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Nutrition support in intubated critically ill adult patients: Enteral nutrition

Nutrition support in intubated critically ill adult patients: Enteral nutrition
Author:
David Seres, MD
Section Editor:
Polly E Parsons, MD
Deputy Editor:
Geraldine Finlay, MD
Literature review current through: Jan 2024.
This topic last updated: Jan 29, 2024.

INTRODUCTION — Enteral nutrition (EN) support refers to the provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids via an intestinal route. EN is the most common mode of delivery for nutrition support in intubated critically ill patients. To initiate EN, appropriate access must be obtained and the prescription needs to be determined.

Typical access used, available formulations and their composition, delivery route, and monitoring of EN in critically ill patients are reviewed in this topic. The indications, contraindications, timing, and prescription of calories and protein are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription".)

INDICATIONS AND CONTRAINDICATIONS — Clinical practice guidelines suggest that EN protocols be designed and implemented in each institution [1,2]. The indications and contraindications (table 1) for EN are described elsewhere. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Assess indications and contraindications'.)

ROUTE OF DELIVERY — In critically ill patients, EN is most commonly delivered into the stomach (gastric feeding) (see 'Gastric' below). However, in select patients it can also be administered into more distal parts of the alimentary tract (eg, post-pyloric feeding) (see 'Post-pyloric' below). Feeding through an enteral tube should not begin until its proper position has been confirmed radiographically.

Gastric — Gastric feeding is typically delivered via an orogastric or nasogastric tube (table 2). Oro- or nasogastric tubes are available in two varieties, sump or feeding tubes, the placement of which are discussed separately (see "Inpatient placement and management of nasogastric and nasoenteric tubes in adults"):

Sump tubes – Sump tubes are larger and stiffer than feeding tubes. They are generally inserted for gastric decompression but may be used for short periods to deliver EN when gastric decompression is no longer necessary (eg, up to two weeks). Concerns about longer-term use include nasal and esophageal erosion and sinusitis.

Feeding tubes – Feeding tubes are of smaller diameter, are more flexible, and often require a stylet for insertion. Many feeding tubes cannot be used for gastric decompression because the soft walls tend to collapse when suction is applied.

On admission, some patients may already have a feeding tube in place for long-term feeding, which can be used in lieu of a placing a new feeding tube (provided they are functioning correctly). These include percutaneous endoscopic gastrostomy (PEG) tubes, percutaneous radiologic gastrostomy tubes, and surgical gastrostomy or jejunostomy tubes (figure 1). Further details regarding gastrostomy tubes are provided separately. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults" and "Gastrostomy tubes: Complications and their management".)

Post-pyloric — Most patients in the intensive care unit do not need post-pyloric feeding (ie, feeding tube tip in the duodenum or beyond the duodenal ligament of Treitz). Placement of post-pyloric feeding tubes is challenging in critically ill patients since they often require endoscopic or radiologic guidance.

Indications (eg, those with delayed gastric emptying or gastric outlet obstruction, failed aspiration precautions) and methods of placement (eg, endoscopic or image-guided) are discussed separately. (See "Enteral feeding: Gastric versus post-pyloric" and "Enteral feeding: Gastric versus post-pyloric", section on 'Difficulty with placement and ease of displacement'.)

FORMULATIONS — Several EN formulations are commercially available for patients with critical illness. Common differences between formulations include osmolarity, caloric density, amount of protein per calorie, and electrolyte content [3,4]. Most are formulated to provide 100 percent of the recommended daily vitamin and mineral dose when a minimum of approximately 1000 kilocalories (kcal) or more are delivered per day. In addition, there may be differences related to whether they are intact or predigested, fiber or disease-specific nutrients are present or absent, and extra supplements are added (eg, glutamine).

Choosing a formulation — No formulation has consistently demonstrated superiority over others. Choosing among formulations depends upon clinical factors including volume status and comorbidities (eg, kidney failure). Our approach is as follows:

Standard formula for most patients – For most critically ill patients, we use standard EN formulations since they provide sufficient nourishment if given with adequate total daily volume. (See 'Standard' below.)

Special formulas in select patients:

Volume restriction – For patients who require volume restriction, we use concentrated EN formulations (eg, 1.5 to 2 times more concentrated than standard formulations). However, when volume is adequately controlled using other means (eg, diuresis, dialysis), standard feedings are acceptable. (See 'Concentrated formulas' below.)

Kidney failure – For patients with kidney failure, we use a renal formula. The exception is patients on continuous kidney replacement therapy since continuous kidney replacement therapy is highly effective at removing electrolytes such as potassium and phosphate. Renal formulas are also typically more concentrated than standard formulas, which can be useful if the patient requires both fluid restriction and electrolyte control. (See 'Renal' below.)

