estimate and evaluate associated mitigation strategies for alleviating adverse animal welfare conditions resulting from movement restrictions.

Postpyloric feeding in critically ill patients: Updated systematic review, meta-analysis and trial sequential analysis of randomized trials

Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population may result in unfavorable outcomes. However, enteral nutrition may be complicated with feeding intolerance, aspiration, pneumonia, and interruption of feeding. Objectives: We updated our systematic review and meta-analysis that compared the effect of postpyloric and gastric feeding on risk of pneumonia, duration of mechanical ventilation (MV), Intensive Care Unit (ICU) length of stay (LOS), gastrointestinal (GI) bleeding, aspiration, vomiting, and mortality. Methods: We searched MEDLINE, EMBASE, and clinical registries for data through April 2017 without language or date of publication restrictions. We included randomized controlled trials (RCTS) comparing postpyloric feeding to gastric feeding. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the Grading of Recommendations, Assessment, Development, and Evaluation methodology to assess the quality of the evidence. We used trial sequential analysis (TSA) as a sensitivity analysis to adjust for sequential testing. Results: We included 21 RCTs (1573 patients). Postpyloric feeding reduced the risk of nosocomial pneumonia (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2 = 11%; moderate quality), ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P = 0.02; I2 = 10%, moderate quality), and duration of MV (mean difference [MD] - 2.10 days, 95% CI −3.93, −0.28; P = 0.02; I2 = 67%, low quality), compared to gastric feeding. There was no difference in mortality (RR 1.07, 95% CI 0.90, 1.27; P = 0.44; I2 = 0%, moderate quality), ICU LOS (MD - 1.01 days, 95% CI −3.32, 1.3; P = 0.39; I2 = 84%, very low quality), aspiration (RR 0.81, 95% CI 0.4, 1.60, P = 0.54; I2 = 21%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P = 0.87; I2 = 33%, very low quality), and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P = 0.56; I2 = 0%, very low quality). Sensitivity analysis using TSA mirrored those of conventional analyses. Conclusions: Moderate quality evidence showed that postpyloric feeding may reduce the risk of pneumonia. Low-quality evidence yielded that duration of MV is shorter with pyloric compared to gastric feeding, with no significant impact on other outcomes. Although the results are promising further assessment in large clinical trials is warranted.

Rebound Feeding in the Wake of Short-Term Suspension of Food Intake Differs in the Presence of Estrous Cycle Peak versus Nadir Levels of Estradiol.

BackgroundShort-term interruption of feeding is ordinary in modern life but negatively impacts appetite control and body weight. Estradiol (E) imposes long-term inhibitory tonus on food consumption; however, E influence on energy repletion secondary to food deprivation (FD) is unclear. This study investigated the hypothesis that E signal strength regulates hyperphagic responses to FD of varying duration.MethodsOvariectomized female rats were implanted with E-containing silastic capsules (30 [E-30] or 300 µg [E-300]/mL) to replicate plasma concentrations at cycle nadir versus peak levels.ResultsData show that food intake was increased equally in E-30 and E-300 rats after 12 hours of food deprivation (FD-12); yet, FD of 18 hours (FD-18) amplified refeeding by E-300 versus E-30. Caudal fourth ventricular administration of the 5′-monophosphate-activated protein kinase (AMPK) inhibitor compound C (Cc) did not modify FD-induced hyperphagia in E-30 (regardless of FD interval) or E-300 animals exposed to FD-12, but diminished refeeding after FD-18 in E-300 rats. Cc-reversible hyperglycemia occurred in refed FD-18 groups. Serum insulin was resistant to FD-12 plus refeeding, but was elevated by AMPK-dependent mechanisms in refed E-300 FD-18 rats; equivalent Cc-insensitive decrements in circulating leptin occurred in all FD groups.ConclusionCurrent results show that estrous cycle peak, but not baseline, E levels engage hindbrain AMPK signaling to intensify hyperphagia in response to prolongation of FD. Observations of hindbrain AMPK-dependent hyperglycemia, alongside elevated insulin secretion, in refed rats exposed to FD-18 implicate this sensor in insulin resistance mechanisms of glucose partitioning in response to this metabolic imbalance.

Enteral nutrition preference in critical care: fibre-enriched or fibre-free?

This study's main aim was to observe the effects of a fibre-enriched nutrition solution on requisite feeding volume, which is directly proportional to energy intake in mechanically ventilated patients with enteral nutrition. Some 120 patients who required mechanical ventilation and enteral nutrition with a nasogastric tube were studied. Upon ICU admission, the patient's age, gender, weight, height, comorbidities, diagnosis and APACHE II score were recorded. We assigned two diets to the patients randomly. The control group received the fibre-free nutrition solution. The study group, received the fibreenriched nutrition solution. Prescribed feeding volume and administered feeding volume, gastric residual volume (GRV), volume ratio (VR), diarrhoea score and gastrointestinal complications (GIC) were recorded, along with daily biochemistry. The two groups did not differ with respect to age, sex, weight, BMI, APACHE II score, target caloric intake or GRV (p>0.05). On days four and five, the study group had higher VR values (p<0.05). Seventy-one (59%) patients had at least one gastrointestinal complication; 44 (73%) of them were controls and 27 (45%) of them study patients. The most commonly observed GIC was diarrhoea. Thirty-eight patients had diarrhoea in control group, and twenty-two patients had diarrhoea in study group, and this difference was statistically significant (p<0.001). There were no significant differences between the groups about vomiting and regurgitation. We suggest that ICU staff initiate enteral nutrition with fibre-enriched formulas rather than fibre-free formulas to avoid frequent feeding interruptions that cause protein energy malnutrition in ICU patients.

