[2], RUTFs are a "homogeneous mixture of lipid-rich and water-soluble foods. ENFit versions are available for all product lines in the United States. Remaining NPO after midnight for diagnostic tests and procedures affects 25%–33% of ICU patients and accounts for up to 25% of cessation time. ENFit is a global change to make all enteral (tube feeding) devices specific to tube feeding. Only 1 recommendation (H3a) did not meet this level of agreement, with a final consensus of 64%. Based on expert consensus, we suggest using a standard polymeric formula when initiating EN in the ICU setting. Cultural, ethnic, religious, or individual patient issues may supersede scientific evidence, in some circumstances necessitating the delivery of ANH. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis, infections. Dr Sacks disclosed other relationships with Fresenius Kabi USA, LLC (research grant recipient) and A.S.P.E.N. When adjustments were made for confounding by matching for propensity score, early EN was associated with decreased hospital mortality.86. The range of food uses requires a variety of fats and oils with characteristics tailored to meet these needs. With increased duration of severe illness, the risk for deterioration of nutrition status increases, and priorities between STD and PN become reversed. Can the intestinal dysmotility of critical illness be differentiated from postoperative ileus? Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The applicability of IC may be limited at most institutions by availability and cost. Evidence that early EN makes anastomoses stronger with greater collagen and fibrin deposition and fibroblast infiltration has been shown in a meta-analysis of early EN versus STD with no worsening effect on anastomotic dehiscence (RR = 0.75; 95% CI, 0.39–1.4; P = .39) with the direction favoring early feeding.422 In a 2009 meta-analysis by Lewis et al, a decrease in mortality was demonstrated (RR = 0.41; 95% CI, 0.18–0.93; P = .03).421 Although this difference was lost in the 2011 meta-analysis by Osland et al (RR = 0.71; 95% CI, 0.32–1.56; P = .39), the direction again favored early feeding.422 Concern that postoperative EN would increase aspiration pneumonia has been shown not to be warranted, as there was no difference in pneumonia between early EN and STD (RR = 0.76; 95% CI, 0.36–1.58; P = .46).421 Feeding in the 24 hours following surgery helps reduce postoperative ileus, attenuate dysmotility, and prevent bowel wall edema. 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. R1. 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. Calorically dense formulas are also considered medically necessary for enteral feedings if they are indicated. I1. For all included RCTs, 2 readers completed data abstraction forms (DAFs) examining the data and assessing the quality of the research methodology to produce a shared evaluation achieved by consensus for each study (example of DAF provided in online supplemental material). Learn about our remote access options, Department of Medicine, University of Louisville, Louisville, Kentucky. Rationale: An early, very small trial (20 patients)294 showed that use of a high-fat/low-carbohydrate enteral formulation in patients with respiratory failure reduced duration of mechanical ventilation, compared with a standard formulation. The beneficial effect of PN appears to be lost if given only postoperatively, and if given in the immediate period following surgery, is associated with worse outcome.435 Aggregation of data from 9 studies that evaluated routine postoperative PN‡‡‡‡ References 243, 244, 246, 249250-251, 436437-438 showed a significant 10% increase in complications compared with STD.435 Because of the adverse outcome effect from PN initiated in the immediate postoperative period, Klein et al recommended delaying PN for 5–10 days following surgery if EN continues not to be feasible. Improvement in the clinical course of critical illness may be achieved by early EN, appropriate macro- and micronutrient delivery, and meticulous glycemic control. Adapted from GRADE Working Group. Nutritionally advanced and made without common allergens. N1. The literature search included MEDLINE, PubMed, Cochrane Database of Systemic Reviews, the National Guideline Clearinghouse, and an Internet search using the Google search engine for scholarly articles through an end date of December 31, 2013 (including ePub publications). 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. For most critically ill patients, protein requirements are proportionately higher than energy requirements and thus are not easily met by provision of routine enteral formulations (which have a high nonprotein calorie:nitrogen ratio [NPC:N]). 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. Few studies have specifically compared OO-based IVFE (omega-9 fatty acids as oleic acid) with SO-based IVFE in critically ill patients. Cessation of EN occurs in >85% of patients for an average of 8%–20% of the infusion time (the reasons for which are avoidable in 23% of planned procedures and 65% of all occasions).97,99 While patient intolerance accounts for a third of cessation time, only half of this represents true intolerance. Rationale: Clinicians should determine energy requirements to establish the goals of nutrition therapy. Explaining variance . This guideline will use this term describe Orogastric, Nasogastric and Gastrostomy tube feeding. 