Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation

Nutritional Support in Critically Ill Trauma Patients

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.

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

BACKGROUND

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

METHODS

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

RESULT

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

CONCLUSION

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

A Quality Improvement Study: Comparison of Volume-Based and Rate-Based Tube Feeding Efficacy and Clinical Outcomes in Critically Ill Patients

BACKGROUND

Adequate nutrition (receiving ≥80% of estimated energy requirements [EER]) is important in preventing and treating malnutrition and improving clinical outcomes. In conventional rate-based tube feeding (RBTF), patients are prescribed a constant infusion rate. Per volume-based tube feeding (VBTF), the hourly infusion rate can be increased (max 150 mL/h) to make up for feeding deficits, ensuring patients receive the targeted 24-hour volume. This study compared clinical outcomes between patients on VBTF vs RBTF.

METHODS

Data were collected from medical charts of patients within a 5-month period. Inclusion criteria included patients ≥18 years of age who were admitted to an intensive care unit and receiving enteral nutrition for at least 24 hours.

RESULTS

More patients on VBTF (n = 77; 55.8% females, age 59.9 ± 18.1 years, body mass index [BMI] 29.7 ± 17.7 kg/m² ) received adequate nutrition (VBTF: 88.3%, 93.1 ± 11.3% EER; RBTF: 36.4%, 71.3 ± 35.8% EER) than those on RBTF (n = 206; 35.9% females, age 61 ± 15 years, BMI 28.3 ± 6.5 kg/m² ) during the first crucial 7 days of nutrition support. No significant differences in adverse outcomes (hyperglycemia P = 0.052, hypoglycemia P = 0.168, emesis P = 0.084, diarrhea P = 0.470, and high gastric output P = 0.096) were found between the groups.

CONCLUSION

VBTF can help promote nutrition adequacy. This study provides evidence for clinicians to be more proactive and aggressive in providing tube feeding in the critical care setting when patients are deemed appropriate for VBTF.

Volume based feeding versus rate based feeding in the critically ill: A UK study

Background

Underfeeding in intensive care patients on enteral nutrition is commonplace and multifactorial. This can be exacerbated by interruptions caused by routine fasting for procedures and investigations. Our study aims to demonstrate that a volume based feeding protocol can overcome the barriers of underfeeding and safely increase energy and protein delivery in UK intensive care patients, potentially improving clinical outcomes.

Methods

In this single centre cohort study, data were collected from adult mechanically ventilated patients. We compared the standard care of rate based feeding, from an International Nutrition Survey (2014/15) to the new intervention of volume based feeding, in a mixed medical and surgical intensive care unit. The primary outcomes were the proportion of energy and protein daily targets delivered. Secondary outcomes compared the effects on gastrointestinal tolerance, glycaemic control, mortality, mechanical ventilation days, length of stay in intensive care unit and hospital.

Results

From a total of 82 patients (rate based feeding = 27, volume based feeding = 55), volume based feeding patients received significantly more prescribed energy (52% versus 81%; p < 0.001) and protein (40% versus 74%; p < 0.001). There was no significant difference in gastrointestinal symptoms such as gastric residual volumes (p = 0.62), glycaemic control (p = 0.94) or insulin usage (p = 0.75). Although there was an improvement in energy and protein delivery, there were no differences in mechanical ventilation days (p = 0.12), mortality (p = 0.06), length of stay in intensive care unit (p = 0.93) and hospital (p = 0.72) between the groups.

Conclusion

Compared to rate based feeding, volume based feeding significantly improved energy and protein provision with no adverse effects on glycaemic control or gastrointestinal tolerance, clinical outcomes were not affected.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A more physiological feeding process in ICU: Intermittent infusion with semi-solid nutrients (CONSORT-compliant)

INTRODUCTION AND OBJECTIVES

The goal of this study is to determine whether the application of semi-solid nutrients could increase the efficiency of the enteral nutrition (EN), which was measured daily by administered volume of nutrition/prescribed volume of nutrition.

METHODS

A total of 28 subjects were finally enrolled in the study and randomized to receive either intermittent feeding (IF) or intermittent feeding with semi-solid nutrients (IS). Three major parameters concerning EN were evaluated in this study: the daily dosage prescribed by doctor, the actual dosage received by subjects, and the acute complications such as diarrhea, vomiting, regurgitation, bowel distension, and lung infection.

