170 Original article

Comparison between the effects of two enteral nutrition support

algorithms on nutrition care outcome in critically ill adult
patients
Ahmed M. Mohamed, Samia A. El- Wakel, Amani A. Aly, Nahla M. Amin
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Department of Anesthesia and Surgical Background

Intensive Care, Zagazig University Hospitals, The use of enteral nutrition (EN) algorithm optimizes nutrition by increasing the intake of
Zagazig, Egypt
calories in critically ill patients, but it does not compensate for loss of feeding time due to
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023

Correspondence to Ahmed Mosallem
Mohammed, PhD, Department of Anesthesia
and Surgical Intensive Care, Zagazig University
Hospitals, Zagazig, Egypt.
Tel: + 20 114 098 9692;
e-mail: mesoayad@yahoo.com
Received 19 November 2016
Accepted 23 March 2017
Research and Opinion in Anesthesia &
Intensive Care 2018, 5:170–177
frequent interruptions as during fasting for operation or investigation.Aims were to
compare implementation of enteral feeding support algorithm based on the SCCM/A.S.
P.E.N guidelines and modifications to this algorithm (using a protocol that shifted from an
hourly rate target goal to a twenty four hour volume goal).
Settings and Design
Case control study in the surgical ICU of zagazig university hospital.
Methods and Material
Patients of group1 were given caloric requirements as five bolus meals, patients of
group 2 were given Fresubin by continuous infusion with hourly rate target goal and
in Group 3 there was a Shift from hourly rate target goal to 24 hour volume goal and
metoclopramide 10 mg I.V. q. 6 hours with the start of EN.
Results
There were statistically significant differences between groups regarding adequacy
of caloric intake in 2nd, 3rd days and the overall adequacy of calories in all four
days, where Group 2 provided more EN adequacy than Group 1 (P=0.02, 0.001,
0.01) respectively, and Group 3 provided more calories adequacy than Group1in
3rd day and overall adequacy (P=0.008 and 0.007) respectively. Also Patients in
Group 2and 3 started accommodating EN earlier and had less episodes of vomiting
than patients in group 1, (P value=0.043 and0.003 respectively).
Conclusion
The use of EN protocol provides more adequacy of calories and proteins from EN in
comparison to bolus meals.

Keywords:
enteral nutrition algorithm, nutrition outcome
Research and Opinion in Anesthesia & Intensive Care 5:170–177
© 2018 Research and Opinion in Anesthesia & Intensive Care
2356-9115

by the Society of Critical Care Medicine (SCCM) (the

Introduction
provision and assessment of nutrient support therapy in
Nutrition of critically ill patients is an essential
adult critically ill patients) and the American Society of
component of their treatment [1]. An understanding
Parentral and Enteral Nutrition (ASPEN) [7].
of nutrient requirements and its technique of delivery
has made the increased survival of critically ill patients
These algorithms do not compensate for frequent
possible [2].
interruptions that lead to loss of feeding time,
although they use conservative reactionary
Enteral nutrient (EN) support modality is preferred
approaches to optimize nutrient. In addition,
over parenteral nutrient for all patients requiring
motility agents are only initiated after development
nutritional support [3] as it is more physiologic, less
of manifestations of delayed gastric emptying [6].
expensive, and less likely to be associated with
hepatobiliary dysfunction [4].
Because of complexity of the care of critically ill
patients, it is difficult to avoid interruptions of
Nutritional support in critically ill or trauma patients
continuous EN, but this may be mitigated somewhat
had many published clinical practice guidelines [5].
by developing EN protocols aimed at this [5].
Protocols of EN are tools designed to enable the
bedside nurse to initiate, modify, and monitor the
administration of EN [6]. This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
Two important guidelines on implementation of non-commercially, as long as appropriate credit is given and the new
nutrient support for the critically ill were published creations are licensed under the identical terms.

