Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.
RubinsonLDietteGBSongXBrowerRGKrishnanJA. Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit. Crit Care Med. 2004;32(2):350-357.
2.
VilletSChioleroRLBollmannMD. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24(4):502-509.
3.
DvirDCohenJSingerP. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr. 2006;25(1):37-44.
4.
TsaiJ-RChangW-TSheuC-C. Inadequate energy delivery during early critical illness correlates with increased risk of mortality in patients who survive at least seven days: a retrospective study. Clin Nutr. 2011;30(2):209-214.
5.
HeylandDKStephensKEDayAGMcClaveSA. The success of enteral nutrition and ICU-acquired infections: a multicenter observational study. Clin Nutr. 2011;30(2):148-155.
6.
FaisyCLerolleNDachraouiF. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr. 2009;101(7):1079-1087.
7.
AlberdaCGramlichLJonesN. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728-1737.
8.
ElkeGWangMWeilerNDayAGHeylandDK. Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Crit Care. 2014;18(1):R29.
9.
WeiXDayAGOuellette-KuntzHHeylandDK. The association between nutritional adequacy and long-term outcomes in critically ill patients requiring prolonged mechanical ventilation. Crit Care Med. 2015;(6):1.
10.
ArabiYMTamimHMDharGS. Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr. 2011;93:569-577.
11.
RiceTWWheelerAPThompsonBT. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8):795-803.
12.
CasaerMPWilmerAHermansGWoutersPJMesottenDVan den BergheG. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med. 2013;187(3):247-255.
13.
WeijsPJMWischmeyerPE. Optimizing energy and protein balance in the ICU. Curr Opin Clin Nutr Metab Care. 2013;16(2):194-201.
14.
HeylandDKWischmeyerPE. Does artificial nutrition improve outcome of critical illness ? An alternative viewpoint!Crit Care. 2013;17(4):324.
15.
HeylandDKCahillNDayAG. Optimal amount of calories for critically ill patients: depends on how you slice the cake!Crit Care Med. 2011;39(12):2619-2626.
16.
NicoloMHeylandDKChittamsJSammarcoTCompherC. Clinical outcomes related to protein delivery in a critically ill population: a multicenter, multinational observation study. JPEN J Parenter Enteral Nutr. 2016;40:45-51.
17.
HeylandDK. Critical care nutrition support research: lessons learned from recent trials. Curr Opin Clin Nutr Metab Care. 2013;16(2):176-181.
18.
McclaveSASextonLKSpainDA. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27(7):1252-1256.
19.
De JongheBAppere-De-VechiCFournierM. A prospective survey of nutritional support practices in intensive care unit patients: what is prescribed? What is delivered?Crit Care Med. 2001;29(1):8-12.
20.
BinnekadeJMTepaskeRBruynzeelPMathus-VliegenEMHde HannRJ. Daily enteral feeding practice on the ICU: attainment of goals and interfering factors. Crit Care. 2005;9(3):R218-R225.
21.
CahillNEDhaliwalRDayAGJiangXHeylandDK. Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med. 2010;38(2):395-401.
22.
HeylandDKHeylandRDCahillNE. Creating a culture of clinical excellence in critical care nutrition: the 2008 “Best of the Best” award. JPEN J Parenter Enteral Nutr. 2010;34(6):707-715.
23.
HeylandDKDhaliwalRWangMDayAG. The prevalence of iatrogenic underfeeding in the nutritionally “at-risk” critically ill patient: Results of an international, multicenter, prospective study. Clin Nutr. 2015;34(4):659-666.
24.
MartinCDoigGHeylandDMorrisonTSibbaldW. Multicentre, cluster-randomized clinical trial of Algorithms for Critical-Care Enteral and Parenteral Therapy (ACCEPT). Nutr Clin Pract. 2004;19(3):309.
25.
MackenzieSLZygunDAWhitmoreBLDoigCJHameedSM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. JPEN J Parenter Enteral Nutr. 2005;29(2):74-80.
26.
WøienHBjørkI. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs. 2006;15:168-177.
27.
KissCMByham-GrayLDenmarkRLoetscherRBrodyRA. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit. Nutr Clin Pract. 2012;27(6):793-801.
28.
SoguelLRevellyJ-PSchallerM-DLongchampCBergerMM. Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med. 2012;40(2):412-419.
29.
HeylandDKCahillNEDhaliwalRSunXDayAGMcClaveSA. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. JPEN J Parenter Enteral Nutr. 2010;34(6):675-684.
30.
HeylandDKCahillNEDhaliwalR. Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care. 2010;14:R78.
31.
HeylandDKMurchLCahillN. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013;41(12):2743-2753.
32.
HeylandDKDhaliwalRLemieuxMWangMDayAG. Implementing the PEP uP protocol in critical care units in Canada: results of a multicenter, quality improvement study. JPEN J Parenter Enteral Nutr. 2015;39(6):698-706.
33.
ReignierJ. Feeding ICU patients on invasive mechanical ventilation: designing the optimal protocol. Crit Care Med. 2013;41(12):2825-2826.
34.
McClaveSAHeylandDK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract. 2009;24(3):305-315.
McClaveSAMartindaleRGVanekVW. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.
37.
DhaliwalRCahillNLemieuxMHeylandDK. The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. Nutr Clin Pract. 2014;29(1):29-43.
