In this post which will be updated continuously, I will be examining the clinical questions regarding ICU nutrition. These data do not apply to the non-ICU patients. The first thing that we need to acknowledge is that nutrition in the critically ill is not one size fits all nor set it and forget it in the ICU. Together, we will tackle many of the question that we have all asked ourselves on how to provide nutrition to our patients who are in the ICU.
I always recommend you read the cited papers for yourself as I will be honestly cherry picking the data. I cannot go through every single nuance of every study. Both of our respective ADHD minds will quickly put this down and start scrolling social media if I were to do that. That is for you to do and hence why I am providing links for my citations so that YOU can peer-review me. This page on ICU Nutrition will be continuously updated as new data comes out.
Also, this body of work has taken me months to go through, learn, and compile onto this webpage. If you use any of these contents on your own work on the matter, it would only be fair if you give me a proper hat tip by citing my work. You can easily do that by citing this as
“Nutrition in the Critically Ill/Intensive Care Unit (ICU)”, eddyjoemd blog, July 24, 2021. Available at: http://eddyjoemd.com/icu-nutrition/.
ADDENDUM: Article Shared on Social Media on 12/15/21 by Dr. Wis on 10 expert tips
Preiser, JC., Arabi, Y.M., Berger, M.M. et al. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Crit Care 25, 424 (2021). https://doi.org/10.1186/s13054-021-03847-4
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Table of Contents for ICU Nutrition
- Should we check for gastric residuals?
- Initiation of Nutrition: Early vs. Delayed
- Trophic vs. Full Nutrition
- Should we Protocolize Enteral Nutrition Inititation?
- Enteral Nutrition vs. Parenteral Nutrition
- Nutrition while in Shock
- Nutrition in Pancreatitis Patients
- Continuous vs. Intermittent Feeds
- Can Proned Patients be Fed?
- Can Paralyzed Patients be Fed?
- Protein/Calorie goals
- High, Medium or Low Protein Diets
- Which formula to use?
- Approaches to Refeeding Syndrome
- Indirect Calorimetry: Should we be using this?
- Do we need fancy stuff to place dobhoff (post-pyloric) feeding tubes?
Should we check for gastric residual tube feeds in our mechanically ventilated patients?
Link to my post on the matter: CLICK HERE. Short answer is not really.
Initiation of Enteral Nutrition: Early or Late in the ICU?
Early, within 24-48 hours, decreases the risk of mortality by 30% and decreases the risk of infectious complications by 26% per the ASPEN 2016 Guidelines.
When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5… on and on. This study by Nguyen et al. shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1.
The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be “start at day 1 vs day 2” or “start at day 1 vs day 3”? We do not know those answers yet. In my practice is start enteral nutrition on day 1 or 2.
Should we try to provide ICU Nutrition within the first 24 hours?
Tian F, Heighes PT, Allingstrup MJ, Doig GS. Early Enteral Nutrition Provided Within 24 Hours of ICU Admission: A Meta-Analysis of Randomized Controlled Trials. Crit Care Med. 2018 Jul;46(7):1049-1056. doi: 10.1097/CCM.0000000000003152. PMID: 29629984.
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Implementing Early ICU Nutrition: Does it Change Outcomes? One-Minute Journal Club (Updated 06.03.22)
This is a one-minute Journal Club-ish.
Check out the full free article for yourself as this is not medical advice.
Hat tip to the authors.
Nutrition in the critically ill is of utmost importance.
Part of the problem is that it is often overlooked.
The authors here attempted to implement evidence-based guidelines for nutrition.
They performed a multi center RCT including almost 1400 patients.
Table 1 shows their protocol.
The feeding guideline group received quicker initiation of nutrition.
Although the initiation in the control group was within 48 hours of enrollment as well.
Seems like the standard practice of the control group was pretty reasonable.
Although they were rather excited to start parenteral nutrition early.
There was no difference in the amount of calories between the two groups.
There was also no difference in how these were tolerated.
All in all, there was no difference in mortality at day 28.
There was no difference in getting out of the ICU sooner.
The authors stated that perhaps mortality as the wrong primary outcome.
How quickly do you start nutrition in your ICU?