© 2018 Research and Opinion in Anesthesia & Intensive Care | Published by Wolters Kluwer - Medknow DOI: 10.4103/roaic.roaic_71_16

Compensation for interruptions of continuous EN was
discussed by Heyland et al. [6], as they developed EN
protocol that shifted from an hourly rate target to a 24 h
volume target.
Benefits from nutritional support therapy were
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
maximized by implementation of nutrition support
guidelines and protocols that also minimized
complications associated with EN [8].
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023
The aim of this study was to compare between our
current practice of EN (bolus meals), implementation
of EN support algorithm based on the SCCM/ASPEN
guidelines, and modifications to this algorithm (using a
protocol that shifted from an hourly rate target goal to a
24 h volume goal) regarding the time of nutrition support
initiation, adequacy of calories, and protein received
from EN during the first four ICU days from the
beginning of EN. We also assessed gastrointestinal
tract intolerance (i.e. vomiting) in each practice.
Patients and methods
After obtaining approval from Institutional Review
Board and written informed consent from the
patient or his relatives (if the patients is unable to
give a consent), this study was conducted on adult
patients above 18 years old of both sexes who were
admitted to the surgical ICU Zagazig University
Hospital from March 2013 until March 2015 and
required ventilatory support, where EN was given
within the first 24 h of admission by either bolus or
infusion protocol.
Exclusion criteria included patients with end-stage
renal failure, hepatic failure, and bronchogenic
carcinoma, brain-dead patients, morbidly obese
patients, ventilator-dependent patients, patients
transferred from other hospitals or healthcare
facility, and patients with contraindication to EN.
Study technique
For all patients the target caloric requirements was
calculated as 25–30 kcal/kg/day, protein requirement
was 1.4 g/kg/day, and EN support started within 24 h
after admission to ICU, using Fresubin (Fresubin Kabi
Ltd., UK) − an unflavored liquid consisting of protein
(milk and soy), fat (soy, medium chain triglycerides,
linseed, sunflower, and fish oils), carbohydrate
(maltodextrin), vitamins, minerals, and trace elements.
A volume of 1500 ml of Fresubin original provides
1500 kcal and 57 g of protein and meets the average
adult recommended daily requirements for vitamins,
minerals, and trace elements.
Enteral nutrition support algorithms Mohamed et al. 171
Enrolled patients were randomly allocated to one of
three groups using a computer-generated table of
random numbers, and the results were placed in
sealed envelopes:
(1) Group 1 (control group): there was no standard
regimen for using antiemetics or prokinetics.
Patients of this group received caloric
requirements in five meal boluses at 4 h intervals,
with gastrointestinal tract rest from 12 to 8 a.m.
(2) Group 2: we used a nutritional support algorithm
based on SCCM/ASPEN guidelines [7]. Enteral
tube feeds started within 24 h of ICU admission at
a rate of 10 ml/h, and then increased by 10 ml/h
every 4 h in the absence of significant gastric
residuals (i.e. >250 ml over 4 h period) until the
target tube feeding rate was reached in each patient
(Figure 1).
(3) Group 3: we used the method described by
Heyland et al. [6], in which there were only two
differences from group 2:
(a) Shift from hourly rate target goal to a 24-h
volume goal (in which nurses can increase the
hourly rate depending on how many hours they
have left in the day to ensure that the patient
received the 24-h volume within the day).
Nurses were given instructions on how to
set the hourly rate based on the 24-h volume
prescribed; e.g. if the total goal for the day
was 2000 ml of a nutritional solution to
meet their caloric requirement, then the
hourly rate would be 83.3 ml/h. If feeds
were held for several hours while the
patient underwent surgery, and now there
are 10 h left in the day and the patient has
only received 700 ml, the new rate would be
(1300 ml/10 h) 130 ml/h for the remaining
10 h. Beginning the next day, the target
would shift back to 83.3 ml/h. We put a
limit of a maximum of 150 ml/h.
(b) To start motility agent (metoclopramide
10 mg intravenous every 6 h) at the same
time EN is started.
Data collection
The following data were collected:
(1) Age, sex, weight, height, Acute Physiology and
Chronic Health Evaluation II score, and primary
admission diagnosis were recorded for the three
groups.
(2) The timing of nutrition support initiation (which
was calculated from ICU admission to time of
initiation of nutrition support therapy).
 172 Research and Opinion in Anesthesia & Intensive Care, Vol. 5 No. 3, July-September 2018

(3) Adequacy of calories and protein (the total
amount of energy or protein received from EN
is divided by the amount prescribed and expressed
as %) over the first four ICU days from the
beginning of EN.
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
from the beginning of EN, the timing of nutrition
support initiation, to determine incidence of vomiting,
and ventilator-associated pneumonia and mortality and
length of ICU and hospital stay.
According to a previous study (in which the percentage

