The Impact of Implementing an Enteral Tube Feeding Protocol on Caloric and Protein Delivery in Intensive Care Unit Patients

Abstract

Background: The purpose of this study was to determine the effect of an enteral tube feeding protocol on caloric and protein delivery to intensive care unit (ICU) patients. Methods: This prospective study consisted of 2 phases: before and after the implementation on an enteral-feeding protocol. The following data were collected: demographics, Acute Physiology and Chronic Health Evaluation II score and Simplified Acute Physiology Score II, caloric and protein requirements, the location of the feeding tube tip, and prokinetic agents use. The primary endpoint was caloric and protein intake as a percentage of the requirement. Secondary endpoints were gastric residuals >150 mL, vomiting episodes, ICU and hospital lengths of stay, mechanical ventilation duration, and ICU and hospital mortality. Results: There were no significant differences between the control (n = 100) and protocol groups (n = 103) in baseline characteristics. The protocol was associated with significant improvement in the 7-day average of caloric intake/requirement (53.9 ± 2.3% vs 64.5 ± 2.2%, p = .001) and protein intake/requirement (56.7 ± 2.6% vs 67.4% ± 2.7%, p = .005). Caloric and protein intake improved whether the patient was receiving prokinetic agent or not. There was a trend toward lower gastric residual volumes and vomiting episodes in the protocol group. Patients receiving gastric feeding showed significant improvement in caloric intake to levels comparable to patients with postpyloric feeding. Conclusions: Enteral tube feeding protocol is effective in improving feeding delivery in ICU patients independent of prokinetic agent use. Protocol for enteral tube feeding should be considered in the management of ICU patients, given the positive impact of this nonpharmacologic, noninterventional tool.

Get full access to this article

View all access options for this article.

References

Cook D, Heyland D, Griffith L, Cook R, Marshall J, Pagliarello J. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation: Canadian Critical Care Trials Group. Crit Care Med. 1999 ;27:2812– 2817.

Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001 ;29:2264– 2270.

Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications: the results of a meta-analysis. Ann Surg. 1992 ;216:172– 183.

Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996 ;39:833– 835.

Kompan L, Kremzar B, Gadzijev E, Prosek M. Effect of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury. Intensive Care Med. 1999 ;25:157– 161.

Zaloga GP. Early enteral nutrition support improves outcome: hypothesis or fact? Crit Care Med. 1999 ;27:259– 261.

Sacks GS, Brown RO, Teague D, Dickerson RN, Tolley EA, Kudsk KA. Early nutrition support modifies immune function in patients sustaining severe head injury. JPEN J Parenter Enteral Nutr. 1995 ;19:387– 392.

Gianotti L, Nelson JL, Alexander JW, Chalk CL, Pyles T. Post injury hypermetabolic response and magnitude of translocation: prevention by early enteral nutrition. Nutrition. 1994 ;10:225– 231.

McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27:1252– 1256.

10.

Adam S, Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Med. 1997 ;23:261– 266.

11.

Kao CH, ChangLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998 ;93:1108– 1112.

12.

Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29:1955– 1961.

13.

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985 ; 13:818– 829.

14.

Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multi-center study. JAMA. 1993 ;270:2957– 2962.

15.

American Dietetic Association. Nutritional assessments of adults. In: Manual of Clinical Dietetics . 6th ed. Chicago, IL: American Dietetic Association; 2000:1– 66.

16.

Spain DA, McClave SA, Sexton LK, et al. Infusion protocol improves delivery of enteral tube feeding in the critical care unit. JPEN J Parenter Enteral Nutr. 1999 ;23:288– 292.

17.

Adamski J, Arabi Y, Sakkijha M, Goraj R, McIntyre R. The impact of a written feeding protocol in critically ill trauma patients. Intensive Care Med. 2000 ;26:S358 .

18.

Montejo JC, Grau T, Acosta J, et al. Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units: multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med. 2002;30:796– 800.

19.

Zaloga GP, Marik P. Promotility agents in the intensive care unit. Crit Care Med. 2000 ;28:2657– 2659.

20.

Kozar RA, McQuiggan MM, Moore EE, Kudsk KA, Jurkovich GJ, Moore FA. Post-injury enteral tolerance is reliably achieved by a standardized protocol. J Surg Res. 2002 ;104:70– 75.

21.

Chapman G, Curtas S, Meguid M. Standardized enteral orders attain caloric goals sooner: a prospective study. JPEN J Parenter Enteral Nutr. 1992;16:149– 151.

22.

Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. JPEN J Parenter Enteral Nutr. 2002;26(Suppl):S51– S57.

23.

Koretz RL, Lipman TO. Postpyloric versus intragastric enteral nutrition: do the lungs care? A systematic review of the randomized trials. JPEN J Parenter Enteral Nutr. 2004 ;28(Suppl):S17– S18.

24.

Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med. 2001;29:1916– 1919.