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

Abstract

BackgroundThe 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 MethodsThis 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).ResultsThe 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.ConclusionVBF 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.

Improving nutrition practices for postoperative high‐risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre– and post–protocol intervention outcome study

“…Volume-based feeding protocols have previously shown to be an effective solution to compensate for excess EN holds that are common in ICU settings; however, these more aggressive EN protocols have not been studied in cardiac surgery populations and are more appropriate for hemodynamically stable patients with a low risk of GI intolerance. 65 These protocols allow the RN to adjust the EN rate to maximize the total 24-h volume delivered, which may result in higher EN delivery rates (ie, 100-150 ml/h). These high EN rates may be poorly tolerated in the first postoperative week for cardiac surgery patients in the setting of hemodynamic instability and risk factors for bowel ischemia.…”

Relationship Between Nutrition Intake and Outcome After Subarachnoid Hemorrhage: Results From the International Nutritional Survey

“…46,47 An alternative is to use a volume based approach to target a total 24 hour volume of enteral nutrition, which is a good strategy to both rapidly achieve goal as well as counteract the impact of interruptions on overall nutrition intake. [48][49][50] A volume based strategy, combined with a nurse directed nutrition educational intervention has been shown to increase protein and calorie delivery in medical and surgical critical care populations, and should be adopted as the optimal method by which to provide nutrition in a critically ill SAH patient population. 51 There are several limitations to this study that warrant further discussion.…”

When is enteral nutrition indicated?

“…Brierley‐Hobson and colleagues 15 reported no difference in the amount of insulin prescribed between patients receiving VBF and RBF but did note higher morning blood glucose levels in the VBF group. Similarly, Holyk et al 16 reported no difference in average blood glucose levels between VBF and RBF but noted an increased incidence of moderate hyperglycemia during catch‐up periods compared with non–catch‐up periods in the same patients. One study reported a decreased occurrence of hyperglycemia and hypoglycemia in the VBF cohort, 17 and another found no difference in hyperglycemia and glycemic variance between groups 18 …”