What are the guidelines for enteral feeding in critically unwell unstable patients in the Intensive Care Unit (ICU)?

From the Guidelines

Early enteral nutrition (EN) should be initiated within 24-48 hours in critically ill unstable ICU patients if the gastrointestinal tract is functional, with either trophic/hypocaloric or early full enteral feeding being appropriate strategies. The choice between these strategies should be based on patient tolerance and clinical judgment, with trophic/hypocaloric feeding potentially being preferred in patients with sepsis or septic shock who are not tolerating enteral feeds 1. Start with a low-rate continuous feeding (10-20 mL/hour) using a standard polymeric formula (1-1.5 kcal/mL) through a nasogastric tube, and gradually increase by 10-20 mL/hour every 4-8 hours as tolerated, targeting 20-25 kcal/kg/day in the acute phase. For patients on vasopressors, begin EN when doses are stable or decreasing (norepinephrine <0.3 mcg/kg/min), monitoring for signs of feeding intolerance such as increased vasopressor requirements, abdominal distension, or high gastric residual volumes (>500 mL) 1. Use prokinetic agents like metoclopramide (10 mg IV every 6 hours) or erythromycin (100-250 mg IV every 6-8 hours) for gastroparesis. Consider post-pyloric feeding in patients with high aspiration risk or persistent intolerance to gastric feeding. Implement a feeding protocol that includes regular assessment of nutritional goals, daily monitoring of tolerance, and checking gastric residual volumes every 4-6 hours. Early EN helps maintain gut barrier function, reduces bacterial translocation, modulates the inflammatory response, and improves overall outcomes in critically ill patients, even those with hemodynamic instability.

Some key considerations in enteral feeding in critically ill patients include:

• The importance of individualizing nutrition therapy based on the patient's specific needs and clinical status 1
• The potential benefits of trophic/hypocaloric feeding in reducing infection risk and improving outcomes 1
• The need to monitor for signs of feeding intolerance and adjust the feeding strategy accordingly 1
• The importance of using prokinetic agents and considering post-pyloric feeding in patients with gastroparesis or high aspiration risk 1

Recent studies have highlighted the importance of avoiding overfeeding in critically ill patients, as this can lead to adverse outcomes such as increased morbidity and mortality 1. Therefore, it is essential to carefully monitor the patient's nutritional status and adjust the feeding strategy to meet their individual needs. Overall, early enteral nutrition is a crucial component of care for critically ill patients, and its implementation should be guided by the latest evidence and clinical expertise.

From the Research

Enteral Feeding Guidelines

• The guidelines for enteral feeding in critically unwell unstable patients in the Intensive Care Unit (ICU) emphasize the importance of early initiation of enteral nutrition, with studies suggesting that commencing enteral nutrition within 12 hours of admission can improve nutritional outcomes 2, 3.
• A nurse-led enteral nutrition feeding protocol can improve nutritional intake in ICU patients, with one study showing that 90% of patients achieved their caloric target within 96 hours after admission 3.
• The choice of feeding route, such as nasojejunal or nasogastric, can also impact tolerance and outcomes, with nasojejunal feeding associated with reduced gastric residual volumes and improved tolerance 4.

Timing of Enteral Nutrition Initiation

• Research suggests that initiating enteral nutrition at admission, rather than delaying until 24 to 48 hours after admission, can improve nutritional status, reduce length of ICU stay, and decrease complications such as gastric retention and pulmonary infection 5.
• However, the optimal timing of enteral nutrition initiation may depend on individual patient factors, and further research is needed to determine the best approach for specific patient populations.

Challenges and Barriers to Optimal Enteral Nutrition Delivery

• Common challenges and barriers to optimal enteral nutrition delivery in the ICU include airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation 2.
• Enteral feeding intolerance, such as high gastric residual volumes, can also impact nutritional outcomes and is associated with a higher mortality rate 6.
• Standardized enteral feeding protocols and interdisciplinary collaboration can help address these challenges and improve nutritional outcomes for critically ill patients 3, 6.