A multicenter randomized controlled trial comparing intermittent enteral feeding while in right lateral tilt position to standard care among mechanically ventilated adult Intensive Care Unit (ICU) patients

This study will compare a strategy of intermittent enteral feeding while in right lateral tilt position (intervention) to the current standard practice of continuous enteral feeding (control) among mechanically ventilated patients in ICU. The choice of feeding bag/formulae, ‘target daily feed volume’ and target continuous infusion rate will be determined as per standard practice or at the discretion of the treating clinician. The ‘target daily feed volume’ will be derived as a product of target continuous infusion rate and the number of hours left in the day (maximum 24 hours). The ‘bolus target’ volume in the intermittent feeding arm will be one-third of the target daily feed volume, and must not exceed 10 ml/kg unless reviewed by the clinician. Patients will have routine posture turns every 3-4 hours as per the standard nursing practice in both arms. The study intervention period is for the duration that a patient require enteral feeding via the gastric feeding tubes while in ICU. Signs of feed intolerance (such as vomiting, oral regurgitation of gastric contents, abdominal pain or tenderness, distension, inability to pass flatus >3 days or abnormal abdominal imaging) and volume of gastric aspirates will be monitored in both arms as per standard practice. If feeding is well tolerated and the gastric aspirate volume is low (<150 ml), then the subsequent feed rate (in the standard arm) or bolus feed volume (in the intermittent arm) should be increased in incremental steps (100 to 150 ml) to gradually achieve the target rate or the target volume. In other words, the subsequent bolus feed volume in the intermittent arm will gradually and incrementally go up only if a patient shows none of the six signs of feed intolerance mentioned above, and has low gastric aspirates (<150 ml). In addition, the protocol is pragmatic and allows clinicians and the unit dietitian to adjust bolus volumes as deemed suitable. The use of pro-kinetic agents will be as per the discretion of the treating clinician in both arms in response to either feed intolerance or large gastric aspirates. The patients in the intervention group will be fed thrice a day with up to one-third of the target feed volume for the day infused within one hour each time. The patients will be nursed in routine semi-recumbent right lateral tilt position (or sitting upright position if out of bed) during the feeding hour and for another two hours post-feeding. The recommended feed times are 5-6 am, 12-1 pm and 8-9 pm, but these timings can be adjusted by the bedside nurse if deemed appropriate. This imply that each day patients in the interventional arm would spend 3 hours thrice a day in right lateral tilt position during feed times and rest of the 15 hours would be spent in supine or left lateral tilt position at the discretion of the bedside nurse. If a patient is being initiated on intermittent enteral feeding for the first time, then the volume of the first feed will be 150 ml, and the subsequent feed volumes will be titrated, in incremental steps until bolus target is attained, according to feed tolerance and volume of gastric aspirates. For all the study patients, gastric tube must be aspirated just before any scheduled upper airway or upper GI procedure. Feeds should restart after the procedure as per the current standard practice if and when there are no medical contraindications. For patients in the intervention group, feed timings can be adjusted at the discretion of the bedside nurse so that the patient do not receive any enteral feeds at least 4 hours before any scheduled upper airway or upper GI procedures.