Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.

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This formal definition and classification of IF, will facilitate communication and cooperation among professionals in clinical practice, organization and management, and research.

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

acid-rich vegetable oil-based enteral and parenteral nutrition is still widely used, newer lipid 53 components such as medium-chain triglycerides and olive oil are safe and well tolerated. Fish 54 oil (FO)-enriched enteral and parenteral nutrition appears to be well tolerated and confers 55 additional clinical benefits, particularly in surgical patients, due to its anti-inflammatory and 56immune-modulating effects. Whilst the evidence base is not conclusive, there appears to be a 57 potential for FO-enriched nutrition, particularly administered peri-operatively, to reduce the rate 58 of complications and intensive care unit (ICU) and hospital stay in surgical ICU patients. The 59 evidence for FO-enriched nutrition in non-surgical ICU patients is less clear regarding its clinical 60 benefits and additional, well-designed large-scale clinical trials need to be conducted in this 61 area. The ESPEN Expert Group supports the use of olive oil and FO in nutrition support in 62 surgical and non-surgical ICU patients but considers that further research is required to provide 63 a more robust evidence base. 64 65 Page 4 of 77 Nutrition support of the critically ill patient 66Patients in an intensive care unit (ICU) are heterogeneous and include surgical and medical 67 patients, mechanically-ventilated or non-ventilated, obese or undernourished, preterm infants to 68 older adults, requiring either short-term or long-term intensive care [1]. Nutrition support is 69 critical in maintaining homeostasis in the ICU patient and to provide nutrients for the 70 maintenance of lean body mass as well as repair and maintenance of organ function and 71 support of defense and healing processes. 72Enteral nutrition (EN) comprises specialized liquid nutrition delivered through a nasogastric or 73 post-pyloric feeding tube into the stomach or small intestine (duodenum/jejunum), respectively 74[2]. The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend 75 that EN should be given to all ICU patients who are not expected to be taking a full oral diet 76 within three days [3]. 77Whilst ESPEN acknowledges that there are no definitive data supporting the early use of EN in 78 terms of clinical outcomes, its guidelines recommend that hemodynamically stable critically ill 79 patients who have a functioning gastrointestinal tract should be fed early (< 24 hours) using an 80 appropriate amount of feed [3]. Early initiation of EN is also recommended by the American 81 Society for Parenteral and Enteral Nutrition (ASPEN) and the Canadian Society of Critical Care 82Medicine (SCCM) [4], as well as the European Society of Intensive Care Medicine (ESICM) [5]. 83Administration of early EN in critically ill patients appears to also have a positive economic 84 impact, with analysis suggesting that it is associated with significantly reduced costs relating to 85 reduction in ICU stay and duration of mechanical ventilation compared with standard care [6]. 86There are a number of nutritional and non-nutritional benefits associa...

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This systematic review and meta-analysis investigated ω-3 fatty-acid enriched parenteral nutrition (PN) vs standard (non-ω-3 fattyacid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω-3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ࣙ70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω-3 fattyacid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49-0.72; P < 0.00001). Patients given ω-3 fatty-acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42-3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36-2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω-3 fatty-acid enriched PN (RR 0.44, 95% CI 0.28-0.70; P = 0.0004). Mortality rate (co-primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65-1.07; P = 0.15) for the ω-3 fatty-acid enriched group. In summary, ω-3 fatty-acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω-3-enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN. (JPEN J Parenter Enteral Nutr. 2020;44:44-57)

Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.