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Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Fourth dimension' (PERFECT) protocol: a before-and-after study

Graham Clarkeⁱⁱ &
Vincent O'Keeffe¹

Critical Care volume 23, Article number:105 (2019) Cite this article

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Abstract

Background

Underfeeding in critical illness is mutual and associated with poor outcomes. Co-ordinate to large prospective hospital studies, volume-based feeding (VBF) safely and finer improves energy and protein commitment to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after report was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit of measurement (ICU).

Methods

The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The showtime accomplice (n = 46) was fed using RBF, the 2d (north = 46) using VBF, and observed for 7 days, or until extubation or decease. Statistical comparison of per centum feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation catamenia, mortality, and length of ICU stay (LOICUS).

Results

Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF grouping increased significantly by eleven.2% (p ≤ 0.001), energy by 13.iv% (p ≤ 0.001) and poly peptide by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients coming together > 90% of free energy requirements increased significantly from 47.viii to 84.8% (p ≤ 0.001); those coming together > xc% of protein requirements changed from 56.five to 73.nine% (p = 0.134).

VBF did not increase symptoms of feed intolerance. Adapted binomial logistic regression found each boosted 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900–0.985], p = 0.010.

No differences in bloodshed or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of poly peptide requirements compared to those meeting < 80%, (p = 0.006). Adapted Cox regression plant the daily probability of existence extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < lxxx%, adventure ratio 3.473, p = 0.021, 95% CI [1.205–10.014].

Conclusion

VBF safely and effectively increased the delivery of free energy and protein to critically sick patients. Increased protein delivery may amend extubation rate which has positive patient-centred and fiscal implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced poly peptide delivery to improve patient outcomes.

Groundwork

Critically ill patients are at high risk of morbidity, bloodshed and prolonged care needs [ane]; implementing practical approaches to better outcomes is of paramount importance [2]. During critical disease, evolutionary survival mechanisms release energy from stored body tissues to fuel life-supporting tasks [iii]. The cede from torso stores is deleterious, and contributes to poor outcomes: when energy and protein is delivered to critically ill patients, this risk is ameliorated and recovery potential improved [1, 4, five].

Despite the potential benefits of nutrition therapy, feeding is stopped intermittently in 85% of critically ill patients due to essential procedures and symptoms of feed intolerance [1]. These feed stops cause patients to meet merely 40–60% of their energy and protein requirements, rather than assuasive optimal delivery and coming together the minimum 80% recommended by clinical practice guidelines (CPGs) [1, 6].

Almost intensive care units (ICUs) worldwide use an hourly 'rate-based' feeding (RBF) approach, without strategies to rectify feed deficits. Testify suggests changing from a rate- to volume-based feeding (VBF) approach helps mitigate these accrued deficits without increasing feed intolerance in medical, and some surgical ICU patients [7,viii,nine,10,11,12], and past corollary, may improve clinical outcomes. Using the VBF arroyo, instead of prescribing an hourly feeding charge per unit of, for example, 50 ml/h, a patient is prescribed 1200 ml/24-h period; systems are put in place to ensure the entire amount is delivered within 24 h.

CPGs encourage adoption of VBF in local ICU practise [1, half dozen]. The Heyland group [x,xi,12], who named their VBF protocol: The Enhanced P rotein- E nergy P rovision via the Enteral Ro u te in Critically Ill P atients (PEPuP) protocol, openly share and encourage use of their resource to facilitate change in local ICUs, and endorse adapting their protocol to local context to facilitate implementation [13].

Non all studies evidence improved outcomes when energy and poly peptide goals are accomplished. The VBF studies by Haskins et al. [eight], Taylor et al. [nine] and Heyland et al. [11] reported no pregnant difference in LOS, mortality or ventilation was enabled by VBF. Some other studies evaluating overall nutritional commitment in the critically ill population [14,15,16,17] suggest reductions in bloodshed, ventilation menstruum and LOS may be achieved when patients meet their energy and/or poly peptide goals. Others warn that coming together ICU feeding targets triggers complex biochemical processes which accept the contrary effect: increasing mortality, ventilation duration and LOS [18, 19], and recommend a less aggressive approach to feeding.