Chylous accumulations – Patients with chylous accumulations (eg, thoracic duct leak, chylothorax, or chylous ascites), digestive defects (eg, short gut or malabsorptive syndromes that are unresponsive to supplementation with pancreatic enzymes), or intolerance of standard EN (eg, persistent diarrhea) may be prescribed predigested formulations. The selected predigested formulation depends upon the suspected underlying problem. (See 'Predigested' below.)

Others – We do not typically use diabetic or other disease-specific formulas (eg, hepatic, pulmonary) since none have demonstrated superiority to standard feeding products in patients who are critically ill.

Diabetic formulas do not improve glycemic control in patients who are continuously fed but may have some benefit if patients are receiving bolus feeding [5]. However, these formulas are generally not useful in critically ill patients since the glycemic index is improved by slowing gastric emptying and not by changing the formulation. Management of enteral feeding in hospitalized patients with diabetes mellitus and glycemic control in critically ill patients are discussed in greater detail separately. (See "Management of diabetes mellitus in hospitalized patients", section on 'Enteral feedings' and "Glycemic control in critically ill adult and pediatric patients".)

No role for other supplements – We do not provide extra supplements (eg, glutamine) since these have not demonstrated any clear benefit. (See 'Extra supplements of no proven benefit' below.)

Standard — Standard feeds are the most common EN formulation used in the intensive care unit (ICU). The following characteristics are typical of standard EN formulations:

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 130:1

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

The prescription of EN is tailored to the nutritional and fluid needs of each patient, the details of which are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Formulations for special circumstances

Concentrated formulas — Use of concentrated EN formulas is not routine. However, they may be appropriate in critically ill patients who require volume restriction (eg, volume overload not responsive to other means). (See 'Choosing a formulation' above.)

The standard composition of concentrated EN is similar to that of standard EN formulas, except that it is mildly hyperosmolar to serum and has a caloric density of 1.2, 1.5, or 2 kcal/mL. (See 'Standard' above.)

The routine use of concentrated EN does not appear to confer benefit when compared with standard formulations. In a randomized trial of 3957 medical ICU patients who were mechanically ventilated and receiving enteral feeds, despite providing an extra 600 kcal per day, patients receiving concentrated formula (1.5 kcal/mL) had similar mortality rates (27 versus 26 percent, respectively), ventilator-free days, duration of hospitalization, and infections compared with patients receiving a standard formula (1 kcal/mL) [6].

The hyperosmolality of concentrated EN was thought to predispose patients to diarrhea or symptoms similar to dumping syndrome. However, adult formulations rarely exceed approximately 750 milliosmoles/L and are rarely the primary cause of diarrhea, if infused slowly. However, concentrated EN is less likely to be tolerated if it is delivered rapidly in feeding tubes placed beyond the pylorus [7]. Dumping syndrome is discussed separately. (See "Postgastrectomy complications".)

Renal — Renal formulas may be helpful in managing patients who require fluid and/or electrolyte restriction, such as patients with acute kidney failure complicated by fluid overload, hyperkalemia, and/or hyperphosphatemia, or those on hemodialysis with difficulties managing electrolytes and volume.

Renal formulas are more concentrated than standard formulas with a caloric density of 1.8 or 2 kcal/mL, are hyperosmolar relative to serum (approximately 750 milliosmoles/L), and contain a slightly higher protein content (44 g/1000 kcal) but are otherwise similar. (See 'Standard' above.)

Predigested — Predigested formulas (previously called chemically defined, semi-elemental, or elemental formula) contain peptides as opposed to intact protein. Predigested EN is not routinely administered as an initial tube feed in critically ill patients [1] but has been proposed as potentially beneficial in patients with specific digestive needs (eg, malabsorption due to mucosal disease), albeit without supporting evidence. (See 'Choosing a formulation' above.)

Predigested EN usually has a caloric density of 1 or 1.5 kcal/mL. It differs from standard EN 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. Essential vitamins, minerals, and micronutrients are similar to standard formulations.

Patients who tolerate predigested EN can sometimes be transitioned to standard EN later, especially if the underlying problem has resolved.

In critically ill patients, studies of predigested feed products have not demonstrated differences in mortality, infectious complications, or the incidence of diarrhea when compared with standard EN [8,9].

COMPOSITION — The daily volume of feed is first based upon estimated calorie needs (ie, carbohydrate and fat content). Then the appropriate formula that best delivers the estimated protein needs is chosen. If protein needs cannot be acceptably met with available feeding products, protein supplements may be administered. Calculating calorie and protein needs is described separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Carbohydrate/fat — Standard EN delivers 49 to 53 percent of calories as carbohydrates and 29 to 30 percent of calories as fat.

