Do

 bolus  enteral  feedings  

offer  more  advantages  
than  continuous  enteral  
feedings  in  the  critical  
care  setting?  

By:  Lauren  Gray,  Rachel  Flynn,  Paige  Dinehart,  Anna  DeCarlo,  Sam  
Heidersdorf,  Bethany  Keenan,  Brianna  Goodwin,  Kristen  Youtsey,  
and  Rachel  Lepore  
Why  is  Nutrition  so  Important?  
● Supply  the  body  with  energy  needed  to  thrive  
● Support  &  healing  
● Maslow’s  hierarchy  of  needs  
https://www.medicalnewstoday.com/articles/320056.php

● Clinical  outcomes

https://www.livingandlovi
ng.co.za/child/12-­‐‑tips-­‐‑
encourage-­‐‑good-­‐‑eating-­‐‑
https://www.chowhound.com/foo habits-­‐‑c hild
d-­‐‑news/194479/how-­‐‑to-­‐‑s tick-­‐‑to-­‐‑
healthy-­‐‑eating-­‐‑resolutions-­‐‑f or-­‐‑the-­‐‑
new-­‐‑year/
 Important  Things  to  Consider
Malnutrition  is  present  in   30-­‐‑50% patients  in  acute-­‐‑care  
settings

● Diminished  organ  function

● Longer  hospital  stays
● Increased  risk  of  falls
● Increased  risk  of  pressure  ulcers
● Loss  of  muscle  mass
● Reduced  functioning  of  immune  system
● Significantly  increased  risk  of  mortality
 Feeding  Options  in  ICU
Enteral  Feeding
● Continuous  Feeding  
● Cyclic  Feeding  
● Intermittent  Feeding  
https://www.saintlukeskc.org/health-­‐‑
library/bolus-­‐‑tube-­‐‑f eeding
● Bolus  Feeding  
https://alaska.providence.org/health-­‐‑
library/content?contentTypeID=3&contentID=83042
Picot  Question
Do  bolus  enteral  feedings  offer  more  
advantages  than  continuous  enteral  
feeding  in  the  critical  care  setting?  

https://hpu.libguides.com/c.php?g=303393&p=20 246 00
Current   Practices
● St.  Joseph’s  
● Yolanda  Fahrney,  RD
○ Continuous  feeding  in  ICU  patients
■ Patient’s  have  less  risk  for  aspiration
■ Less  cost  to  the  hospital  
■ GI  motility  is  already  decreased  
https://www.facebook.com/CarondeletStJosephsHospital/
Current   Practices
● Mayo  Clinic  
● Renee  Crawford,  RDN
○ Continuous  feeding  in  ICU  patients
https://www.bizjournals.com/phoenix/blog/healt
h-­‐‑c are-­‐‑daily/2013/04/mayo-­‐‑c linic-­‐‑hospital-­‐‑i n-­‐‑
phoenix-­‐‑tops.html

■ Too  much  fluid  with  water  flushes  before  and  after  bolus  feeds  
■ Time  consuming  for  nursing  staff
■ Patients  are  unstable  so  continuous  feeding  is  what  is  needed  for  
these  patients  
■ Patients  metabolic  needs  may  vary,  so  there  are  different  formulas  
that  can  be  used
■ Diarrhea  is  a  common  side  effect  
Current   Practices
● Loma  Linda  University  Health  
○ Registered  Dietician
○ Continuous  feeding  in  ICU  patients
■ Continuous  protein  and  nutrient  
delivery  to  the  patient  which  is  needed  
for  their  current  state
■ Depends  on  metabolic  needs
https://www.onescdvoice.com/place/loma-­‐‑l inda-­‐‑
university-­‐‑medical-­‐‑c enter/
Current   Practices
● HonorHealth  -­‐‑ Dietician  
○ Dependant  on  the  patient  condition
○ Intermittent  is  most  natural
○ Continuous  is  able  to  go  at  a  much  slower  
rate  so  it  is  easier  for  the  patient  to  digest
○ Convenience  
○ Continuous  is  used  unless  there  is  an  issues   https://www.wellness.com/dir/6512886/hospital/honorhe
alth-­‐‑s cottsdale-­‐‑s hea-­‐‑medical-­‐‑c enter/scottsdale/az#referrer

(then  changed  to  Bolus)