In addition, we determined whether episodes of of protein delivered of target at the fourth day in bolus
vomiting and ventilator-associated pneumonia had meals group was 21.5% and continuous infusion groups
occurred, and determined the incidence of mortality was 54.7%), using power of 80 and 95% confidence
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023

and length of ICU and hospital stay.
Our primary outcome was adequacy of protein over the
first 4 ICU days from the beginning of EN. Our
secondary outcomes were adequacy of calories and
protein received from EN over the first 4 ICU days
interval, the sample size of our study was 84 (28 in each
group) [9].
Data were collected and analyzed by using statistical
package for the social sciences, version 20 (SPSS; SPSS
Inc., Chicago, Illinois, USA). Data were expressed as

Figure 1

The nutrition support algorithm for enteral nutrition support in group 2 based on Society of Critical Care Medicine/American Society of Parentral
and Enteral Nutrition guidelines [7]. RV, residual volume; TF, tube feeding.

Table 1 Comparison of demographic data and admission Acute Physiology and Chronic Health Evaluation II score of the three
groups
Variables Group I (n=28) Group II (n=28) Group III (n=28) P
Age (years) 37.79±16.68 37.36±17.74 44.43±16.7 0.17
Sex
Male 12 (42.9) 18 (64.3) 13 (46.4) 0.23
Female 16 (57.1) 10 (35.7) 15 (53.6)
Weight (kg) 76.25±8.46 76.43±8.03 75.71±7.29 0.94
Height (cm) 169.82±8.44 173.93±11.73 171.79±10.20 0.33
BMI (kg/m2) 26.62±3.78 25.72±5.3 25.99±4.42 0.75
APACHE II score 25.82±2.72 24.21±2.88 23.82±2.32 0. 14
Values are presented as mean±SD or number (percentage). APACHE II score, Acute Physiology and Chronic Health Evaluation II score.
 Enteral nutrition support algorithms Mohamed et al. 173

median, mean±SD for quantitative variable, number
and percentage for qualitative one, and χ 2-test and
analysis of variance were used when appropriate. P less
than 0.05 was considered significant.
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Chronic Health Evaluation II score at admission, there
were no statistically significant differences between the
three groups (P>0.05) (Table 1).
Table 2 shows that there was no statistically significant
difference among the three studied groups as regards

Results admission diagnosis of patients (P>0.05).

This study was performed on 84 patients who were
randomly allocated into three groups, each comprising Table 3 shows that there was a statistically significant
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023

28 patients. Regarding demographic data (age, sex, difference between three groups as regards adequacy of
weight, height, and BMI) and Acute Physiology and EN on second and third days and the overall adequacy
Table 2 Comparison of admission diagnosis of patients among the three groups
Diagnosis Group I (n=28) Group II (n=28) Group III (n=28) Total P value
Polytrauma 11 (40) 12 (43) 10 (36) 33 0.839
Head trauma 12 (43) 9 (32) 10 (36) 31
Respiratory 3 (11) 4 (15) 2 (7) 9
Vascular 1 (3) 0 (0) 2 (7) 3
Postoperative 1 (3) 2 (7) 2 (7) 5
Others 0 (0) 1 (3) 2 (7) 3
Total 28 28 28 84
Values are presented as number (percentage).

Table 3 Comparison of the calorie intake in 4 days among the three groups
Variables Group I (n=28) Group II (n=28) Group III (n=28) K P LSD
Adequacy first day 43.03±23.4 48.05±27.42 45.22±23.93 0.28 0.87 (NS) –
Adequacy second day 57.87±38.88 68.6±27.9 78.7±29.24 6.68 0.04* 0.02 (P1)* 0.22 (P2) 0.24 (P3)
Adequacy third day 60.37±39.76 81.6±24.11 86.53±20.66 9.45 0.009** 0.001 (P1)* 0.008 (P2)* 0.53 (P3)
Adequacy fourth day 74.09±30.68 86.35±19.71 88.89±15.24 4.99 0.08 (NS) –
Two-way F 12.67 38.08 65.52
P 0.005** <0.001** <0.001**
Overall adequacy 59.06±19.20 75.17±11.61 73.12±15.27 4.00 0.027** 0.01 (P1)* 0.007 (P2)* 0.233
Values are presented as mean±SD. P1, group I versus group II; P2, group I versus group III; P3, group II versus group III. *Significant.
**Highly significant.

