Current Guidelines on Enteral Nutrition in Intensive Care Unit (ICU): Nestle

Speaker: Dr. Subhash Kumar Todi, Critical Care Consultant, Director – Critical Care & Emergency Medicine, Head of Department – Dept of Academics & Health Research, AMRI Hospitals, Kolkata. Presented at: CRITICARE 2011 New Delhi, Workshop on Nutrition in Critical Care

Summary

Guidelines are a means of recommendations through which experts share their clinical insights on existing information. There needs to be a carefully selected enteral formulation which should be handed out with caution. The amount of enteral nutrition to be fed to a patient is determined on the basis of the nature of the disease. This dosage needs to be carefully monitored and the reactions should be thoroughly recorded for an effective impact. Dr. Todi explains various usages and grades with the help of colour codes in terms of ‘should do’ (green), ‘may be done’ (amber) and ‘should not be done’ (red).

Guidelines are used for the review and analysis of the pertinent availability of current literature by a team of experts and blend of expert’s opinion and clinical practicality. Practice guidelines are not intended as absolute requirements. The use of the practice guidelines does not, in anyway, project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. Heterogeneous population, elective surgery, trauma, burn, transplant, sepsis etc. are also limitations. Changing standard of care glucose control, hypoalimentation, reduced line sepsis should also be included.

All patients who are not expected to be on a full oral diet within 3 days should receive EN, if they have a functioning gut. In patients with functioning gut, enteral feeding is preferred over parenteral. In the setting of hemodynamic compromise (patients requiring significant hemodynamic support, including high-dose catecholamine agents, alone or in combination with large volume fluid or blood product resuscitation to maintain cellular perfusion), EN should be withheld until the patient is fully resuscitated and/or stable. If early EN is not feasible or available over the first 7 days following admission to the ICU, no nutrition support therapy (standard therapy) should be provided. Enteral feeding should be started early within the first 24-48 hours following admission. The feedings should be advanced towards goal over the next 48-72 hours. The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy (SCCM/ASPEN). During the acute and initial phase of critical illness, an exogenous energy supply in excess of 20-25 kcal/kg BW/day may be associated with a less favorable outcome. During recovery (anabolic flow phase), the aim should be to provide 25-30 total kcal/kg BW/day.

Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. In units where obtaining small bowel access is feasible, the Canadians recommend the routine use of small bowel feedings. Either gastric or small bowel feeding is acceptable in the ICU setting (SCCM). In adjunctive therapy administration of probiotic agents has been shown to improve outcome (most consistently by decreasing infection) in specific critically ill patient populations involving transplantation, major abdominal surgery, and severe trauma. No recommendation can currently be made for use of probiotics in the general ICU population because of a lack of consistent outcome effect.