November 2014 E-Journal Club


Our trainees for November hailed from Tampa, FL; Ethridge, TN; Austin, TX; Danville, PA and Lewes, DE.  We had unseasonably cool weather for Virginia, but considering the snow that so many others in the US received, we were just glad that the weather did not interfere with anyone’s travel.

Our journal club article for November was another study of strategies to optimize the provision of enteral nutrition (EN) in the ICU (see April/May 2014 and October 2013 ejournal clubs).

November Citation:

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 Aug 25. [Epub ahead of print]


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 ME (Feed Early Enteral Diet adequately for Maximum Effect) 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.

The protocol utilized a 350 mL cut-off threshold for gastric residuals, a maximum feeding rate of 120 mL/hr if small bowel fed (or 400 mL every 4 hours if intermittent feeding if gastrically-fed), and unlike the PEP uP protocol, did not routinely begin prokinetics, protein supplements or specify the EN formula to be used.  Patients were placed on the “make-up” portion of the FEED ME protocol only after they had achieved their target EN rate.  If EN was held, the nurse would use a chart to provide an increased feeding rate after feedings were resumed, and then return back to the original rate after a specified time.

The primary outcome of the study was the mean proportions of EN volume, calories, and protein received compared to those prescribed during the first 7 days in the STICU. The safety of the volume protocol was compared with the rate-based approach by documenting the prevalence of GRV >350 mL, emesis, and diarrhea.

An educational campaign was undertaken after the volume based protocol was started, with didactic sessions combined with individual instruction, bedside tools, frequent reminders at the nurses’ station and unit newsletter for nursing as well as meal ticket incentives.  Physician education was conducted at the monthly quality improvement meeting, individually and via email.  Nursing compliance with the FEED ME protocol was intermittently monitored and feedback provided to individual nurses and management.

Inclusion and Exclusion Criteria were:

Inclusion criteria:

Adults admitted over a 14-month period (January 2012–April 2013), mechanically ventilated upon arrival or within 6 hours, length of stay of at least 7 days, and received at least 72 hours of EN after reaching goal rate.

Exclusion criteria:

Previously admitted to the STICU for extubation and observation, patients ordered to receive only “trophic” rate of tube feeding due to their hemodynamic status.

Major Results:

A total of 3748 patients were admitted during the 14 month period and after inclusion-exclusion criteria were applied, there were 54 patients in the rate-based group and 56 in the FEED ME group for the final sample (2.9% of STICU population).

The mean percent of calories delivered (calories delivered/calories prescribed) significantly increased during the FEED ME protocol period (rate based, 63% ± 20%; FEED ME, 89% ± 9%; P < 0.0001).  The grams of protein per kilogram of actual body weight was significantly increased during the FEED ME protocol (1.13 ± 0.29 (rate based) to 1.26 ± 0.37 (FEED ME) (P = .036); this difference was numerically, but not significantly different when ideal weight was used for protein (rate based, 1.41 ± 0.30; FEED ME, 1.56 ± 0.36; P = 0.07).

The incidence of emesis (rate based, 5 times; FEED ME, 2 times; P = 0.22) was comparable between the groups, but there was a significantly greater incidence of diarrhea in the volume-based group (rate based, 0 times; FEED ME, 6 times; P = 0.046).

There were 11 deaths in the rate-based group and 7 deaths in the FEED ME group (P = 0.264). There was a trend toward a longer length of stay in the FEED ME group (rate based, 12.2 days; FEED ME, 15.0 days; P = 0.053), but when the patients who died were excluded, the strength of this trend was decreased (P = 0.09). Time on mechanical ventilation (11.2 vs 13.5 days; P = 0.146) was similar.

Author’s Conclusions:

“A change in standard of practice to an EN volume-based feeding approach in a STICU led to a significant improvement in adequacy of calories and protein delivered, with only a slight increase in diarrhea.”


This study, along with several others has demonstrated that enteral feeding protocols that provide “make-up” feeding can provide increased calories and protein to critically ill patients.1-3 In the current study, the volume-based protocol was combined with an intensive education program for nurses and physicians.  It is unclear if facilities can expect similar results of adopting the protocols, unless adequate resources are dedicated to the educational component and monitoring with feedback.

Importantly, none of these studies of volume-based feeding have demonstrated that increasing calorie and protein delivery have improved patient outcome. 1-3   In fact, one previous cohort study demonstrated increased length of stay with increased nutrition provision, and a second study in patients with acute lung injury had to be terminated early due to increased mortality in the group receiving increased nutrition.1,3  Although observational studies may have identified an association between patients with improved outcome and receiving 80% of nutrition goals, it would be inappropriate to suggest that we know that increasing nutrition to 80% of goal will improve patient outcome.

The current study is notable for reasonable initial calorie goals, a reduced maximum upper limit to feeding rates compared to previous studies, and waiting until patients had tolerated goal feeding rates before implementing the “make-up” nutrition.  Nonetheless, there was still a trend towards increased length of stay in the group receiving volume based feeding. Obviously, this study enrolled far too few patients to form any strong conclusions about patient outcome.  However, combined with the data about possible compromised outcomes from previous studies suggests that patient outcome with volume based feeding needs further investigation.

One aspect of volume based feeding that has not been investigated is the effect of “make-up” nutrition on glucose variability.  Increased variability of serum glucose in the ICU may have a much more negative impact on patient outcome than the absolute glucose values.4  Although an effective insulin infusion policy may be able to adequately compensate for dialing feeding rates up and down, glucose variability should be considered in future studies.

Our Take Home Message (s)

  1. Volume-based enteral feeding, with an intensive education campaign allows increased calorie and protein provision in a surgical/trauma population.
  2. Current evidence suggests that here is a need for larger studies with adequate numbers of patients to fully evaluate the effects of volume-based feeding on patient outcome/s before wholesale clinical application of enhanced or volume-based feeding protocols are put into effect.
  3. Future studies should investigate the effect of “make-up” nutrition on glucose variability.
  4. Outcome differences between continuous vs. bolus feeding in critically ill patients is an area ripe for study.



  1. Braunschweig CA, Sheean PM, Peterson SJ, et al.  Intensive Nutrition in Acute Lung Injury:  A Clinical Trial (INTACT).  JPEN J Parenter Enteral Nutr 2014 Apr 9 [Epub ahead of print]
  2. Heyland DK, Murch L, Cahill N, et al.  Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients: Results of a Cluster Randomized Trial.  Crit Care Med. 2013 Dec;41(12):2743-2753.
  3. Sheean PM, Peterson SJ, Zhao W, et al.  Intensive medical nutrition therapy: methods to improve nutrition provision in the critical care setting.  J Acad Nutr Diet. 2012;112(7):1073-1079.
  4. Krinsley JS. Glycemic variability: a strong independent predictor of mortality in critically ill patients. Crit Care Med. 2008;36(11):3008-3013.


Other News on the UVAHS GI Nutrition Website: (

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Latest Practical Gastroenterology article:

— Knotts L, Havrila C.  Celebrating the Holidays for our Friends and Family with Dysphagia.  Practical Gastroenterology 2014;XXXVIII(11):30.


Joe Krenitsky MS, RD

Carol Rees Parrish MS, RD


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