Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient
Publication Date: January 14, 2016
Last Updated: March 14, 2022
Recommendations
Nutrition Assessment
Based on expert consensus, we suggest a determination of nutrition risk (eg, nutritional risk screening [NRS 2002], NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy. ()
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Based on expert consensus, we suggest that nutrition assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. We suggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care. ()
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We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement. (VL)
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Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/d) be used to determine energy requirements. ()
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Based on expert consensus, we suggest an ongoing evaluation of adequacy of protein provision be performed. ()
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Initiate EN
We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake. (VL)
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We suggest the use of EN over PN in critically ill patients who require nutrition support therapy. ()
(Low to Very Low)
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Based on expert consensus, we suggest that, in the majority of MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN. ()
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We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration or those who have shown intolerance to gastric EN. ()
(Moderate to High)
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Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach. ()
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Based on expert consensus, we suggest that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support. ()
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Dosing of EN
Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (eg, NRS 2002 ≤3 or NUTRIC score ≤5) who cannot maintain volitional intake do not require specialized nutrition therapy over the first week of hospitalization in the ICU. ()
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We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS) / acute lung injury (ALI) and those expected to have a duration of mechanical ventilation ≥72 hours, as these 2 strategies of feeding have similar patient outcomes over the first week of hospitalization. (H)
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Based on expert consensus, we suggest that patients who are at high nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5, without interleukin 6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24–48 hours while monitoring for refeeding syndrome. Efforts to provide >80% of estimated or calculated goal energy and protein within 48–72 hours should be made to achieve the clinical benefit of EN over the first week of hospitalization. ()
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We suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.2–2.0 g/kg actual body weight per day and may likely be even higher in burn or multitrauma patients. (VL)
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Monitoring Tolerance and Adequacy of EN
Based on expert consensus, we suggest that patients should be monitored daily for tolerance of EN. We suggest that inappropriate cessation of EN should be avoided. We suggest that ordering a feeding status of nil per os (NPO) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery. ()
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We suggest that GRVs not be used as part of routine care to monitor ICU patients receiving EN. (L)
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We suggest that, for those ICUs where GRVs are still utilized, holding EN for GRVs <500 mL in the absence of other signs of intolerance should be avoided. (L)
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We recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided. ()
(Moderate to High)
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Based on expert consensus, we suggest that use of a volume-based feeding protocol or a top-down multistrategy protocol be considered. ()
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Based on expert consensus, we suggest that patients receiving EN should be assessed for risk of aspiration and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed. ()
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We recommend diverting the level of feeding by postpyloric enteral access device placement in patients deemed to be at high risk for aspiration. ()
(Moderate to High)
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Based on expert consensus, we suggest that for high-risk patients or those shown to be intolerant to bolus gastric EN, delivery of EN should be switched to continuous infusion. ()
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We suggest that, in patients at high risk of aspiration, agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), be initiated where clinically feasible. (L)
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Based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and VAP be employed. In all intubated ICU patients receiving EN, the head of the bed should be elevated 30°–45° and use of chlorhexidine mouthwash twice a day should be considered. ()
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Based on expert consensus, we suggest that neither blue food coloring nor any coloring agent be used as a marker for aspiration of EN. Based on expert consensus, we also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the critical care setting. ()
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Based on expert consensus, we suggest that EN not be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment. ()
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Selection of Appropriate Enteral Formulation
Based on expert consensus, we suggest using a standard polymeric formula when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU. ()
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We suggest immune-modulating enteral formulations (arginine with other agents, including eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], glutamine, and nucleic acid) should not be used routinely in the MICU. Consideration for these formulations should be reserved for patients with TBI and perioperative patients in the SICU. (VL)
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We cannot make a recommendation at this time regarding the routine use of an enteral formulation characterized by an anti-inflammatory lipid profile (eg, omega-3 FOs, borage oil) and antioxidants in patients with ARDS and severe ALI, given conflicting data. ()
(Low to Very Low)
