VOLUME-BASED VS. RATE-BASED FEEDING

Transcription

1 VOLUME-BASED VS. RATE-BASED FEEDING Amanda Holyk Critical Care Pharmacist Mount Nittany Medical Center Society of Critical Care Medicine Annual Symposium November 10,

2 Disclosure I have no actual or potential conflict of interest in relation to this presentation 1

3 Learning Objectives Compare and contrast the pros and cons to ratebased vs. volume-based feeding Discuss primary literature and local research supporting volume-based feeding 2

4 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 impaired immune response, poor wound healing, and increased mortality, length of hospital stay, and cost Haskins IN, J Parenter Enteral Nutr Zheng YL, J Parenter Enteral Nutr

5 Background Discrepancies between prescribed nutrition goals and actual administration Gaps in feeding due to: Procedures NPO status Aspiration concerns Malfunctioning enteral access 4

6 Background Rate-based feeding Traditional method of feeding Consistently associated with failure to meet goals Low start and slow titration Fixed rate McClave SA, Crit Care Med 2014;42(12): McClave SA, Nutr Clin Pract 2009;24:

7 Background Volume-based feeding (VBF) is an alternative method of nutrition delivery Establishes a 24 hour tube feeding goal volume Bedside nurse changes hourly rate based on how much of the goal volume is left to be administered, allowing for a catchup to account for interruptions in tube feeds 6

8 Background VBF example Total 24 hour volume: 1800 mls (starting rate of 75 ml/hr) Patient fed 450 mls in 6 hours EN put on hold for 5 hours New feeding goal: =1350 mls Time remaining: =13 hrs Use the chart to locate new rate of 104 ml/hr (1350/13) 7

9 Literature Nutr Clin Pract Oct;29(5): JPEN J Parenter Enteral Nutr. 2015;39: Critical Care Medicine: 2013 Dec; 41(12): Haskins IN, J Parenter Enteral Nutr J Acad Nutr Diet July;112(7): Journal of Parenteral and Enteral Nutrition 40.2 (2016):

10 Literature 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 multistrategy protocol be considered. 9 Journal of Parenteral and Enteral Nutrition 40.2 (2016):

11 Local Research Implementation and Evaluation of a Volume-Based Enteral Nutrition Protocol in the ICU 10

12 Study Design Single center, retrospective, quasi-experimental (before-and-after) 948 bed academic medical center (5 ICUs, 129 total beds) 23 bed medical ICU (MICU) 20 bed neuro ICU (NICU) Patients admitted to the MICU or NICU from September 1, 2015 to August 31, 2016 (Ratebased) and November 22, 2016 to March 31, 2017 (Volume-based) Exempt from institutional review board (IRB) 11

13 Eligibility Criteria 12

14 Study Design Rate-based protocol Goal calories and protein based on BMI and weight per guideline recommendations Calories: BMI<30: 25 kcal/kg ABW BMI 30-50: kcal/kg ABW BMI>50: kcal/kg IBW Protein: BMI<30: Protein g/kg ABW BMI 30-40: 2 g/kg IBW BMI>40: 2.5 g/kg IBW CRRT or daily HD: 2.5 g/kg IBW Goal rate determined using daily goal calorie requirements and formula Daily volume determined from charted hourly rates Time zero: first charted tube feed rate No formula restrictions Journal of Parenteral and Enteral Nutrition 40.2 (2016): CRRT: Continuous Renal Replacement Therapy HD: Hemodialysis 13

15 Study Design VB protocol Day 1 Using body mass index (BMI) and weight, physician will determine goal volume, rate, and formula for first 24 hours using the formula initiation pathway 14

16 Study Design 15

17 Study Design VB protocol Day 2 Catch-up phase occurs at least once daily 16

18 Study Design Volume Left to be Fed Number of Hours Remaining Max Rate: 150 ml/hr 17

19 Study Design Dietitian evaluates patient within 24 hours Standard gastric residual volume (GRV) policy GRV threshold 400 ml Precautions for use include patients on multiple/high dose vasopressors, high risk of intolerance/refeeding, ileus, post diabetic ketoacidosis (DKA)/ hyperglycemic hyperosmolar syndrome (HHS) 18

20 Results Patients in MICU/NICU with tube feed order and feeding tube (n=331) Exclusion (n=142): Washout period (n=10) Tube feeds <24 hours (n=22) ICU LOS <24 hours (n=108) Never initiated on feeds (n=2) Eligible for inclusion (n=189) Rate Based (n=100) Volume Based (n=89) 19

