A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice

Abstract

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

Medical nutrition therapy and clinical outcomes in critically ill adults: a European multinational, prospective observational cohort study (EuroPN)

“…Similar to this longitudinal survey, we also identified a ramp-up of intakes reaching a plateau about one week after ICU admission. This shows that the current clinical practice is already following the recently published recommendations made by a group of experts in critical care nutrition with the intention to provide practical tips in complement to the active ESPEN guideline [ 25 ].…”

“…This prospective multinational cohort study in critically ill patients staying more than 5 days in the ICU showed that median calorie intake was slightly below the recommend target of 20–25 kcal/kg of the 2019 ESPEN guideline, whereas protein intake was clearly below the 2019 recommendation of 1.3 g/kg. Outcome analyses showed that moderate daily macronutrient intake of 10–20 kcal/kg and 0.8–1.2 g protein/kg, both approaching currently recommended targets [ 25 ], was associated with earlier weaning from IMV, and, for calories, with longer survival compared to a daily intake above or below these moderate intakes.…”

Identification, Prevention and Management of Malnutrition in the Critically Ill Patients

“…While a protein target of greater than 1.2 g/kg/day could be taken into consideration during the rehabilitation phase, low-dose protein maximum up to 0.8 g/kg/day can be given during the early stages of critical illness. The prevalence of refeeding syndrome should be monitored daily by measuring plasma phosphate, and a phosphate loss of 30% should be treated with high-dose thiamine and a reduction in the rate of enteral feeding (17). Events happening before, during, and after the ICU stay is probably significant to the overall recovery trajectory; therefore, nutrition for the critically sick patient should not be evaluated in isolation time periods.…”

Safety in enteral nutritional therapy: knowledge of patients and caregivers

“…Nutritional therapy, indicated for patients at nutritional risk or with malnourishment, is considered an important resource for reducing these rates and financial costs (Williams et al, 2020). Frequently, enteral nutrition therapy (ENT) has been the alternative of choice to promote the maintenance or recovery of the nutritional status of patients with chronic diseases and in critical conditions (Schneider, Momma & Manns, 2007;Friesecke, Schwabe, Stecher & Abel, 2014;Preiser et al, 2021).…”