title: Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes.
abstract: BACKGROUND
  Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections.
  
  
  METHODS
  We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery.
  
  
  RESULTS
  The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83).
  
  
  CONCLUSIONS
  In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: D Dante
authors.initials: DD
authors.lastname: Yeh
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Catrina
authors.initials: C
authors.lastname: Cropano
authors.affiliation: 2 Department of Anesthesiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Sadeq A
authors.initials: SA
authors.lastname: Quraishi
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Fuentes
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Haytham M A
authors.initials: HM
authors.lastname: Kaafarani
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
authors.affiliation: 3 Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D015992:Body Mass Index; D016638:Critical Illness / Q000628:therapy; D003428:Cross Infection / Q000517:prevention & control*; D004044:Dietary Proteins / Q000008:administration & dosage; D004750:Enteral Nutrition; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D044342:Malnutrition / Q000628:therapy*; D008875:Middle Aged; D009752:Nutritional Status; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D004044:Dietary Proteins
keywords: clinical protocols; critical illness; enteral nutrition; intensive care unit; nutritional support; protein