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We suggest that a commercial mixed fiber formula not be used routinely in the adult critically ill patient prophylactically to promote bowel regularity or prevent diarrhea. (L)
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Based on expert consensus, we suggest considering use of a commercial mixed fiber-containing formulation if there is evidence of persistent diarrhea. We suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. We suggest considering use of small peptide formulations in the patient with persistent diarrhea, with suspected malabsorption or lack of response to fiber. ()
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Adjunctive Therapy
Based on expert consensus, we suggest that a fermentable soluble fiber additive (eg, fructo-oligossaccharides [FOSs], inulin) be considered for routine use in all hemodynamically stable MICU/SICU patients placed on a standard enteral formulation. We suggest that 10–20 g of a fermentable soluble fiber supplement be given in divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea. ()
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We suggest that, while the use of studied probiotics species and strains appear to be safe in general ICU patients, they should be used only for select medical and surgical patient populations for which RCTs have documented safety and outcome benefit. We cannot make a recommendation at this time for the routine use of probiotics across the general population of ICU patients. (L)
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We suggest that a combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients be provided to those patients who require specialized nutrition therapy. (L)
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We suggest that supplemental enteral glutamine not be added to an EN regimen routinely in critically ill patients. (M)
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When to Use PN
We suggest that, in the patient at low nutrition risk (eg, NRS 2002 ≤3 or NUTRIC score ≤5), exclusive PN be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible. (VL)
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Based on expert consensus, in the patient determined to be at high nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5) or severely malnourished, when EN is not feasible, we suggest initiating exclusive PN as soon as possible following ICU admission. ()
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We recommend that, in patients at either low or high nutrition risk, use of supplemental PN be considered after 7–10 days if unable to meet >60% of energy and protein requirements by the enteral route alone. Initiating supplemental PN prior to this 7- to 10-day period in critically ill patients on some EN does not improve outcomes and may be detrimental to the patient. (M)
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When Indicated, Maximize Efficacy of PN
Based on expert consensus, we suggest the use of protocols and nutrition support teams to help incorporate strategies to maximize efficacy and reduce associated risk of PN. ()
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We suggest that hypocaloric PN dosing (≤20 kcal/kg/d or 80% of estimated energy needs) with adequate protein (≥1.2 g protein/kg/d) be considered in appropriate patients (high risk or severely malnourished) requiring PN, initially over the first week of hospitalization in the ICU. (L)
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We suggest withholding or limiting SO-based IVFE during the first week following initiation of PN in the critically ill patient to a maximum of 100 g/wk (often divided into 2 doses/wk) if there is concern for essential fatty acid deficiency. (VL)
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Alternative IVFEs may provide outcome benefit over soy-based IVFEs; however, we cannot make a recommendation at this time due to lack of availability of these products in the United States. When these alternative IVFEs (SMOF [soybean oil, MCT, olive oil, and fish oil emulsion], MCT, OO, and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN. ()
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Based on expert consensus, use of standardized commercially available PN versus compounded PN admixtures in the ICU patient has no advantage in terms of clinical outcomes. ()
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We recommend a target blood glucose range of 140 or 150–180 mg/dL for the general ICU population; ranges for specific patient populations (postcardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline. (M)
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We recommend that parenteral glutamine supplementation not be used routinely in the critical care setting. (M)
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Based on expert consensus, we suggest that, as tolerance to EN improves, the amount of PN energy should be reduced and finally discontinued when the patient is receiving >60% of target energy requirements from EN. ()
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Pulmonary Failure
We suggest that specialty high-fat/low-carbohydrate formulations designed to manipulate the respiratory quotient and reduce CO2 production not be used in ICU patients with acute respiratory failure. (VL)
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Based on expert consensus, we suggest that fluid-restricted energy-dense EN formulations be considered for patients with acute respiratory failure (especially if in a state of volume overload). ()
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Based on expert consensus, we suggest that serum phosphate concentrations should be monitored closely and phosphate replaced appropriately when needed. ()
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Renal Failure
Based on expert consensus, we suggest that ICU patients with acute renal failure (ARF) or AKI be placed on a standard enteral formulation and that standard ICU recommendations for protein (1.2–2 g/kg actual body weight per day) and energy (25–30 kcal/kg/d) provision should be followed. If significant electrolyte abnormalities develop, a specialty formulation designed for renal failure (with appropriate electrolyte profile) may be considered. ()
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We recommend that patients receiving frequent hemodialysis or CRRT receive increased protein, up to a maximum of 2.5 g/kg/d. Protein should not be restricted in patients with renal insufficiency as a means to avoid or delay initiating dialysis therapy. (VL)
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Hepatic Failure
Based on expert consensus, we suggest a dry weight or usual weight be used instead of actual weight in predictive equations to determine energy and protein in patients with cirrhosis and hepatic failure, due to complications of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia. We suggest that nutrition regimens avoid restricting protein in patients with liver failure, using the same recommendations as for other critically ill patients. ()
