Robot-guided nutrition management platform improves feeding efficacy in ICU patients

Key takeaways:

• The robot-guided smART+ Platform vs. manual care for enteral feeding demonstrated higher feeding efficacy.
• Patients in the smART+ group spent fewer days in the ICU and on ventilation.

Compared with manual care for enterally fed ICU patients, a nutrition management platform guided by a robot met feeding goals more frequently and shortened stay and ventilation duration, according to results published in Clinical Nutrition.

The smART+ Platform (ART MEDICAL) is a robot-guided tool that can control “tube positioning, reflux, gastric pressure and malnutrition,” to ensure timely enteral feeding, according to researchers.

Pierre Singer

“For many years, nutrition in the ICU has been neglected,” Pierre Singer, MD, director of the general intensive care department and head of the Institute of Nutrition Research at Rabin Medical Center, told Healio. “There have been no monitoring tools, no new technological advancements and no studies demonstrating significant advantages, which is why the impact of this comparative study should be important.

“This is a breakthrough in the technology of enteral feeding,” Singer added. “For 40 years, it has been very low tech: a bag with a liquid formula hanging and related to a pump to push by rate/volume of administration a fixed amount of energy/protein during the ICU stay.”

In a randomized clinical trial, Singer and colleagues analyzed 98 adults receiving mechanical ventilation and enteral feeding in the ICU to assess differences in feeding efficacy among patients who received smART+ guided nutrition (n = 48) and patients who received standard/manual care as outlined by the European Society for Clinical Nutrition and Metabolism guideline (n = 50) for 2 to 14 days.

Researchers also sought to find any differences between the groups in terms of gastric residual volumes, ICU duration and ventilation duration.

“In the ICU daily practice, we fail to reach the daily energy/protein target and as a consequence, we may induce undernutrition,” Singer told Healio. “The clinical consequences are a decrease in energy balance, nitrogen balance, increased risks of infection and increased length of ICU stay and length of ventilation.”

Feeding efficacy

Compared with patients receiving standard manual nutrition, patients receiving smART+ guided nutrition showed a lower mean deviation from daily targeted nutrition (energy targets per calorimetry; 10.5% vs. 34.3%), signaling 89.5% feeding efficacy in the smART+ group vs. 65% efficacy in the manual care group.

“This [result] means that from today, the energy/protein target can be reached despite all the obstacles occurring in the ICU journey,” Singer said.

Over the course of the study, patients receiving nutrition by the smART+ Platform were within 90% to 110% of the feeding goal 75.7% of days, whereas this goal was only met 23.3% of the days among patients receiving standard care (P < .0001). Further, those in the standard care group experienced major deviations from feeding goals (> 140% or < 60%) on 29.1% of days, whereas this degree of deviation was only found on 4.8% of days in the smART+ group.

According to researchers, overfeeding was more prevalent in the standard care group vs. smART+ group (13 patients vs. one patient), and these patients received nutrition 33.7% over the target compared with 2.7% over the target in smART+ group patients.

Although underfeeding occurred in more patients receiving nutrition by the smART+ Platform (47 patients vs. 37 patients), researchers found that the degree of underfeeding based on the target was smaller in these patients vs. patients receiving standard care nutrition (10.6% below the target vs. 34.5% below the target).

ICU stay, ventilation duration, safety

Patients in the smART+ group also spent fewer days in the ICU (mean, 10.4 days vs. 13.7 days; aHR = 1.71; 95% CI, 1.13-2.6) and on ventilation (mean, 9.5 days vs. 12.8 days; aHR = 1.64; 95% CI, 1.08-2.51) than patients in the standard care group, which was unexpected, Singer told Healio.

“We know that gastrointestinal intolerance is associated with increased length of stay, but this study is suggesting that if we are able to adapt the enteral feeding according to gastric tolerance, we may reduce length of stay,” he said. “This of course has to be confirmed by further studies.”

Another surprising finding was that smART+ nasogastric tube sensors detected reflux events and were able to monitor gastric function, Singer said.

“As a consequence, the study group had a significantly lower gastric residue and the control group needed much more anti-peristaltic drugs,” he said. “According to the gastric tolerance, the platform was able to adapt itself and provide enteral feeding only when well tolerated. It could be compared to an intelligent ventilator not providing volume if the pressure does not allow it.”

Additionally, patients in the smART+ group only used metoclopramide, a drug to treat nausea and vomiting, for an average of 2 days, whereas patients in the standard care group used it for 25 days.

Notably, no patients from either group reported any treatment-related adverse events, and ICU mortality did not differ between groups.

A ‘holistic solution’

This new nutrition management platform overcomes many challenges to enteral feeding, Singer said.

“The smART+ Platform provides a holistic solution to overcoming many obstacles that usually are not solved in daily practice,” Singer told Healio. “First, it evaluates by measurement of the energy needs. Secondly, it helps the physician to prescribe according to the energy protein target. Third, the nutritional goal is achieved. If tomorrow, the platform is used in the daily practice in the ICU, the administration of enteral feeding will be efficient, safer and give medical nutritional therapy its recognized place.”

Singer further told Healio that this platform is a “game changer” for future studies.

“Until now, most studies were using predictive equations to determine the energy target and mainly were providing this energy with a success of around 60% at best,” he said. “Such an approach would not be acceptable if we were speaking about antibiotic therapy! With the smART + Platform, studies will achieve the target and it will be much more acceptable to compare high- vs. low-energy targets for instance. In addition, the new tool for detecting reflux events and managing enteral feeding should be more explored to better define the gastric tolerance of specific enteral products for specific conditions and its tolerance to the patient, for instance.”

In terms of the future of the smART+ platform, Singer hopes that it will be widely adopted.

“This platform’s future is its integration around the ICU patient bed,” Singer said. “The data which will be accumulated can be used to better predict a patient’s reaction using machine learning. It is a key step toward personalized nutrition. Measuring the needs, prescribing the right regimen and providing it optimally with the lowest rate of complications is clearly an advantage. Integrating this technology into the complexity is another challenge that will be taken in the future.”