{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T17:24:47Z","timestamp":1787073887213,"version":"build-2736575974"},"reference-count":19,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Critically ill surgical patients frequently fail to achieve prescribed enteral nutrition targets because of feeding interruptions and variability in conventional physician-directed feeding practices. Although volume-based feeding (VBF) has been proposed to improve nutritional delivery, concerns remain regarding refeeding syndrome and gastrointestinal intolerance. The aim of this study was to evaluate whether a Volume-Based Plus (VBF+) protocol integrating volume-targeted feeding with mandatory refeeding risk stratification and a standardized semi-elemental enteral formula improves nutritional delivery without increasing gastrointestinal or metabolic complications. Materials and Methods: We conducted an ambispective before-and-after implementation study (retrospective control phase, prospective intervention phase) in the surgical intensive care unit of a tertiary care center between January 2023 and March 2026. Ninety-six patients requiring enteral nutrition for \u22653 days were enrolled (48 control and 48 intervention). Both groups underwent the same refeeding risk stratification to guide feeding strategy, while the intervention group additionally received the standardized VBF+ protocol with risk-stratified caloric advancement and volume-based compensation for feeding interruptions, and a standardized semi-elemental enteral formula. The primary outcomes were median daily caloric delivery (% of target) and mean daily protein delivery (g\/kg\/day). Multivariable regression analyses adjusted for Nutritional Assessment Form (NAF), APACHE II score, and Charlson Comorbidity Index (CCI) were performed. Results: The VBF+ protocol was independently associated with higher caloric delivery (\u03b2 = 31.2 percentage points, 95% CI 17.6 to 44.8; p &lt; 0.001) and higher protein delivery (\u03b2 = 0.168 g\/kg\/day, 95% CI 0.040\u20130.297; p = 0.011). Longitudinal analysis showed a significantly faster increase in protein delivery in the intervention group (p &lt; 0.001), while the group-by-time interaction for caloric delivery did not reach statistical significance (p = 0.073). Rates of gastrointestinal intolerance and metabolic complications were comparable between groups; as VBF+ bundled the compensatory algorithm with a semi-elemental formula, this gastrointestinal benefit is hypothesis-generating. Conclusions: In this before-and-after study, the VBF+ bundle protocol was associated with improved caloric and protein delivery and reduced gastrointestinal intolerance; because the algorithm and formula were not evaluated independently, the gastrointestinal benefit remains hypothesis-generating and requires confirmation in randomized trials.<\/jats:p>","DOI":"10.3390\/medicina62081591","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T16:12:11Z","timestamp":1787069531000},"page":"1591","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Risk-Stratified, Volume-Based Plus Enteral Nutrition Protocol with Semi-Elemental Formula in Critically Ill Surgical Patients: A Before-and-After Implementation Study"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-3507-5497","authenticated-orcid":false,"given":"Pawit","family":"Aue-apinya","sequence":"first","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4922-8099","authenticated-orcid":false,"given":"Gelan","family":"Miao","sequence":"additional","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0285-6596","authenticated-orcid":false,"given":"Kaweesak","family":"Chittawatanarat","sequence":"additional","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"},{"name":"Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-9515-3483","authenticated-orcid":false,"given":"Srisuluk","family":"Kacha","sequence":"additional","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"},{"name":"Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9963-0365","authenticated-orcid":false,"given":"Natsuda","family":"Phothikun","sequence":"additional","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"},{"name":"Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-1998-8587","authenticated-orcid":false,"given":"Atirut","family":"Supphapipat","sequence":"additional","affiliation":[{"name":"Division of Surgical Critical Care, Nutrition and Metabolism, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"},{"name":"Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"R268","DOI":"10.1186\/cc10546","article-title":"Identifying critically ill patients who benefit the most from nutrition therapy: The development and initial validation of a novel risk assessment tool","volume":"15","author":"Heyland","year":"2011","journal-title":"Crit. 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