Volume-based Feeding Research Articles

412 Volume vs. Rate-Based Tube Feeding in Burn Patients: Improving Nutrition

Proper nutrition is critical in healing from burns. Tube feeding is routinely employed to help meet nutritional goals, especially in intubated patients and large burns; however, the complexities of burn care frequently involve pausing tube feeding. Volume-based tube feeding is a strategy that provides goal volumes based on available hours per day compared to fixed hourly rates. This study aims to assess whether volume-based tube feeding is superior to traditional rate-based tube feeding at meeting nutritional goals. Starting in January 2016, a single burn center implemented a volume-based tube feeding protocol. All patients for calendar year 2016 requiring tube feeds for at least 5 continuous days were compared to all patients from the prior calendar year 2015. Demographics, burn characteristics, and tube feeding details were compared with univariate analysis. Daily tube feed goals and length of stay were primary outcomes; both were assessed with multivariate analysis using linear modeling. Thirty patients met study criteria. The cohort was 30.0% female and 93.3% flame burned, with a mean age of 44.2 years and mean TBSA of 30.6%. All patients suffered 3rd degree burns. Pausing tube feeds for perioperative care was the most common reason tube feeds were held at 33.7% of all held days. Volume-based tube feeding was the only independent predictor of increasing tube feed goals with an average goal met of 91.41% (SD 19.41) vs. 74.14% (SD 21.72), (linear coefficient 10.05, 95% CI 4.49–15.61, p-value 0.001). Tube feed hours held was the only independent predictor of lower tube feed goals (linear coefficient -5.52, 95% CI -7.73 - -3.31, p-value <0.001). Volume-based tube feeding was not associated with a significant difference in length of stay after controlling for covariates. Rate-based feeds showed an adjusted mean stay of 33.6 (SD 7.5) days vs. 36.3 (SD 11.1) days for volume-based feeds (linear coefficient 0.84, 95% CI -13.6 - 15.2, p=0.905). Perioperative care was the most common reason for holding tube feeding. Volume-based tube feeding was superior to rate-based tube feeding in maximizing daily nutritional goals. Additional studies are needed to assess whether volume-based feeding is associated with improved clinical outcomes. Volume-based tube feeds optimize nutritional goals and thus should be the preferred method of tube feeding in patients who require such nutritional support.

Targeted full energy and protein delivery in critically ill patients: a study protocol for a pilot randomised control trial (FEED Trial)

BackgroundCurrent guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes.MethodsThis prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes.DiscussionThis trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.

Overview of Enteral Nutrition

Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed. This review contains 1 figure, 4 tables, and 48 references. Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based feeding

Overview of Enteral Nutrition

Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed. This review contains 1 figure, 4 tables, and 48 references. Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based feeding

Overview of Enteral Nutrition

Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed. This review contains 1 figure, 4 tables, and 48 references. Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based feeding

Overview of Enteral Nutrition

Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed. This review contains 1 figure, 4 tables, and 48 references. Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based 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?

Optimal Energy Delivery, Rather than the Implementation of a Feeding Protocol, May Benefit Clinical Outcomes in Critically Ill Patients.

Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01–2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.

Impact of a nurse-led feeding protocol in a pediatric intensive care unit

Background: To determine effectiveness of a nurse-led, volume-based feeding protocol in our pediatric intensive care unit (PICU), we evaluated patients’ nutrition adequacy pre- and post-protocol implementation. Methods: We conducted an observational study of patients admitted for more than three days in the PICU during pre- and post-feeding protocol periods. We recorded energy and protein intake and feed interruptions in patients started on enteral nutrition over the first seven days of admission. We excluded patients with septic shock requiring more than two inotropes, post-cardiac and post-gastrointestinal surgeries. To determine nutrition adequacy, actual energy and protein intakes were compared with calculated requirements, expressed as percentages. Results: We had a total of 40 patients (20 in the pre- and post-protocol groups, respectively) with median age of 9.4 (interquartile range (IQR) 2.8, 57) months. Median time to feed initiation was similar between groups (20.0 (IQR 17.0, 37.5) vs. 21.5 (IQR 10.5, 27.0) hours, p = 0.516). There was no difference in median energy (55 (IQR 12, 102) vs. 59 (IQR 25, 85) %, p = 0.645) and protein intake (53 (IQR 16, 124) vs. 73 (IQR 22, 137) %, p = 0.069) over the seven-day period between groups; the proportion of patients meeting their energy (10 vs. 35%, p = 0.127) and protein goal (15 vs. 30%, p = 0.451) by day three also did not differ significantly pre- and post-protocol implementation. The most common reasons for feed interruption were intubation/extubation and radiological procedures. Conclusion: Our current feeding protocol did not improve nutrient adequacy. The effectiveness of a more aggressive protocol in units where enteral nutrition is initiated within 24 hours should be investigated.

Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes

Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes. We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice. The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG. Mean caloric deficit was not significantly different between groups (-6796 ± 4164 kcal vs -8817 ± 7087 kcal, P = .305). CLD days per patient (0.1 ± 0.5 vs 0.6 ± 0.9), length of stay in the intensive care unit (3.5 ± 5.5 vs 5.2 ± 6.8 days), and duration of mechanical ventilation (1.6 ± 3.7 vs 2.8 ± 5.0 days) were all reduced in the EG compared with the CG (P < .05). EG patients had fewer nosocomial infections (10.6% vs 23.6%) and less organ failure (10.6% vs 18.2%) than did the CG, but these differences did not reach statistical significance. Implementation of specific educational strategies succeeded in greater delivery of nutrition therapy, which favorably affected patient care and outcomes.

Volume-Based Feeding in the Critically Ill Patient.

Critically ill patients placed on enteral nutrition (EN) are usually underfed. A volume-based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate-based feeding (RBF) method. This single-center, randomized (3:1; VBF/RBF) prospective study evaluated critically ill patients on mechanical ventilation expected to receive EN for ≥ 3 days. Once goal rate was achieved, the randomized feeding strategy was implemented. In the VBF group, physicians used a total goal volume of feeds to determine an hourly rate. For the RBF group, physicians determined a constant hourly rate of infusion to meet goal feeds. Sixty-three patients were enrolled in the study with a mean age of 52.6 years (60% male). Six patients were excluded after randomization because of early extubation. The VBF group (n = 37) received 92.9% of goal caloric requirements with a mean caloric deficit of -776.0 kcal compared with the RBF group (n = 20), which received 80.9% of goal calories (P = .01) and a caloric deficit of -1933.8 kcal (P = .01). Uninterrupted EN was delivered for 51.7% of all EN days in VFB patients compared with 54.5% in RBF patients. On days when feeding was interrupted, VFB patients overall received a mean 77.6% of goal calories (while RBF patients received 61.5% of goal calories, P = .001). No vomiting, regurgitation, or feeding intolerance occurred due to VBF. A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate-based strategy.

Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies.

Background: This study describes the results of an evaluation of educational strategies used to implement a novel enteral feeding protocol in 9 North American intensive care units (ICUs). Materials and Methods: Members of the protocol implementation teams at each ICU distributed a questionnaire to ICU nurses after the implementation of the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP) protocol. Eight different educational strategies were evaluated. Questionnaires were distributed in both paper and electronic format to all nursing staff and used both a visual analog Likert-type scale and open-ended questions. Results: The response rate to the questionnaire was 166 of 434 or 38.2%. More than 70% of respondents rated 5 of the educational strategies as very useful or somewhat useful, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 and group bedside teaching, and a self-learning module. The percentage of nurses who found the bedside protocol tools of the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either "very easy" or "somewhat easy" to use were 64.0%, 60.5%, and 59.1%, respectively. Conclusion: The use of multiple teaching formats, including the long and short PowerPoint presentations and self-teaching module, appeared to meet the learning needs of most of the group. The majority of the bedside tools developed to facilitate the implementation of the PEP uP protocol were considered easy to use.

Volume-Based Feeding in the Critically Ill Admitted to the Medical Intensive Care Unit: A Proof of Concept

Volume-Based Feeding in the Critically Ill Admitted to the Medical Intensive Care Unit: A Proof of Concept