Table 4 Comparison of adequacy of the protein intake in 4 days among the three groups
Adequacy of protein intake Mean±SD F-test P value LSD
First day
Group I 35.15±20.71 0.13 0.878
Group II 39.31±22.61
Group III 37.63±19.68
Second day
Group I 37.22±22.39 7.78 0.001 0.091 (P1) 0.001 (P2)* 0.018 (P3)*
Group II 50.71±16.61
Group III 66.78±15.72
Third day
Group I 38.76±25.67 8.38 0.001 0.043 (P1)* 0.0009 (P2)* 0.029 (P3)*
Group II 56.87±17.57
Group III 72.65±16.94
Fourth day
Group I 59.16±26.46 1.65 0.206
Group II 70.31±16.35
Group III 72.34±12.96
Total intake in the 4 days
Group I 42.56±20.14 4.55 0.017 0.087 (P1) 0.011 (P2)* 0.155 (P3)
Group II 54.29±13.2
Group III 62.35±14.8
Values are presented as mean±SD. P1, group I versus group II; P2, group I versus group III; P3, group II versus group III. *Significant.
 174 Research and Opinion in Anesthesia & Intensive Care, Vol. 5 No. 3, July-September 2018

of EN on all 4 days; however, there was no statistically
significant difference between three groups as regards
adequacy of EN on first and fourth days, where group 2
provided more EN adequacy than group 1 (P=0.02,
0.001, 0.01), respectively, and group 3 provided more
EN adequacy than group 1 on the third day and overall
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
and 0.011), respectively; in addition, group 3
provided more protein intake adequacy than group 2
on third and fourth days (P=0.018 and 0.029),
respectively.
Table 5 shows that there was a statistically significant

adequacy (P=0.008 and 0.007), respectively. difference between three groups as regards the time of
EN initiation. Patients in groups 2 and 3 started
Table 4 shows that there was a statistically significant accommodated EN earlier than patients in group 1
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023

difference between three groups as regards (P=0.043).

adequacy of protein intake on second and third days
and the overall adequacy of protein intake in all 4 days;
however, there was no statistically significant difference
between three groups as regards adequacy of protein
intake on first and fourth days, where group 2 provided
more protein intake adequacy than group 1 on the third
day (P=0.043) and group 3 provided more protein
intake adequacy than group 1 on the third and
fourth days and overall adequacy (P=0.001, 0.0009
Table 6 shows that there was a statistically significant
difference between the three groups as regards
episodes of vomiting. Patients in groups 2 and 3
showed less episodes of vomiting than those in
group 1 (P=0.003).
Table 7 shows that there was no statistically
significant difference between three groups as

Table 5 Comparison of the time of enteral nutrition initiation among the three groups
Timing of EN initiation by hours Group I (n=28) Group II (n=28) Group III (n=28) K P
12 to <24 7 12 12 12.969 0.043*
24 to <36 7 10 7
36 to <48 2 4 5
>48 12 2 4
Values are presented as numbers.

Table 6 Comparison of episodes of vomiting of the three groups

Variable Group I (n=28) Group II (n=28) Group III (n=28) χ2 P
Vomiting
No 9 (32.1) 14 (50) 16 (57.1) 19.7 0.003**
Mild 3 (10.7) 10 (35.7) 5 (17.9)
Moderate 11 (39.3) 4 (14.3) 7 (25)
Sever 5 (17.9) 0 (0) 0 (0)
Values are presented as number (percentage).

Table 7 Comparison of the incidence of mortality and incidence of pneumonia among the three groups
Group I (n=28) Group II (n=28) Group III (n=28) χ2 P value
Incidence of Mortality 8 (28) 7 (25) 5 (18) 0.919 0.631
Incidence of pneumonia 10 (36) 7 (25) 8 (28) 0.797 0.671
Values are presented as number (percentage).