Low carbohydrate/high fat formulations and high carbohydrate/low fat formulations are available. Neither is recommended for routine feeding, nor do they have evidence for efficacy. However, they have been proposed for use in patients who are obese with critical illness (low carbohydrate/high fat [10-14]) or patients with chyle leak or maldigestion (high carbohydrate/low fat).

Protein — Standard EN delivers an intact (nonhydrolyzed) protein content of about 40 g/1000 kilocalories (kcal) while most "high nitrogen" and renal EN formulas deliver a protein content of 44 g/1000 kcal. High protein feeds contain 60 to 65 g/1000 kcal.

Other (vitamins, minerals, trace elements, fiber) — Most formulations contain the daily recommended allowances of essential vitamins, minerals, and trace elements. (See "Vitamin intake and disease prevention", section on 'Vitamin deficiency and definitions of adequate intake'.)

Some formulas also contain variable amounts of dietary fiber; however, these are infrequently used unless the patient has EN-related diarrhea. (See 'Diarrhea' below.)

Extra supplements of no proven benefit — The following nutrients and additives, provided in amounts in excess of the daily recommended requirements, have been studied in critically ill patients. However, the available evidence has not demonstrated a clear benefit of these supplements, and we therefore suggest against using them.

Omega-3 fatty acids – Omega-3 fatty acids have anti-inflammatory properties [15] and have been studied in patients with sepsis [16,17], patients with acute respiratory distress syndrome [18-22], and patients undergoing cardiac surgery [23]. While early trials suggested a possible benefit, subsequent trials and meta-analyses failed to detect a meaningful mortality benefit from omega-3 fatty acids with or without antioxidants [17,22,23].

Glutamine and its precursor, ornithine ketoglutarate (OKG) – Glutamine is necessary for nucleotide synthesis and is rapidly depleted in catabolic states. In a meta-analysis of 36 randomized trials involving 3454 critically ill patients randomly assigned to glutamine supplementation or control, hospital mortality was lower in the glutamine group (17.5 versus 19.7 percent); however, the difference was not statistically significant (relative risk [RR] 0.89, 95% CI 0.78-1.02) [24]. Glutamine supplementation modestly reduced infectious complications (32 versus 40 percent; RR 0.79, 95% CI 0.71-0.87). However, many of the trials included in the meta-analysis had important limitations (lack of blinding, incomplete or selective reporting) and the meta-analysis found evidence of publication bias. Thus, the certainty of these findings is low.

OKG is a glutamine precursor that restores pools of glutamine in catabolic patients. A meta-analysis of three randomized trials involving 163 burn patients found that mortality was similar in patients who did and those who did not receive OKG supplementation (10 percent in both groups) [25].

Arginine – Arginine is required for normal immune function and healing and has important roles in nitrogen and ammonia metabolism and the generation of nitric oxide. In a meta-analysis of 14 trials involving 1624 critically ill patients, mortality was similar in patients who did and those who did not receive arginine supplementation (24 versus 23 percent; RR 1.05, 95% CI 0.79-1.38) [26].

Beta-hydroxy-beta-methylbutyrate (HMB) – HMB is a metabolite of the essential amino acid leucine that has anabolic effects on protein metabolism. Supplementation with HMB has been proposed as a possible intervention for critically ill patients to prevent muscle wasting. Data on use of HMB in this setting are very limited. Based on the available clinical trial data, HMB does not appear to reduce muscle wasting in critically ill patients [27,28].

Prebiotics and probiotics – Prebiotics are nondigestible carbohydrates (fiber) that promote the growth of beneficial bacteria and hinder the growth of harmful bacteria in the bowel. Probiotics (eg, Lactobacillus species) are living microorganisms that are purported to provide a health benefit to the host when ingested.

In a meta-analysis of 49 trials (27 investigating probiotics; 22 investigating combined prebiotic/probiotic supplements) that involved 6746 critically ill patients, mortality rates were similar in patients who did and those who did not receive probiotics or prebiotics (21 versus 23 percent, respectively; RR 0.93, 95% CI 0.85-1.02) [29]. Probiotics appeared to lower the incidence of diarrhea and infectious complications when all trials reporting this outcome were analyzed (29 trials; 5455 patients); however, when analysis was restricted to high-quality trials, there was no apparent reduction in either outcome [29].