Development and Implementation of a Feeding Protocol for Infants in a Pediatric Cardiac Intensive Care Unit

Purpose: It is crucial to provide adequate enteral nutrition for postoperative recovery, wound healing and normal growth in infants in pediatric cardiac ICUs. This study was done to develop a feeding protocol using the vaso-active inotropic (VAI) score and to evaluate the impact of nutritional outcomes following the new feeding protocol for infants who underwent cardiac surgery. Methods: This study consisted of three phases. First, a feeding protocol was developed based on a literature review. Second, ten experts rated the content validity. Third, a comparison study was conducted to evaluate the impact of the new feeding protocol. Data were analyzed using SPSS Version 20. Results: Twenty-nine infants were enrolled in the pre-protocol group, and 22 infants in the post-protocol group. Patients in the 2 groups were similar. Time to reach feeding goal was significantly decreased from 56.0 (27-210) hours to 28.5 (10-496) hours in the post-protocol group (Z=-4.22, p＜.001). Level of enteral feeding knowledge among nurses increased significantly after implementation of the protocol. Conclusion: The feeding protocol using VAI score facilitates the achievement feeding goal to decrease feeding interruptions and help nurses in their practice. Larger studies are necessary to examine clinical outcomes following the implementation of this feeding protocol.

SwarmSight: Measuring the temporal progression of animal group activity levels from natural-scene and laboratory videos.

We describe SwarmSight (available at https://github.com/justasb/SwarmSight ), a novel, open-source, Microsoft Windows software tool for quantitative assessment of the temporal progression of animal group activity levels from recorded videos. The tool utilizes a background subtraction machine vision algorithm and provides an activity metric that can be used to quantitatively assess and compare animal group behavior. Here we demonstrate the tool's utility by analyzing defensive bee behavior as modulated by alarm pheromones, wild-bird feeding onset and interruption, and cockroach nest-finding activity. Although more sophisticated, commercial software packages are available, SwarmSight provides a low-cost, open-source, and easy-to-use alternative that is suitable for a wide range of users, including minimally trained research technicians and behavioral science undergraduate students in classroom laboratory settings.

Problems With Optimal Energy and Protein Delivery in the Pediatric Intensive Care Unit.

Optimal nutrition therapy (NT) delivery is associated with improved outcomes in critically ill children. However, avoidable barriers impede delivery of optimal energy and protein in the pediatric intensive care unit (PICU). This study aims to describe the gap between energy and protein prescription and actual intake. Single-center prospective cohort study, including consecutive children (age: 1 month to 15 years) admitted to the PICU in southern Brazil. Demographics, clinical characteristics, and NT details were recorded. We enrolled 130 patients: 37% female; median (interquartile range) age, 29.43 months (4.03, 100.63); PICU length of stay, 6 days (4, 13). Median predicted energy expenditure by Schofield equation and prescribed and actual energy intake were 47.13 kcal/kg/d (38.60, 55.38), 31.94 kcal/kg/d (13.99, 51.90), and 25.06 kcal/kg/d (10.21, 46.92), respectively. On average, actual energy intake was 47% of the predicted energy expenditure, and 68% of patients were underfed. Actual protein intake was 49% of the estimated requirement. NT was interrupted in 64% of patients. There were significant gaps among the predicted requirement, prescription, and actual delivery of energy and protein in the PICU. Suboptimal prescription and multiple feeding interruptions resulted in underfeeding.

Safety of minimizing preoperative starvation in critically ill and intubated trauma patients.

Cessation of enteral nutrition prior to an operation/procedure is the most common reason for feeding interruption in critically ill trauma patients and contributes to substantial calorie deficits. This study reports on a strategy to increase calorie intake by continuing feeds until transfer for operations/procedures. Nutrition guidelines were modified in 2006 to allow continuation of feeding in intubated patients up until transfer to the operating room. Prior to 2006, enteral feeding was stopped at least 6 hours prior to surgery. A retrospective cohort design from 2003 to 2010 compared clinical outcomes in groups of adult trauma subjects before and after guideline changes and in subjects at other centers without guideline changes. During the first week, subjects in the preimplementation cohort (n = 245) received a median of 3,787 kcal per person per week, while subjects in the postimplementation cohort (n = 368) received a median of 6,662 kcal per person per week (p < 0.001). There was no change in calorie intake for subjects at other centers (n = 1,002). The risks of acute respiratory distress syndrome, pneumonia, and mortality were decreased after implementation relative to the preimplementation cohort (acute respiratory distress syndrome: relative risk ratio [RR], 0.69; 95% confidence interval [CI], 0.59-0.81; pneumonia: RR, 0.82; 95% CI, 0.65-1.00; mortality: RR, 0.67; 95% CI, 0.46-0.99). Ventilator-free days increased by 1.4 days (95% CI, 0.1-2.7), while intensive care unit stay and hospital length of stay were unchanged. These outcomes showed similar trends over time at other participating centers. Allowing intubated trauma patients to continue enteral nutrition until transfer for operations or procedures was associated with increased caloric intake without evidence of increased pulmonary complications. This represents an important strategy to reduce calorie deficits in the trauma intensive care unit. Therapeutic study/care management, level III.