Table 8 Comparison of length of hospital stay and ICU stay among the three groups
Range (days) Mean±SD F-test P value
Length of hospital stay (days)
Group I 11–19 15.14±2.69 1.65 0.198
Group II 12–17 14.35±1.7
Group III 10–19 13.96±0.32
Length of ICU stay (days)
Group I 7–12 9.3571±1.7043 1.56 0.216
Group II 8–12 9.8929±1.4231
Group III 8–10 9.3214±0.7724
Values are presented as range and mean±SD.

regards incidence of mortality and pneumonia
(P>0.05).
Table 8 shows that there were no statistically
significant differences between three groups as
regards length of hospital stay and length of ICU
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
stay (P>0.05).
Discussion
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023
This study found that the use of EN protocol based on
SCCM/ASPEN guidelines resulted in the earlier
accommodation of EN, and in providing patients
more adequacy of their total needs of calories and
proteins from EN in comparison with bolus meals.
Twenty-four-hour volume target goal of EN had better
overall adequacy of EN and proteins of 4 days through
compensation for periods of fasting (for operation or
investigation) by increasing the rate of EN infusion in
comparison with bolus meals and hourly rate target
goal using SCCM/ASPEN guidelines.
Despite the importance of adequate nutritional intake,
critically ill patients receiving nutrition through enteral
route often receive less caloric and protein intake than
recommended. Evidence indicates that critically ill
patients given nutrition through enteral route have
received mean caloric intake ranging from 50 to 95%
of requirements and protein intake from 38 to 82% of
requirements [10].
Kim et al. [10] performed a prospective cohort study of
34 critically ill adults who were diagnosed medically and
received enteral feeding as a bolus. Energy and protein
intake prescribed and received were recorded for 4
consecutive days after beginning of enteral feeding.
The causes and duration of feeding interruptions were
also recorded. They found that the prescribed energy
amount did not reach patients’ requirements even after
72 h of feeding. Enteral feeding was under-prescribed,
and the prescribed enteral feeding was even under-
delivered, and the authors had no specific protocol in
the ICU of slowly increasing volume as indicated by a
patient’s tolerance. Therefore, under-prescription
contributed significantly to insufficient intake.
Many factors affect the adequacy of EN in ICU patients
in the USA. Under-prescription combined with
insufficient delivery of prescribed nutrients results in
inadequate nutritional intake. Inappropriate stopping
and delay in restarting EN cause a large volume of
enteral formula to be wasted. Interruptions due to
gastrointestinal intolerance of EN, displacement or
obstruction of the feeding tube, diagnostic or
therapeutic procedures, routine nursing procedures,
Enteral nutrition support algorithms Mohamed et al. 175
and airway management result in marked
underfeeding in ICU patients [11].
Heyland et al. [6] explained the effect of feeding
protocols and why are they needed. There is
tendency for hospitalized patients to receive nothing
by mouth, to be placed on clear liquids, or to receive
inadequate nutrition therapy.
When physicians do initiate enteral feeding, there is a
tendency to order insufficient calories (ordering ∼65%
of mean goal calories day in and day out). Once feeds
are initiated, they are frequently interrupted such that
only a fraction of what is prescribed is given. The result
is an overall inadequacy in delivery of enteral feeding,
and patients receive only ∼50% of goal requirements
and may be even lower, with patients receiving as little
as 20% of goal calories [12].
The reasons for poor delivery of EN are based primarily
on dogma. Failure to initiate EN was shown in one
study to be due to concerns for ileus (29.7% of cases),
perioperative dietary management (28.8% of cases),
and diagnostic tests (7.7%). In 15% of cases,
physicians were unclear as to why patients received
nothing by mouth. The value of protocols in this
situation is related to promotion of feeding patients
with ileus, decreasing the number and duration of
cessation periods from EN, hastening earlier
initiation of feeds, increasing volume, and reducing
barriers to delivery of EN [6].
A cluster-randomized controlled trial was performed in
the ICUs of 11 community and three teaching
hospitals and randomized to the intervention of
guideline-driven nurse protocols or control arm. The
result was that the ICUs that received an aggressive
intervention increased the number of days that enteral
feeding was delivered in the first week of
hospitalization, improved hospital length of stay by
10 days, and reduced mortality by 10% compared with
control ICUs with no protocol [13].
Taylor et al. [14] evaluated three aspects of an enteral
feeding protocol (rapid vs. slow ramp-up in the rate,
different levels for gastric residual volume, and gastric
versus small bowel feeding), and found that a more
aggressive regimen nearly doubled the volume of
enteral feeding delivered and improved patient
outcome.
Our results are in agreement with those of Hurt et al.