The role of probiotics in the management of patients with diarrheal illnesses (eg, Clostridioides difficile infection, antibiotic-associated diarrhea) is discussed separately. (See "Clostridioides difficile infection in adults: Treatment and prevention", section on 'Alternative therapies' and "Probiotics for gastrointestinal diseases", section on 'Diarrheal illnesses'.)

Extra fiber – Standard formulations are not routinely supplemented with extra fiber since the available evidence suggests that it does not prevent diarrhea [30,31]. Fiber supplementation is an option for patients with EN-related diarrhea, as discussed below. (See 'Diarrhea' below.)

Antioxidant vitamins and trace elements – Antioxidant nutrients include selenium, copper, zinc, vitamin A, vitamin C, vitamin E, and N-acetylcysteine. These can be given as single additives or in combination. The available clinical trial data do not support the routine use of antioxidant supplements above the recommended daily allowance [32-34]. In a network meta-analysis that included 36 randomized trials (4885 critically ill patients) and compared various antioxidant micronutrient supplements (alone or in combination), none appeared to be more effective than placebo for reducing all-cause mortality [34].

Additional data on vitamin C supplementation in patients with sepsis are discussed separately. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Vitamin C'.)

Combined immune modulator supplements – In a randomized trial evaluating enteral supplementation with a combination of some of the additives discussed above (glutamine plus omega-3 fatty acid plus antioxidant vitamins and trace elements [vitamins C and E, selenium, and zinc]), hospital mortality was similar in patients who did and those who did not receive the supplement (25 versus 22 percent, respectively) [35]. Rates of infectious complications were also similar in both groups (53 versus 52 percent).

Vitamin D – Levels of vitamin D, which is protein bound, drop in critical illness, much in the same way a decrease in albumin lowers calcium levels. Despite a correlation between low vitamin D levels and intensive care unit mortality, vitamin D supplementation has no clinical impact [36,37].

DELIVERY STRATEGY — The daily amount of EN is tailored to the nutritional and fluid needs of each patient. Unless fluid overload is an issue, we generally choose a nonconcentrated standard formulation. (See 'Choosing a formulation' above and 'Standard' above.)

Continuous versus bolus — EN is typically administered as a continuous infusion (over a 24-hour period) or cycled infusion (over 12 hours in a 24-hour period). While we prefer infusions to decrease the risk of vomiting, reflux, and aspiration, data comparing infusions with bolus feeding have not shown any differences in mortality, infections, or intensive care unit length of stay [38-40].

Delivery volume and rate — Our approach is the following:

Nutritional goal – Calculating the goal target rate involves calculating the dosing weight as well as the calorie and protein target goal. Details regarding the calculation of such goals are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Volume/rate – The volume and rate are calculated based upon the caloric needs of the patient and the calorie concentration of the formulation used. For most patients, we initiate EN at an hourly rate that is less than the full desired target (eg, 30 to 50 percent of the ultimate target goal), then slowly increase the rate over three to seven days until the full target is reached. This approach should result in the patient reaching a stable target rate within a reasonable period of time, provided that the EN is not repeatedly paused. Support for this approach is discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Example – For a 60 kg patient, assuming caloric and protein needs are 25 kilocalories (kcal)/kg and 1.5 g/kg per day, respectively:

Target caloric intake = 25 kcal/kg per day x 60 kg = 1500 kcal per day

Target protein intake = 1.5 g/kg per day x 60 kg = 90 g protein per day

The best match for this patient would be a high-protein formula with a caloric density of 1 kcal/mL and a protein concentration of 60 g/L.

The total volume required to meet caloric needs = 1500 kcal per day ÷ 1 kcal/mL = 1500 mL per day

Total protein from this volume = 1500 mL x 60 g/1000 mL = 90 g of protein per day

The target rate for full continuous feeds = 1500 mL ÷ 24 hours = 62.5 mL/hour (rounding up to 65 mL/hour is reasonable)

An appropriate starting rate = 30 to 50% x 65 mL/hour (which is approximately 20 to 30 mL/hour)

Water supplementation — Most patients require supplementation of water (eg, 100 mL every six to eight hours) in addition to the EN formulation. All feeding tubes should also have periodic water flushes to minimize clogging. Only water should be used for flushing. Acidic fluids, such as soda or fruit juice, should be specifically avoided as they increase the risk of feeding tube blockage [41]. (See 'Fluid/water/electrolyte disturbance' below.)

