Enteral Nutrition Initiation and Advancement

Volume-Based and Top-Down Feeding Protocols

Among the many challenges to the delivery of a “goal” dose of enteral calories is the cessation of tube-feeding for procedures, patient “intolerance,” tube dislodgment, diarrhea, transfers, imaging, or other common ICU events. Improved delivery of total caloric goals has consistently been demonstrated through the use of a protocolized approach that aims to minimize interruptions and to empower the bedside caregiver (ICU nurse) to make adjustments to ensure that caloric goals are met. A “volume-based” protocol targets a daily volume of enteral feeding rather than an hourly rate, and allows adjustments in the infusion rate or additional boluses to make up for volume lost when enteral feeds are held or interrupted.1 When initiating and advancing enteral nutrition the following is recommended:

1. Start enteral tube feed with full strength formula at 20 ml/hour.
2. Increase rate by 20 ml/hour every 6-8 hours to goal rate if low risk for intolerance.
3. If high risk for enteral feed intolerance, open abdomen, or known severe ileus, maintain trophic rate (20-30 ml/hr) for first 24 hours, then advance if well tolerated.
4. For BURN and HEAD injured patients with no abdominal trauma or other contraindications, advance 20 ml every 4 hours to goal rate.

NOTE: When a patient is transferred from one level of care to the next in a rapid fashion (e.g., Forward Operating Base (FOB) to Role 3 to Role 4 (e.g., Landstuhl Regional Medical Center (LRMC)), it is difficult to monitor feeding tolerance during AE or Critical Care Air Transport Team (CCATT) evacuation. It may be best to hold initiation of feeds until patient will be at one location for at least 24 hours. The risk of aspiration in an awake patient or intolerance in an intubated patient is real and necessitates appropriate repeated examinations until feeding tolerance is well established prior to any flights.