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Smith LD, Hoy H, Whitmore S. Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit. Crit Care Nurse 2024; 44:54-64. [PMID: 38821527 DOI: 10.4037/ccn2024622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings. LOCAL PROBLEM This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed. METHODS This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project. RESULTS During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients. CONCLUSIONS Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.
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Affiliation(s)
- L Douglas Smith
- L. Douglas Smith Jr is the lead critical care advanced practice provider and critical care nurse practitioner, HCA Healthcare Intensivist Services, HCA Healthcare TriStar Centennial Medical Center, Nashville, Tennessee, and a faculty member at Vanderbilt University School of Nursing, Nashville
| | - Haley Hoy
- Haley Hoy is a professor, University of Alabama in Huntsville College of Nursing, Huntsville, Alabama, and a lung transplant nurse practitioner at Vanderbilt University Medical Center, Nashville
| | - Sage Whitmore
- Sage Whitmore is the Medical Director for the intensive care unit and a staff intensivist, HCA Intensivist Services, HCA TriStar Centennial Medical Center
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Williams R, Yeh DD. Nutritional Support in Critically Ill Trauma Patients. Surg Clin North Am 2024; 104:405-421. [PMID: 38453310 DOI: 10.1016/j.suc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.
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Affiliation(s)
- Renaldo Williams
- Department of Surgery, Denver Health Medical Center, University of Colorado, Ernest E. Moore Shock Trauma Center, MC0206, 777 Bannock Street, Denver, CO 80204-4507, USA
| | - Daniel Dante Yeh
- Department of Surgery, Denver Health Medical Center, University of Colorado, Ernest E. Moore Shock Trauma Center, MC0206, 777 Bannock Street, Denver, CO 80204-4507, USA.
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Wang L, Wang Y, Li HX, Zhang RP, Chang L, Zeng J, Jiang H. Optimizing enteral nutrition delivery by implementing volume-based feeding protocol for critically ill patients: an updated meta-analysis and systematic review. Crit Care 2023; 27:173. [PMID: 37147701 PMCID: PMC10161662 DOI: 10.1186/s13054-023-04439-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/11/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND This study aims to provide an updated assessment of the efficacy of optimized enteral nutrition (EN) delivery by implementing the volume-based feeding (VBF) protocol in critically ill patients. METHODS We updated our previous literature retrieval with no language restrictions. The inclusion criteria were:1) Participants: Critically ill patients (Patients who was admitted in ICU; 2) Intervention: The VBF protocol was adopted for EN administration; 3) Comparison: The rate-based feeding (RBF) protocol was adopted for EN administration; 4) Major outcomes: EN nutrition delivery. The exclusion criteria included participants aged < 18 years, duplicated literature, animal and cellular experiments, and studies lacking any of the outcomes mentioned in the inclusion criteria. The databases included MEDLINE (through PubMed), Web of Science, Cochrane Library, Chinese Biomedical Literature Service System (SinoMed), Wanfang Data Knowledge Service Platform, and China National Knowledge Infrastructure. RESULT Sixteen studies involving a total of 2896 critically ill patients are included in the updated meta-analysis. Compared with the previous meta-analysis, nine new studies were added that included 2205 more patients. The VBF protocol significantly improved energy (MD = 15.41%, 95% CI: [10.68, 20.14], p < 0.00001) and protein (MD = 22.05%, 95% CI: [10.89, 33.22], p = 0.0001) delivery. The patients in the VBF group stayed in the ICU for a shorter time (MD = 0.78, 95% CI: [0.01, 1.56], p = 0.05). The VBF protocol did not increase the risk of death (RR = 1.03, 95% CI: [0.85, 1.24], p = 0.76) or prolong the mechanical ventilation duration (MD = 0.81, 95% CI: [-0.30,1.92], p = 0.15). In addition, the VBF protocol did not affect EN complications, such as diarrhea (RR = 0.91, 95% CI: [0.73, 1.15], p = 0.43), emesis (RR = 1.23, 95% CI: [0.76, 1.99], p = 0.41), feeding intolerance (RR = 1.14, 95% CI: [0.63, 2.09], p = 0.66), and gastric retention (RR = 0.45, 95% CI: [0.16, 1.30], p = 0.14). CONCLUSION Our study revealed that the VBF protocol significantly improved calorie and protein delivery in critically ill patients with no additional risk.
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Affiliation(s)
- Lu Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yu Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua-Xin Li
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Rui-Peng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Li Chang
- Department of Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, Sichuan Province, China
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
- Department of Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, Sichuan Province, China.
