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Roberts S, Brody R, Rawal S, Byham-Gray L. Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control. JPEN J Parenter Enteral Nutr 2018; 43:365-375. [PMID: 30229952 DOI: 10.1002/jpen.1428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/13/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Susan Roberts
- Nutrition Services, Baylor University Medical Center/Aramark Healthcare, Dallas, Texas, USA.,School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Rebecca Brody
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Shristi Rawal
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Laura Byham-Gray
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
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Heyland DK, Lemieux M, Shu L, Quisenberry K, Day AG. 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. JPEN J Parenter Enteral Nutr 2017; 42:308-317. [PMID: 27875285 DOI: 10.1177/0148607116673301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/15/2016] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Margot Lemieux
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Lin Shu
- Phoenix VA Health Care System, Arizona, USA
| | | | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Declercq B, Deane AM, Wang M, Chapman MJ, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation. Anaesth Intensive Care 2016; 44:93-8. [PMID: 26673594 DOI: 10.1177/0310057x1604400114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Suboptimal levels of feeding in critically ill patients are associated with poor clinical outcomes. The Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol was developed to improve nutritional delivery in the critically ill and has been studied in several hospitals. However, the experience with this protocol in surgical patients is limited to date. The objective of this analysis was to describe the experience with this protocol in surgical patients. We analysed observational patient data obtained from the 2013 International Nutrition Survey. We compared nutritional practices and outcomes of patients admitted for surgical and medical reasons to ICUs in sites that implemented the PEPuP protocol. We used surgical ICU patients in non-PEPuP sites as a concurrent control group. In sites that implemented the PEPuP protocol, surgical patients received a smaller proportion of prescribed calories (43% versus 61%, P=0.004) and protein (38% versus 57%, P=0.002) compared to medical patients. When compared to the cohort of surgical patients from control sites, the surgical patients from PEPuP sites received similar amounts of calories and protein. Although surgical PEPuP patients were more likely to receive trophic and volume-based feeds compared to surgical patients in control sites, other aspects of the PEPuP protocol were not adequately implemented. We conclude that nutritional delivery to surgical patients remains inadequate and the PEPuP protocol seems ineffective in improving nutritional intake in this population. Further research to determine methods of optimising PEPuP protocol implementation and adherence in surgery patients is needed.
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Affiliation(s)
- B Declercq
- Royal Adelaide Hospital, North Terrace, Adelaide, South Australia
| | - A M Deane
- Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - M Wang
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - M J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, and Discipline of Acute Care Medicine, North Terrace, Adelaide, South Australia
| | - D K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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Dijkink S, Fuentes E, Quraishi SA, Cropano C, Kaafarani HMA, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Velmahos G, Yeh DD. Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates. Nutr Clin Pract 2015; 31:86-90. [PMID: 26673198 DOI: 10.1177/0884533615621047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. MATERIALS AND METHODS This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. RESULTS EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%). CONCLUSIONS In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
BACKGROUND Nutrition support is important in critical illness, and accurate recording is particularly important to determine whether nutritional goals are met both from a caloric and volume perspective. OBJECTIVE To assess accuracy of enteral feeding records, to increase nursing education and to improve nutritional documentation. METHODS An uncontrolled, prospective, pre- and post-intervention study was completed as part of a quality improvement initiative. This study was performed in a 950-bed university hospital (Philadelphia, Pennsylvania) and focused in a 25-bed, closed intensive care unit (ICU) with a multidisciplinary rounding team of intensivist, nurse, pharmacist, dietitian and respiratory therapist. Nurse researchers reviewed 188 patient electronic medical records (EMR) and compared the data to volume data saved on enteral feeding pump. Data analysis revealed inconsistencies between the pump readings and EMR. The need for a prospective intervention was recognized and implementation of this intervention included pump calibration and teaching modules aimed at improving enteral feeding protocols. During post-intervention, another 234 records were reviewed. RESULTS The intervention of an education program reduced the documented discrepancy between the pump readings and charted volumes from 44 to 33%. A correlation analysis also showed a tighter relationship post-intervention (rpost = 0.84 vs. rpre = 0.76, both had a p < 0.01). CONCLUSION This study highlights the importance of accurate nutritional monitoring in the ICU and demonstrates that educational interventions can improve enteral feeding protocols. Pump calibrations, frequent interrogation and vigilant nutritional documentation can improve enteral nutrition delivery. Future studies are needed to determine if the effects are sustainable and if further education will further improve documentation and delivery.
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Affiliation(s)
- Susan Gonya
- a Pulmonary and Critical Care , Thomas Jefferson University , Philadelphia , PA , USA
| | - Michael Baram
- a Pulmonary and Critical Care , Thomas Jefferson University , Philadelphia , PA , USA
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