Volume-based vs Rate-based feeding - saspen

Volume based vs Rate based feeding

Vanessa McEwan RD (SA)

CCSSA SASPEN August 2019

Learning Objectives

• Background• Definitions of volume- and rate-based enteral feeding • Discuss primary literature and other related research• Education and protocol implementation in the ICU • Compare and contrast the pros and cons to

volume-based vs. rate-based enteral feeding

Background

ICU SURVIVORS

• Frequently experience significant post-ICU morbidities:

-muscle weakness-loss of lean body mass-impairment in physical functioning

Stoppe et al. Critical Care 2019

Background

ICU SURVIVORS

which results in significant healthcare-associated

COSTsStoppe et al. Critical Care 2019

Background

ICU SURVIVORS

CustomiseOptimiseSurviveThrive

Critical Care National Congress2019

Background

ICU SURVIVORS

• Recent randomized trials demonstrate:-providing increased calories alone to ICU patientsmay not improve outcomes

• However, observational studies report that optimizing daily protein intake decreases infections, mechanical ventilationduration, time to discharge and mortality

Arabi YM, N Engl J Med 2015;372:398-408

Heyland DK, Nutrients 2018;10:462

Prieser J-C, Crit Care 2018;22:261


Background

Optimal nutrition in critically ill patients is difficult to achieve

• Studies indicate these patients receive 50-70% of goal calories• Underfeeding may lead to malnutrition, increased infectious

complications, increased mechanical ventilation days, impairedimmune response, poor wound healing, and increased mortality,length of hospital stay and cost Rubinsin L, Crit Care Med 2004

Villet S, Clin Nutr 2005

Alberda C, Int Care Med 2009

Lewis SJ, J Gasto Sug, 2009

Haskins IN, JPEN 2015

Zheng YL, JPEN 2016

Compher C, Crit Care Med 2017

Background

Common reasons for NOT achieving our Nutrition Goals

• Delays in initiation of feeding OR NPO status• Frequent cessation of feeding for diagnostic testing and

multiple operative procedures• Aspiration concerns – GRV volumes• Malfunctioning Enteral access• Lack of feeding protocols (<60% protein delivered)• GIT complications McClave SA, Crit Care Med 1999

Drover JW, JPEN 2010

Peev MP, JPEN 2015

Background

Prevalence of GI Symptoms

Background

ENTERAL NUTRITION (EN)

Remains the preferred route of feeding in ICU’s

Dhaliwal R: Canadian Crit Care Nutr guidelines, Nutr Clin Prac 2014

Kreymann KG: ESPEN guidelines on EN, Clin Nutr 2016

McClave SA, JPEN 2016

Reintam Blaser A: ESICM clin prac guidelines 2017

Background

? ? ?HOW DO WE OVERCOME THESE

BARRIERS TO ADEQUATE DELIVERY OF EN

Background

USE OF ANEN FEEDINGPROTOCOL/S

Background

WHY EN FEEDING PROTOCOLS?

PERMIT MORE TIMELY AND COMPLETE NUTRITION

J Krenitsky-Prac Gastro, Aug 2018

Comparision

VOLUME BASED RATE BASED

VS

Definition

RATE BASED FEEDING (RBF)

McClaveSA, Crit Care Med 2014;42(12):2600-2610.McClaveSA, Nutr Clin Pract 2009;24:305-315.

–Traditional method of feeding–Consistently associated with failure to meet goals

–Low start and slow titration–Fixed rate

Definition

VOLUME BASED FEEDING (VBF)

–Establishes a 24 hour tube feeding goal volume

–Uses a nurse-driven algorithm to increase the EN infusion rate after interruptions (Max: 150ml/hr)

S Roberts-JPEN, March 2019;43(3):365-375M Bharal-J of Int. Care Soc, 2019

VBEN algorithm

S Roberts-JPEN, March 2019;43(3):365-375

EXAMPLE OF VBF:

–Total 24 hour volume: 1800 ml(starting rate of 75 ml/hr)

–Patient fed 450 ml in 6 hours–EN put on hold for 5 hours

•New feeding goal: 1800-450=1350 ml•Time remaining: 24-6-5=13 hrs•Use the chart to locate new rate of 104 mL/hr

(1350/13)

https://criticalcarenutrition.com/pepup/study-tools

Volume left to be fed

Number of hours remaining

Max Rate – 150 ml/hr

Protocol Implementation:

Interdisciplinary roles–Physician–Dietitian–Nursing–Pharmacy

h

Protocol Implementation:

Education• In-services for all disciplines, pocket cards email

notification, FAQ binder, bedside VBF schedule, practice scenarios, bedside competencies