MONITORING AND MANAGEMENT OF COMPLICATIONS — For patients on enteral feeding, we monitor daily for complications including the following:

Feeding intolerance (see 'Feeding intolerance' below)

Aspiration (see 'Aspiration' below)

Gut dysfunction (eg, diarrhea, constipation) (see 'Diarrhea' below and 'Constipation' below)

Fluid and electrolyte imbalance (eg, extremity or pulmonary edema, hypo-/hyperkalemia, hypo-/hyperphosphatemia) (see 'Fluid/water/electrolyte disturbance' below)

Refeeding syndrome (see 'Refeeding syndrome' below)

Feeding intolerance — Once EN is initiated, patients are observed at the bedside, most often by nursing staff, for signs of intolerance including gastric distention, abdominal discomfort, diarrhea, nausea, reflux of feeds, and vomiting. There is no optimal approach to managing intolerance. General principles include measuring gastric residual volume (GRV), addressing the etiology, and resuming feeds once the cause has been treated.

Measure gastric residual volume — We do not routinely measure GRV as a way to assess tolerance of feeding to prevent aspiration. We only measure GRV in patients exhibiting signs of intolerance and if the GRV is >500 mL, we hold feeding. The cause for elevated GRV should be investigated and should be addressed prior to attempting to feed again (eg, ileus, delayed gastric emptying). Although it is unclear how long feeds should be held, we resume feeds as quickly as is feasible to reduce the risk of malnutrition from delayed feeding. Assessment of intolerance of feeding is discussed below. (See 'Address the etiology' below.)

Our approach is based upon studies that have shown poor correlation between GRV and pneumonia risk and that the practice of holding feeds for high GRV (eg, >250 mL) is associated with a decrease in calorie delivery [42-45]. In an unblinded trial, 449 intensive care unit (ICU) patients were randomly assigned to monitoring of GRV every six hours, with adjustment of feeding rate for residuals over 250 mL or only monitoring when enteral feeds were adjusted only when patients experienced vomiting or regurgitation [45]. While there were almost twice as many vomiting episodes in the group without monitoring, there was a similar rate of ventilator-associated pneumonia in both groups (16 percent each). The proportion of patients who received 100 percent of their calories was greater in the group that did not undergo routine GRV assessment. Other ICU outcomes were similar, such as duration of ICU-acquired infection, mechanical ventilation duration, hospital length of stay, and short- and long-term mortality.

Address the etiology — In most cases, feeding intolerance is due to ileus or constipation. Rarely is it due to mechanical obstruction, delayed gastric emptying syndrome, ischemic gut, Ogilvie syndrome, or organic issues (eg, intrabdominal leak, abscess, Clostridioides difficile infection, or retroperitoneal bleed).

We typically obtain an abdominal radiograph. If the radiograph and clinical examination are not helpful, we obtain abdominal computed tomography (preferably with contrast) or (less commonly) gastroscopy to look for more serious pathology.

We correct the suspected etiology and resume feeding. In many cases, treating constipation and/or ileus with laxatives and a motility agent resolves intolerance. Rarely, post-pyloric feeding or jejunal feeding is needed. (See 'Constipation' below and "Enteral feeding: Gastric versus post-pyloric" and 'Post-pyloric' above.)

Aspiration — Patients receiving EN have an increased incidence of aspiration. However, it is not clear whether most aspiration events, such as microaspiration, cause harmful clinical outcomes (eg, aspiration of a large volume causing hypoxia or pneumonitis).

In support of this, nutrition support early in the course of critical illness has been associated with a decrease in the rate of infections including nosocomial pneumonia. In addition, microaspiration during sleep occurs in up to 50 percent of individuals in the general population and without obvious harm [46]. Numerous studies have also confirmed that aspiration of oropharyngeal secretions is the main cause of nosocomial pneumonia in the ventilated patient and have failed to demonstrate that aspiration of gastric contents is a significant cause. Data that support the benefit of early feeding and risk factors for ventilator-associated pneumonia are described separately. (See "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults".)

Prevention — Backrest (also known as head of the bed) elevation and the selective measurement of GRV (in patients who are intolerant of EN) are considered preventive measures for aspiration. Other measures such as post-pyloric feeding, percutaneous or surgical feeding devices, or motility agents are not routine but may be considered in select cases (eg, high risk of aspiration or long-term need for EN); however, supportive efficacy data are lacking.

Backrest elevation – We advocate backrest elevation at 30 to 45 degrees during enteral feeding as a maneuver to prevent aspiration. When 30 to 45 degrees is not feasible, we elevate the backrest as much as possible and limit laying the patient flat as much as is possible.

Limited data support this practice. At best, backrest elevation likely prevents aspiration [43], but may not reduce the incidence of clinically significant pneumonia [47]. As an example, a meta-analysis of three randomized trials (337 patients) [48-50] failed to find a reduction in the rate of pneumonia [47] and there did not appear to be an impact on issues such as decubitus ulcers or mortality.