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. Rationale: Use of high-protein hypocaloric feeding in hospitalized patients with obesity is associated with at least equivalent (and possible better) outcomes as use of high-protein eucaloric feeding.455 In a retrospective study of 40 obese critically ill surgical and trauma patients, use of high-protein hypocaloric EN was associated with shorter ICU stay, decreased duration of antibiotics, and fewer days of mechanical ventilation compared with use of a high-protein eucaloric diet.465 In 1 of 2 RCTs, use of a parenteral high-protein hypocaloric diet resulted in similar outcomes (hospital LOS and mortality) as a high-protein eucaloric PN regimen.269 Multiple observational trials have shown equivalent nutrition outcomes and nitrogen balance studies between the 2 types of diets (whether by EN or PN).455 Low intake of protein in combination with a hypocaloric diet may worsen mortality in obese patients, as was shown in a prospective observational cohort study of adult ICU patients with class II obesity (BMI, 35–39.9).466. All other consensus-based recommendations reached a level of agreement of 80% or higher. While results from 3 small RCTs comparing an immune-modulating formula (2 with arginine and FO, 1 with FO alone) with a standard enteral formula suggest that such an immunonutrition formula may be shown to provide additional outcome benefits in the future, numbers are insufficient to make a recommendation at this time.176,343,344. 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. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study, Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial, North American summit on aspiration in the critically ill patient: consensus statement, Gastric emptying measurement of liquid nutrients using the (13)C-octanoate breath test in critically ill patients: a comparison with scintigraphy, A model of gastric emptying using paracetamol absorption in intensive care patients, Gastric motility function in critically ill patients tolerant vs intolerant to gastric nutrition. Rationale: Only 1 small trial in adults (40 patients) compared the use of immune-modulating formulations (containing arginine, glutamine, prebiotic fiber, and omega-3 fatty acids) with standard enteral formulations in TBI patients and demonstrated decreased infections.379 The use of EPA and DHA in the neurologically injured population has recently gained significant attention in accelerating recovery after TBI, and future studies may provide further support for this strategy.380. and SCCM conflict-of-interest form for copyright assignment and financial disclosure. This collection of 35 reproducible chapters and 16 food reference charts was written by Marsha and Suzanne, along with parents of children fed by tube, a physician and dietitians, Ellen Duperret, RD and Jude Trautlein, RD. It is for parents ... Objective measures of baseline nutrition status have been described by A.S.P.E.N. 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. [3], RUTFs are used by UNICEF Kid Power malnutrition program, which uses celebrities to go on "global missions" to help save impoverished areas in Africa. Rationale: The risk/benefit ratio for use of PN in the ICU setting is much narrower than that for use of EN. Now imagine “eating” these same foods using your feeding tube. Rationale: At the height of critical illness, EN is being provided to patients who are prone to GI dysmotility, sepsis, and hypotension and thus are at increased risk for subclinical ischemia/reperfusion injuries involving the intestinal microcirculation. Q7. After all the ingredients are added and vigorous stirring is maintained, the mixture is then stirred with more speed and for several minutes. Program within @mayoclinicgradschool is currently accepting applications! In 2001, a landmark trial showed that tight glucose control (TGC) (80–110 mg/dL) with intensive insulin therapy (IIT) was associated with reduced sepsis, reduced ICU LOS, and lower hospital mortality compared with conventional insulin therapy (keeping blood glucose levels <200 mg/dL).280 The effect was more pronounced in SICU than MICU patients.280,281 However, study results were controversial because it was a single-center unblinded trial with high mortality in both arms, and patients received 200–300 g of IV dextrose in the early postoperative regimen.280 The Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) trial282 of 535 patients conducted in 18 ICUs in Germany and the Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock (COIITSS)283 trial of 509 patients conducted in 11 ICUs in France studied the effect of TGC in combination with another therapy compared with moderate glucose control (MGC) in a range of 140–180 mg/dL in a 2 × 2 factorial design. Rationale: The literature supports the concept that bowel sounds and evidence of bowel function (ie, passing flatus or stool) are not required for initiation of EN. Rationale: Use of PN in moderate to severe acute pancreatitis as initial nutrition therapy should be avoided. enteral feeding.) This strategy may optimize the efficacy of PN in the early phases of critical illness by reducing the potential for hyperglycemia and insulin resistance. I2. Found inside – Page 125in selecting enteral formulas depending on the patient's nutritional status and disease state. Enteral feeding protocol Current ... Two types of enteral feeding protocols have been categorized: bolus feeding and continuous infusion. It has been concluded that … 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. Rationale: Early EN is directed toward maintaining gut integrity, reducing oxidative stress, and modulating systemic immunity. No new forest plots were created when a meta-analysis was evaluated. 