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Recommendations Summary

EE: Thermic Effect of Feeding in Critically Ill 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    EE: Thermic Effect of Continuous Feeding in Critically Ill

    Whether or not a critically ill patient is receiving continuous infusion of an energy source (e.g., energy-containing intravenous fluids or medications, enteral nutrition or parenteral nutrition), the registered dietitian nutritionist (RDN) may proceed with the indirect calorimetry measurement. Based on limited evidence comparing continuous feeding to fasting, the presence of a thermic effect of continuous feeding (TEF) is inconclusive. Waiting for infusion of an energy source or holding continuous feedings before conducting a measurement of resting metabolic rate (RMR), may not be necessary.

    Rating: Weak
    Conditional

    EE: Thermic Effect of Bolus or Intermittent Feeding in Critically Ill

    Following a bolus or intermittent feeding in the critically ill patient, the RDN should wait at least four hours to do an indirect calorimetry measurement. Delaying the indirect calorimetry measurement is recommended, because of the potential TEF during the post-absorptive state.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are no potential risks or harms associated with the application of this recommendation.

    • Conditions of Application

      • The recommendation EE: Thermic Effect of Continuous Feeding applies to critically ill patients who are fasting or receiving any continuous energy sources
      • The recommendation: EE: Thermic Effect of Bolus or Intermittent Feeding applies to critically ill patients who are receiving any bolus or intermittent energy sources.

    • Potential Costs Associated with Application

      No obvious costs are associated with the application of this recommendation.

    • Recommendation Narrative

      EE: Thermic Effect of Continuous Feeding in Critically Ill

      Three studies were included in the evidence analysis of this recommendation:

      • Two neutral-quality validity and reliability studies (Alves et al, 2009; Frankenfield and Ashcraft, 2012)
      • One neutral-quality randomized controlled trial (RCT) (Cankayali et al, 2004).

      Three studies address the thermic effect of continuous feeding in critically ill patients. Due to methodological limitations of the available research, no conclusions can be drawn.

      EE: Thermic Effect of Bolus or Intermittent Feeding in Critically Ill

      No studies were included in the evidence analysis of this recommendation. However, two review articles provide support for the recommendation.

      • Discontinuing EN and PN at least four hours before indirect calorimetry testing will ensure a post-absorptive state (McClave and Snider, 1992)
      • If patients are receiving intermittent feedings (EN, PN or meals), then indirect calorimetry should be conducted four hours after the feeding. However, if thermogenesis is to be included in the REE, then measure at 12 hours (da Rocha et al,  2006).

    • Recommendation Strength Rationale

      • Conclusion statement is Grade III for continuous feeding
      • Conclusion statement is Grade V for bolus or intermittent feeding and thus the recommendation EE: Thermic Effect of Bolus or Intermittent Feeding in Critically Ill is consensus.

    • Minority Opinions

      None.