3 recent meta-analyses [xx,21,22] found no difference in bloodshed, ventilation or hospital- or ICU-LOS when patients did or did not come across their energy or poly peptide needs. The randomised controlled trials included in analyses used diverse strategies to improve nutritional delivery, such as faster feed starts and rate increase to ameliorate deficits [19], or managing gastric residual volumes or small bowel feeding. All meta-analyses found patients met sub-optimal levels of protein, which may be important. Emerging bear witness suggests that with an increased turnover of up to 80% in critical disease, ICU patients have a much larger protein need than previously accepted [23,24,25,26,27]. It is common for protein to be targeted secondary to total free energy in this patient grouping and is considered a neglected area of research [28, 29].

Deciding the optimal dose and timing of meeting the energy and protein needs of ICU patients remains controversial and bailiwick to the impact of variable influences [30]. ASPEN [ane] propose assessing for malnutrition risk, using either the Nutritional Risk Screening (NRS) 2002 or the Nutrition Risk in the Critically ill (NUTRIC) scores. NUTRIC was developed by Heyland et al. [31] to identify which ICU patients benefit nigh from nutritional back up. The score has been externally validated in large prospective observational trials and found to identify the sickest patients more than likely to accept increased morbidity and mortality [32, 33]. Testify suggests the NUTRIC score predicts free energy and protein deficits in critically ill patients, merely NRS does not [34], and that energy- and protein-related improvements in mortality are greatest in those patients with longer stay, and at highest risk calculated using NUTRIC [33, 35].

In January 2016, a Local Health Board (LHB) medical-surgical ICU multidisciplinary team commenced a prospective before-and-after study designed to compare nutritional delivery betwixt RBF and VBF. The report was designed with the principal aim of confirming the hypotheses: that changing from RBF to VBF would significantly increase the percentage of prescribed feed volume, free energy and protein delivered to adult critically sick patients, without altering feed tolerance. Secondary observations of involvement included betwixt-group comparisons of patients' outcomes including mortality, length of ICU stay (LOICUS) and mechanical ventilation.

Methods

Permissions to undertake study

The study did non crave informed patient consent: the arrangement-level quality improvement initiative was designed to undertake a minimal-chance change in feed procedure which did not exceed the boundaries of standard clinical care, and could not take place practically if prior consent were required [11, 36]. The LHB 'Research and Development' section consented to the piece of work as a service evaluation project without need to pursue upstanding review. The required University Healthcare Sciences and Medical Sciences Academics Ethics Committee approval was obtained earlier data analysis.

ICU characteristics

The adult, medical-surgical ICU is within a commune general pedagogy hospital comprising 600–700 beds. Staffing is provided in a 1-to-one nurse-to-patient ratio, and patients are overseen by a Consultant Intensivist. In the years spanning 2012–2015, quarterly ICU admissions were consistent at 181–204 patients, and average length of mechanical ventilation was iii.vii–iv.0 days [37].

Recruitment

Data collection was undertaken prospectively in consecutively admitted, adult (≥ 18 years) patients who were mechanically ventilated for 72 h or more than and fed for at to the lowest degree 48 h. The Local Health Board intensive intendance unit of measurement (LHB-ICU) does non currently utilize NUTRIC, and the 72-h duration was selected a priori as a method of sample restriction to define a level of illness acuity and longer stay.

Enteral feeding was commenced within 24 h of ventilation in stable patients. Simply patients deemed clinically advisable to receive full feeding by the medical or surgical team were included. VBF was undertaken from day 2 onwards, or in one case a patient was considered suitable to come across full-volume feeds. Patients initially aught by mouth, prescribed trophic feeding, or fed cautiously due to a chance of refeeding syndrome, were included if they were able to progress to full feeding within 72 h of ventilation.

