ENTERAL NUTRITION.pptx

Nutrition support in critically ill patients: Enteral nutrition
David Seres, MD, Nutrition support in critically ill patients: Enteral nutrition-Uptodate Feb 04,
2019
Dr. Kanika Chaudhary

OVERVIEW
• INTRODUCTION
• DEFINITION
• BENEFITS OF ENTERAL NUTRITION
• PATIENT SELECTION-INDICATIONS & CONTRAINDICATIONS
• INITIATION OF EN
• ESTIMATING ENERGY/PROTEIN REQUIREMENTS
• FORMULATIONS
• AMOUNT & RATE
• MONITORING
• COMPLICATIONS OF EN

INTRODUCTION
• Critically ill patients are at particular risk of malnutrition, which occurs in up to
40% of the cases.
• The metabolic changes that occur in response to stress lead to an increase in protein
catabolism, resulting in a significant loss of lean body mass, which in turn results in
a higher incidence of complications, especially infection, increase in wound
dehiscence and other unfavourable outcomes.
Seron-Arbeloa C, Zamora-Elson M, Labarta-Monzon L, Mallor-Bonet T. Enteral nutrition in critical care. J Clin Med Res. 2013 Feb;5(1):1-11. doi:
10.4021/jocmr1210w. Epub 2013 Jan 11. PMID: 23390469; PMCID: PMC3564561.

INTRODUCTION
• The main purpose of nutritional support is to prevent malnutrition and its associated complications, by
modulating the stress response of the patients.
• This can be achieved by:
(1) providing the appropriate doses of macro- and micronutrients to meet the calculated or measured needs
(2) avoiding complications associated with nutritional support
(3) reducing nitrogen deficits
(4) modulating the inflammatory response through the use of different substrates

DEFINITION
• Enteral nutrition support refers to the provision of calories, protein, electrolytes,
vitamins, minerals, trace elements, and fluids via an intestinal route.
David Seres, MD, Nutrition support in critically ill patients: Enteral nutrition-Uptodate Feb 04, 2019

Benefits of Enteral Nutrition(EN)
1) Maintaining structural/functional gut integrity, thus attenuating intestinal permeability
2) Attenuate oxidative stress and inflammatory response, while maintaining humoral
immune responses
3) Decreased bacterial translocation
4) Modulation of metabolism to decrease insulin resistance
Barash M, Patel JJ. Gut luminal and clinical benefits of early enteral nutrition in shock. Current Surgery Reports. 2019 Oct;7(10):1-8.
Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020 Jan;48(1):122-125. doi:
10.1097/CCM.0000000000003965. PMID: 31414992.

5) In shock, enteral feeding improve the hepatic, portal and mesenteric blood flow, hepatic and intestinal
tissue oxygenation, and hepatic energy store
6) EN promotes enterocyte secretion of mucin-2 protein, which maintains a mucus layer and helps flush
pathogens
7) EN promotes commensal bacteria to protect against enteric pathogens
8) Improved wound healing-> reduces the severity of illness, complications, and ICU Length of stay (LOS)
Benefits of Enteral Nutrition(EN)
Barash M, Patel JJ. Gut luminal and clinical benefits of early enteral nutrition in shock. Current Surgery Reports. 2019 Oct;7(10):1-8.
Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020 Jan;48(1):122-125. doi:
10.1097/CCM.0000000000003965. PMID: 31414992.

PATIENT SELECTION
 INDICATIONS
 Intensive care unit patients who present with malnutrition or a high probability of
developing malnutrition during their hospital stay and those who are not expected to
be on a full oral diet within three days should receive specialized enteral and/or
parenteral nutritional support.

 CONTRAINDICATIONS
Hemodynamic instability by
itself, unless severe, is not a
contraindication for enteral
nutrition if there is evidence for
adequate volume resuscitation and
tissue perfusion
Khalid I, Doshi P, DiGiovine B. Early enteral
nutrition and outcomes of critically ill patients
treated with vasopressors and mechanical
ventilation. Am J Crit Care. 2010
May;19(3):261-8. doi: 10.4037/ajcc2010197.
Erratum in: Am J Crit Care. 2010
Nov;19(6):488. PMID: 20436064.

 CONTRAINDICATIONS

1. Medical nutrition therapy shall be considered for all patients staying in the
ICU, mainly for more than 48 h
Grade of Recommendation: GPP- strong consensus (100% agreement)
2. Every critically ill patient staying for more than 48 h in the ICU should be
considered at risk for malnutrition.
Strong consensus (96% agreement)
2019 ESPEN guideline on clinical nutrition in the intensive care unit
Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC. ESPEN
guideline on clinical nutrition in the intensive care unit. Clinical nutrition. 2019 Feb 1;38(1):48-79.

