Michelle Moriarty Journal Article Summary Title: Compensatory increased enteral feeding goal rates: a way to achieve optimal

nutrition Authors: Lichtenberg K, Guay-Berry P, Pipitone A et al. Journal: Nutrition in Clinical Practice Volume: 25 number 6 Pages: 653-657 Year: 2010

Introduction:
Review of Literature: The purpose of this study was to determine the difference of daily enteral nutrition (EN) volume deficits between traditionally calculated infusion rate of 24 hours and a compensatory, higher rate in which the 24 hours volume is delivered over a 20 hour period. Rationale: It has been found that adequate nutrition positively affects patient outcomes while inadequate nutrition negatively affects outcomes. Traditionally, EN goal rates have been determined based on a 24 hour continuous infusion rate. However, many enterally fed patients in ICUs have been found to be underfed due to the frequent, sometimes avoidable, interruptions in feeding due to medical or surgical procedures. This study looked to evaluate the daily calorie discrepancy from feeding interruptions in order to find a more effective way of delivering EN. Hypotheses or Objective: The authors hypothesize that a compensatory, higher calculated infusion rate based on 20 hours of administration would decreased the daily calorie deficit to more adequately meet the estimated needs of enterally fed ICU patients.

Study Design and Methods:

General Approach: Hypothesis testing Level of Measurement: Individual Population at Risk: Patients receiving EN were chosen from the ICU at Suburban Hospital in Bethesda, Maryland, a level II trauma center. Sampling Method and Sample Size: 268 patient days in 37 patients were evaluated. 110 patient days in the control group based on a 24 hour infusion rate and 158 patient days in the intervention group that used the 20 hour infusion rate. Selection and Exclusion Criteria for Study Group: Days in which EN was initiated, advanced, discontinued, the goal rate was adjusted or the patient was transferred were excluded from the study. All documentation of intake/output and hourly infusion was done by nurses using standardized ICU flow

sheets. There were not any days in which documentation on the flow sheet was incomplete, therefore, patients days did not have to be omitted. Dependent Variable: Enterally fed ICU patients receiving the feed at the 24 hour infusion rate. For all patients, caloric needs were based on the clinical severity of illness using the range of 25-35 kcal/kg/d. Daily goal volume and hourly goal rates as well as the caloric needs were established by a registered dietitian (RD). Indirect calorimetry was used when the RD deemed it necessary and it was conducted by a trained respiratory therapist. Data collection included the review of the ICU flow sheets to obtain the actual volume of EN infused during the previous day. This was then compared to the volume of formula ordered, thereby revealing each patients daily EN volume discrepancy (intended volume minus actual volume infused). Adequacy of EN for each variable was designated as underfeeding/inadequate if less than 90% of the EN goal volume was met. Adequate/appropriate feeding if the volume administered was +/- 10% of goal. Overfeeding if greater than 110% of EN goal volume was delivered. Ration for EN adequacy was defined as: (actual volume infused/intended volume infused) x 100. Independent Variable: Enterally fed ICU patients receiving the feed at the 20 hour infusion rate. The RD calculated the patients 24 hour requirement of EN and divided by 20 rather than 24 to establish a compensatory, higher hourly infusion rate. Potential Confounding or Effect-Modifying Variable: Controlled by study design: all patients received continuous enteral infusions through a closed system, documentation of intake/output and hourly infusion was done by nurses using standardized ICU flow sheets, any reason for EN feeding interruption needed to be recorded on the flow sheets.

Results:
Missing Data: All patient days were able to be used since the proper documentation was kept by the ICU nurses on the flow sheets. Major Findings: For the control group, the mean goal rate was 50 ml/hr and the intervention groups meal goal rate was 47 ml/hr. Mean daily volume for the control group was 79.7% of goal volume. The intervention group received 97.3% of its mean daily volume. 110 EN days were evaluated in the control group with a mean infusion volume deficit of (+/-) 247 ml/day or 79% of goal calories. 158 patient days in the intervention group were evaluation and found a mean volume deficit of (+/-) 45 ml/day pr 97.3% of goal calories (P<0.001).

In the intervention group, 17 patients were overfed for a total of 92 patient days. 85 (92%) of those days were attributable to patients who were receiving EN from a more concentrated formula ( 1.2 kcal/ml).

Of the 17 patients who received >110% of their estimated needs, 14 (82%) were on formulas that exceeded 1.0 kcal/ml. The authors re-evaluated the data of the overfed patients, eliminating those that were receiving a more concentrated formula and found the overfeeding rate decreased to 9%. A correlation between overfeeding and duration of therapy was found. Of the patients receiving >110% of their needs, they were most commonly to have a length of stay in the ICU 2 weeks. The authors recommend to decreased the incidence of overfeeding, to only apply the compensatory, higher rate to patients only receiving isocaloric feedings and limiting it to patients with less than a 2 week ICU length of stay.

Control for Confounding: All nurses were informed and reminded throughout the study that data were being collected regarding each patients hourly enteral infusion volumes to ensure complete documentation. Statistical Analysis: Students t test was used to determine significance of categorical, continuous variables.

Discussion and Conclusions:

Internal Validity: Data was collected on all patients admitted to the ICU that were receiving EN via orogastric, nasogastric or percutaneous gastrostomy over a 6 week period. The study looked at a long enough period of time but the sample size was only 37 patients. External Validity: The results can be generalized to other ICU patients receiving EN. Patients will be similar in all ICUs and therefore the idea of infusing EN over 20 hours rather than 24 hours could benefit most. Strengths and Limitations: One negative aspect of the compensatory, higher infusion goal rate is the potential for overfeeding, which may result in increased physiological stress such as fluid overload, hyperglycemia or hepatic dysfunction. Another limitation stated by the authors was the lack of ability to utilize indirect calorimetry on all patients. This required the use of predictive equations for estimated calorie needs. The authors recommendation of only using the compensatory rate on patients receiving an isocaloric formula to decreased the incidence of overfeeding may not be practical in many ICUs since the patients are critically ill and commonly require a concentrated formula to meet their increased needs.

Consistency with Other Studies: The authors discussed other studies that have shown improved patient outcomes when a volume of EN closer to the caloric and protein goals was administered. Theoretical Importance of Results: The study was able to show that using a compensatory, higher infusion rate, the authors were able to significantly improve the ability of the patients to receive their goal nutrition requirements in a 24 hour period. Since the traditional method is to infuse EN over a 24 hour period and is therefore used in most institutions, this study can be applied to all ICUs to better ensure that patients are receiving their estimated needs and are not being underfed. Practical Importance of Results: With the results of this study, hospitals could begin to measure the actual EN infusion volume versus what is the recommended volume to determine if their patients are being underfed. Further Study: The authors state that further research would need to be done in order to develop appropriate interventions for the increased incidence of overfeeding in patients receiving the 20 hour infusion volume rate.