Journal Article Assignment:

Rate-Based vs. Volume-Based Feedings for EN Delivery in the ICU

Environment

Rob Fancher
NUTR 4630 Adv. Medical Nutrition Therapy
Section: HA
Prof. Emily LaRose
4/18/16

Introduction
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Malnutrition among critically ill patients in the ICU is a serious concern and a challenge

to overcome. It is linked with a greater risk of complications and poor clinical outcomes during

hospitalization, and is frequently exacerbated by malnourishment at baseline of hospital

admission (1). Specifically, patients with a caloric deficit are at greater risk for infections, a

longer hospital stay, and prolonged time on ventilation. Conversely, high-quality nutrition

provided at an adequate level of at least 80% of prescribed calories can positively influence

clinically relevant outcomes. For example, patients who are sufficiently fed will experience faster

wound healing, a smaller incidence of nosocomial infections, and less time on mechanical

ventilation (2,3). In fact, critically ill patients with severe disease are more notable for gaining an

appreciable benefit from increased enteral nutrition (EN) than those who are not critically ill (3).

Despite this, critically ill patients are routinely underfed, only receiving between 50%-

80% of prescribed calories on average. One reason for this inadequate nutrient delivery is the

periodic cessation of EN infusions throughout the day to allow for surgical procedures,

diagnostic tests, and other events. Per the traditional, rate-based method of EN delivery, a goal

daily volume is calculated along with a fixed flow rate that delivers such a volume over 24 hours

(1). Interruptions such as intubations, surgical procedures, body imaging studies, or high gastric

residual volumes would conclude with a recommencement of the original fixed target rate,

thereby giving rise to an accumulating caloric deficit (1,2).

Although feeding protocols are implemented with intentions to alleviate this problem,

many do not address feeding interruptions and the large caloric debt to which they contribute.

Volume-based feeding (VBF) has been recently proposed as a method in which feeding loss

due to interruptions is compensated for via adjustment of the hourly EN infusion rate based on

hours remaining in the day, and the original target volume. Ideally, the calorie and protein deficit

is minimized; the patient receives the entire volume of prescribed nutrition, and has better

clinical outcomes thanks to optimal nutritive status. VBF has been demonstrated to result in

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significantly more energy delivered to critically ill patients compared to rate-based feeding (RBF)

(2). However, it is yet to be determined whether VBF will appreciably affect clinical outcomes.

Because VBF is considered more aggressive, it is linked with concerns of refeeding

syndrome. Overfeeding may itself contribute to increased incidence of infection, liver

dysfunction, and prolonged ventilator time. To prevent overfeeding, high-risk patients should be

identified before commencement of VBF, supplemented with vitamins, and monitored for

electrolytes and fluid balance at regular intervals (2).

Discussion and Presentation of Research

The evaluated literature by Haskins, et al. describes a prospective, unblinded, single-

center cohort study that compared the volume-based and rate-based methods relative to their

efficacy in delivering prescribed calories and influence on various clinical outcomes. 77 patients

were included in the study, where 38 patients received RBF and 39 received VBF. Eligible

patients were 18 years of age or older and had received continuous EN for at least 24 hours at

any time during ICU stay. Exclusion criteria were as follows: age younger than 18, lack of ICU

admission, and any incidence of parenteral nutrition. There were no significant differences in

stated baseline characteristics. The primary endpoints included percent of goal calories

delivered, total number of ventilator days, lengths of ICU and hospital stay, and mortality. The

secondary endpoint reflected the rates of nosocomial infections, such as urinary tract infections

and ventilator-associated pneumonia (4).

Results indicated significant difference in regard to the primary endpoint of percent

calories delivered, in favor of the VBF group (74% vs 57%, P<.001). However, there was no

difference in the overall hospital length of stay (LOS) or mortality. While ICU LOS and days on

ventilation were significantly longer in the VBF group, this difference disappeared after

controlling for the admission APACHE II score. Similarly, there was no significant difference in

rates of infection among the two groups. Based on these findings, the authors conclude that

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although a VB protocol is superior to an RB protocol in boosting prescribed nutrition delivery, it

may not influence clinical outcomes as hoped (4).

Several shortcomings exist in this study. The small number of enrolled patients and

single-center setting limit the generalizability of results to other hospitals or more diverse patient

populations. Furthermore, the baseline demographics did not speak to co-morbid conditions,

such as diabetes mellitus, which may have influenced patient-specific EN. Although the two

groups appeared to be well-matched, a randomized, clinical trial-like approach might lead to

clarified and more reproducible results. Finally, the enteral formulas were in all cases chosen at

the discretion of the dietitians and thus were not standardized, resulting in differing amounts of

protein and fatty acids taken in by patients, which may have affected clinical outcomes. Haskins

and colleagues also did not include any charts or other tangible examples of how the adjusted

flow rates were calculated (4).

The literature by McClave, et al. discusses a prospective, single-center, randomized

study that compared caloric delivery between VBF and RBF in critically ill patients on a

ventilator. 63 patients were originally enrolled in the study; after 6 patients were excluded due to

early extubation, 37 received VBF and 20 received RBF. Eligible patients were 18 years of age

or older, admitted to the ICU, and were anticipated to require EN for 3 or more days. Exclusion

criteria were as follows: pregnancy, contraindication to EN, failure to obtain consent, and any

parenteral nutrition therapy. There were no significant differences between baseline

characteristics, which included co-morbid conditions and reasons for ICU admit. The primary

endpoint was the percent of goal calories delivered, and the total caloric balance, defined as

total calories delivered subtracted from prescribed goal calories. As in the Haskins study, the

maximum rate to which the infusion could be adjusted, to protect from overfeeding

complications, was 150mL/hr for small bowel feeding, and 280mL/hr for gastric feeding. Any

feeding intolerances, such as vomiting, cramping, pulmonary aspiration, or a GRV of >400ml

were noted and monitored (5).

