September 2017 E-Journal Club

Greetings, We have not hosted a training program through July and August, and have been training new team members and welcoming our new dietetic interns. Since we don’t have a photo of trainees, or our group in a journal club, here is one of me standing astride the Appalachian Trail in the Roan Highlands of Tennessee. This also helps to explain the absence of recent e-journal clubs.

Our journal club article this month is an investigation into the effects of providing a multifaceted enhanced enteral feeding protocol on outcomes of adult trauma ICU patients.

September Citation:

Lee JC, Williams GW, Kozar RA, et al., Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit. Journal of Parenteral and Enteral Nutrition. Published online March 16, 2017.[Epub ahead of print]

Summary:

This was a before-after cohort study of 239 total adult trauma ICU patients, to investigate the effects of a multifaceted enhanced enteral nutrition (EN) feeding protocol compared to baseline feeding practices. Data was collected only for adult trauma patients who required ≥ 7 days of mechanical ventilation and who did not receive parenteral nutrition. The enhanced EN protocol consisted of early start of EN, a physician education program, intraoperative small bowel tube placements, EN ordering “bundle”, continued EN prior to procedures (excluding GI or airway procedures or proning) until patients were called to the OR (no NPO after midnight), and a volume based feeding protocol with “catch-up” feeding rate if feedings were held. Dietitians recorded daily EN volumes on a spreadsheet that calculated calorie and protein balances and cumulative nutrition deficits.

Clinical outcomes recorded included 28-day ventilator free days, STICU length of stay, hospital LOS, pneumonia, overall complications, wound complications, ARDS incidence and decubitus ulcers. Stepwise regression modeling was used to develop a multivariate logistic model for prediction of pneumonia.

Inclusion and Exclusion Criteria:

Inclusion criteria:

Adult trauma patients admitted to the STICU who required mechanical ventilation for ≥ 7 days and receiving EN.

Exclusion criteria:

Patients with non-trauma injuries, deemed to have nonsurvivable injuries, received any PN, required mechanical ventilation < 7 days, or who were re-admitted to the STICU.

Major Results:

There were 676 patients screened (LOS ≥3 days) during the 2 study periods. The baseline group consisted of 121 patients admitted between 5/2012-6/2013 and the intervention group was 118 patients admitted between 4/2014 and 5/2015. Seventy percent of patients in the intervention group received EN within 24 hours of ICU admission, and 97% received EN within 48 hours of ICU admission.

The baseline group required a median of 4.8 days to reach 80% of nutrition goal, and increased to (but did not achieve greater than) 90% of goal by day 7. The intervention group received significantly increased calories during the first 3 days compared to baseline and received 100% of calorie goals after day 3. The cumulative calorie deficit was -1907 (-4610 to +242) in the intervention group and was -7240 (-13,133 to -4435) in the baseline group. Cumulative protein balance was +80 gm (-171 to +242) in the intervention group compared to -398 (-707 to -213) n the baseline group.

Although the intervention group had significantly (p=0.23) decreased incidence of pneumonia (49/118, 42%) compared to the baseline group (68/121, 56%), the intervention group had significantly (p=0.03) fewer 28-day ventilator free days (12) compared to the baseline group (16).

There was no significant difference in any other clinical outcomes (ICU LOS, Hospital LOS, overall complications, wound complications, ARDS or decubitus ulcers) between the 2 groups.

Author’s Conclusions:

“…multitargeted feeding strategies led to earlier initiation of EN, a shorter time to achieve EN goal, improved overall EN administration, and reduced pneumonia in critically ill trauma patients mechanically ventilated for more than 1 week.…”

Evaluation:

The authors outline a number of this study’s limitations in the discussion section, including the possible confounding introduced from the 3 year timespan of the study. Additionally, they mention that the multifaceted EN protocol makes it difficult to know the potential effect of each different component of the feeding protocol. Our group discussed the fact that that one component of the feeding protocol was similar to early recovery after surgery (ERAS) protocols. Decreasing the length of time that feeding is stopped prior to operative procedures may provide outcome benefits by decreasing insulin resistance and improving GI motility post procedure, similar to ERAS protocols.

We also discussed that the incidence of pneumonia in the baseline group (68/121, 56% of patients) seemed very high compared to our trauma ICU population. Undoubtedly, the high percentage of patients with motor vehicle accidents, and the analysis of patients receiving mechanical ventilation ≥ 7 days played a role in the baseline pneumonia incidence, but it is possible that the baseline group had an unusual increased pneumonia incidence by chance, and the intervention group was more consistent with usual pneumonia incidence.¹

However, the major emphasis of our discussion was that the fact that although pneumonia incidence was less, there was a negative outcome in the feeding intervention group of fewer “ventilator free days”. The finding of less time off a ventilator/more time on a ventilator is a negative consequence that is shared by several other “enhanced” feeding protocols.^2-4 We were a bit surprised that the article title and conclusions seemed to emphasize the positive finding of pneumonia reduction, without stressing that the feeding protocol may have had negative consequences for trauma ICU patients. It is also possible that the methodology of this study, of including only those patients who received mechanical ventilation more than 7 days in the analysis, may have underrepresented possible harm. Patients who died prior to day 7, would simply not have been included in the analysis. One previous study of enhanced EN protocols was stopped prematurely because the group receiving increased nutrition/make-up feeding had significantly increased mortality.¹

This study was single-center, unblinded study with an inadequate number of patients enrolled to adequately study patient outcomes in the ICU, so it is possible that any difference in patient outcomes was not solely related to the difference in feeding protocol, or the amount of nutrition received. However, the fact remains that every study of enhanced EN protocols has demonstrated negative, or trends towards negative outcomes.^2-5

It is possible that early delivery of increased calories/protein, or using “make-up” to increase nutrition in the early part of critical illness may have negative consequences. There is a need for further study before adopting routine use of enhanced feeding protocols in the ICU.

Our Take Home Message(s)

A multitargeted EN feeding strategy provided earlier goal nutrition with decreased cumulative nutrition deficit to adult critically ill trauma patients, but may have produced negative consequences of fewer ventilator free days, despite a decreased pneumonia incidence.
There is a need for further study of the effects of make-up feeding strategies and early goal nutrition in critically ill patients before advocating the adoption of early volume based feeding or enhanced EN protocols.

References:

Mangram AJ, Sohn J, Zhou N, et al. Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients. Am J Surg. 2015 Dec;210(6):1056-61
Braunschweig CA, Sheean PM, Peterson SJ, et al. Intensive Nutrition in Acute Lung Injury: A Clinical Trial (INTACT). JPEN J Parenter Enteral Nutr 2015;39(1):13-20.
Compher C, Chittams J, Sammarco T, et al. Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-163.
Taylor B, Brody, 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(5):639-648.
Yeh DD, Cropano C, Quraishi SA, et al. Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes. Nutr Clin Pract. 2017;32(2):175-181.

Other News on the UVAHS GI Nutrition Website: (www.ginutrition.virginia.edu):

Spring Program Dates now Posted!

5 Day Traineeship: March 12-16

GI Focused Weekend Warrior: March 24-25

3 Day Traineeship: April 19-21

Upcoming Webinars 2017:

November 19: Adult Cystic Fibrosis

December 12: Nutrition Support in Pancreatitis

Latest Practical Gastroenterology article: Seeking Enteral Autonomy with Teduglutide

Joe Krenitsky MS, RDN

PS – Please feel free to forward on to friends and colleagues.