Professional Documents
Culture Documents
Ebp Presentation
Ebp Presentation
Continuous vs.
Intermittent
GROUP B: AIMEE A., ANTONIO S., ASHLEY H., DOUG T.,
DUYEN P., HOLLY Z., JANET D., MELISSA D., RUTHLYN K.
PICOT Question
In high acuity patients, how does bolus versus
continuous enteral feedings influence patient
outcomes over the course of the patients admission
to the high acuity care unit?
Evidence-Based Recommendations
There was no significant difference between continuous vs.
intermittent feeding.
With bolus feeding, it was found that there was an increased risk for
GI issues.
Currently, there is no national recommendation on whether
intermittent or continuous feeding is preferred.
The evidence based recommendation is:
The provider will determine whether continuous or intermittent
enteral feeding is appropriate on a case-by-case basis based on
patient indicators, such as GI status, acuity, and nutritional needs.
Cost Analysis
Most patients at Carondelet use Jevity for enteral nutrition.
There are four basic types of enteral formula: polymeric, modular, elemental, and
specialty.
Direct cost
Tube insertion = $26
After an enteral tube is inserted, verification of tube placement by X-ray film
examination needs to occur before the patient receives the first enteral feeding.
Indirect cost
Jevity 1.2 Cal Ready-to-Hang - 1000 mL = $35/bottle
Run at 40 ml/hr and tubing has to be changed every 24 hours
1 bottle per day per patient
Cost Analysis
Kangaroo pump cost $620
Feeding pump set $130
Additional costs
Costs to verify the correct placement of the NG-tube, chest x-ray
Costs for accidental tube removal
If the patient has a metabolic disorder or other diagnosis (obese, DM,
Cardiac disorders), which may necessitate a different or more formula,
this may come at an increased cost
Needed amount
per week
Total cost
Tube formula
$ 35
7 bottles
$ 245
Feeding pump
$ 620
1 pump
$ 620
Costs NG-tube
$ 26
1( replace every 2
w)
$ 110
Feeding tube
$ 10
$ 70
Total amount NG
per week
$ 961
$ 1045
Risk-Benefit Analysis
Benefits:
No significant clinical difference between the two
techniques was found overall; but each study had
varying short term results.
Ex: nutritional intake may have differed at first in
some studies, but equalized by the third day.
Risk-Benefit Analysis
Benefits:
Technique can be up to the physicians discretion
without high risk of one or the other.
Patients on intermittent feeds were extubated
earlier, and had a lower risk of aspiration
pneumonia. (aspiration pneumonia linked to high
doses of dopamine) (Yu-Chih et al, 2006)
Risk-Benefit Analysis
Risks:
Incidence of aspiration warrants further
investigation.
Staff prefer continuous feeding over intermittent.
(Steevens et al, 2002)
Continuous: nurse may not be as vigilant as
with intermittent feeding
Intermittent: gives the nurse extra nursing care
to keep track of
Risk-Benefit Analysis
Risks:
There may still be risk that is unknown and the
limitations of the studies and the differences in patient
conditions and possible comorbidities have prevented
us from isolating specific complications.
Risk for aspiration pneumonia is associated with
feedings at night and supine position.
Intermittent feeds increase the patients
gastrointestinal complications, including diarrhea.
Summary of Literature
Current clinical recommendations allow the physician to decide
which type of feeding is best for the patient, either intermittent
(bolus) or continuous.
After reviewing 9 different studies, no statistical difference or
benefit was found between implementing either an intermittent
or continuous feeding regimen.
Given our findings after reviewing the literature, our
recommendation is to continue with the current national clinical
recommendations regarding enteral feedings.
References
Evans, D. C., Forbes, R., Jones, C., Cotterman, R., Njoku, C., Thongrong, C., ... & Stawicki, S. P. (2016).
Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding
volume, caloric intake, or insulin utilization?. International Journal of Critical Illness and Injury Science,
6(1), 9.
Kadamani, I., Itani, M., Zahran, E., & Taha, N. (2014). Incidence of aspiration and gastrointestinal
complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: A
pseudo-randomised controlled trial. Australian Critical Care, (27) 4, 188-193. doi:
http://dx.doi.org/10.1016/j.aucc.2013.12.001
Lee, J.S.W., Kwok, T., Chui, P.Y., Ko, F.W.S., Lo, W.K., Kam, W.C.,...Woo,J. (2010). Can continuous pump
feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled
trial. Clinical Nutrition, 29, 453-458. doi:10.1016/j.clnu.2009.10.003
MacLeod, J. B., Lefton, J., Houghton, D., Roland, C., Doherty, J., Cohn, S. M., & Barquist, E. S. (2007).
Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill
trauma patients. The Journal of Trauma, 63(1), 57-61. doi:10.1097/01.ta.0000249294.58703.11 [doi]
References
Maurya, I., Pawar, M., Garg, R., Kaur, M., & Sood, R. (2011). Comparison of respiratory quotient and resting energy
expenditure in two regimens of enteral feeding continuous vs. intermittent in head-injured critically ill patients.
Saudi Journal of Anaesthesia, 195-201. doi:10.4103/1658-354X.82800
Serpa, Letcia Faria, Kimura, Miako, Faintuch, Joel, & Ceconello, Ivan. (2003). Effects of continuous versus bolus
infusion of enteral nutrition in critical patients. Revista do Hospital das Clnicas, 58(1), 9-14. Retrieved March 04,
2016, from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0041-87812003000100003&lng=en&tlng=en.
Steevens, E. C., Lipscomb, A. F., Poole, G. V., & Sacks, G. S. (2002). Comparison of continuous vs intermittent
nasogastric enteral feeding in trauma patients: Perceptions and practice. Nutrition in Clinical Practice : Official
Publication of the American Society for Parenteral and Enteral Nutrition, 17(2), 118-122. doi:17/2/118 [pii]
Tavares de Araujo V. & Cervantes Caporossi P. (2014). Enteral nutrition should in critical patients; should the
administration be continuous or intermittent? Nutr Hosp. 2014; 29(3): 563-567. doi :10.3305/NH.2014.29.3.7169
Yu-Chih, C., Shin-Shang, C., Li-Hwa, L., Li-Fen, W., (2006). The Effect of Intermittent Nasogastric Feeding on
Preventing Aspiration Pneumonia in Ventilated Critically Ill Patients. The Journal of Nursing Research, 14(3), 167180.