Ke L, Lin J, Doig GS, van Zanten ARH, Wang Y, Xing J, Zhang Z, Chen T, Zhou L, Jiang D, Shi Q, Lin J, Liu J, Cheng A, Liang Y, Gao P, Sun J, Liu W, Yang Z, Zhang R, Xing W, Zhang A, Zhou Z, Zhou T, Liu Y, Tong F, Wang Q, Pan A, Huang X, Fan C, Lu W, Shi D, Wang L, Li W, Gu L, Xie Y, Sun R, Guo F, Han L, Zhou L, Zheng X, Shan F, Liu J, Ai Y, Qu Y, Li L, Li H, Pan Z, Xu D, Zou Z, Gao Y, Yang C, Kou Q, Zhang X, Wu J, Qian C, Zhang W, Zhang M, Zong Y, Qin B, Zhang F, Zhai Z, Sun Y, Chang P, Yu B, Yu M, Yuan S, Deng Y, Zhao L, Zang B, Li Y, Zhou F, Chen X, Shao M, Wu W, Wu M, Zhang Z, Li Y, Guo Q, Wang Z, Gong Y, Song Y, Qian K, Feng Y, Fu B, Liu X, Li Z, Gong C, Sun C, Yu J, Tang Z, Huang L, Ma B, He Z, Zhou Q, Yu R, Tong Z, Li W; Chinese Critcal Care Nutrition Trials Group (CCCNTG). Actively implementing an evidence-based feeding guideline for critically ill patients (NEED): a multicenter, cluster-randomized, controlled trial. Crit Care. 2022 Feb 16;26(1):46. doi: 10.1186/s13054-022-03921-5. Erratum in: Crit Care. 2022 Apr 21;26(1):115. PMID: 35172856; PMCID: PMC8848648.
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Trophic or Full Enteral ICU Nutrition?
The EDEN Trial in 2012 looked at trophic vs. full enteral nutrition for the first 6 days. They restricted both calories as well as protein. There was no difference in outcomes. The PermiT trial in 2015 also looked at permissive underfeeding versus standard enteral feeding. They found no difference in the probability of survival nor other outcomes. A meta-analysis looking at these and other data found that lower calorie intake was better for blood stream infections and incident renal replacement therapy. The EAT-ICU trial in 2016 looked at early goal-directed nutrition (enteral + parenteral to reach certain goals) vs. standard nutrition. They also found no benefit nor harm to the regimens.
Trophic will get the job done and may be better in some cases (4,5,6,7,8). Lower calorie intake seems to be better for blood stream infections and incident renal replacement therapy (7).
Nutrition in Pancreatitis Patients
Yao H, He C, Deng L, Liao G. Enteral versus parenteral nutrition in critically ill patients with severe pancreatitis: a meta-analysis. Eur J Clin Nutr. 2018 Jan;72(1):66-68. doi: 10.1038/ejcn.2017.139. Epub 2017 Sep 13. PMID: 28901335.
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Enteral vs. Parenteral: Is TPN really that bad for you?
The CALORIES trial in 2014 found no difference in mortality nor infectious complications when providing TPN.
Please use EN when possible due to cost and logistics. That being said, PN isn’t as evil as we once thought regarding infections in the ICU. (9,10,13)
If a patient needs parenteral nutrition, when should we start it?
Do not start within 7 days in adequately nourished critically ill patients (11). Early initiation leads to more renal failure, longer hospital length of stay, and costs more money (12). If malnourished then start earlier.
ICU Nutrition and Vasopressors
Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr. 2020 Feb;39(2):460-467. doi: 10.1016/j.clnu.2019.02.020. Epub 2019 Feb 15. PMID: 30808573.
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Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, Argaud L, Asehnoune K, Asfar P, Bellec F, Botoc V, Bretagnol A, Bui HN, Canet E, Da Silva D, Darmon M, Das V, Devaquet J, Djibre M, Ganster F, Garrouste-Orgeas M, Gaudry S, Gontier O, Guérin C, Guidet B, Guitton C, Herbrecht JE, Lacherade JC, Letocart P, Martino F, Maxime V, Mercier E, Mira JP, Nseir S, Piton G, Quenot JP, Richecoeur J, Rigaud JP, Robert R, Rolin N, Schwebel C, Sirodot M, Tinturier F, Thévenin D, Giraudeau B, Le Gouge A; NUTRIREA-2 Trial Investigators; Clinical Research in Intensive Care and Sepsis (CRICS) group. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018 Jan 13;391(10116):133-143. doi: 10.1016/S0140-6736(17)32146-3. Epub 2017 Nov 8. PMID: 29128300.
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Nutrition and Paralytics: Can you feed these folks?
Yes you can per these data. Best caloric intake is unknown, though.
Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, Fruhwald S, Hiesmayr M, Ichai C, Jakob SM, Loudet CI, Malbrain ML, Montejo González JC, Paugam-Burtz C, Poeze M, Preiser JC, Singer P, van Zanten AR, De Waele J, Wendon J, Wernerman J, Whitehouse T, Wilmer A, Oudemans-van Straaten HM; ESICM Working Group on Gastrointestinal Function. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med. 2017 Mar;43(3):380-398. doi: 10.1007/s00134-016-4665-0. Epub 2017 Feb 6. PMID: 28168570; PMCID: PMC5323492.
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Can proned patients be fed safely?
Yes. The first not-so-robust data I was able to find was published in 2016. More recently in 2021, a prospective observational study was performed to assess “the feasibility, tolerance and effectiveness of enteral nutrition”. They found that providing enteral nutrition was both feasible and well tolerated. There was no statistically significant difference in gastric residual volumes, vomiting nor diarrhea. So just feed these patients and be done with it. Thanks.
Al-Dorzi HM, Arabi YM. Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers. Nutr Clin Pract. 2021 Feb;36(1):88-97. doi: 10.1002/ncp.10621. Epub 2020 Dec 29. PMID: 33373481.
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Which is better: Continuous or intermittent enteral nutrition in the ICU?
I have worked at some institutions where patients are bolus fed. You know, every 4, 6 or 8 hours. The thought process behind this, amongst many other factors, is that we don’t eat continuously. At some institutions where I have worked, however, continuous feeds are the way things are. The argument includes less intolerance. But what does the data say regarding outcomes?
In this paper they looked at acute skeletal muscle wasting because it is associated with morbidity and mortality. I would hate to lose my gains if I were to become critically ill. They investigated if continuous was better than intermittent or vice versa.
The looked at 121 patients who were on the vent with multiple organ failure. Obviously all these patients were in the ICU in this nutrition study. They were either in the intermittent group, feeds every 4 hours for 6 feeds per day, or the continuous feeds which is what you expect. They measured muscle mass on the rectus femoris muscle via ultrasound. The 10 day loss of muscle density here was the primary endpoint. Based on how I read the introduction, it seems as if the researchers were expecting intermittent feeding to be the winner.
Shout out to my dietitian friends as they dosed the nutritional components to meet the needs of the patient. Energy targets seemed to be 25kcal/k on the weight-based equation. They also used a modified Penn State equation which I am not familiar with. Patients also received 1.2g/kg of protein as a minimum.
What did they find? Well, there was no difference in muscle mass. That also includes the fact that the intermittent feeding group resulted in greater nutrition delivery regarding energy (kcal) and protein. There was no difference in the physical function milestones or discharge destination either.
Systematic Review and Meta-analysis: October 2022
On October 25th, 2022 there was a systematic review and meta-analysis published on the topic. After including 13 different studies into their paper they made several findings.
There was no difference in mortality.
There was no difference in pneumonia.
There was a trend towards less diarrhea in the continuous group but this was not statistically significant.
Seems as if giving constipated patients bolus feeds rather than continuous is the right thing to do.
There was no difference in patients with increased gastric residuals.
Heffernan, A.J., Talekar, C., Henain, M. et al. Comparison of continuous versus intermittent enteral feeding in critically ill patients: a systematic review and meta-analysis. Crit Care 26, 325 (2022). https://doi.org/10.1186/s13054-022-04140-8
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High Protein, Medium or Low Protein Diet for ICU Nutrition?
An RCT published out of Japan looked at high protein (1.8g/kg/day) vs. medium protein (0.9g/kg/day). After enrolling 117 patients, they were able to note that patients were able to maintain more muscle mass in the high protein group. The caveat here is that they needed early rehabilitation, though, to see these benefits.
Citation for Post Shared on Instagram on 07/24/21
Lee ZY, Yap CSL, Hasan MS, Engkasan JP, Barakatun-Nisak MY, Day AG, Patel JJ, Heyland DK. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2021 Jul 23;25(1):260. doi: 10.1186/s13054-021-03693-4. PMID: 34301303; PMCID: PMC8300989.
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Davies ML, Chapple LS, Chapman MJ, Moran JL, Peake SL. Protein delivery and clinical outcomes in the critically ill: a systematic review and meta-analysis. Crit Care Resusc. 2017 Jun;19(2):117-127. PMID: 28651507.
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Nakamura K, Nakano H, Naraba H, Mochizuki M, Takahashi Y, Sonoo T, Hashimoto H, Morimura N. High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial. Clin Nutr. 2021 Mar;40(3):796-803. doi: 10.1016/j.clnu.2020.07.036. Epub 2020 Aug 7. PMID: 32800385.