Data was collected for up to 7 days, cessation of mechanical ventilation, death or ICU discharge, whichever occurred first.

Patients were excluded if they were pregnant, and/or were receiving parenteral or oral nutrition to limit the confounding effect of alternative nutritional support [5].

Energy and poly peptide requirements

The following principles were adhered to throughout the RBF and VBF periods.

Exterior the dietitian's working hours, the ICU used a 'starter feeding regimen' devised to closely run across the American Order for Parenteral and Enteral Nutrition (ASPEN) [1] energy and protein recommendations. Information technology used a high protein, i kcal/ml feed containing 6.26 grand of protein/100 ml for most patients (Osmolite HP [38]), or an isocaloric, lower protein, renal-conserving [39] feed for patients with established chronic kidney disease (Osmolite). The dietitian changed the feed prescription if required post-obit assessment, using ASPEN [one] or other relevant guidelines [39, 40], and prescribing additional protein supplements when indicated (Additional file one: Table S1).

Feed was progressed to target rate within 6 h of starting feed, unless prescribed trophic feeding, or considered at risk of refeeding syndrome, when feed targets were met gradually [1].

The 'PERFECT' feeding protocol

The VBF protocol was adapted from PEPuP [13] and entitled: Protein & Energy Requirements Fed for Every Critically ill patient every Fourth dimension (PERFECT); unlike PEPuP, baseline semi-elemental feeds, protein supplements and prophylactic prokinetics were non used.

The PERFECT toolkit instructed nurses how to increase feed rates, (maximum 150 ml/h) to compensate for feed-stops, and render to the initial goal rate at the beginning of the ICU 24 h period. For example, a patient prescribed 1200 ml would commence feeding at 50 ml/h at 0800 h; if the patient'due south feed was off for 8 h, they had received 400 ml of feed prior, and there remained 8 h in the day on recommencing feeding, the deficit 800 ml (1200–400 = 800) would be given over eight h at 100 ml/h (800/8). The 50 ml/h rate would recommence at 0800 h. A single finish-of-day feed bolus up to 200 ml was given to supercede remaining deficits. Boluses were not administered to jejunally fed patients.

Patients' heads were elevated to thirty–45° to reduce aspiration risk, and gastric-residual book (GRV) was checked every 4–6 h. The ICU accepts and replaces GRVs up to 500 ml, with no change in feeding charge per unit in the absence of other signs of intolerance.

Ward pedagogy was delivered by nurse-champions and the dietitian throughout December 2016 at daily and weekly team meetings. 'How to' booklets were kept at each bedside. One-to-one education and feedback was provided at the bedside, and connected advertizement hoc as required. Nursing daily documentation charts included an area to document feed deficits and corrections.

Information collection

Baseline RBF data was collected prospectively for 7 months from April 2016. PERFECT was implemented January 2017, and information again collected prospectively in consecutive admissions for 6 months.

Information included age, gender, weight, height and torso mass index (BMI) in kg/chiliad²; ideal body weight (IBW) if obese, daily energy and protein requirements, the calories and grammes of protein prescribed per kilogramme, hours without feed, and the feed-book prescribed and delivered in millilitres. The hateful daily percent of prescribed feed-volume, protein and free energy delivered (including energy from propofol) was calculated for each patient, based on minimum requirement. Each patient'southward mean daily kilocalories per kilogramme and grammes of protein per kilogramme delivered were noted. A whole 24-hour interval of '0' energy and protein delivery was included as 0% achieved.

Total episodes of witnessed airsickness (gastric contents external to rima oris) and regurgitation (gastric contents within the rima oris) were noted; the expression 'vomit' hereon includes both. Mean daily episodes for patients who vomited were calculated. Patients with diarrhoea were noted. Iii or more daily liquid stools were classified equally diarrhoea using the World Health Organisation definition [41], based on nurse perception of type 6–7 stools using the Bristol Stool Nautical chart [42].