Despite the recommendations, adherence is poor and maintenance of the optimal semirecumbent position is challenging. In one multicenter study, the average amount of backrest elevation was approximately 20 degrees, which did not confer any clinical benefits [49]. In another study [51], which set 30 degrees as the goal, mean compliance was only 53.6 percent.

There is no contraindication to EN when patients are ventilated in the prone position. Further details that discuss feeding in the prone position are provided separately. (See "Prone ventilation for adult patients with acute respiratory distress syndrome", section on 'Feeding'.)

Measuring GRV in select patients – We measure GRV in select patients exhibiting signs or symptoms of intolerance. Data to support this practice are described above. (See 'Measure gastric residual volume' above.)

Other strategies (not routine) – We do not routinely perform post-pyloric feeding, insert percutaneous or surgical feeding devices, or administer motility agents (eg, metoclopramide, erythromycin) to prevent aspiration in the critically ill since data show little to no benefit. However, for patients at high risk of aspiration (eg, significant reflux, poor gastric tolerance to enteral feedings) or for those with long-term needs for EN, some of these strategies may be used.

Post-pyloric feeding – Most data report little to no benefit from the routine placement of feeding tubes to promote post-pyloric feeding [52,53]. While one meta-analysis found a reduction in the incidence of pneumonia [54], this benefit disappeared after one controversial study was removed from the analysis [1,2]. We only target post-pyloric feeding in those with indications, which are discussed in a separate topic review. (See "Enteral feeding: Gastric versus post-pyloric" and "Enteral feeding: Gastric versus post-pyloric", section on 'Difficulty with placement and ease of displacement' and 'Post-pyloric' above.)

Percutaneous or surgical feeding – We only place percutaneous or surgical feeding tubes in patients in whom there is an anticipated long-term need for enteral feeding. Surgical feeding tubes may be considered earlier than usual if there is a contraindication to nasal tubes and long-term feeding is anticipated, although parenteral nutrition is also an option in this population.

Whether percutaneous or surgical feeding devices reduce aspiration and pneumonia is unclear. Some data suggest that long-term complications in non-critically ill patients with swallowing problems are no different when gastrostomy feeding is compared with nasogastric or nasoenteric feeding [55] while other data suggest a higher rate of adverse effects when gastrostomy feeding is compared with nasal feeding [56].

There is a growing practice of simultaneous insertion of percutaneous endoscopic gastrostomy (PEG) tubes at the same time as tracheostomy [57]. While this practice may be convenient, the benefit is unproven and may be driven by the need to reduce length of acute hospital stay and skilled nursing home policies [58,59]. For example, one study reported that the rate of acceptance of patients with temporary nasal tubes was significantly lower in New York City compared with the national average (18 versus 62 percent) [60]. In keeping with this observation, it has been reported that gastrostomies are being inserted earlier during hospitalization and in sicker patients [57].

Motility agents – We only administer motility agents to patients who are at high risk of aspiration (eg, patients with known reflux or aspiration) or who have poor gastric tolerance to enteral feedings. A meta-analysis of four randomized trials (494 patients) found that routinely administering metoclopramide and erythromycin did not change mortality or the incidence of nosocomial pneumonia compared with placebo or no intervention [61-63].

Management — Management of aspiration pneumonia is discussed separately. (See "Aspiration pneumonia in adults" and "Treatment of hospital-acquired and ventilator-associated pneumonia in adults".)

Diarrhea — Diarrhea is estimated to occur in approximately 15 to 18 percent of critically ill patients who receive EN, compared with only 6 percent of patients who do not receive EN [64,65]. This is likely to be higher in patients with greater severity of illness and longer length of stay. The precise mechanism is unknown, but proposed mechanisms include alteration of intestinal transit or the intestinal microflora and concomitant administration of medications that can cause diarrhea (eg, antibiotics, proton pump inhibitors). Enteral electrolyte supplementation and medications delivered in sorbitol suspension are also likely to cause diarrhea. Concentrated feedings are only mildly hypertonic and are unlikely to induce significant diarrhea. (See 'Concentrated formulas' above.)

We evaluate suspected EN-related diarrhea by excluding other etiologies, such as antibiotic- or Clostridioides difficile-related diarrhea. EN does not need to be interrupted for diarrhea and should be continued while the etiology is being investigated. If diarrhea persists and enteral feeding is still suspected as the etiology, we switch to a mixed fiber-containing EN formula [66]. However, we use fiber with caution in patients with impaired peristalsis (eg, patients receiving vasopressors) due to the risk of precipitating a fiber bezoar. (See 'Constipation' below and 'Fiber bezoar' below.)