3. Oral diet shall be preferred over EN or PN in critically ill patients who are able to
eat.
Grade of recommendation: GPP - strong consensus (100% agreement)
4. If oral intake is not possible, early EN (within 48 h) in critically ill adult patients
should be performed/initiated rather than delaying EN
Grade of recommendation: B-strong consensus (100% agreement)
5. If oral intake is not possible, early EN (within 48 h) shall be performed/initiated
in critically ill adult patients rather than early PN
Grade of recommendation: A - strong consensus (100% agreement)

INITIATION OF EN
Baiu I, Spain DA. Enteral Nutrition. JAMA. 2019;321(20):2040. doi:10.1001/jama.2019.4407
 ACCESS
Short-term Nutrition
• The preferred route for enteral nutrition is through the stomach. A nasogastric or NG tube can be
inserted into the stomach. Liquid nutrition can be given this way at a continuous, set rate or intermittently.
• A nasojejunal (NJ) tube is inserted into the jejunum. This can be done for gastroparesis, in which the
stomach is not working but the rest of the intestine is.
Therefore, nasojejunal tubes are also referred to as postpyloric tubes.

Long-term Nutrition
If patients are expected to require enteral nutrition for longer than a couple of weeks, a long-term solution
is needed.
A gastrostomy (G) tube or a jejunostomy (J) tube can be placed into the stomach or the jejunum,
respectively.
There are 3 main ways to place these tubes:
(1) surgically (open or laparoscopic technique)
(2) fluoroscopically via x-ray guidance
(3) endoscopically (called a percutaneous endoscopic gastrostomy or PEG tube)
 ACCESS
Baiu I, Spain DA. Enteral Nutrition. JAMA. 2019;321(20):2040. doi:10.1001/jama.2019.4407

1. Gastric access should be used as the standard approach to initiate EN.
Grade of recommendation: GPP-strong consensus (100% agreement)
2. In patients with gastric feeding intolerance not solved with prokinetic agents,
postpyloric feeding should be used.
Grade of recommendation:B- strong consensus (100% agreement)
3. In patients deemed to be at high risk for aspiration, postpyloric, mainly jejunal
feeding can be performed.
Grade of recommendation: GPP-strong consensus (95% agreement)

NUTRITION SCREENING AND ASSESSMENT
• The American Society of Parenteral and Enteral Nutrition (ASPEN) 2016 guidelines
recommend using Nutrition Risk Screening-2002 and NUTRIC score for the
determination of nutrition risk in critically ill patients.
• Among the assessment tools available, subjective global assessment (SGA) is
inexpensive, quick and can be conducted at the bedside. It is a reliable tool for
inferring outcomes in critically ill patients
Mehta Y, Sunavala JD, Zirpe K, Tyagi N, Garg S, Sinha S, Shankar B, Chakravarti S, Sivakumar MN, Sahu S, Rangappa P, Banerjee T, Joshi A,
Kadhe G. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med. 2018 Apr;22(4):263-273.
doi: 10.4103/ijccm.IJCCM_3_18. PMID: 29743765; PMCID: PMC5930530.

Kondrup JE, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clinical
nutrition. 2003 Aug 1;22(4):415-21.

• The American Society of Parenteral and Enteral Nutrition 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.
ASPEN 2016 guidelines:Suggestions
2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care
Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

• 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.
ASPEN 2016 guidelines:Suggestions

• A general clinical assessment should be performed to assess malnutrition in the
ICU, until a specific tool has been validated.
Remark:
General clinical assessment could include anamnesis, report of unintentional weight
loss or decrease in physical performance before ICU admission, physical examination,
general assessment of body composition, and muscle mass and strength, if possible.
Grade of recommendation: GPP - strong consensus (100% agreement)

ESTIMATING ENERGY/PROTEIN REQUIREMENTS

• In critically ill mechanically ventilated patients, EE should be determined by
using indirect calorimetry.
Grade of recommendation: B e strong consensus (95% agreement)
Statement
If calorimetry is not available, using VO2 (oxygen consumption) from pulmonary arterial
catheter or VCO2 (carbon dioxide production) derived from the ventilator will give a
better evaluation on EE than predictive equations. Consensus (82% agreement)

• The weakness of predictive equations and the use of indirect calorimetry have been
subject to multiple evaluations and recommendations from ESPEN and ASPEN,
both preferring the use of indirect calorimetry to evaluate ICU patient needs (rated a
very weak recommendation by ASPEN).
• In the absence of indirect calorimetry, VO2 or VCO2 measurements, use of simple
weight-based equations (such as 20-25 kcal/kg/d):the simplest option may be
preferred.