• May consider: posters, daily checklists, self-learning module

h

Heyland et al. Critical Care 2010, 14:R78http://ccforum.com/content/14/2/R78

Criticalcarenutrition.com, May 2014

GASTRIC FEEDING FLOWCHART

Criticalcarenutrition.com, May 2014

Main features of PEPuP Protocol

1. Three feeding options:• Volume-Based Feeds: Stable patients start EN at goal rate • Trophic Feeds: Unstable patients start at 10 mL/hour, re-assess daily• NPO: Re-assess daily 2. Volume-based feeding: target a 24-hour volume vs. traditional hourly volume

goal rate3. Nurse driven: adjust hourly rate to make up the 24-hour volume4. Semi-elemental/peptide-based 100% whey formula: start and progress to

polymeric5. Whey protein modular supplements (if required) and motility agents 6. Gastric residual volumes: tolerating higher thresholds (300ml)

Critical Care Nutrition, March 2016

PEPuP Protocol

Heyland DK, JPEN 39(6);Aug 2015:698-706

Study design

• Multicentre Study• 2013, 24 ICU’s from Canada• Participated in the International Nutrition

Survey (INS)• 8 ICU’s – PEPuP and 16 ICU’s – Control sites• Nutrition practices and outcomes compared


Data Collection

• Critically Ill patients, mechanically ventilated• At least a 72 hour ICU stay• Daily nutrition data – Max 12 days• Patient outcomes (60-days)

* ICU and hospital discharge* Duration of mechanical ventilation* Mortality


Data Collection


Results


Overall, 25 % of patients in both groupsdied by day 60 Median LOS in ICU and hospital was 11 days and 26.9 days respectivelyNO difference between groups

Results


Results


ENERGYPEPuP – 60.1%

vsControl – 49.9%

PROTEINPEPuP – 61%

vsControl – 49.7%

Results


PROTEINPEPuP

>80% by DAY 3

Conclusion

PEPuP Protocol

• Significant improvements in nutrition practices and nutrition outcomes

• NO difference in Patient OutcomesHeyland DK, JPEN 39(6);Aug 2015:698-706

A.S.P.E.N. Guidelines 2016: –“Based on expert consensus, we suggest that use of a volume-based feeding protocol or a top-down multi-strategy protocol be considered.”

Journal of Parenteral and Enteral Nutrition 40.2 (2016): 159-211

Literature

NutrClinPract. 2014 Oct;29(5):639-48JPEN J ParenterEnteral Nutr. 2015;39:707-712Critical Care Medicine: 2013 Dec; 41(12):2743–2753Haskins IN, J ParenterEnteral Nutr. 2015J Acad Nutr Diet. 2012 July;112(7):1073–1079Journal of Parenteral and Enteral Nutrition 40.2 (2016): 159-211

FEED ME vs PEPuP

B Taylor, Nutr in Clin Prac, Oct 2014;29(5):639-648

Results


CALORIESFEED ME – 89%

vsRATE based – 63%

P<.0001

Results


PROTEIN (g/kg)FEED ME – 1.26

vsRATE based – 1.13

P.36

Results


Trend towards a longer LOS in

FEED ME15 vs 12.2 days

P.053

Literature

S Roberts, JPEN March 2019;43(3):365-575

Study design

• Restrospective Study• Mechanically ventilated within 48 hrs• ICU stay ≥ 72 hrs• VBEN vs RBEN• EN-related and Glucose control outcomes


Study design

BLOOD GLUCOSE

• Hyperglycaemia defined as BG >180 mg/dLbased on the first morning BG level


Data Collection


Results


ENERGYVBEN – 79.6%

vsRBEN – 67.6%

P<.001

PROTEINVBEN – 79.3%

vsRBEN – 68.6%

P<.001

Results


HYPERGLYCAEMIANo difference

between 2 groupsP = .27

Literature

J Krenitsky, MS, RD-Practical Gastroenterology, Aug 2018

Literature

J Krenitsky, MS, RD-Practical Gastroenterology, Aug 2018

Exceeded Energyrequire-

ments at 30 kcal/kg in a large

obese

cohort

Literature

? ? ?NO IMPROVEMENT IN PATIENT

OUTCOMES WITH VBENDESPITE

IMPROVED EN DELIVERY

Background

ICU SURVIVORS

• Recent randomized trials demonstrate:-providing increased calories alone to ICU patientsmay not improve outcomes

• However, observational studies report that optimizing daily protein intake decreases infections, mechanical ventilationduration, time to discharge and mortality

Arabi YM, N Engl J Med 2015;372:398-408

Heyland DK, Nutrients 2018;10:462

Prieser J-C, Crit Care 2018;22:261


Literature

Literature

PERFECT FEEDING PROTOCOL

Brierley-Hobson et al. Crit Care 2019 23:105

VBF Group

Volume ↑ 11.2% (p ≤ 0.001)

Energy ↑ 13.4%(p ≤ 0.001)

Protein ↑8.4%(p ≤ 0.02)

Literature

PERFECT FEEDING PROTOCOL


VBF Group

↑ extubation rate with > 90% protein requirements met

compared to < 80 %

NOMORTALITYDIFFERENCE

Literature

OPTIMAL TIMING ???