 Synopsis
1. Bolus   enteral  feedings
2. Continuous  enteral  feedings
3. Neither  one  is  better
 Synopsis  of  Current  Literature
Bolus   Feedings:
● EARLY  feedings  allow  faster  consumption   of  sufficient  calories
● Rapid  nutrition  given  through  a  bolus  may  cause  colonic  and  gastric  
distension
● Greater  risk  of  diarrhea  and  aspiration  
● Overall  improved  protein  synthesis  in  critically  ill  patients
● Significant  increases   in  gastric  volume,  velocity,  and  superior  mesenteric   flow  
compared   to  continuous   enteral  feedings
● Make  up  for  “missed”  feeds
 Synopsis  of  Current  Literature
Continuous   Feedings:
● Most  commonly  used   to  help   with  diarrhea,   prevention   of  
dumping   and  increasing   pH  of  gastric   contents
● Greater   incidence   of  constipation
● Reduces   antro-­‐‑pyloric   pressure   and  causes   colonic  
hypomotility
● Abolishes   entero-­‐‑hormonal   response   to  ingestion
● Decreases   insulin   and  release   of  Cholecystokinin  
(gallbladder)
● Unphysiological http://www.brainkart.com/article/Nursing-­Process-­-­The-­Patie nt-­Rece ivi ng-­
a-­Tube-­Feeding_32067/
 Synopsis  of  Current  Literature
Continuous   Feedings:
● Better  controlled  blood  sugar  and  prealbumin  levels
● Improves  protein  balance
● More  anti-­‐‑catabolic
● Low  aspiration  risk  and  improved  tolerance
● Increase  in  metabolic  advantages
● Ability  to  check  pH  is  an  issue
 Synopsis  of  Current  Literature
Inconclusive  evidence:

● No  difference  regarding  adequate  calories  or  complications  with  diarrhea,  

constipation,  emesis,  or  abdominal  distention
● No  differences  between  the  two  on  their  impact  on  insulin  usage  and  
glycemic  variability
● No  differences  in  time  to  reach  the  goal  nutrition

https://chartcons.com/100-­‐‑unanswerable-­‐‑
questions-­‐‑will-­‐‑blow-­‐‑mind/
Strengths  and  Limitations  
● Strength  of  articles  as  a  whole:  from  well  
respected  journals    and  research  is  current
● Strength  of  specific  articles:  Level  of  
evidence

Strengths  That  Can   Also  Be  Weaknesses   ...mobile-­

cuisine.com
Strengths  and  Limitations  
● Limitation  of  all  the  articles  as  
a  whole:  conflicting  or  
inconclusive  evidence  
● Limitation  of  specific  articles:  
Low  level  of  evidence    for  some  
articles  or  poorly  designed  
Strengths  That  Can  Also  Be  Weaknesses  

studies ...mobile-­cuisine.com
As  a  group,  we  recommend...
As  a  group,  we  recommend...

CONTINUOUS  
ENTERAL  FEEDINGS
Evidenced   Based  Nursing  Recommendations  
● Interdisciplinary  team  considerations:
○ Type  of  Formula  needed
○ Caloric  needs
○ Blood  sugar  limitations
○ Interruptions
○ Aspiration  risk    
○ Muscle  mass   https://www.healthecareers.com/article/healthcare-­ news/i nterd iscip lin ary-­
healthcare-­team

● Ultimately,  need  more  research

Overall  Application
● More  research  is  needed
● Approach  hospitals  about  performing  
this  research
● Government  funding
● Funding  through  U  of  A
Timeline
● 1  month:  present  to  St.  Joseph’s  and  Banner  
about  possibility  of  doing  research  with  them
● 2  months:  apply  for  funding
● 4  months:  gather  willing  participants  and  start  
the  study
Timeline
● 5  months:  finish  gathering  data
● 6  months:  finish  analyzing  data
● 9  months:  publish  findings
○ present  findings  to  all  healthcare  staff  at  St.  
Joseph’s  and  Banner  University  Hospital  
○ Spend  2  months  teaching  hospital  staff  in  
ICUs
Timeline
● 10  months:  ensure  adequate  equipment  
available
○ Determine  costs
○ Determine  feasibility
● 11  months:  policy  changes  to  ICUs
● 12  months:  reevaluate  effectiveness  in  clinical  
setting
The  Cost  of  Nutrition
● Factors  to  consider:
○ Staffing
○ Supplies
○ Home  nutrition
○ Complications https://www.wpclipart.com/money/dollar_symbol/symb ol
_2/dollar_sign_13_ gree n.pn g.html
Study  Costs
● Outreach
● Personnel
○ training
● Equipment
● Patient  outcomes
Risks  vs   Benefits
PATIENT
● Aspiration
● Diarrhea  
● Vomiting
● Improves  protein  synthesis  with  bolus
● Bolus  feeding  more  physiologically  normal  
Risks  vs   Benefits
HOSPITAL
● More  expensive
○ Extra  staff  time
○ More  complications
Overall  Summary
● Continuous  feeding  more  common  in  
hospital  ICU’s  
● Research  varies  depending  on  location  and  
hospital  preference  
● Feeding  is  critical  
 Evaluation
● Group  recommendation  of  continuous  feeding  
● Further  research  needed;  would  like  to  look  into  
continuous  feeding  with  the  use  of  bolus  feeding
● Earlier  feedings  =  Better  outcomes  
Questions

https://www.learngeek.co/2016/07/4-­‐‑vital-­‐‑l d-­‐‑questions/
How  do  Maslow’s  
hierarchy  of  needs  
pertain  to  the  
importance  of  
feeding  in  the  
hospital  setting?
https://medium.com/m/global-­
identity?redirectUrl=https%3A%2F%2Fhack erno on.com% 2Fwh at-­maslo w-­can-­te ach-­ us-­
about-­leadership-­a10 881 98 874
Which  of  the  following  is  NOT  true  about  
malnutrition  in  hospitalized  patients?