Daily patient GRV (millilitres) and the amount replaced were recorded. Prior to commencing VBF, the ICU changed from using 8-French (Fr) and x-Fr NGTs (used in the RBF catamenia) to using 12-Fr tubes, which withdraw substantially more than GRV [43, 44], making the planned between-group comparison of aspirated volumes meaningless. Prokinetic prescription and the mean pct GRV withdrawn and replaced per patient was compared between groups.

Subgroups of patients meeting < 80%, eighty–89.9% and ≥ 90% of prescribed energy or protein were prepared for comparison, to explore whatsoever differences in clinical outcomes when patients accomplished 'over' 80% of the ASPEN guideline recommendations, or specifically exceeded this.

Mean daily morning blood glucose and insulin requirement (mmol/Fifty) per patient was noted, plus diabetes in by history equally relevant to the frequency of hyperglycaemia [9].

Clinical measures recorded from the Instance Mix Programme Database (coordinated by the Intensive Intendance National Inspect & Research Center) [45] included the Astute Physiology and Chronic Health Evaluation Two (APACHE-Two) severity of illness score, advanced mechanical ventilation (days), ICU and 60-day infirmary bloodshed (days) and length of ICU stay (LOICUS) (days: calculated from day 1 of ICU admission to when 'ready for ICU discharge' to account for delays in discharge); ICU access diagnoses were summarised by surgery, respiratory, cardiovascular and 'other' (pancreatitis, gastrointestinal, neurological, sepsis, trauma, metabolic and haematological).

Statistical analysis

Power analysis

The primary outcomes of interest were energy and poly peptide delivery and feed tolerance, while secondary observations of involvement included ICU and threescore-day mortality, ventilation menses and LOICUS.

For the primary outcomes of interest, the improvements seen in protein and energy delivered to patients in the published VBF studies were classified as a medium-to-large effect size (0.seventy) for free energy, and small-to-medium issue size (0.iv) for protein. The G*Power 3 Ability Analysis Plan [46], version three.1.ix.2, was used to bear a priori analysis for one-tailed t tests and Mann-Whitney U using the estimated consequence sizes, an α-mistake level of 0.05 and an eighty% ability. A minimum sample requirement of 37 patients per group was noted.

Information management

IBM SPSS version 22 (IBM Corp., The states, 2013) [47] was used in descriptive and inferential statistical tests unless otherwise stated. Statistical significance was accustomed at the α-mistake level ≤ 0.05; post hoc significance levels are cited in reporting.

Chiselled variables are reported as counts and percentages. These were analysed for differences in proportional frequency between RBF and VBF groups using χ ² (chi-square) Test of Homogeneity, Test of 2 Proportions, or Fisher's verbal test when jail cell counts were less than 5. Continuous variables are described by their means and standard deviations (±) when usually distributed, or by medians and interquartile range (IQR) when non-normally distributed. Mean and median group differences were compared using independent ii-sample t tests for normally distributed data, or Mann-Whitney U for non-normal distributions.

Effect sizes are reported for percentage differences in the volume, protein and/or energy delivered between the RBF and VBF groups.

Equivalence between the VBF and RBF groups for mean episodes of airsickness was explored [48, 49] using 'ii one-sided tests' (TOST). NCSS version 11 (NCSS, LLC: USA, 2016) statistical analysis software was used with a pre-stated margin of equivalence of xx% of baseline [48]. Combining both patient groups, binomial logistic regression was used to predict the probability of airsickness, adjusted for daily mean GRV, percentage feed volume delivered, and group.

Secondary outcomes of interest: 60-twenty-four hours survival, discharge and extubation charge per unit were subjected to Kaplan-Meier and Cox Regression.

