Volume-Based Feeding Enhances Enteral Delivery by Maximizing the Optimal Rate of Enteral Feeding (FEED MORE)

BACKGROUND

The importance of enteral nutrition (EN) in critically ill patients is well documented. However, actual administration of EN frequently does not amount to prescribed nutrition goals. Persistent underfeeding may lead to impaired immune response, increased mortality, and higher costs. Traditionally, EN uses a rate-based approach, utilizing slow titration to goal and a final fixed hourly rate, regardless of interruptions in feeding. Volume-based feeding (VBF) establishes a 24-hour EN goal volume, and the rate varies to achieve this daily goal when interruptions occur.

MATERIALS AND METHODS

This was a retrospective, single-center, quasi-experimental study comparing traditional rate-based feeding (RBF) to VBF in adult patients admitted to the medical and neurosurgical intensive care units (ICUs). The primary outcome was mean percentage of total goal energy received after EN initiation until 7 days, transfer from ICU, removal of feeding tube, or oral diet order placed. Secondary outcomes included mean percentage of total goal protein received, percentage of patients meeting 80% of nutrition goals, incidence of gastric residual volumes >400 mL, and incidence of moderate hyperglycemia (>250 mg/dL).

RESULTS

The study enrolled 189 patients. Mean percentage of goal energy delivered (75% RBF, 102% VBF; P < .001) and goal protein delivered (68% RBF, 87% VBF; P < .001) was significantly higher with VBF compared with RBF.

CONCLUSION

VBF demonstrated a significant increase in energy and protein delivery with no major safety or tolerability issues. VBF should be considered for use in ICU patients to optimize nutrition delivery.

Volume-Based Protocol Improves Delivery of Enteral Nutrition in Critically Ill Trauma Patients

BACKGROUND

Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase delivery of EN over the conventional hourly rate method (CM).

METHODS

This study compared patients on CM to those on VP. The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours, hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube.

RESULTS

We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%, P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM 2.04% vs VP 1.61%; P = .51).

CONCLUSION

Implementation of a VP significantly increased delivery of EN by 8.3% over that given by the CM in critically ill trauma patients with no difference in feeding-related complications.

Volume-Based Feeding in the Critically Ill Patient

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate-based strategy.