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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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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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Pohlenz-Saw JAE, Merriweather JL, Wandrag L. (Mal)nutrition in critical illness and beyond: a narrative review. Anaesthesia 2023; 78:770-778. [PMID: 36644786 DOI: 10.1111/anae.15951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 01/17/2023]
Abstract
Close liaison with ICU-trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients- this should be done while monitoring closely for refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient-centred outcomes including complications and mortality. Obesity is part of that story, and isocaloric and high-protein provision of nutrition is important in this group of patients who comprise a growing proportion of people treated. Assessing protein stores and appropriate dosing is, however, challenging in all groups of patients. It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post-pyloric feeding and a multidisciplinary framework to support the importance of nutritional education.
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Affiliation(s)
| | | | - L Wandrag
- Department of Nutrition & Dietetics, King's College Hospital, London, UK.,Department of Critical Care Medicine, King's College Hospital, London, UK
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Chan LN. Forty-Fourth ASPEN Presidential Address: The 2020 Overture-A New Tune for the Future. JPEN J Parenter Enteral Nutr 2020; 45:193-203. [PMID: 33180961 DOI: 10.1002/jpen.2044] [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: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
The provision of safe nutrition care to patients is the fundamental vision of the American Society for Parenteral and Enteral Nutrition (ASPEN). Yet we are facing important challenges in our field and society, requiring us to reflect, rethink, and adjust to make new breakthroughs to meet the needs for the future. In developing new plans to address these challenges, we must focus on 2 critical elements: people and the scientific process. Government and organizations cannot carry on their missions without people. But with the challenges of healthcare finance, biotechnology disruption, the desire to facilitate knowledge transfer and now the impact of the global pandemic, we need to develop a forward-thinking and sustainable approach to connect people and foster continued learning. Burnout is a recognized occupational problem that affects providers and researchers across all disciplines. The coronavirus disease 2019 pandemic has amplified the challenges associated with burnout. Supporting the needs and promoting the well-being of people, therefore, are critical to move forward successfully. At the same time, the scientific advances in our field rely on sound scientific principles and integrity. Information overload, pressure to produce immediate outcomes (such as cost-saving initiatives), and misinformation can compromise the scientific process and research evidence. The two common missteps that affect researchers, clinicians, and administrators include premature factulation and binary thinking. We will discuss how these missteps can occur and the approaches to minimize their influence in making sound decisions and policies to meet the future's needs.
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Affiliation(s)
- Lingtak-Neander Chan
- Interdisciplinary Faculty in Nutritional Sciences, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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