Timing of Target Enteral Feeding in the Mechanically Ventilated Patient

Mechanically ventilated patients, within 48 hours of initiating mechanical ventilation, are randomized in a 1:1 fashion to receive trophic enteral feedings for 96 hours followed by advancement to goal feeding rates or initial advancement to goal feeding rates. Primary endpoints are ventilator free days, ICU-free days, gastrointestinal intolerances, development of nosocomial infections, and mortality.

Inclusion criteria

Patients will be eligible for inclusion in the study if they meet the following criteria:

• Mechanical ventilation expected to last at least 72 hours.
• Presence of, or primary physician's intent to place, an enteral feeding tube and begin enteral feeds.

Exclusion criteria

• More than 48 hours elapsed since both inclusion criteria met.
• Patient, legal representative, or physician refuses consent or is unavailable to provide consent.
• Patient, legal representative, or physician not committed to full support (Exception: A patient will not be excluded if he/she would receive all supportive care except for attempts at resuscitation from cardiac arrest).
• Presence of malignant or irreversible condition and estimated 28 day mortality greater than 50%.
• Severe or refractory shock.
• Moribund patients not expected to survive 24 hours from start of enteral feeding (as determined by primary medical team).
• Child-Pugh score greater than 10.
• Presence of partial or complete mechanical bowel obstruction, or ischemia, or infarction.
• Current TPN use or intent to use TPN within 7 days.
• Severe malnutrition with BMI less than 18.5 and/or loss of more than 30% total body weight in the previous 6 months.
• Neuromuscular disease impairing the ability to ventilate spontaneously.
• Laparotomy expected within 7 days.
• Unable to raise head of bed 45°.
• greater than 30% total body surface area burns.
• Absence of GI tract/short bowel syndrome - defined as entire length of small bowel totaling 4 feet or less.
• Presence of high-output (> 500 cc/day) enterocutaneous fistula.
• Age less than 13 years
• Allergy to enteral formula