Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Published in the recent issue of Indian Journal of Critical Care, practice guidelines specific to Indian context, for the use of EN in critically ill patients have been published. Various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials, and review articles were reviewed for their contextual relevance and strength.
The recommendations address challenges regarding EN versus parenteral nutrition, nutrition screening and assessment, nutrition in hemodynamically unstable, route of nutrition, tube feeding and challenges, tolerance, optimum calorie-protein requirements, selection of appropriate enteral feeding formula, micronutrients and immune-nutrients standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices.
Grading Criteria
Level 1: “existing guidelines” ; Level 2: “RCTs/meta-analysis” ; Level 3: “controlled trials/studies” ; Level 4: “uncontrolled trials/studies” ; Level 5: “review articles” ; Level 6: “expert opinion/advisory board opinion”
Grade A practice guidelines were supported by Level I/II evidence and denote “strongly recommended”
Grade B practice guidelines were supported by Level III/IV/V evidence and denote “recommended”
Grade C practice guidelines were supported by Level VI evidence and denote “suggested”
Importance/indications/timing of nutrition in critically ill patients
• All the critically ill patients should undergo nutrition assessment on admission (A I)
• Observation of signs of malnutrition (e.g., cachexia, edema, muscle atrophy, BMI <20 kg/m 2) is critical (A I)
• EN should be started early, preferably within first 24–48 h (A I)
• In case the nutrition requirement is not met adequately with EN even after 7 days of ICU admission, then usage of parenteral nutrition (PN) may be considered (A I)
• Nutritional support should to be considered as of therapeutic benefits and not just supportive or adjunctive (A I)
• Electrolytes should be strictly monitored in the patient on nutrition therapy (B V)
• Assessment of drug–nutrient interaction to be done on daily basis (B V)
• Tube feeding to be considered if even 50%–60% of nutrition targets are not met adequately within 72h of oral nutrition support (C)
Feeding practices in hemodynamically unstable patients
• Clinical monitoring of gut functioning should be started early when the patient is HD stable (C)
• Once the patient has been fluid resuscitated and stabilized on declining doses of <2 vasopressors, EN may be started cautiously at low rates (A I)
• EN should be administered within 24–48 h once the patient is stable with vasopressors (A I)
• In persistent shock, early EN should be avoided (A I)
Nutrition screening and assessment
• Nutrition status of Indian malnourished patients can be assessed by Subjective global assessment form (B III)
• Initial monitoring of nutrition intervention must be done on daily basis and nutrition plans should be modified accordingly (A I)
• It is imperative that nutritional assessment is done by well-qualified and trained nutritionists, dedicated to the ICU (A I)
• It is desirable that nutritionist-to-critically ill patient ratio be maintained at 1:25 (C)
• Wherever feasible, computed tomography (cross-sectional imaging) or ultrasonography (U/S) can be used to assess the lean muscle mass (B V)
• Facilitation of nutrition assessment will require good coordination between intensivist and nutritionist (C)
Estimating energy/protein requirements
• Feeding should be tailored as per the patient's requirement and level of tolerance (C)
• Protein requirement for most critically ill patients is in range of 1.2-2.0 g/kg body weight/day (A I)
• Calories should be in range of 25-30 Kcal/kg body weight/day for most critically ill patients (A I)
• In severely hypercatabolic patients such as extensive burns and polytrauma, ratio of Kcal: nitrogen should be 120:1 or even 100:1 has been accepted (B V)
• For obese patients, adjustment in calorie and proteins must be done on basis of the body weight and BMI (A I)
• Toronto formula is useful for estimating energy requirements in acute stages of burn injury and must be assessed and adjusted to changes in monitoring parameters (C)
• Harris–Benedict tool may not be suitable because the equations in this method are too long and time-consuming and overestimate the energy requirements (C)
• Weight-based equations are preferred for energy-protein calculations (A I)
Route of nutrition (enteral tube feeding vs. parenteral): Preference in critical-care settings
• EN should be considered over PN (A I)
• Combination of EN and PN should not be routinely recommended, except for specific indications (A II)
Tube feeding
• NG route should be the first choice of enteral feeding. Jejunal route can be used if required (A I)
• Continuous formula feeding with pumps or gravity bags can be preferably done via fine bore (8F–12F) tubes (A I)
Tube feeding and nosocomial infections
• Scientific formula feed should be preferred over blenderized feeds to minimize feed contamination (B III)
• Whenever feasible, closed system ready-to-hang formula feeds should be preferred (B III)
• Blenderized formulae are more likely to have bacterial contamination than other hospital prepared diets (B IV)
• Hygienic methods of feed preparation, storage, and handling of both formula feeds and blenderized feeds are necessary (B III)
Permissible underfeeding
• Intentional underfeeding can be restricted to specific indications (A I)
• Obese patients can be subjected to underfeeding (A I)
Monitoring tolerance and adequacy
• GRV (gastric residual volume) should be measured by syringe aspiration and not by suction pump (A II)
• GRV of <300 ml can be refed (B V) if it is not blood stained