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support. J Acad Nutr Diet 2021; 121:2071-2086.e59. [PMID: 34556313 DOI: 10.1016/j.jand.2021.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022]
Abstract
Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
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Corrigan ML, Bobo E, Rollins C, Mogensen KM. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support. Nutr Clin Pract 2021; 36:1126-1143. [PMID: 34543450 DOI: 10.1002/ncp.10774] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutrition requirements of individuals who are unable to meet nutrition and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
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Affiliation(s)
- Mandy L Corrigan
- Baxter Healthcare, Deerfield IL (at the time the manuscript was written, she was a clinical nutrition manager, Cleveland Clinic, Cleveland, OH)
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Goelen N, Doperé G, Byloos K, Ghysels S, Putzeys G, Vandecaveye V, Morales J, Van Huffel S, Tack J, Janssen P. Gastric accumulation of enteral nutrition reduces pressure changes induced by phasic contractility in an isovolumetric intragastric balloon. Neurogastroenterol Motil 2021; 33:e14088. [PMID: 33534195 DOI: 10.1111/nmo.14088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND An isovolumetric intragastric balloon to continuously measure gastric phasic contractility was recently developed by us. We aimed to investigate the readout of this technique in relation to gastric content and gastric emptying. METHODS In this crossover investigation, the VIPUNTM Gastric Monitoring System, which comprises a double lumen nasogastric feeding tube with integrated intragastric balloon, was used to assess phasic gastric contractility by interpretation of the pressure in an isovolumetric balloon in 10 healthy subjects. Balloon pressure was recorded in fasted state, during a 2-hour intragastric nutrient infusion (1 kcal/ml at 25, 75, or 250 ml/h) and 4 hours post-infusion, and quantified as Gastric Balloon Motility Index (GBMI), ranging from 0 (no contractility) to 1 (maximal contractility). Gastric accumulation was quantified with magnetic resonance imaging and gastric emptying with a13 C-breath test. Results are expressed as mean(SD). KEY RESULTS GBMI was significantly lower during infusion at 250 ml/h compared to baseline (0.13(0.05) versus 0.46(0.12)) and compared to infusion at 25 (0.54(0.21)) and 75 ml/h (0.43(0.20)), all P < 0.005. Gastric content volume was larger after infusion at 250 versus 75 ml/h (P < 0.001). Half-emptying time and accumulation were both negatively correlated with postprandial contractility. Postprandial GBMI was significantly lower when GCV>0 ml compared to when the stomach was empty. CONCLUSIONS AND INFERENCES Enteral nutrition dose-dependently decreased the contractility readout. This decrease was linked to gastric accumulation of enteral nutrition.
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Affiliation(s)
- Nick Goelen
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Glynnis Doperé
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Kris Byloos
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Stefan Ghysels
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Guido Putzeys
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | | | - John Morales
- Department of Electrical Engineering ESAT, Signal Processing and Data Analytics, STADIUS Center for Dynamical Systems, KU Leuven, Leuven, Belgium
| | - Sabine Van Huffel
- Department of Electrical Engineering ESAT, Signal Processing and Data Analytics, STADIUS Center for Dynamical Systems, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Pieter Janssen
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,VIPUN Medical, Mechelen, Belgium
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Peterson SJ, Foley S. Clinician's Guide to Understanding Effect Size, Alpha Level, Power, and Sample Size. Nutr Clin Pract 2021; 36:598-605. [PMID: 33956359 DOI: 10.1002/ncp.10674] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Abstract
Effect size, α level, power, and sample size are misunderstood concepts that play a major role in the design and interpretation of studies. Effect size represents the magnitude of a change in an outcome or the strength of a relationship. Often, the effect size may be more important than just relying on the α level when interpreting results from a study because it informs a researcher of the actual magnitude of the difference or relationship. Confidence intervals can also assist in making this assessment. Power represents the probability of rejecting the null hypothesis when it is false. Effect size, power, and α level are all important in the calculation of sample size needed to conduct a study. Calculating the sample size a priori and including the required number of participants is essential. Studies with small sample sizes, relative to the needed number provided from a power analysis, may lead to false negative results. Studies with grossly large sample sizes may yield statistically significant findings with small effect sizes that may not be clinically relevant. It is beneficial when all four components are clearly presented in analytic studies. Failure to include these elements may limit the ability of other researchers to replicate the study's findings and lead to difficulty when interpreting the study's results.