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Results indicated a significantly greater amount of EN received by the VBF group

(92.9% vs. 80.9%, P=.01) as an average over the cumulative 280 infusion days, also evidenced

by the total caloric balance (-776.0 kcal vs. -1933.8 kcal, P=.01).This significant difference

persisted during days when infusion was interrupted (n=50) by a procedure or other event

(77.6% vs. 61.5%, P=.001), also seen in the total caloric balance (-1182.6 kcal vs. -2590.8 kcal,

P<.05). No evidence of feeding intolerance was noted in any participant, and the statistically

greater volume of EN in the VBF group was achieved despite frequent non-compliance to the

novel protocol from nursing staff (5).

This study has several shortcomings. Firstly, similar to the study by Haskins, the small

number of patients and single-center location may underpower the study and make it less

applicable to a wider public. Furthermore, this study would have benefited from attention to

clinically relevant measures such as lengths of stay in the ICU and hospital, time on the

ventilator, or presence of nosocomial infections. Finally, although the results were in favor of

VBF regardless, bias may have been introduced due to the varying and non-standardized EN

deliveries done by the nurses to each VBF patient. Although some nurses were eager to learn

the new program, others demonstrated resistance towards having to take responsibility for

continually managing and adjusting flow rates. Standardizing and implementing a totally novel

VBF protocol would surely come with some challenges in the workplace (5).

Conclusion

Both studies are clear in describing the statistically significant dominance of a volume-

based protocol over a rate-based protocol in terms of the amount of calories delivered to the

ICU patient (4,5). Although the performed mechanisms for doing so were clearly not ideal (or

else the infused calories would be closer to providing 80% of est. energy needs) and need

fine-tuning, it is certainly anticipated that re-calculating a goal rate to adjust for missed feeding

time would add to total calories delivered. It is also doubtful that infused calories could ever be

at 100% of goal, considering that maximum flow rates must be honored for patient protection.

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This conclusion speaks to suspected correlations that the higher the percentage of

prescribed calories given to a patient, the better clinical outcomes they will experience. The

agreed-upon target from several sources is 80% (1-3), which both studies approached with VBF,

but did not reach fully. This goal can be reached with uninterrupted feeding, and VBF can clearly

aid in achieving that goal in a situation with one or more interruptions.

The Haskins study did demonstrate no significant difference between clinical outcomes

in VBF and RBF protocols, suggesting that it may be a waste to try to implement such a new

and different technique that would certainly take time to adapt to. However, this was a small,

non-randomized study that suffered from confounding variables and non-standardized methods.

It was also one of the first to investigate the effect of VBF on clinical outcomes. It would be

valuable to repeat it on a larger and more consistent scale in order to get a true sense of how

VBF may influence factors such as infectious complications and length of stay in ICU and

hospital. Regardless, the impact on caloric delivery was undeniable.

Clearly, VBF is a highly promising protocol that, while having not demonstrated improved

clinical outcomes on its own, can certainly boost the nutritional status of a critically ill patient to

target energy needs, which has been demonstrated by background evidence to improve

outcomes. While the theoretical concern of refeeding syndrome exists due to the aggressive

and proactive nature of VBF, it can be diminished by following proper procedures and adhering

to maximum flow rates. In the studies cited, feeding tolerance was either stated to not be a

problem, or was not mentioned at all. Further studies with a larger sample size and more

standardized methods of EN delivery under a VB protocol are definitely necessary to fully

understand its influence on specific clinical outcomes. However, until then, to optimize outcomes

for critically ill ICU patients, it is recommended to proceed with the VBF method after a

standardized system is in place, and is successfully taught to those delivering EN.

Reference List

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1. Peev MP, Yeh DD, Quaishi SA, Osler P, Chang Y, Gillis E, Albano CE, Darak S,
Velmahos GC. Causes and consequences of interrupted enteral nutrition: a prospective
observational study in critically ill surgical patients. ASPEN. 2015:39(1): 21-27. doi:
10.1177/0148607114526887

2. Lee ZY, Barakatun-Nisak MY, Airini IN, Heyland DK. Enhanced protein-energy provision
via the enteral route in critically ill patients (PEP uP Protocol): a review of evidence.
ASPEN. 2016;31(1):68-69. doi: 10.1177/0884533615601638

3. Heyland DK, Stephens KE, Day AG, McClave SA. The success of enteral nutrition and
ICU-acquired infections: a multicenter observational study. Clinical Nutrition. 2011:30:
148-155.
https://0-www.clinicalkey.com.helin.uri.edu/service/content/pdf/watermarked/1-s2.0-
S0261561410001846.pdf?locale=en_US. Accessed April 4, 2016.

4. Haskins IN, Baginski M, Gamsky N, Sedghi K, Yi S, Amdur RL, Gergely M, Sarani B. A

volume-based enteral nutrition support regimen improves caloric delivery but may not
affect clinical outcomes in critically ill patients. ASPEN. 2015: 1-5. doi:
10.1177/0148607115617441

5. SA, Saad MA, Esterle M, Anderson M, Jotautas AE, Franklin GA, Heyland DK, Hurt RT.
Volume-based feeding in the critically ill patient. ASPEN. 2015:39(6): 707-712. doi:
10.1177/0148607114540004