Kaplan-Meier for 60-day hospital survival used ICU admission appointment as start; censoring was based on hospital discharge alive or up to threescore days in hospital alive. For extubation charge per unit analysis, patients who died on the ICU were excluded; day 1 of intubation was the starting point; extubation up to and including 24-hour interval ten was the upshot, with ventilated patients thereafter censored. For LOICUS, censoring was undertaken after day 14.

Cox regression was adjusted for APACHE-II, group, and the per centum of energy or protein delivered; the covariate diagnosis of 'respiratory disease' was added to extubation-rate analysis [50], and BMI 25–35 kg/mⁱⁱ/< 25 and > 35 kg/m² to extubation-rate and bloodshed analyses.

Other

To identify predictors of increased hateful morning blood glucose, insulin and propofol, multiple regression was adjusted for the percentage of prescribed free energy delivered, APACHE-Ii, group, BMI and/or having diabetes.

Results

Patient characteristics

Both the RBF and VBF groups comprised 46 patients. There were no significant differences between the groups' patient demographic, anthropometric and baseline clinical characteristics; other than patients in the VBF group were prescribed more propofol (288.9ml) compared to the RBF group (221.6ml) (p = 0.025), and there were more than patients with a BMI 25–35 kg/m^two in the VBF group (65.two%) than in the RBF group (43.five%) (p = 0.036) (Tabular array one).

Table 1 Baseline demographic and clinical characteristics and diet practices

Full size table

Nutrition practices

All patients were fed by nasogastric tube, bar one in each grouping fed by nasojejunal tube. At that place was no difference in the number of evaluable feeding days (Fig. 1), p = 0.639, or duration without feed (p = 0.379) between groups (Table 1).

There was no significant departure in the volume of feed, total energy or protein prescribed to patients in the RBF and VBF groups (Table one). Mean daily feed volume prescribed was 1312 ml (± 273 ml) in the RBF group, and 1323 ml (± 285 ml) in the VBF group, p = 0.843. Patients in the RBF group were prescribed a hateful 1755 kcal/day (± 398 kcal/twenty-four hours) and the VBF group 1787 kcal/day (± 283 kcal/twenty-four hours) p = 0.662. Daily protein prescription in the RBF group was 85.0 g/day (IQR 70.0–110.0) and ninety.v thousand/mean solar day (IQR 83–120) in the VBF group, p = 0.062.

Prescribed feed volume delivered increased by xi.2% (Table 2) from a median 87.4% in the VBF group to 98.ii% in the VBF group, p ≤ 0.001; r = 0.7 indicated a big issue size. The departure in feed volume delivered was significantly increased in the VBF group compared to the RBF group every day of the evaluable feeding period (Fig. 2). Feed book delivered besides increased significantly past 16.6% in surgical patients receiving VBF (n = 8) compared to those receiving RBF (n = 12), p = 0.001.

Table 2 Difference in feed volume, energy and protein delivered between the RBF and VBF groups

Total size table

The pct of prescribed energy (Table 2) delivered increased significantly by thirteen.iv% in the VBF compared to the RBF group, from 87.9% (± 13.8%) to 101.3% (± 11.vii%), 95% CI [8.1–eighteen.7], p ≤ 0.001; eta² = 0.22 indicated this was a large deviation. Patients in the VBF group received more than daily free energy (1785 kcal/24-hour interval, ± 245 kcal/day) than the RBF group (1541 kcal/day; ± 380 kcal/day), 95% CI [111.1–376.half-dozen], p ≤ 0.001.

The proportion of patients receiving > 90% of their energy prescription increased significantly from 47.eight% in the RBF group to 84.eight% in the VBF group (p ≤ 0.001) (Additional file 1: Table S2).