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Affiliation(s)
- Sarah J Peterson
- Department of Clinical Nutrition, College of Health Sciences, Rush University/Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Foley
- Department of Clinical Nutrition, College of Health Sciences, Rush University/Rush University Medical Center, Chicago, Illinois, USA
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9
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Bonomo A, Blume DL, Davis K, Kim HJ. Implementing Volume-Based Feeding to Optimize Delivery of Enteral Nutrition. Crit Care Nurse 2021; 41:16-26. [PMID: 33791759 DOI: 10.4037/ccn2021556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND At least 80% of ordered enteral nutrition should be delivered to improve outcomes in critical care patients. However, these patients typically receive 60% to 70% of ordered enteral nutrition volume. In a practice review within a 28-bed medical-surgical adult intensive care unit, patients received a median of 67.5% of ordered enteral nutrition with standard rate-based feeding. Volume-based feeding is recommended to deliver adequate enteral nutrition to critically ill patients. OBJECTIVE To use a quality improvement project to increase the volume of enteral nutrition delivered in the medical-surgical intensive care unit. METHODS Percentages of target volume achieved were monitored in 73 patients. Comparisons between the rate-based and volume-based feeding groups used nonparametric quality of medians test or the χ2 test. A customized volume-based feeding protocol and order set were created according to published protocols and then implemented. Standardized education included lecture, demonstration, written material, and active personal involvement, followed by a scenario-based test to apply learning. RESULTS Immediately after implementation of this practice change, delivered enteral nutrition volume increased, resulting in a median delivery of 99.8% of ordered volume (P = .003). Delivery of a mean of 98% ordered volume was sustained over the 15 months following implementation. CONCLUSIONS Implementation of volume-based feeding optimized enteral nutrition delivery to critically ill patients in this medical-surgical intensive care unit. This success can be attributed to a comprehensive, individualized, and proactive process design and educational approach. The process can be adapted to quality improvement initiatives with other patient populations and units.
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Affiliation(s)
- Angela Bonomo
- Angela Bonomo is a senior professional staff nurse at the University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania. She was a senior clinical nurse I at the University of Maryland St. Joseph Medical Center, Towson, Maryland, when this article was written
| | - Diane Lynn Blume
- Diane Lynn Blume is a clinical practice specialist at the University of Maryland St. Joseph Medical Center
| | - Katie Davis
- Katie Davis is a clinical dietitian and certified nutrition support clinician at the University of Maryland St. Joseph Medical Center
| | - Hee Jun Kim
- Hee Jun Kim is an assistant professor, Ajou University, School of Nursing, Suwon, South Korea
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10
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Bruen T, Rawal S, Tomesko J, Byham-Gray L. Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting. Nutr Clin Pract 2020; 35:522-532. [PMID: 31990098 DOI: 10.1002/ncp.10442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. METHODS This retrospective analysis (N = 61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n = 36) and post-implementation (n = 25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts. RESULTS Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P = 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8 ± 22.2% vs 55.9 ± 24.0%; P = 0.01) and energy requirements (93.4 ± 36.9% vs 69.6 ± 35.3%; P = 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition). CONCLUSION Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.
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Affiliation(s)
- Tracy Bruen
- Nutritional Services Williamson Medical Center, School of Health Professions, Franklin, Tennessee, USA.,Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Shristi Rawal
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Jennifer Tomesko
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Laura Byham-Gray
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
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11
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Prest PJ, Justice J, Bell N, McCarroll R, Watson CM. A Volume-Based Feeding Protocol Improves Nutrient Delivery and Glycemic Control in a Surgical Trauma Intensive Care Unit. JPEN J Parenter Enteral Nutr 2019; 44:880-888. [PMID: 31529520 DOI: 10.1002/jpen.1712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/11/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Inadequate delivery of nutrition in critically ill patients has been shown to have adverse outcomes. A surgical trauma intensive care unit provides unique challenges to enteral feeds. Although volume-based feeding protocols, like Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP), have been successfully used in medical intensive care patients, data are sparse on its safety and efficacy in a surgical intensive care unit population. METHODS A PEP uP protocol was recently initiated at our American College of Surgeons Level 1 verified trauma center. Medical records of 197 patients before this change (pre-PEP uP) were compared with 295 patients after this change (post-PEP uP). RESULTS The post-PEP uP group met/exceeded energy goals (defined as 80% of target) more often (57.0% compared with 26.9%, P-value < .001), with an adjusted odds ratio (OR) of 4.98 (95% CI 3.49-7.10), and more often met/exceeded protein goals (57.4% compared with 18.6%, P-value < .001), with an adjusted OR of 11.84 (95% CI 7.94-17.64). There was no significant difference in emesis during this time. Additionally, patients in the post-PEP uP arm had less episodes of hyperglycemia (9% compared with 14.4%, P-value < .001). CONCLUSIONS Volume-based feeding protocols like PEP uP are safe in critically ill trauma patients and are more effective at delivering energy and protein while limiting hyperglycemic episodes when compared with a traditional delivery method.
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Affiliation(s)
- Phillip J Prest
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Jessica Justice
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA
| | - Nathanial Bell
- The University of South Carolina College of Nursing, Columbia, South Carolina, USA
| | - Richard McCarroll
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Christopher M Watson
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
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