Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Abstract

PurposeTo provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.MethodsWe aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.ResultsWe formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.ConclusionsWe suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.

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“…Early enteral nutrition is generally recommended as standard of care in critical illness . It should only be postponed in uncontrolled shock, severe acidosis, hyperlactatemia and/or hypoxemia, increased gastric residual volume, abdominal obstruction, and/or abdominal compartment syndrome . Details are found in Supplementary Table .…”

Esophageal feeding tube placement and the associated complications in 248 cats

“…Anorexia is a common clinical manifestation of illness that can compromise clinical outcome and it is often observed as a nonspecific sign of illness in cats . Early and appropriate nutritional support is crucial for recovery from illness in both human and veterinary medicine . This support addresses the nutrient requirements to assist in recovery, including but not limited to cellular metabolism, tissue healing, and immunocompetence …”

Nutrition Therapy in Australia and New Zealand Intensive Care Units: An International Comparison Study

“…The provision of nutrition therapy to critically ill patients is a widely accepted international standard of care . Practice guidelines assist clinicians to implement evidence‐based nutrition therapy and generally recommend that nutrition, delivered via an enteric tube (termed enteral nutrition [EN]), be started within 24–48 hours of admission to the intensive care unit (ICU) in the hemodynamically stable patient . Delivery of nutrition in this way has been associated with reduced infective complications, length of ventilation, time in the ICU, and mortality .…”

“…Practice guidelines assist clinicians to implement evidence‐based nutrition therapy and generally recommend that nutrition, delivered via an enteric tube (termed enteral nutrition [EN]), be started within 24–48 hours of admission to the intensive care unit (ICU) in the hemodynamically stable patient . Delivery of nutrition in this way has been associated with reduced infective complications, length of ventilation, time in the ICU, and mortality . Beyond these elements, however, there exists several areas of uncertainty due to lack of definitive evidence, specifically, the effect of nutrition risk, use of indirect calorimetry vs predictive equations, optimal timing of nutrition, the amount of energy and protein to provide, and how best to optimize nutrition delivery.…”