Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition

Abstract

Background This guideline updates recommendations from the 2016 American Society for Parenteral and Enteral Nutrition (ASPEN)/Society of Critical Care Medicine (SCCM) critical care nutrition guideline for five foundational questions central to critical care nutrition support. Methods The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose, (2) higher vs lower protein dose, (3) exclusive isocaloric parenteral nutrition (PN) vs enteral nutrition (EN), (4) supplemental PN (SPN) plus EN vs EN alone, (5A) mixed‐oil lipid injectable emulsions (ILEs) vs soybean oil, and (5B) fish oil (FO)–containing ILE vs non‐FO ILE. To assess safety, weight‐based energy intake and protein were plotted against hospital mortality. Results Between January 1, 2001, and July 15, 2020, 2320 citations were identified and data were abstracted from 36 trials including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Owing to a lack of certainty regarding harm, the energy prescription recommendation was decreased to 12–25 kcal/kg/day. Conclusion No differences in clinical outcomes were identified among numerous nutrition interventions, including higher energy or protein intake, isocaloric PN or EN, SPN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors.

Early Versus Delayed Enteral Nutrition in Mechanically Ventilated Patients with Circulatory Shock: A Prospective Multicenter, Multi-National Cohort Study

“…(23) Major nutrition societal guidelines recommend initiating EN in patients with circulatory shock after hemodynamic stability and EN initiation beyond 48 hours may be due to greater initial severity of illness. (11,24,25) However, our study found the EEN group had greater baseline severity of illness, including higher mNUTRIC, APACHE II, and SOFA scores. The signi cant delay, beyond the recommended 48 hours, may be due to a paucity of data on the optimal timing of EN initiation in circulatory shock.…”

“…Unlike the recommendation to initiate EEN in the general ICU patient, which is supported by multiple RCTs (that did not include patients with circulatory shock), the evidence base informing timing of EN in circulatory shock consists of pre-clinical and human observational and small RCTs, including a phase II pilot feasibility study demonstrating protocol compliance and safety of early trophic EN in septic shock. 24 Furthermore, critical care nutrition guidelines recommend, based on expert opinion, that EN be withheld until the patient is fully resuscitated and/or stable. (11,26) The de nition of stability is unspeci ed and, therefore, ambiguous.…”

Critical Care Nutrition Support following Cardiac Surgery in the Pediatric and Adult Population—A Review Article

“…A comparative narrative of chief guideline points in pediatric and adult is presented in Table 1 and Table 2 . 4…”

Enteral Nutrition Overview

“…In early critical illness, research has shown that there is no difference in clinical outcomes in patients that are fed EN vs. PN for short periods of time (5 to 7 days). Thus, PN may be an appropriate substitute should EN not be feasible in this population [ 3 ].…”