[15], who performed a prospective trial of trauma
patients (n=121) assigned to 1 of 2 groups. The
 176 Research and Opinion in Anesthesia & Intensive Care, Vol. 5 No. 3, July-September 2018
first group received targeted education consisting of
strategies to increase intake of early EN. Strategies
included early enteral feeding, avoidance of fasting
and clear liquid diets, volume-based feeding, early
resumption of feeds after procedure, and charting
caloric deficits. The control group did not receive
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
targeted education but was allowed to practice in a
standard ad-hoc manner. Both groups were provided
with dietitian recommendations on a multidisciplinary
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023
nutrition team as per standard practice. They stated
that volume-based feeds (i.e. prescribing based on
total volume of formula to be delivered in 24 h as
opposed to traditional rate per hour prescribing)
empower the nurse to increase or alter the rate of
delivery to make up for lost time, as occurs when
patients leave the unit for diagnostic tests or
therapeutic procedures.
Heyland et al. [6] developed an EN protocol that shifted
from an hourly rate target to a 24 h volume target, and
found that patients who were prescribed volume-based
feeds achieved almost 90% of their prescribed protein
and energy requirements, and their results are in
accordance with group 3 in our study.
Lichtenberg et al. [16] evaluated the difference of daily
EN volume deficits between a traditionally calculated
infusion rate and a compensatory, higher calculated
infusion rate in which the 24-h volume was delivered
over a 20-h infusion period. (For the 20-h group, the
calculated daily requirement of EN was divided by 20
rather than 24 for the higher hourly rate but still
delivered for 24 h.) They found that EN was most
often held for extubation or procedures. They also
found that calculating and prescribing higher EN
infusion rates, assuming 20 h of actual infusion daily,
improved delivery of optimal nutrient provisions and
helped in avoidance of unintended malnutrition by
significantly reducing caloric deficit from frequent
EN holding, but a higher level of overfeeding was
noted in the 20-h infusion group.
Chung et al. [17] examined nutritional support
received by blunt trauma patients from eight trauma
centers. They grouped patients according to mean daily
enteral caloric intake during the first 7 days. Group 1
was given the lowest (0 kcal/kg/day) and group 5 the
highest (15–30 kcal/kg/day) number of calories in the
first week. They focused their examinations on the
patients remaining in the ICU for 8 days or longer and
compared clinical outcomes among the groups. They
found that the main causes for interruptions to EN
were resuscitation, diagnostic imaging, and operative
procedures.
Passier et al. [18] conducted a retrospective single-
center study in trauma ICU of a university-affiliated
teaching hospital. Instead of compensating periods of
fasting for operation or investigation procedures by
increasing the rate of EN infusion in our study,
Passier et al. [18] applied a decreased fasting
protocol for patients scheduled for a tracheostomy,
permanent feeding tube, orthopedic procedure,
inferior vena-caval filter placement, eye surgery, or
ear, nose, and throat surgery. Their patients were
allowed to receive small bowel feedings until the
time of the procedure or gastric feeding until 45 min
before the procedure. The authors found that patients
in the examination group received more EN and there
was no significant difference in complications
(including regurgitation and aspiration).
Our results are in agreement with those of Taylor et al.
[19], who demonstrated that a change in feeding
technique to a volume-based approach increases the
intake of EN volume, calories, and protein to patients,
without increasing gastric residual volume or vomiting
and only slightly increasing diarrhea. This study was a
before–after cohort investigation comparing 7 months
of patient outcomes during a standard rate-based
protocol for EN with the next 7 months after
implementation of a volume-based EN protocol plus
educational campaign, in a surgical-trauma ICU
population. The volume-based Feed Early Enteral
Diet adequately for Maximum Effect (FEED ME)
protocol is described as a modified PEP uP protocol
and was designed to ‘make up’ for lost EN infusion
time due to diagnostic testing, radiographic studies,
and operations.
Mackenzie et al. [20] evaluated the changes in EN
delivery as a result of the implementation of evidence-
based nutrition support protocol, and they found
improvement in the proportion of patients meeting
greater than 80% of their goals in the ICU, and
improved overall delivery of EN. However, they did
not find a difference in time of initiation of EN
between the groups.
The limitation of this study was that this study was not
blinded. However, to reduce any bias, the data were
collected by observers who were not involved in the study.
Conclusion
An increase in the adequacy of EN calories and
proteins taken by the critically ill patients occurs
after application of EN algorithm based on the
SCCM/ASPEN guidelines and improved more by