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Based on expert consensus, we suggest that EN be used preferentially when providing nutrition therapy in ICU patients with acute and/or chronic liver disease. ()
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Based on expert consensus, we suggest that standard enteral formulations be used in ICU patients with acute and chronic liver disease. There is no evidence of further benefit of branched-chain amino acid (BCAA) formulations on coma grade in the ICU patient with encephalopathy who is already receiving first-line therapy with luminal-acting antibiotics and lactulose. ()
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Acute Pancreatitis
Based on expert consensus, we suggest that the initial nutrition assessment in acute pancreatitis evaluate disease severity to direct nutrition therapy. Since disease severity may change quickly, we suggest frequent reassessment of feeding tolerance and need for specialized nutrition therapy. ()
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We suggest not providing specialized nutrition therapy to patients with mild acute pancreatitis, instead advancing to an oral diet as tolerated. If an unexpected complication develops or there is failure to advance to oral diet within 7 days, then specialized nutrition therapy should be considered. (VL)
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We suggest that patients with moderate to severe acute pancreatitis should have a naso-/oroenteric tube placed and EN started at a trophic rate and advanced to goal as fluid volume resuscitation is completed (within 24–48 hours of admission). (VL)
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We suggest using a standard polymeric formula to initiate EN in the patient with severe acute pancreatitis. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time. (VL)
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We suggest the use of EN over PN in patients with severe acute pancreatitis who require nutrition therapy. (L)
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We suggest that EN be provided to the patient with severe acute pancreatitis by either the gastric or jejunal route, as there is no difference in tolerance or clinical outcomes between these 2 levels of infusion. (L)
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Based on expert consensus, we suggest that, in patients with moderate to severe acute pancreatitis who have intolerance to EN, measures should be taken to improve tolerance. ()
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We suggest that the use of probiotics be considered in patients with severe acute pancreatitis who are receiving early EN. (VL)
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Based on expert consensus, we suggest that, for the patient with severe acute pancreatitis, when EN is not feasible, use of PN should be considered after 1 week from the onset of the pancreatitis episode. ()
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Surgical Subsets
Trauma
We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate posttrauma period (within 24–48 hours of injury) once the patient is hemodynamically stable. (VL)
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We suggest that immune-modulating formulations containing arginine and FO be considered in patients with severe trauma.
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We recommend that, similar to other critically ill patients, early enteral feeding be initiated in the immediate posttrauma period (within 24–48 hours of injury) once the patient is hemodynamically stable. (VL)
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Based on expert consensus, we suggest the use of either arginine-containing immune-modulating formulations or EPA/DHA supplement with standard enteral formula in patients with TBI. ()
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Based on expert consensus, we suggest early EN (24–48 hours postinjury) in patients treated with an OA in the absence of a bowel injury. ()
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Based on expert consensus, we suggest providing an additional 15–30 g of protein per liter of exudate lost for patients with OA. Energy needs should be determined as for other ICU patients. ()
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Burns
Based on expert consensus, EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. PN should be reserved for those burn patients for whom EN is not feasible or not tolerated. ()
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Based on expert consensus, we suggest that IC be used when available to assess energy needs in burn patients with weekly repeated measures. ()
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Based on expert consensus, we suggest that patients with burn injury should receive protein in the range of 1.5–2 g/kg/d. ()
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Based on expert consensus, we suggest very early initiation of EN (if possible, within 4–6 hours of injury) in a patient with burn injury. ()
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Sepsis
Based on expert consensus, we suggest that critically ill patients receive EN therapy within 24–48 hours of making the diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and the patient is hemodynamically stable. ()
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We suggest not using exclusive PN or supplemental PN in conjunction with EN early in the acute phase of severe sepsis or septic shock, regardless of patients' degree of nutrition risk. (VL)
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We cannot make a recommendation regarding selenium, zinc, and antioxidant supplementation in sepsis at this time due to conflicting studies. (M)
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Based on expert consensus, we suggest the provision of trophic feeding (defined as 10–20 kcal/h or up to 500 kcal/d) for the initial phase of sepsis, advancing as tolerated after 24–48 hours to >80% of target energy goal over the first week. We suggest delivery of 1.2–2 g protein/kg/d. ()
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We suggest that immune-modulating formulas not be used routinely in patients with severe sepsis. (M)
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Postoperative Major Surgery (SICU Admission Expected)
Based on expert consensus, we suggest that determination of nutrition risk (eg, NRS 2002 or NUTRIC score) be performed on all postoperative patients in the ICU and that traditional visceral protein levels (serum albumin, prealbumin, and transferrin concentrations) should not be used as markers of nutrition status.