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. Mortality is lowest in subjects with BMI in the range of 30–40 (class I and II obesity).452,453 This protective effect of moderate obesity is the obesity paradox. The primary etiology of malnutrition in hepatic disease is poor oral intake from multiple factors, including alterations in taste, early satiety, autonomic dysfunction with resultant gastroparesis, slow small bowel motility, and slow orocecal transit. 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. Rationale: Trophic feeds (usually defined as 10–20 mL/h or 10–20 kcal/h) may be sufficient to prevent mucosal atrophy and maintain gut integrity in low- to moderate-risk patients but may be insufficient to achieve the usual end points desired for EN therapy in high-risk patients. Rationale: Diarrhea in ICU patients receiving EN is common but may be serious, as the incidence ranges from 2%–95% and often results in electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination.152 If unable to control the diarrhea, clinicians often stop EN, with resulting inadequate nutrition intake. The EPaNiC study by Casaer et al, in which one-fifth of patients had a sepsis diagnosis, reported that early supplemental PN added to hypocaloric EN resulted in longer hospital and ICU stays, longer durations of organ support, and a higher incidence of ICU-acquired infection than late supplementation.240 Because this patient population has an exaggerated stress response and handles exogenous fuels poorly, the wide risk/benefit ratio with PN may be problematic.405. While clear liquids may be swallowed more easily and, if isotonic, may leave the stomach more rapidly, they are more readily aspirated.439 In an early RCT of 241 patients who had undergone an abdominal operation, there were no significant differences in dietary intolerance between those receiving a clear-liquid diet (n = 135) or a regular diet (n = 106).440 In an RCT involving >400 patients undergoing major GI surgery, Lassen et al showed that giving “normal food” on the first day postoperatively did not increase morbidity or mortality.441 Postoperative nausea occurs with the same frequency (approximately 20%) whether patients are advanced first to clear liquids or to solid meals; symptoms are transient; and there is no difference in postoperative complications.439 Early advancement to oral diet attenuates postoperative dysmotility, and the time to resume bowel function (as evidenced by passage of gas and stool with normal intake of food at will) may be shorter with early diet advancement.441. The recommendation that an anticipated duration of feeding ≥7 days is necessary to ensure a beneficial outcome effect from use of PN postoperatively is extrapolated from the studies on preoperative/perioperative PN.434,435 The findings of Klein et al in 1997 may have been influenced by practice patterns at the time, including hypercaloric feeding and poor glycemic control, both of which are no longer the norm in most ICU settings.435 In another meta-analysis, patients (>60% surgical admissions) who had a relative contraindication to early EN randomized to early PN versus STD showed no difference in 60-day mortality, ICU or hospital LOS, or new infections.242 In a situation in which emergency surgery is performed in a patient at high nutrition risk and the option of preoperative PN or EN does not exist, shortening the period to initiation of postoperative PN may be a reasonable strategy. and Dietitians in Nutrition Support (chair of the Symposium Planning Committee). M1a. Limited support comes from studies showing benefit (trend toward reduced mortality) from early EN compared with STD338339-340 and improved outcomes from early EN (reduced infection, organ failure, ICU LOS, and SIRS) versus delayed EN.341,342 What is not known is what percentage of patients with moderate to severe acute pancreatitis would tolerate advancing to oral diet (similar to the data on patients with mild disease) within 3–4 days from the time of admission and thus not need specialized nutrition therapy. In an observational study of 63 ICU patients with systemic inflammatory response syndrome (SIRS), a stool analysis showed that those with feeding intolerance (14 patients) had significantly lower amounts of anaerobes, including Bifidobacteria, and higher amounts of Staphylococus than those patients without feeding intolerance (49 patients; P ≤ .05). [4], The standard treatment of childhood malnutrition is administered in two phases. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Rationale: Use of ICU- or nurse-driven protocols that define goal EN infusion rate, designate more rapid start-ups, and provide specific orders for handling GRVs, frequency of flushes, and conditions or problems under which EN may be adjusted or stopped has been shown to be successful in increasing the overall percentage of goal energy provided.80,113114115116-117 In addition, volume-based feeding protocols in which 24-hour or daily volumes are targeted instead of hourly rates have been shown to increase volume of nutrition delivered.116 These protocols empower nurses to increase feeding rates to make up for volume lost while EN is held. Multiple companies have created special cleaning brushes to allow for thorough cleaning of all ENFit connectors. In an early study of trauma patients, Jeevanandam et al showed that obese subjects in a SICU derived only 39% of their REE from fat metabolism, compared with 61% in their lean counterparts.451 These patients derived a higher percentage of energy needs from protein metabolism, indicating greater potential for erosion of lean body mass. Contact a qualified healthcare professional if you have any questions regarding your tube feeding product, prescription, supplies or issues related to any of these. RUTFs should be ready to eat without needing to be cooked. It is therefore suggested that a fluid-restricted energy-dense