a. It  increases  mortality  rate

b. It  promotes  development   of  pressure  ulcers
c. It  affects    ~1-­‐‑5%  of  hospitalized  patients
d. It  can   lead   to  longer   hospital  stays
What  are  the  benefits  of  
bolus  feeding  a  patient?

https://alfa.saddleback.edu/data/tube-­feeding
What  are  some  factors  to  
take  into  consideration  
when  deciding  whether  a  
patient  would  benefit  
more  from  continuous  or  
bolus  enteral  feeding?
 Open-­‐‑ended  discussion:  
Do  you  think  bolus  or  
continuous  enteral  
feeding  is  more  beneficial  
for  patients  in  the  hospital  
setting?
 Case  study:  A  74-­‐‑year-­‐‑old   woman  has   been  in   the  
hospital  for  72   hours,  after  a  fall,  for  a  severe  hip  
fracture  and   subdural  hematoma.     She  has   been  placed  
on  bed   rest  and   the  providers  have  decided   to  start  her  
on  enteral   feeding  due   to  her  being   sedated  for  the  past  3  
days.  She   has  a  history  of  diabetes  mellitus,  
hypertension,  and   aspiration  pneumonia.   She   is  
currently   very  frail  and   has  hypoactive  bowel  sounds.  
Based  on  the  patient’s  current  state,  would  continuous  
or  bolus   enteral  feeding   be  more  beneficial  for  this  
patient?  Why?  
 Resources
Bear, D.E., Hart, N., Puthucheary, Z. (2018) Continuous or intermittent feeding: Pros and cons. Current Opinion in Critical

Care 24(4): 256-261. DOI: 10.1097/MCC.0000000000000513

Chowdhury, A. H., Murray, K., Hoad, C. L., Costigan, C., Marciani, L., Macdonald, I. A., … Lobo, D. N. (2016). Effects of

Bolus and Continuous Nasogastric Feeding on Gastric Emptying, Small Bowel Water Content, Superior Mesenteric

Artery Blood Flow, and Plasma Hormone Concentrations in Healthy Adults: A Randomized Crossover Study. Annals of

Surgery, 263(3), 450–457. http://doi.org/10.1097/SLA.0000000000001110

Di Girolamo, F., Situlin, R., Fiotti, N., & Biolo, G. (2017). Intermittent vs. continuous enteral feeding to prevent catabolism in

acutely ill adult and pediatric patients. Current opinion in clinical nutrition and metabolic care, 20(5), 390-395. doi:

10.1097/MCO.0000000000000397

Evans, C. D., Forbes, R., Jones, C., Cotterman, R., Njoku, C., Thongrong, C., … Stawicki, S. P. (2016). Continuous versus

bolus feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization?. International Journal of

Critical Illness & Injury Science, 6(1), 9-15. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795366/
 Resources
Japar, S., Soh, K. L., Hussin, H. C., Ibrahim, N. A., Ong. S. L., & Soh, K. G. (2017), Trend of enteral feeding among

critically-ill patients in adult icus in malaysia. International Journal of GEOMATE, 12(30), 115-120. DOI:

http://dx.doi.org/10.21660/2017.30.2631.

Kadamani, I., Itani, M., Zahran, E., and Taha, N. (2014). Incidence of aspiration and gastrointestinal complications in critically

ill patients using continuous versus bolus infusion of enteral nutrition: A pseudo-randomized control trial. Australian

Critical Care 27(4), 188-193. doi: https://doi.org/10.1016/j.aucc.2013.12.001.

Patel, J., Rosenthal, M., & Heyland, D. (2018). Intermittent versus continuous feeding in critically ill adults. Current opinion in

critical nutrition and metabolic care 21(2), 116-120. doi: 10.1097/MCO.0000000000000447

Powers, J. & Samaan, K. (2014). Malnutrition in the ICU population. Critical Care Nursing Clinics of North America, 26(4),

227-242. doi: https://doi.org/10.1016/j.ccell.2014.01.003

 Resources
Shahriari, M., Rezaei, E., Bakht, L., & Abbasi, S. (2015). Comparison of the effects of enteral feeding through the bolus and

continuous methods on blood sugar and prealbumin levels in ICU in-patients. Journal of Education and Health

Promotion 4(95). doi:10.4103/2277-9531.171809

Tavares de Araujo, M.V., Gomes, C.P. & Caporossi, C (2014). Enteral nutrition in critical patients; should the administration

be continuous or intermittent?. Nutricion Hospitalaria 29(3), 563-567 DOI:10.3305/NH.2014.29.3.7169

University Hospital, Basel, Switzerland. (2018). Protein delivery in intermittent and continuous enteral nutrition in ICU

patients. Clinical Trials.gov. Retrieved from https://clinicaltrials.gov/ct2/show/NCT03587870