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We suggest that EN be provided when feasible in the postoperative period within 24 hours of surgery, as it results in better outcomes than use of PN or STD. (VL)
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We suggest the routine use of an immune-modulating formula (containing both arginine and fish oils) in the SICU for the postoperative patient who requires EN therapy.
()(Moderate to Low)
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We suggest enteral feeding for many patients in difficult postoperative situations such as prolonged ileus, intestinal anastomosis, OA, and need of vasopressors for hemodynamic support. Each case should be individualized based on perceived safety and clinical judgment. ()
(Low to Very Low)
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Based on expert consensus, we suggest that, for the patient who has undergone major upper GI surgery and EN is not feasible, PN should be initiated (only if the duration of therapy is anticipated to be ≥7 days). Unless the patient is at high nutrition risk, PN should not be started in the immediate postoperative period but should be delayed for 5–7 days. ()
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Based on expert consensus, we suggest that, upon advancing the diet postoperatively, patients be allowed solid food as tolerated and that clear liquids are not required as the first meal. ()
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Chronically Critically Ill
Based on expert consensus, we suggest that chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS >21 days) be managed with aggressive high-protein EN therapy and, when feasible, that a resistance exercise program be used. ()
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Obesity in Critical Illness
Based on expert consensus, we suggest that early EN start within 24–48 hours of admission to the ICU for obese patients who cannot sustain volitional intake. ()
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Based on expert consensus, we suggest that nutrition assessment of the obese ICU patient focus on biomarkers of metabolic syndrome, an evaluation of comorbidities, and a determination of level of inflammation, in addition to those parameters described for all ICU patients. ()
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Based on expert consensus, we suggest that nutrition assessment of the obese ICU patient focus on evidence of central adiposity, metabolic syndrome, sarcopenia, BMI >40, SIRS, or other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality. ()
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Based on expert consensus, we suggest that high-protein hypocaloric feeding be implemented in the care of obese ICU patients to preserve lean body mass, mobilize adipose stores, and minimize the metabolic complications of overfeeding. ()
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Based on expert consensus, we suggest that, for all classes of obesity, the goal of the EN regimen should not exceed 65%–70% of target energy requirements as measured by IC. If IC is unavailable, we suggest using the weight-based equation 11–14 kcal/kg actual body weight per day for patients with BMI in the range of 30–50 and 22–25 kcal/kg ideal body weight per day for patients with BMI >50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight per day for patients with BMI of 30–40 up to 2.5 g/kg ideal body weight per day for patients with BMI ≥40. ()
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Based on expert consensus, we suggest that, if available, an enteral formula with low caloric density and a reduced NPC:N be used in the adult obese ICU patient. While an exaggerated immune response in obese patients implicates potential benefit from immune-modulating formulas, lack of outcome data precludes a recommendation at this time. ()
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Based on expert consensus, we suggest additional monitoring to assess worsening of hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation in the obese critically ill patient receiving EN. ()
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Based on expert consensus, we suggest that the obese ICU patient with a history of bariatric surgery receive supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy. In addition, evaluation for and treatment of micronutrient deficiencies such as calcium, thiamin, vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, along with the trace minerals iron, selenium, zinc, and copper, should be considered. ()
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Nutrition Therapy End-of-Life Situations
Based on expert consensus, we suggest that ANH is not obligatory in cases of futile care or end-of-life situations. The decision to provide ANH should be based on evidence, best practices, clinical experience and judgment; effective communication with the patient, family, and/or authorized surrogate decision maker; and respect for patient autonomy and dignity. ()
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Recommendation Grading
Overview
Title
Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient
Authoring Organizations
American Society for Parenteral and Enteral Nutrition
Society of Critical Care Medicine
Publication Month/Year
January 14, 2016
Last Updated Month/Year
July 27, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult
Health Care Settings
Hospital, Long term care
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D018529 - Nutritional Support
Keywords
enteral nutrition, parenteral nutrition, Nutrition Support