Protein delivery

Prescribed protein delivered (Table 2) increased significantly past 8.4% (p = 0.02), by a mean 20 thou per day, 95% CI [11.0–29.0], (p ≤ 0.001): from 89.2% (± 19.five%) in the RBF group to 97.half dozen% (± 14.8%) in the VBF group, 95% CI [i.ii–15.6], p = 0.02; a moderately sized difference co-ordinate to the effect size eta² = 0.06. Subgroup analysis found patients receiving over ninety% of prescribed protein increased from 56.v% in the RBF group to 73.ix% in the VBF group, p = 0.134 (Additional file one: Tabular array S3).

Feed tolerance

There was no significant difference in patients experiencing at least 1 day of diarrhoea, with 26 in the RBF grouping (56.five%), and 18 (39.1%) in the VBF group, p = 0.095 (Tabular array iii).

Table 3 Summary of descriptive and inferential assay for feed tolerance

Total size table

The GRV replaced in the RBF (100.0%) and VBF groups (100.0%) p = 0.521 were like, and there was a non-significant difference in prokinetic prescription, with 28% of patients in the RBF group and xxx% in the VBF grouping prescribed prokinetics, p = 0.819 (Tabular array 3).

A Isle of man-Whitney U TOST identified episodes of airsickness reduced by over 20% in the VBF group (Additional file ane: Tabular array S4). The binomial logistic regression adapted odds ratio (Additional file 1: Table S5) constitute that for each boosted one% of prescribed feed delivered, in that location was a 0.942 (5.viii%), 95% CI [0.900–0.985], p = 0.010 decreased odds of airsickness.

Mean morning BG (Table 3) was significantly college in the VBF grouping (8.5 mmol/L) than the RBF group (8 .0 mmol/L), p = 0.034. Adapted multiple regression found diabetes to exist the only predictor of increased mean morning blood glucose, being ane.05 mmol/L greater in people with diabetes, than those without, 95% CI [0.456–1.646], p = 0.001 (Table 4).

Tabular array 4 Multiple regression analysis: showing analysis of morning BG, plus insulin and propofol requirement

Full size table

There was no significant difference in the mean insulin units prescribed to patients between the RBF (median 6.seven; IQR 0.0–38.seven) and VBF (median 24.3; 0.0–39.7) groups, p = 0.248. Though not significantly different in distribution [51], the medians were notably dissimilar (Tabular array iii). Adjusted multiple regression found mean daily insulin prescription was predicted to exist xl.1 units greater in people with diabetes than those without, 95% CI, [29.013–51.163], p ≤ 0.001, and for each increment in APACHE-2 score, insulin prescription was predicted to increment by i.4 units per day, 95% CI [0.514–2.234], p = 0.003.

None of the variables, specifically grouping, BMI, percent free energy delivered or APACHE-2 score used in adjusted multiple regression, predicted propofol prescription (Table 4).

Clinical outcomes

Bloodshed

Total ICU and hospital deaths were the same or similar in each group (Boosted file 1: Table S6). Kaplan-Meier (Additional file 1: Tabular array S6; Fig. 3) and log-rank exam constitute no pregnant difference in survival distribution between groups (p = 0.693). Adjusted Cox regression (Additional file ane: Table S7) constitute neither the per centum of prescribed free energy or protein delivered nor group or BMI range predicted survival time.

Mechanical ventilation

Kaplan-Meier (Fig. four; Additional file ane: Table S6) with log-rank test found patients in the RBF group had a median time to extubation of 8 days, 95% CI [4.7–eleven.3], and the VBF group had a median time of seven days, 95% CI [5.3–viii.7]; p = 0.342.

Adjusted Cox regression (Additional file ane: Table S7) plant that each 1% boosted protein delivery increased the daily probability of extubation 1.022-fold (by 2.two%), p = 0.040, 95% CI [ane.001–1.043]. The surviving 64 patients (minus one extreme outlier) were grouped by percent of prescribed protein delivered: < fourscore%, eighty–89.nine% and ≥ xc%. A further adjusted Cox regression (Boosted file 1: Tabular array S7) found patients receiving fourscore–89.9% of prescribed poly peptide did non have a significantly different time to extubation compared to those meeting < 80%, risk ratio (HR) one.635, p = 0.498, 95% CI [0.395–half dozen.772]; however, the daily probability of being extubated more than than tripled in patients receiving > ninety% of their protein needs compared to the grouping receiving < 80%, Hour 3.473, p = 0.021, 95% CI [1.205–10.014].

