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Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia. annika.reintam.blaser@ut.ee. Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland. annika.reintam.blaser@ut.ee. Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia. Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia. Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. Services of Adult Intensive Care Medicine and Burns, Lausanne University Hospital, Lausanne, Switzerland. Department of Intensive Care Medicine, University Hospital Leuven, Louvain, Belgium. Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia. Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria. Klinische Abteilung für Herz-Thorax-Gefäßchirurgische Anästhesie & Intensivmedizin, Medizinische Universität Wien, Vienna, Austria. Intensive Care Unit, Hôpital Pasteur 2, University of Nice, Nice, France. Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland. Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín de La Plata, Buenos Aires, Argentina. Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium. Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain. Anesthesiology and Perioperative Care Medicine Department, Hôpital Beaujon APHP, Clichy, France. Department of Surgery/IntensiveCare Medicine, Maastricht University Medical Center, Maastricht, The Netherlands. Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. Intensive Care Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel. Anesthesia and Intensive Care Division, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands. Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium. Department of Intensive Care Medicine, Division of Immunobiology and Transplantation, King's College London, King's College Hospital, London, UK. Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden. Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK. Medical Intensive Care Unit, University Hospital Leuven, Leuven, Belgium. Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.

Intensive care medicine. 2017;(3):380-398
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Abstract

PURPOSE To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. METHODS We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. RESULTS We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. CONCLUSIONS We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Methodological quality

Publication Type : Comparative Study ; Meta-Analysis ; Review

Metadata

MeSH terms : Critical Illness