using a protocol that shifted from an hourly rate target
goal to a 24-h volume goal. This study provides a
solution to overcome inadequate calories and proteins
given to the patient because of frequent interruptions.
Financial support and sponsorship
Downloaded from http://journals.lww.com/raic by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Nil.
Conflicts of interest
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/04/2023
There are no conflicts of interest.
References
1 Bailey N, Clark M, Nordlund M, Shelton M, Farver K. New paradigm in
nutrition support: using evidence to drive practice. Crit Care Nurs Q 2012;
35:255–267.
2 Ramprasad R, Kapoor MC. Nutrition in intensive care. J Anaesthesiol Clin
Pharmacol 2012; 28:1.
3 Brantley SL. Implementation of the enteral nutrition practice
recommendations. Nutr Clin Pract 2009; 24:335–343.
4 Barr J, Hetch M, Flavin K, Khorana A, Gould MK. Outcomes in critically ill
patients before and after the implementation of an evidence-based
nutritional management protocol. Chest 2004; 125: 1446–1457.
5 Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G,
et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;
25:210–223.
6 Heyland DK, Cahill NE, Dhaliwal R, Wang M, Day AG, Alenzi A, et al. 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.
7 McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B,
et al. 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
(ASPEN). J Parenter Enteral Nutr 2009; 33:277–316.
8 Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, et al. Effect
of evidence-based feeding guidelines on mortality of critically ill adults: a
cluster randomized controlled trial. JAMA 2008; 300:2731–2741.
Enteral nutrition support algorithms Mohamed et al. 177
9 Kiss CM, Byham-Gray L, Denmark R, Loetscher R, Brody RA. The impact
of implementation of a nutrition support algorithm on nutrition care
outcomes in an intensive care unit. Nutr Clin Pract 2012; 27:793–801.
10 Kim H, Stotts NA, Froelicher ES, Engler MM, Porter C. Enteral nutritional intake
in adult korean intensive care patients. Am J Crit Care 2013; 22:126–135.
11 O’Leary-Kelley CM, Puntillo KA, Barr J, Stotts N, Douglas MK. Nutritional
adequacy in patients receiving mechanical ventilation who are fed enterally.
Am J Crit Care 2005; 14:222–231.
12 Franklin G, McClave SA, Lowen C. Physician-delivered malnutrition: why
do patients remain NPO or on clear liquids in a university hospital setting. J
Parenter Enteral Nutr 2006; 30:S32–S33.
13 Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ, Southwestern
Ontario Critical Care Research Network. Multicentre, cluster-randomized
clinical trial of algorithms for critical-care enteral and parenteral therapy
(ACCEPT). Can Med Assoc J 2004; 170:197–204.
14 Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized and
controlled trial to determine the effect of early enhanced enteral nutrition on
clinical outcome in mechanically ventilated patients suffering head injury.
Crit Care Med 1999; 27:2525–2531.
15 Hurt RT, McClave SA, Evans DC, Jones C, Miller KR, Frazier TH, et al.
Targeted physician education positively affects delivery of nutrition therapy
and patient outcomes results of a prospective clinical trial. J Parenter
Enteral Nutr 2015; 39:948–952.
16 Lichtenberg K, Guay-Berry P, Pipitone A, Bondy A, Rotello L.
Compensatory increased enteral feeding goal rates: a way to achieve
optimal nutrition. Nutr Clin Pract 2010; 25:653–657.
17 Chung CK, Whitney R, Thompson CM, Pham TN, Maier RV, O’Keefe GE.
Experience with an enteral-based nutritional support regimen in critically ill
trauma patients. J Am Coll Surg 2013; 217:1108–1117.
18 Passier RH, Davies AR, Ridley E, McClure J, Murphy D, Scheinkestel CD.
Periprocedural cessation of nutrition in the intensive care unit: opportunities
for improvement. Intensive Care Med 2013; 39:1221–1226.
19 Taylor B, Brody R, Denmark R, Southard R, Byham-Gray L. 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;
29:639–648.
20 Mackenzie SL, Zygun D, Whitmore MBA, Doig CJ, Hameed SM.
Implementation of a nutrition support protocol increase the proportion of
mechanically ventilated patients reaching enteral nutrition targets in the
adult intensive care unit. J Parenter Enteral Nut 2005; 29:74–80.