Another Kaplan-Meier was run using the same subgroups of per centum prescribed protein delivered. Kaplan-Meier curves (Fig. 5) suggested a essentially increased extubation rate in patients receiving > 90% of their protein needs; the cumulative probability of this group remaining ventilated at twenty-four hour period 10 was 24%; probability was 56% in the group meeting 80–89.ix%, and 69% in the patients who met < 80% of their poly peptide requirements.

Log-rank test found significant differences in the distribution of extubation fourth dimension between the 3 protein ranges, p = 0.012. Pairwise log-rank comparisons (Additional file 1: Tabular array S8) were undertaken to compare ventilation distributions. Using a Bonferroni correction, with significance accepted at the p < 0.0167 level, there was a significant deviation in ventilation distribution between the groups of patients receiving < 80% and ≥ xc% protein, p = 0.006.

The 75th centile is shown in Fig. 5 and Additional file i: Table S8 and demonstrates the time by which 25% of patients were extubated: 25% of those receiving < eighty% of protein were extubated past day ten, 95% CI [4.half dozen–15.4], those receiving 80–89.nine% past twenty-four hour period six, (SE not calculated), and > xc% by day 5, 95% CI [3.ix–5.9].

Length of ICU stay

Kaplan-Meier (Fig. 6; Additional file 1: Table S6) with a log-rank test establish no statistically meaning difference in the LOICUS betwixt groups, χ ² (1) = 0.815, p = 0.367. Adjusted Cox regression identified no significant predictors of discharge rate (Additional file 1: Table S7).

Discussion

This prospective earlier-and-later on study suggests volume-based feeding safely improved patients' feed volume, energy and protein commitment, and that increasing protein delivery increased the rate of extubation, just these factors did not influence mortality or LOICUS.

Changes to delivery of feed volume, energy and poly peptide

The percent free energy increase in the VBF group compares similarly to the VBF studies in other medical-surgical ICUs which improved commitment by 9.1–17% [8, 10,11,12]. The 8.vi% protein increase achieved in the PERFECT written report was exceeded in the Heyland et al. [10,xi,12] PEPuP studies, with their improvements ranging from 11.iii to 14%, which is explained by the broad prescription of 24-g protein modules daily to patients, which were not used in the PERFECT study. In the PERFECT report, the increase in energy and poly peptide delivery in the VBF group meant that patients in this group more closely met the ASPEN diet guideline recommendations targeted by the LHB-ICU, albeit protein targets were still not achieved in the accomplice of patients with a BMI > xxx kg/yardⁱⁱ. The achievement of ane.3 thou of protein per kilogramme bodyweight in patients with a BMI < 29.9kg/1000² meets the minimum prescription recommended by the newly published European Society of Parenteral and Enteral Diet (ESPEN) ICU nutrition guidelines [52].

Like Taylor et al. [9], the pocket-sized subgroup of surgical patients in the PERFECT study'southward VBF group received significantly more than energy and protein than the RBF group. These findings are unlike the surgical ICU study past Declercq et al. [seven], who found no departure in energy or poly peptide delivery using VBF, which was attributed to poor protocol compliance. Heyland et al. [11, 12] acknowledge that simply using a protocol may be bereft to overcome individual unit cultural and systemic barriers. The PERFECT report utilised diverse system-level improvement techniques to facilitate adoption, such every bit identified project leadership, team coproduction, local adaptation, and staff education [53, 54]. Notably, the PERFECT report's RBF group met over 85% of prescribed energy and poly peptide needs, demonstrating the existing positive attitude to diet exercise in the LHB-ICU, which likely fostered readiness to adopt the new approach.