Clinical nutrition in ICU: Latest ESPEN guideline

The European Society for Clinical Nutrition and Metabolism (ESPEN) has released an updated version of its enteral nutrition (EN) and parenteral nutrition (PN) in adult critically ill patients published 2006 and 2009 respectively.

The present guideline is published in the journal Clinical Nutrition.

Key Recommendations:

• Medical nutrition therapy shall be considered for all patients staying in the ICU, mainly for more than 48 h.


• A general clinical assessment should be performed to assess malnutrition in the ICU until a specific tool has been validated.


• Every critically ill patient staying for more than 48 h in the ICU should be considered at risk for malnutrition.


• Oral diet shall be preferred over enteral nutrition, EN or parenteral nutrition, PN in critically ill patients who are able to eat.


• If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN.


• If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients rather than early PN.


• In the case of contraindications to oral and EN, PN should be implemented within three to seven days.


• Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished patients.


• To avoid overfeeding, early full EN and PN shall not be used in critically ill patients but shall be prescribed within three to seven days.


• Continuous rather than bolus EN should be used.


• Gastric access should be used as the standard approach to initiate EN.


• In patients with gastric feeding intolerance not solved with prokinetic agents, postpyloric feeding should be used.


• In patients deemed to be at high risk for aspiration, postpyloric, mainly jejunal feeding can be performed.


• In critically ill patients with gastric feeding intolerance, intravenous erythromycin should be used as a first line prokinetic therapy.


• Alternatively, intravenous metoclopramide or a combination of metoclopramide and erythromycin can be used as a prokinetic therapy.


• In critically ill mechanically ventilated patients, EE should be determined by using indirect calorimetry.


• If indirect calorimetry is used, isocaloric nutrition rather than hypocaloric nutrition can be progressively implemented after the early phase of acute illness.


• Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute illness.


• After day 3, caloric delivery can be increased up to 80-100% of measured EE.


• If predictive equations are used to estimate the energy need, hypocaloric nutrition (below 70% estimated needs) should be preferred over isocaloric nutrition for the first week of ICU stay.


• In patients who do not tolerate full dose EN during the first week in the ICU, the safety and benefits of initiating PN should be weighed on a case-by-case basis.


• PN, parenteral nutrition should not be started until all strategies to maximize EN tolerance have been attempted.


• During critical illness, 1.3 g/kg protein equivalents per day can be delivered progressively.


• The amount of glucose (PN) or carbohydrates (EN) administered to ICU patients should not exceed 5 mg/kg/min.


• The administration of intravenous lipid emulsions should be generally a part of PN.


• Intravenous lipid (including non-nutritional lipid sources) should not exceed 1.5 g lipids/kg/day and should be adapted to individual tolerance.


• In patients with burns > 20% body surface area, additional enteral doses of GLN (0.3-0.5 g/kg/d) should be administered for 10-15 days as soon as EN is commenced.


• In critically ill trauma, additional EN doses of GLN (0.2-0.3 g/ kg/d) can be administered for the first five days with EN. In case of complicated wound healing, it can be administered for a longer period of ten to 15 days.


• In ICU patients except for burn and trauma patients, additional enteral GLN should not be administered.


• In unstable and complex ICU patients, particularly in those suffering from liver and renal failure, parenteral GLN -dipeptide shall not be administered.


• High doses of omega-3-enriched EN formula should not be given by bolus administration.


• EN enriched with omega-3 FA within nutritional doses can be administered.


• High doses omega-3 enriched enteral formulas should not be given on a routine basis.


• Parenteral lipid emulsions enriched with EPA þ DHA can be provided in patients receiving PN.


• To enable substrate metabolism, micronutrients should be provided daily with PN.


• Antioxidants as high dose monotherapy should not be administered without proven deficiency.


• In critically ill patients with measured low plasma levels, vitamin D3 can be supplemented.


• EN should be delayed
  
  
  
  • if shock is uncontrolled and hemodynamic and tissue perfusion goals are not reached, whereas low dose EN can be started as soon as shock is controlled with fluids and
    vasopressors/inotropes, while remaining vigilant for signs of bowel ischemia;
  
  
  • in case of uncontrolled life-threatening hypoxemia, hypercapnia or acidosis, whereas EN can be started in patients with stable hypoxemia, and compensated or permissive hypercapnia and acidosis;
  
  
  • in patients suffering from active upper GI bleeding, whereas EN can be started when the bleeding has stopped and no signs of re-bleeding are observed;
  
  
  • in patients with overt bowel ischemia;
  
  
  • in patients with abdominal compartment syndrome; and
  
  
  • if gastric aspirate volume is above 500 ml/6 h.
  
  
  
  


• Low dose EN should be administered
  
  
  
  • in patients receiving therapeutic hypothermia and increasing the dose after rewarming;
  
  
  • in patients with intra-abdominal hypertension without abdominal compartment syndrome, whereas temporary reduction or discontinuation of EN should be considered when intra-abdominal pressure values further increase under EN; and
  
  
  • in patients with acute liver failure when acute, immediately life-threatening metabolic derangements are controlled with or without liver support strategies, independent
    on grade of encephalopathy.
  
  
  
  


• Early EN should be performed
  
  
  
  • in patients receiving ECMO
  
  
  • in patients with traumatic brain injury
  
  
  • in patients with stroke (ischemic or hemorrhagic)
  
  
  • in patients with spinal cord injury
  
  
  • in patients with severe acute pancreatitis
  
  
  • in patients after GI surgery
  
  
  • in patients after abdominal aortic surgery
  
  
  • in patients with abdominal trauma when the continuity of the GI tract is confirmed/restored
  
  
  • in patients receiving neuromuscular blocking agents
  
  
  • in patients managed in the prone position
  
  
  • In patients with the open abdomen
  
  
  • regardless of the presence of bowel sounds unless bowel ischemia or obstruction is suspected in patients with diarrhea
  
  
  
  


• In non-intubated patients not reaching the energy target with an oral diet, oral nutritional supplements should be considered first and then EN.


• In non-intubated patients with dysphagia, texture-adapted food can be considered. If swallowing is proven unsafe, EN should be administered.


• In non-intubated patients with dysphagia and a very high aspiration risk, postpyloric EN or, if not possible, temporary PN during swallowing training with removed nasoenteral tube can be performed.


• Trauma patients should preferentially receive early EN instead early PN.


• In obese patients, energy intake should be guided by indirect calorimetry. Protein delivery should be guided by urinary nitrogen losses or lean body mass determination (using CT or other tools). If indirect calorimetry is not available, energy intake can be based on "adjusted body weight." If urinary nitrogen losses or lean body mass determination are not available, protein intake can be 1.3 g/kg "adjusted body weight"/d.


• Electrolytes (potassium, magnesium, phosphate) should be measured at least once daily for the first week.


• In patients with refeeding hypophosphatemia ( < 0.65 mmol/l or a drop of > 0.16 mmol/l), electrolytes should be measured 2- 3 times a days and supplemented if needed.


• In patients with refeeding, hypophosphatemia energy supply should be restricted for 48 h and then gradually increased.

For further reference follow the link: https://doi.org/10.1016/j.clnu.2018.08.037