Fibers contained in tube feeding products vary in their composition and are usually a mixture that does not clog feeding tubes. When supplementing EN with extra fiber, we prefer highly soluble fibers where the effect is primarily osmotic. This includes guar gum, wheat dextrin, inulin, or fructooligosaccharides, which do not gelatinize when dissolved and do not block the feeding tube. We do not use less soluble or gelatinous fibers, such as that from psyllium, which can help solidify stool but can block the feeding tube. If diarrhea persists in patients receiving highly soluble fiber supplementation, we discontinue fiber supplementation and search for other causes of diarrhea.

Limited data support the use of highly soluble fibers in those with diarrhea. Three [67-69] of five randomized trials [30,68] in critically ill patients showed a reduction in diarrhea using fiber supplementation. None showed changes in any other outcome. It is theorized that their fermentation to short-chain fats improves colonic biology. But we theorize that because they do not gel, they may be equally likely to make diarrhea worse due to their osmotic effect. Thus, their use should be on a trial basis only. The evaluation and management of diarrhea in non-critically ill patients are discussed separately. (See "Approach to the adult with acute diarrhea in resource-abundant settings" and "Approach to the adult with acute diarrhea in resource-limited settings".)

Constipation — Constipation can cause impaction, bowel distention, perforation, and death if not treated early, although these sequelae are very rare.

Constipation is a well-known consequence of critical illness despite prophylactic laxatives, which are often prescribed in this population. Fecal impaction is less common. We maintain adequate hydration (an increase in free water may be needed) and prescribe laxatives (eg, polyethylene glycol, magnesium containing laxatives) for the treatment of constipation. If these measures fail, concentrated nonabsorbable sugar alcohols (eg, sorbitol, lactulose) or enemas may be required. While many ICU patients receive docusate and/or senna prophylactically, their role in the treatment of constipation is limited [70].

Evaluation and management of constipation is described separately. (See "Etiology and evaluation of chronic constipation in adults" and "Management of chronic constipation in adults".)

Fluid/water/electrolyte disturbance — All feeding products consist of only 70 to 80 percent water. As a result, they are generally unable to meet patients' normal water requirements (EN providing 25 kilocalories (kcal)/kg with a 1 kcal/mL formula provides an average of only 20 mL/kg of water). This may be beneficial for patients who require fluid restriction, but most patients require another source of water. Feeding tubes must be flushed regularly with water to avoid clogging; flushing can also occur with medication, and patients in ICU are rarely without sources of intravenous fluids. Such supplements may suffice, but volume status and sodium level should be monitored daily until the patient is stable on their feeding regimen.

Adverse metabolic consequences of EN include hyperglycemia, micronutrient deficiencies, and electrolyte abnormalities (including hyper-/hypokalemia and hyper-/hypophosphatemia). We perform daily electrolyte monitoring until stable. Electrolyte abnormalities should be promptly treated. Glucose control in critically ill patients is discussed separately. (See "Glycemic control in critically ill adult and pediatric patients".)

Refeeding syndrome — Refeeding syndrome is a potentially fatal condition resulting from rapid changes in fluids and electrolytes when patients who have been malnourished are given oral, enteral, or parenteral feedings [71]. It is defined primarily by the development of hypophosphatemia, hypokalemia, and hypomagnesemia. Diagnosis, prevention, and management of refeeding syndrome are described in greater detail elsewhere. (See "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

Feeding tube complications — Complications can be due to the feeding tube itself.

Insertion or dislocation of an orogastric, nasogastric, or nasoenteric tube can cause mechanical complications, such as insertion into the lung or esophageal perforation. Placement and management of nasogastric and nasoenteric tubes are described separately. (See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Complications'.)

Patients who receive enteral feedings through a gastrostomy tube are also at risk for complications related to the tube (eg, bleeding following insertion, tube dysfunction, wound infection, or ulceration). Further details regarding the management of gastrostomy complications are described separately. (See "Gastrostomy tubes: Complications and their management".)

Fiber bezoar — Development of a fiber bezoar is a rare complication that can occur among patients receiving enteral feedings with extra fiber. Fiber bezoars can cause impaction, bowel distention, perforation, and death if not treated early, although these sequelae are very rare. Fiber bezoars may be more prevalent when peristalsis is impaired, such as in patients on vasopressors [1,72,73]. The risk factors for bezoars are poorly understood, and the incidence is rare. The diagnosis and management of gastric bezoars are provided separately. (See "Gastric bezoars".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Nutrition support (parenteral and enteral nutrition) in adults".)