• High protein intakes during the early phase of critical illness has been associated with detrimental effects

-? Increased production of glucagon -? Increased oxidation of amino acids-? Inhibition of AUTOPHAGY

Casaer MP, EPaNIC trial:a post hoc analysis Am J respir Cit Care Med 2013;187:247-55

Thiessen SE, Am J Respir Crit Care Med 2017; 196:1131-43

Wischmeyer PE, TOP-UP pilot trial Crit Care 2017;21:142

Patients at LOW

NUTRITIONAL RISK

Literature

Literature

OPTIMAL TIMING and DOSE???

• Several RCT’s however have demonstrated the safety of high-dose protein application, even in the early phase of critical illness in HIGH-RISK patients with prolongedICU stay

• More RCT’s are however needed to determine the optimal protein DOSE

Casaer MP, EPaNIC trial:a post hoc analysis Am J respir Cit Care Med 2013;187:247-55

Thiessen SE, Am J Respir Crit Care Med 2017; 196:1131-43

Wischmeyer PE, TOP-UP pilot trial Crit Care 2017;21:142

FUTURE Literature

EFFORT Trial

• Randomized • HIGH RISK patients

• Protein ≤ 1.2 g/kg/d OR ≥ 2.2 g/kg/d• VBF strategies• EN or PN protein supplemention


Literature

Literature

Singer et al, ClinNutr2018

NUTRITION AND STRESS RESPONSE

Literature

Berger et al, ClinNutr2018; Singer et al, ClinNutr2018Sourced from R Blaauw: Consensus Guidelines, CNE 2019

NUTRITION AND STRESS RESPONSE

Late phase/ Post-acute phase(>7 days)• Rehabilitation and restoring

of losses =anabolismPICS (> 14 days)• Chronic critically ill• Decrease lean body massFeeding:• 25 30 kcal/kg• Monitor and increase as

needed

Late acute phase• Stabilization of metabolic

disturbances• Increased muscle wastingFeeding:• 80-100% EE• 20-25 kcal/kg

Literature

WHAT ABOUT REEFEEDING?

Literature

Criteria for Refeeding Hypophosphatemia:▪Serum PO4< 0.65 mmol/L OR▪Serum PO4drop > 0.16 mmol/L

Incidence in ICU is common 37-52%

WHAT ABOUT REEFEEDING?

Fuentes et al, 2016Olthof et al, 2017Ralib & Mat Nor, 2018

Comparision

VOLUME BASED RATE BASED

VS

SUMMARY

VOLUME BASED RATE BASE

VS• Increased delivery of nutrition• Flexibility in protocol

design - ??protein supplementation• Nursing driven• Considerations for glucose control• May not be appropriate for all

patient populations• Extensive training necessary to

implement

• Historical use• Familiarity• Less nursing intensive• Easier glucose management• Consistently does not

meet minimum nutritiongoals

• Usually is slower to start and titrate

THANK YOU!

1. How to achieve nutrition goals by actual nutrition guidelines, Stoppe et al. Crit Care 2019;23:216

2. Full Force Enteral Nutrition: A New Hope, or the Dark Side? A Critical look at Enhanced Enteral Feeding protocols, J Krenitsky, Practical gastroenterology Aug 2018

3. 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 QualityImprovement Review, Taylor B et al. Nutr. in Clin Prac Oct 2014;29:639-648

4. Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adultsusing the ‘Protein & Energy Requirements Fed for Every Critically ill patient every Time(PERFECT) protocol: a before-and-after study, Brierley-Hobson et al. Crit Care 2019;23:105

5. Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on NutritionDelivery and Glycemic Control, S Roberts et al. JPEN Mar 2019;43:3 365-375

6. Implementing the PEP uP Protocol in Critical Care Units in Canada: Results of a Multicenter,Quality Improvement Study, DK Helyland et al. JPEN Aug 2015;39:6 698-706

7. Enhanced protein-energy provision via the enteral route in critically ill patients: a single centerfeasibility trail of the PEP uP protocol, DK Heyland et al. Crit Care 2010

8. Volume based feeding versus rate based feeding in the critically ill: A UK study,M Bharal et al. J of Int. Care Society 2019

9. Volume- vs. rate-based tube feeding in burn patients: A Case-control study. C Sheckter et al.

Burns Open 2 (2018) 165-170

References

Volume-based vs Rate-based feeding - saspen

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