Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario

Abstract

Background and aim: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field. Materials and methods: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences. Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered. Conclusion: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.

Methodological Rigor and Transparency in Clinical Practice Guidelines for Nutrition Care in Critically Ill Adults: A Systematic Review Using the AGREE II and AGREE-REX Tools

“…Characteristics of included CPGs are summarized in Table 1. Five (45%) were developed by researchers and clinicians in Europe [16][17][18][19][20], four (36%) in North America [21][22][23][24], and two (18%) in Asia [25,26]. Eight (73%) were published between 2016 and 2021 [16,18,19,21,[23][24][25][26] and the remaining three (27%) between 2011 and 2013 [17,20,22].…”

“…Five (45%) were developed by researchers and clinicians in Europe [16][17][18][19][20], four (36%) in North America [21][22][23][24], and two (18%) in Asia [25,26]. Eight (73%) were published between 2016 and 2021 [16,18,19,21,[23][24][25][26] and the remaining three (27%) between 2011 and 2013 [17,20,22]. The GRADE tool was the most common tool used to assess the quality of included evidence and support CPG recommendations (seven (64%)) [16,17,19,20,23,24,26].…”

“…Overall, there was "substantial" agreement between assessors across all 11 CPGs (0.66 [0.51-0.72]). Agreement was considered "substantial" for seven CPGs (64%) [17][18][19]21,23,25,26], "moderate" for two (18%) [16,24], and "fair" for the remaining two (18%) [20,22].…”