RESULTS

There were no statistical differences in NRS-2002, and acute gastrointestinal injury between both groups. The IS group (0.98 ± 0.06, P < .01) could receive higher percentage of daily prescribed calories compared to IF (0.73 ± 0.15). The total caloric intake during the first 3 days was higher in IS (2589.29 ± 844.02 vs. 1685.71 ± 388.00, P < .01). The incidence of feeding intolerance (FI) was lower in the IS group (2/14) compared with IF (8/14). However, semi-solid nutrients did not decrease the length of stay, lung infection, or 30-day mortality. Similarly, there was no difference in glycemic variability and stress hyperglycemia.

CONCLUSIONS

In our cohort of critically ill subjects, the efficiency of the EN was increased by IS, which might be related to the improvement of FI (NCT03017079).

Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding

There are several methods of enteral nutrition (EN) administration, including continuous, cyclic, intermittent, and bolus techniques, which can be used either alone or in combination. Continuous feeding involves hourly administration of EN over 24 hours assisted by a feeding pump; cyclic feeding involves administration of EN over a time period of <24 hours generally assisted by a feeding pump; intermittent feeding involves administration of EN over 20-60 minutes every 4-6 hours via pump assist or gravity assist; and bolus feeding involves administration of EN over a 4- to 10-minute period using a syringe or gravity drip. In practice, pump-assisted continuous feeding is generally acceptable for critically ill patients to prevent EN-related complications. However, a limited number of studies have been conducted to support this practice. In addition, regarding muscle protein synthesis and gastrointestinal hormone secretion, intermittent or bolus feeding may be more beneficial than continuous EN feeding for critically ill patients. For medically stable patients with feeding tubes terminating in the stomach, bolus feeding is favored with respect to practical factors, such as cost, convenience, and patient mobility. However, few studies have shown whether intermittent or bolus feeding is beneficial in a critical care setting at present. Additional randomized controlled studies comparing intermittent with bolus feeding are required.

Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early or Late Feeding after ICU Admission?

The feeding of critically ill patients has recently become a controversial issue, as several studies have provided unexpected and contradictory results. Earlier beliefs regarding energy requirements in critical illness-especially during the initial phase-have been challenged. In the current review, we summarize existing evidence about fasting and the impact of early vs. late feeding on the sick organism's responses. The most important points are the non-nutritional advantages of using the intestine, and recognition that early endogenous energy production as an important player in the response must be integrated in the nutrient prescription. There is as of yet no bedside tool to monitor dynamics in metabolism and the magnitude of the endogenous energy production. Hence, an early "full-feeding strategy" exposes patients to involuntary overfeeding, due to the absence of an objective measure enabling the adjustment of the nutritional therapy. Suggestions for future research and clinical practice are proposed.

Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: A before and after study

BACKGROUND AND OBJECTIVE

Enteral nutrition (EN) feeding protocol was proposed to have positive impact on critically ill patients. However, current studies showed conflicting results. The present study aimed to investigate whether enteral feeding protocol was able to improve clinical outcomes in critically ill patients.

METHODS

A before (stage 1) and after (stage 2) interventional study was performed in 10 tertiary care hospitals. All patients expected to stay in the intensive care unit (ICU) for over three days were potentially eligible. Clinical outcomes such as 28-day mortality, ICU length of stay, duration of mechanical ventilation (MV), and nosocomial infection were compared between the two stages.

MAIN RESULTS

A total of 410 patients were enrolled during the study period, including 236 in stage 1 and 174 in stage 2. EN feeding protocol was able to increase the proportion of EN in day 2 (41.8±22.3 vs. 50.0±28.3%; p = 0.006) and day 6 (70.3±25.2 vs. 77.6±25.8%; p = 0.006). EN percentages tended to be higher in stage 1 than that in stage 2 on other days, but statistical significance was not reached. There was no difference in 28-day mortality between stage 1 and 2 (0.14 vs. 0.14; p = 0.984). Implementation of EN feeding protocol marginally reduced ICU length of stay (19.44±18.48 vs. 16.29±16.19 days; p = 0.077). There was no difference in the duration of MV between stage a and stage 2 (14.24±14.49 vs. 14.51±17.55 days; p = 0.877).

CONCLUSIONS

The study found that the EN feeding protocol was able to increase the proportion of EN feeding, but failed to reduce 28-day mortality, incidence of nosocomial infection or duration of MV.