SUMMARY AND RECOMMENDATIONS

Delivery route – Enteral nutrition (EN) refers to the provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids via an intestinal route. EN is most commonly delivered to the stomach via an orogastric or nasogastric tube (table 2). Post-pyloric feeding is typically reserved for those who are at high risk of aspiration (eg, gastric outlet obstruction) or fail standard aspiration precautions. (See 'Route of delivery' above.)

Choosing a formulation – Several formulations are available. Choosing one depends upon the presence of specific comorbidities. Our approach is as follows (see 'Formulations' above and 'Choosing a formulation' above):

Standard enteral formulas are appropriate for most critically ill patients in whom EN is prescribed. Standard formulas provide sufficient nourishment if an adequate daily volume is given. Standard EN comprises 49 to 53 percent of calories as carbohydrate and 29 to 30 percent of calories as fat, approximately 40 g of protein per 1000 kilocalories, and the daily recommended allowances of essential vitamins, minerals, and micronutrients. (See 'Choosing a formulation' above and 'Standard' above.)

Special formulations may be required in certain circumstances. Examples include (see 'Formulations for special circumstances' above):

-Patients who require volume restriction may require concentrated EN (eg, 1.5 to 2 times more concentrated than standard formulations). (See 'Concentrated formulas' above.)

-Patients with kidney failure (except for those on continuous kidney replacement therapy) may require a special renal formula. (See 'Renal' above.)

-Patients with chylous accumulations, digestive defects, or intolerance of standard EN may require predigested formulations. (See 'Predigested' above.)

For most patients, we suggest not routinely supplementing EN with omega-3 fatty acids, glutamine, ornithine ketoglutarate, arginine, beta-hydroxy-beta-methylbutyrate, prebiotics, probiotics, fiber, or antioxidant vitamins and trace elements (eg, vitamins A, C, or E; selenium; copper; zinc) in excess of daily recommended requirements (Grade 2C). Clinical trial evidence on use of these supplements in patients with critical illness is either limited or has not demonstrated any meaningful clinical benefit. (See 'Extra supplements of no proven benefit' above.)

Initiation and delivery – EN is typically administered as a continuous infusion (over a 24-hour period) or cycled infusion (over 12 hours in a 24-hour period). In most patients, we initiate feeds at a rate that is 30 to 50 percent of the full target goal. Feeds are then increased over three to seven days until the full target is reached. Water supplementation is typically used to avoid clogging of the feeding tube and may also be needed to meet daily fluid requirements. (See 'Delivery strategy' above and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Feeding intolerance – Patients should be observed at the bedside for clinical signs of feeding intolerance, which include gastric distention, abdominal discomfort, diarrhea, nausea, reflux of feeds, and vomiting. In patients with clinical signs of intolerance, the gastric residual volume should be measured and if >500 mL, feeds should be stopped. Once the etiology has been addressed, tube feed can be resumed. (See 'Feeding intolerance' above.)

Aspiration – Aspiration is common in mechanically ventilated patients. To prevent aspiration, backrest (head of the bed) elevation at 30 to 45 degrees during enteral feeding is common practice, although data to support it are limited and maintenance of positioning is challenging. Management of aspiration pneumonia is discussed separately. (See 'Aspiration' above and "Aspiration pneumonia in adults" and "Treatment of hospital-acquired and ventilator-associated pneumonia in adults".)

Other complications – We typically manage the following complications if they arise:

Diarrhea – EN does not need to be interrupted for diarrhea and should be continued while the etiology is being investigated (eg, antibiotic- or Clostridioides difficile-related diarrhea). If diarrhea persists and enteral feeding is suspected as the etiology, switching to a mixed fiber-containing EN formula may reduce diarrhea. (See 'Diarrhea' above and "Approach to the adult with acute diarrhea in resource-abundant settings".)

Constipation – The maintenance of adequate hydration and administration of laxatives (eg, polyethylene glycol, magnesium-containing laxatives) for the treatment of constipation is typically required. If these measures fail, concentrated nonabsorbable sugar alcohols (eg, sorbitol, lactulose) or enemas may be required. (See 'Constipation' above and "Management of chronic constipation in adults".)

Electrolyte disturbance – Adverse metabolic consequences of EN include hyperglycemia, micronutrient deficiencies, and electrolyte abnormalities (including hyper-/hypokalemia and hyper-/hypophosphatemia). Daily electrolyte monitoring is required until stable. (See 'Fluid/water/electrolyte disturbance' above.)

Feeding tube complications, refeeding syndrome, bezoars – Feeding tube complications, refeeding syndrome, and fiber bezoars are uncommon complications of EN. Further details regarding these complications are described separately. (See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Complications' and "Gastrostomy tubes: Complications and their management" and "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

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Topic 1605 Version 44.0

References

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