21 Baseline Characteristics Characteristic Rate-based (n=100) Volume-based (n=89) P value Mean age yr (SD) 67.5 (16.3) 66.5 (17.5) Male - no. (%) 47 (47) 45 (51) Mean body weight kg (SD) 71.1 (15.6) 77.9 (22.7) Mean BMI- kg/m 2 (SD) 25.6 (6) 27.8 (8.3) BMI < 30 no. (%) 80 (80) 63 ( 70.8) BMI no. (%) 20 (20) 24 (27) BMI > 50 no. (%) 0 2 (2.2) -- Mean baseline glucose - mg/dl (SD) (42.6) (45.7) Mean length of enteral nutrition on day 1 hrs. (SD) 12.3 (6.3) 13 (5.2) Mean length of enteral nutrition - days (SD) 4.0 (2.1) 4.6 (2.0) Post-pyloric route no. (%) 20 (20) 17 (19) MICU patients no. (%) 71 (71) 68 (76.4)

22 Outcomes 21

23 Outcomes 22

24 Outcomes Outcome Rate-based (n=100) Volume-based (n=89) P value Time to goal rate hrs. (IQR) 13 (9.12;25) 7.7 (4.1;16.1) Mean glucose mg/dl (SD) (35.5) (37.2) Incidence of patients with GRVs >400 mls no. (%) Median length of hospital stay days (IQR) 15.6 (10.6;26.1) 2 (2) 3 (3.4) (14;31) Median length of ICU stay days (IQR) 5.7 (3.8;10.7) 5 (3;9) Median days of mechanical ventilation no. (IQR) 6.6 (2.5; 18.8) 7 (4;12) In-hospital mortality no. (%) 12 (12%) 12 (13.5%)

25 Volume-based Protocol Evaluation Patients (n=89) Incidence of catch up no. (%) 51 (57.3) Removed from protocol no. (%) 6 (6.7) Incidence of hyperglycemia during catch up vs. non- catch up 16.7% vs. 6.7%; P<

26 Study Conclusion The results of our study demonstrate: Increase in overall calories delivered Increase in the number of patients meeting eighty percent of goal calories Limitations: study design, protocol awareness, reliance on nursing documentation 25

27 Protocol Implementation Interdisciplinary roles Physician Dietitian Nursing Pharmacy 26

28 Protocol Implementation Education In-services for all disciplines, pocket cards notification, FAQ binder, bedside VBF schedule, practice scenarios, bedside competencies May consider: posters, daily checklists, self-learning module 27

29 Protocol Implementation Versatility in protocol design Use of nutritional risk assessment tool Starting rates Max rates Formula choice Trophic option Protein supplements Motility agents 28

30 Overall Positives Volume-based feeding Increased delivery of nutrition Greater adherence to guideline recommendations Flexibility in protocol design Nursing driven Rate-based feeding Historical use Familiarity Less nursing intensive Easier glucose management 29

31 Overall Negatives Volume-based feeding Considerations for glucose control May not be appropriate for all patient populations Extensive training necessary to implement Rate-based feeding Consistently does not meet minimum nutrition goals Usually is slower to start and titrate 30

32 Future Directions Gaps in current literature Use in all subtypes of patients Benefit with early EN Clinical outcomes 31

33 Conclusion Volume-based feeding should be considered for eligible ICU patients Clear increased nutritional delivery Guideline recommended Implementation takes buy-in and education Unanswered questions regarding certain patient populations and long term clinical outcomes 32

34 Acknowledgements Matt Wanat, PharmD, BCPS, BCCCP SCCM-Texas Chapter Valerie Belden, PharmD, BCPS Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Kathryn Chiles, RD, LD, CNSC Nicole Fontenot, MSN, APRN-BC, CCNS, CCRN Annette Lista, PharmD Mary K. Broadway MSN, RN, CNRN, SCRN Raul Sanchez, MD Leanne Fitzgerald, MS, RD, LD, CNSC Stella Smith, MS, RD, LD, CNSC 33

35 VOLUME-BASED VS. RATE-BASED ENTERAL NUTRITION PROTOCOL IN THE ICU Amanda Holyk Critical Care Pharmacist Mount Nittany Medical Center Society of Critical Care Medicine Annual Symposium November 10,