DoigGSHeighesPTSimpsonFSweetmanEADaviesAR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009;35(12):2018-2027.
40.
RiceTWSwopeTBozemanSWheelerAP. Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition. 2005;21(7-8):786-792.
41.
KimHStottsNAFroelicherESEnglerMMPorterC. Why patients in critical care do not receive adequate enteral nutrition? A review of the literature. J Crit Care. 2012;27(6):702-713.
42.
KhalidIDoshiPDiGiovineB. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19(3):261-268.
43.
DesachyAClavelMVuagnatANormandSGissotVFrançoisB. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med. 2008;34(6):1054-1059.
44.
McClaveSASaadMAEsterleM. Volume-based feeding in the critically ill patient. JPEN J Parenter Enteral Nutr. 2015;39:707-712.
45.
TaylorBBrodyRDenmarkRSouthardRByham-GrayL. Improving enteral delivery through the adoption of the “Feed Early Enteral Diet Adequately for Maximum Effect (FEED ME)” protocol in a surgical trauma ICU: a quality improvement review. Nutr Clin Pract. 2014;29(5):639-648.
46.
MehannaHMMoledinaJTravisJ. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008;336(7659):1495-1498.
47.
JabbarAChangW-KDrydenGWMcClaveSA. Gut immunology and the differential response to feeding and starvation. Nutr Clin Pract. 2003;18(6):461-482.
48.
HofferLJBistrianBR. Appropriate protein provision in critical illness: a systematic and narrative review. Am J Clin Nutr. 2012;96(3):591-600.
49.
AllingstrupMJEsmailzadehNWilkens KnudsenA. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012;31(4):462-468.
50.
UklejaA. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract. 2010;25(1):16-25.
GungabissoonUHacquoilKBainsC. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448.
53.
PinillaJSamphireJArnoldCLiuLThiessenB. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. JPEN J Parenter Enteral Nutr. 2001;25(2):81-86.
Van der MeerYGVenhuizenWAHeylandDKvan ZantenAR. Should we stop prescribing metoclopramide as a prokinetic drug in critically ill patients?Crit Care. 2014;18:1-5.
58.
DeaneAChapmanMJFraserRJBryantLKBurgstadCNguyenNQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007;13(29):3909-3917.
59.
NguyenNQChapmanMFraserRJBryantLKBurgstadCHollowayRH. Prokinetic therapy for feed intolerance in critical illness: one drug or two?Crit Care Med. 2007;35(11):2561-2567.
60.
OrbanZMacDonaldLLPetersMAGuslitsB. Erythromycin-induced cardiac toxicity. Am J Cardiol. 1995;75(12):859-861.
61.
MontejoJCMiñambresEBordejéL. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386-1393.
62.
ReignierJMercierELe GougeA. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256.
63.
ElkeGHeylandDK. Enteral nutrition in critically ill septic patients—less or more?JPEN J Parenter Enteral Nutr. 2015;39(2):140-142.
64.
Juvé-udinaMValls-miróCCarreno-GraneroA. To return or to discard? Randomised trial on gastric residual volume management. Intensive Crit Care Nurs. 2009;25:258-267.
65.
SingerPDoigGSPichardC. The truth about nutrition in the ICU. Intensive Care Med. 2014;40(2):252-255.
66.
DissanaikeSSheltonMWarnerKO’KeefeGE. The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition. Crit Care. 2007;11(5):R114.
67.
GrauTBonetARubioM. Liver dysfunction associated with artificial nutrition in critically ill patients. Crit Care. 2007;11(1):R10.
68.
KleinCStanekGWilesCIII. Overfeeding macronutrient to critically ill adults: metabolic complications. J Am Diet Assoc. 1998;98:795-806.
69.
SchulmanRCMechanickJI. Metabolic and nutrition support in the chronic critical illness syndrome. Respir Care. 2012;57(6):958-978.
70.
McClaveSAMartindaleRGKiralyL. The use of indirect calorimetry in the intensive care unit. Curr Opin Clin Nutr Metab Care. 2013;16(2):202-208.
71.
PichardCOshimaTBergerMM. Energy deficit is clinically relevant for critically ill patients: yes. Intensive Care Med. 2015;41(2):335-338.
72.
WooleyJASaxHC. Indirect calorimetry: applications to practice. Nutr Clin Pract. 2003;18:434-439.
73.
CompherCNicoloMChittamsJKangYDayAGHeylandDK. Clinical outcomes in critically ill patients associated with the use of complex vs weight-only predictive energy equations. JPEN J Parenter Enteral Nutr. 2015;39:864-869.
74.
McCallMCahillNMurchL. Lessons learned from implementing a novel feeding protocol: results of a multicenter evaluation of educational strategies. Nutr Clin Pract. 2014;29(4):510-517.
75.
BostRBCTjanDHTZantenARH Van. Timing of (supplemental) parenteral nutrition in critically ill patients: a systematic review. Ann Intensive Care. 2014;4:31.
76.
HarveySEParrottFHarrisonDA. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371(18):1673-1684.
77.
RiceTW. Gastric residual volume: end of an era. JAMA. 2013;309(3):283.
78.
McClaveSAMartindaleRGRiceTWHeylandDK. Feeding the critically ill patient. Crit Care Med. 2014;42(12):2600-2610.