• Dosing weight — The appropriate body weight from which to calculate caloric
and protein intake (ie, the dosing weight) must first be determined.
• Males: IBW (kg) = 50 kg + 2.3 kg for each inch over 5 feet.
• Females: IBW (kg) = 45.5 kg + 2.3 kg for each inch over 5 feet.
• AdjBW = IBW + (0.4 * [Actual weight - IBW])
Nutrition support in critically ill patients: An overview-Uptodate Oct14,2020

• The most commonly employed method is to add 0.4 times the difference between the
ideal body weight (IBW) and the actual body weight (ABW) to the IBW.
Dosing weight = IBW + 0.4 (ABW - IBW)
●An alternative method is to use 110 percent of the ideal body weight.
Dosing weight = 1.1 * IBW

• A safe starting point for most critically ill patients is approximately 8 to 10 kcal/kg
per day. Attempting to achieve a goal of 25 to 30 kcal/kg of dosing weight per day
after one week is reasonable for most stable patients
• Practice is to give patients with only mild to moderate illness 0.8 to 1.2 g/kg protein
per day. Critically ill patients are generally prescribed 1.2 to 1.5 g/kg per day and
patients with severe burns may benefit from as much as 2 g/kg per day.

1. If indirect calorimetry is used, isocaloric nutrition rather than hypocaloric
nutrition can be progressively implemented after the early phase of acute illness
Grade of recommendation: 0-strong consensus (95% agreement)
2. Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the
early phase of acute illness.
Grade of recommendation: B-strong consensus (100% agreement)
3. After day 3, caloric delivery can be increased up to 80-100% of measured EE.
Grade of recommendation:0-strong consensus (95% agreement)

FORMULATIONS
1. STANDARD
The following characteristics are typical of standard enteral nutrition:
●Isotonic to serum
●Caloric density of approximately 1 kcal/mL
●Lactose-free
●Intact (nonhydrolyzed) protein content of about 40 g/1000 mL (40 g/1000 kcal)
●Nonprotein calorie to nitrogen ratio of approximately 130
●Mixture of simple and complex carbohydrates
●Long-chain fatty acids (although some are now including medium-chain and omega-3
fatty acids)
●Essential vitamins, minerals, and micronutrients

• Standard enteral nutrition provides sufficient nourishment for most critically ill
patients if given with caloric adequacy, although concentrated and predigested
enteral nutrition may be preferable for selected patients
1. STANDARD
FORMULATIONS

FORMULATIONS
2. CONCENTRATED
• Critically ill patients frequently require volume restriction (eg, patients with
respiratory failure, or volume overload). Concentrated enteral nutrition may be
useful for such patients.
• The standard composition of concentrated enteral nutrition is similar to that of
standard enteral nutrition, except that it is mildly hyperosmolar to serum and has
a caloric density of 1.2, 1.5, or 2.0 kcal/mL.

• The hyperosmolality of concentrated enteral nutrition predispose patients to diarrhea or
symptoms similar to dumping syndrome if infused rapidly
• Concentrated enteral nutrition is less likely to be tolerated if it is delivered rapidly in
tubes placed beyond the pylorus
2. CONCENTRATED
FORMULATIONS

FORMULATIONS
2. PREDIGESTED
• Predigested enteral nutrition (previously called chemically defined, semi-elemental,
or elemental) differs from standard enteral nutrition in that the protein is hydrolyzed
to short-chain peptides and the carbohydrates are in a less complex form.
• The total amount of fat may be decreased, with an increased proportion of medium-
chain triglycerides, or the triglycerides altered or structured to contain various
mixes of fatty acids.

FORMULATIONS
2. PREDIGESTED
• Predigested enteral nutrition usually has a caloric density of 1 or 1.5 kcal/mL.
• It may be used as an initial tube feed in patients with marginal gut function or a short
gut because it is believed to be better tolerated.
• Patients who tolerate the predigested enteral nutrition can then be transitioned to
standard enteral nutrition.
• The original formulations of predigested enteral nutrition included amino acids instead
of peptides or proteins.

FORMULATIONS
2. PREDIGESTED
Predigested enteral nutrition may be beneficial in patients with the following problems:
●Thoracic duct leak, chylothorax, or chylous ascites, since the medium-chain
triglycerides do not enter the lymphatic capillaries in the small intestine
.
●Digestive defects (eg, malabsorptive syndromes that are unresponsive to
supplementation of pancreatic enzymes).
●Failure to tolerate standard enteral nutrition, such as persistent diarrhea.

CONTINUOUS VERSUS BOLUS
• There is no evidence that either continuous or bolus (ie, intermittent) enteral
nutrition is superior to the other{David Seres, MD, Nutrition support in critically ill patients: Enteral
nutrition-Uptodate Feb 04, 2019}
• Continuous rather than bolus EN should be used.
Grade of recommendation: B- strong consensus (95% agreement)
{Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC,
Pichard C, Preiser JC. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical nutrition. 2019 Feb
1;38(1):48-79.}

AMOUNT AND RATE
• The daily amount of enteral nutrition is tailored to the nutritional and fluid needs of
each patient.
• A calorie goal of 18 to 25 kcal/kg/d is a reasonable initial range to use to meet the
needs of a critically ill patient of normal weight.
• Enteral feeding has to be initiated in critically ill patients at a rate of 10 to 30 mL/hour
(for standard enteral formulations), called "trophic" feeding, for six days and then
incrementally increased to the target rate.

• Initiate feeds at 25 to 30 percent of estimated goal rate.
• In patients who are subjectively more critically ill, we do not attempt to increase further
toward goal until the fifth to seventh day of critical illness.
AMOUNT AND RATE

MONITORING
• It has long been standard clinical practice to check the patient's gastric residual
volume (GRV) at regular intervals and/or prior to increasing the infusion rate of
gastric tube feeding.
• Enteral feeding should be delayed when GRV is >500 mL/6 h. In this situation, and if
examination of the abdomen does not suggest an acute abdominal complication,
application of prokinetics should be considered.

• In ICUs in India, there is a marked difference of opinion regarding the exact
volume of GRV tolerance, and till such time this is resolved, IJCCM recommend
that in all high-risk patients who cannot be assessed and are unconscious or on
ventilator or are on bolus/intermittent feeds, GRV monitoring can be done every 6–
8 hourly and the cutoff range be kept between 300 and 500 ml.
MONITORING:RECOMMENDATIONS

• ASPEN/SCCM and the Surviving Sepsis initiative recommend the use of
prokinetics metoclopramide (10 mg three times a day) and erythromycin (3-7
mg/kg/day) in the case of feeding intolerance (weak recommendation, low quality
of evidence for the surviving sepsis initiative, and for ASPEN/SCCM)
• In critically ill patients with gastric feeding intolerance, intravenous erythromycin
should be used as a first line prokinetic therapy.
Grade of recommendation: B-strong consensus (100% agreement) {ESPEN 2019}
MONITORING:RECOMMENDATIONS

COMPLICATIONS OF EN

CONCLUSION
• Nutrition is now regarded to be of therapeutic benefit and not just an adjunctive or
support, in improving patient outcomes.
• Early, optimum, and adequate nutrition helps improve patients’ overall prognosis
and at the same time reduce the length of stay.
• EN is preferable in majority of cases.
• Scientific nutrition in the form of standard formula feeds should be preferred in
majority of ICU patients

REFERENCES
1. Seron-Arbeloa C, Zamora-Elson M, Labarta-Monzon L, Mallor-Bonet T. Enteral nutrition in critical care. J Clin Med Res. 2013 Feb;5(1):1-11.
doi: 10.4021/jocmr1210w. Epub 2013 Jan 11. PMID: 23390469; PMCID: PMC3564561.
2. David Seres, MD, Nutrition support in critically ill patients: Enteral nutrition-Uptodate Feb 04, 2019
3. Barash M, Patel JJ. Gut luminal and clinical benefits of early enteral nutrition in shock. Current Surgery Reports. 2019 Oct;7(10):1-8.
4. Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020 Jan;48(1):122-125. doi:
10.1097/CCM.0000000000003965. PMID: 31414992.
5. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC. ESPEN
6. Baiu I, Spain DA. Enteral Nutrition. JAMA. 2019;321(20):2040. doi:10.1001/jama.2019.4407
7. Mehta Y, Sunavala JD, Zirpe K, Tyagi N, Garg S, Sinha S, Shankar B, Chakravarti S, Sivakumar MN, Sahu S, Rangappa P, Banerjee T, Joshi A,
Kadhe G. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med. 2018 Apr;22(4):263-
273. doi: 10.4103/ijccm.IJCCM_3_18. PMID: 29743765; PMCID: PMC5930530.
8. Kondrup JE, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clinical nutrition. 2003 Aug 1;22(4):415-21.
9. 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care
10. Nutrition support in critically ill patients: An overview-Uptodate Oct14,2020

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