• Holding EN for GRVs <500 mL in the absence of other signs of intolerance should be avoided (A I)
• However, GRV cutoff range of 300–500 mL can be considered in Indian ICUs (C)
• In case of high GRVs, efforts should be made to continue feeding with reduced volumes (C)
• Prokinetic agents such as metoclopramide and erythromycin can be recommended in patients with intolerance and risk of aspiration (A I)
• Nurses should be trained for monitoring tolerance (C)
Selection of appropriate enteral formula
• Standard polymeric formula feed should be recommended in critically ill patients (A I)
• Inconsistency in nutrient level can be avoided using the standard polymeric formula feeds (B III)
• Routine use of specialty formula feeds should be avoided (A I)
Enteral feeding and diarrhea
• EN should not be interrupted in the event of diarrhea (A I)
• Feeds can be continued while evaluating the etiology of diarrhea (A I)
• Use of a soluble fiber-containing formula or small peptide semi-elemental formula in divided doses over 24 h may benefit to patients with persistent diarrhea (after exclusion of hyperosmolar agent intake and C. difficile infection) (A I)
• Routine use of probiotics across the general population of ICU patients is not recommended. Probiotics should be used only for select medical and surgical patient populations, for which RCTs have documented safety and outcome benefit (A I)
Importance of micronutrients
• Preexisting micronutrients' deficiency should be evaluated/assessed (B V)
• Patients on formula feeds may not require additional micronutrients, vitamins, and trace elements, if they are on complete and balanced formula feeds (A I)
• Micronutrients can be supplemented in patients on blenderized feeds and those on PN (C)
Immune-enhancing enteral nutrition
• Immune-modulating nutrients should not be used routinely (A I)
• In ICU patients with very severe illness and not tolerating more than 700 mL enteral formulae per day, immune nutrients should not be used (A I)
• Immune-modulating nutrients could be considered for patients with TBI and perioperative patients in the surgical ICU (A I)
• Glutamine is not recommended in critically ill patients with multiple organ failure (B V)
Standard nutrition in hepatic failure
• EN should be preferred in patients with acute and/or chronic liver disease, admitted to ICU (A I)
• No beneficial effects of branched-chain amino acid formulations in critically ill patients with encephalopathy who are receiving first-line luminal antibiotics (A I)
• Protein supplementation is recommended in liver failure. Protein-energy determination should be based on “dry” body weight or usual weight instead of actual weight (A I)
• Protein restriction should be avoided in refractory encephalopathy (B V)
• A whole-protein formula providing 35–40 kcal/kg body weight/day energy intake and 1.2–1.5 g/kg body weight/day protein is recommended (A I)
• Tailor sodium restriction to absolute need (B V)
Standard nutrition in traumatic brain injury
• Initiation of EEN (Early enteral nutrition) after posttrauma period (within 24–48 h of injury), once the patient is HD stable, is recommended (A I)
• Protein recommendations should be in the range of 1.5–2.5 g/kg/day (A I)
• Arginine-containing immune-modulating formulations or eicosapentaenoic acid/docosahexaenoic acid supplement with standard enteral formula in TBI patients is recommended (A I)
Standard nutrition in respiratory compromised
• Calorie-dense EN formulations should be recommended for patients with ARF (especially if in state of volume overload) (A I)
• Small frequent feeds should be preferred to improve nutritional compliance (A I)
• Monitoring of serum phosphate concentration and replacement of phosphate when needed is recommended (A I)
• A specialty high-fat/low-carbohydrate formulation is not recommended for ICU patients with ARF (A I)
• There is no additional advantage of disease-specific low-carbohydrate and high-fat over standard or high-protein or high-energy oral nutritional supplement in stable COPD patients (A I)
Standard nutrition in acute kidney injury
• Standard enteral formula is recommended for ICU patients with AKI (A I)
• Protein should not be restricted in patients with renal insufficiency (A I)
• Daily protein intake should be in the range of 1.2–1.7 g/kg actual body weight in AKI patients (C)
• Provision of adequate nonprotein calories should be maintained to achieve total energy intake in patients with AKI (B V)
• In case of significant electrolyte imbalance, a specialty formulation designed for renal failure should be considered (A I)
• Low potassium and low phosphate diets can be implemented where corresponding serum levels are high (A I)
Documentation of nutrition practices
• Documentation of body weight and its review on weekly basis is recommended.[75] (A II)
• Documentation of the below mentioned is also recommended (C)
Scientific nutrition intervention is very important to achieve better clinical outcomes. Based on the Discussions and Practice Guidelines, below is an ICU nutrition protocol has been devised in to be used in critical-care settings
About ISCCM & IJCCM
The Indian Society of Critical Care Medicine (ISCCM) was formed on 9th October 1993. It promotes academic and scientific activity in the field of medicine. It establishes guidelines for running and staffing of ICUs. The Indian Journal of Critical Care Medicine (IJCCM) is specialty periodical published under the auspices of Indian Society of Critical Care Medicine. Journal encourages research, education and dissemination of knowledge in the fields of critical and emergency medicine.
Note: This list is a brief compilation of some of the key recommendations included in the guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/xV7Z7