nutrient formulation (1.5–2 kcal/mL) be considered for patients with acute respiratory failure that necessitates volume restriction.297. The need to achieve timely enteral access should be addressed when possible in the operating room. They do not reflect the patient's nutrition status.20,21 While hypoalbuminemia may have prompted the surgeon to initiate nutrition therapy in the first place, serum albumin concentrations would not be expected to change through the course of management until the stress metabolism abates. The task force reached only 64% agreement (9 for and 5 against) to “withhold or limit” SO-based IVFE to 100 g/wk, as opposed to simply “withhold.” Trauma patients provided IVFE-free PN over the first 10 days of hospitalization had a significant reduction in infectious morbidity (pneumonia, P = .05; catheter-related sepsis, P = .04) (Figure 10),266,268 decreased hospital and ICU LOS (P = .03 and P = .02), and shorter duration of mechanical ventilation (P = .01) compared with those receiving SO-based IVFE-containing PN.268 However, the IVFE-free PN formulation was hypocaloric (21 kcal/kg/d vs 28 kcal/kg/d) as a result of leaving off the fat.268 A similar study comparing a hypocaloric IVFE-free regimen (1000 total kcal/d and 70 g of protein/d) versus an SO-based IVFE standard admixture (25 kcal/kg/d and 1.5 g of protein/d) found no significant differences in infectious complications, hospital LOS, or mortality.266 This finding was confirmed by a large observational study that reviewed outcomes in patients who received PN for ≥5 days in multi-international ICUs. A meta-analysis of 5 multicenter trials involving 2463 patients showed a significantly greater mortality in those patients receiving glutamine than in those randomized to placebo (35% vs 31%, respectively; P = .015). 🚨 Our Ph.D. and you may need to create a new Wiley Online Library account. • Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract). Email: compherc@nursing.upenn.edu, Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri, Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon, Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon, Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin, Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington, Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York, Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio, Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana, Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama, Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma, Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. 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. RCTs have investigated the question of whether PN should be administered with or without SO-based IVFE during the first week of hospitalization. B1. Moore et al helped further define the process of chronic critical illness in severely injured trauma patients as the “persistent inflammation, immunosuppression, and catabolism syndrome.”443 In a series of studies, genomic and clinical data from trauma patients and SICU patients with a prolonged course of recovery (>14 days) demonstrated chronic inflammation and a maladaptive immune response that contributed to secondary nosocomial infections and severe protein catabolism.443,444 Clinical features reflect the consequences of chronic critical illness and include prolonged ventilator dependence, brain dysfunction, neuromuscular weakness, neuroendocrine and metabolic changes, muscle wasting, malnutrition, skin breakdown, and symptom distress (eg, pain, anxiety, and depression).445, Recommendations for the chronically critically ill patient have surfaced from experienced institutions and are extrapolated from the critical care literature presented throughout this guideline. Note: Effective 2016, The Joint Commission (TJC) requires that all enteral feeding tubes be outfitted with a ENFit-type connector to prevent inadvertent connection of tubes with different functions (e.g., connecting a feeding administration set to a tracheostomy tube, or an intravenous (I.V.) The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. Found inside – Page 9In patients with diabetes who are on enteral nutrition, the enteral feeds provided can be in the form of either Standard Formulas (SF) or Diabetes Specific Formulas (DSF). Enteral feeding formulas have a tendency to promote ... Rationale: There is a lack of studies addressing the use of exclusive or supplemental PN early in the acute phase of sepsis. EN is clearly not feasible postoperatively if there is evidence of continued obstruction of the GI tract, bowel discontinuity, increased risk for bowel ischemia, or ongoing peritonitis. Rationale: There is no evidence to suggest that a formulation enriched in BCAA improves patient outcomes compared with standard whole-protein formulations in critically ill patients with liver disease. Since disease severity may change quickly, we suggest frequent reassessment of feeding tolerance and need for specialized nutrition therapy. This is usually used for long-term enteral feeding or for patients who cannot use a tube in the nose and throat. It is not intended to replace the advice or instruction of your healthcare professionals, or to substitute medical care. Basically, there is a formula for every need. Based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and VAP be employed. [5] Phase one usually deals with children who are severely malnourished and very ill as a result. Post was not sent - check your email addresses! elemental EXPLANATION: elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb. 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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