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Refeeding Syndrome: Take it easy or push through?
Take it easy, my friends. Less is more.
Cioffi I, Ponzo V, Pellegrini M, Evangelista A, Bioletto F, Ciccone G, Pasanisi F, Ghigo E, Bo S. The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature. Clin Nutr. 2021 Jun;40(6):3688-3701. doi: 10.1016/j.clnu.2021.04.023. Epub 2021 Apr 22. PMID: 34134001.
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Should we be using indirect calorimetry to feed our ICU patients?
To be honest I did not know what indirect calorimetry was even after I finished fellowship. I figured it was some fancy tool that existed at the fancy institutions with a lot of money to do research. There was never any compelling evidence nor quality of study high enough to pique my interest to go down this rabbit hole. Throughout my career thus far, I have never worked at an institution that has the ability to measure energy expenditure in our critically ill patients. How’s that for a disclaimer? If you want to become more knowledgable immediately on the matter, check out this fantastic post by Alex Yartsev over on derangedphysiology.com.
The first question you have, and I had not too long ago, is what in the world is indirect calorimetry and how is it performed. This is where a trusty registered dietician can school me and potentially explain it better. Porter, et al. states that “indirect calorimetry is based on the equations for oxidation of carbohydrate, protein and fat”. You need to obtain the following variables: O2 consumption (inspired and expired O2), CO2 excretion (end-tidal CO2), and the minute volume. This seems to be much easier for patients on the vent. Math happens and one gets a number called the energy expenditure which is abbreviated to the resting energy expenditure.
What device(s) do you need to do this?
A quick google search for indirect calorimetry device showed some clunky-looking machines that need to be hooked up to the ventilator. In fact, there seems to be a future where both the indirect calorimeter hardware and software is within the ventilator. To make it easier, if you don’t have these devices already, chances are that you’ll get a significant amount of pushback from the administrators because this all looks expensive.
When it comes to looking at the systematic review and meta-analysis performed by Duan et al, we are shown that it has been quite the challenge to gather robust data on indirect calorimetry in the critically ill. They used 8 RCTs with a combined 991 patients. They performed their statistical jumping jacks and found that “IC-guided energy delivery significantly reduces short-term mortality in critically ill patients”. The patients in whom indirect calorimetry is performed on have 0.77 times the risk of mortality compared to those who do not. There was no difference in duration of mechanical ventilation, ICU nor hospital length of stay.
The authors recommended more studies to confirm these findings but I would like to know what you all think. I dedicate this much effort to ICU nutrition because I feel we can be doing a better job with this.
Do we need fancy stuff to place dobhoff (post-pyloric) feeding tubes?
New article shared on IG on 5/12/21
Wang Q, Xuan Y, Liu C, Lu M, Liu Z, Chang P. Blind placement of postpyloric feeding tubes at the bedside in intensive care. Crit Care. 2021 May 11;25(1):168. doi: 10.1186/s13054-021-03587-5. PMID: 33975642.
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Nutrition in COVID ICU Patients
Citations:
Lambell KJ, Tatucu-Babet OA, Chapple LA, Gantner D, Ridley EJ. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care. 2020 Feb 4;24(1):35. doi: 10.1186/s13054-020-2739-4. PMID: 32019607; PMCID: PMC6998073.
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McNelly AS, Bear DE, Connolly BA, Arbane G, Allum L, Tarbhai A, Cooper JA, Hopkins PA, Wise MP, Brealey D, Rooney K, Cupitt J, Carr B, Koelfat K, Damink SO, Atherton PJ, Hart N, Montgomery HE, Puthucheary ZA. Effect of Intermittent or Continuous Feed on Muscle Wasting in Critical Illness: A Phase 2 Clinical Trial. Chest. 2020 Jul;158(1):183-194. doi: 10.1016/j.chest.2020.03.045. Epub 2020 Apr 2. PMID: 32247714.
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Nguyen NQ, Besanko LK, Burgstad C, Bellon M, Holloway RH, Chapman M, Horowitz M, Fraser RJ. Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients. Crit Care Med. 2012 Jan;40(1):50-4. doi: 10.1097/CCM.0b013e31822d71a6. PMID: 21926614.
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McClave SA, Lukan JK, Stefater JA, Lowen CC, Looney SW, Matheson PJ, Gleeson K, Spain DA. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005 Feb;33(2):324-30. doi: 10.1097/01.ccm.0000153413.46627.3a. PMID: 15699835.
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Poulard F, Dimet J, Martin-Lefevre L, Bontemps F, