Background
      Feeding protocols are considered to be an effective strategy              
           to maximize the benefits and minimize the risks of enteral nutrition 
          in critically ill patients. 
      Components of feeding protocols may include orders for
         Early initiation of enteral nutrition
         Use of motility agents
         Gastric residual volumes
         Head of the bed elevation
         Use of small bowel feeding tubes
      The benefits of such protocols would be:
         to standardize the delivery of EN
          to automate the provision of EN 
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      What do Guidelines say?
     “Use of a feeding protocol that incorporates prokinetics at initiation, 
     higher GRVs (250 mls) and use of post pyloric feeding tubes should 
     be considered”
                                                    “Evaluating gastric residual volume 
                                                    (GRV) in critically ill patients is an 
                                                    optional part of a monitoring plan 
         “Use of enteral feeding protocols          to assess tolerance of EN. “ Avoid 
         increases the overall percentage of        holding EN when GRV < 250 mls.
         goal calories provided and should          Consensus, imperative
         be implemented.” Avoid holding EN 
         for GRVs < 500 mls.  Grade: C, B
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      RCT Level of Evidence
         RCTs of aggressive feeding protocols
             Results in better protein-energy intake
             Associated with reduced complications and improved survival
           Taylor et al Crit Care Med 1999; Martin CMAJ 2004; Doig GS JAMA 2008
        However, the estimates of their effectiveness are limited due to:
                the nature of small single-center studies 
              
                 the bundling with many other interventions in cluster 
                  randomized controlled trials.
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  Purpose
  Purpose
    To evaluate the effect of an ICU site-based feeding protocol on 
    nutrition practices and outcomes in the context of an international 
    multicenter, observational study. 
    Objective
    To compare the following performance criteria between             
    sites that did or did not use a feeding protocol: 
       
         Use of EN
       
         Time to start  EN
       
         Adequacy of enteral nutrition
       
         Adequacy of overall nutrition
       
        Clinical outcomes  
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   Primary Outcomes
            Overall nutritional adequacy
            Enteral nutrition adequacy
   Overall nutritional adequacy = as the total amount of calories or protein 
     received (from EN + appropriate PN + propofol) /prescribed x 100%
     Overall EN adequacy = as the total amount of calories or protein 
            received (from EN) /prescribed x 100%
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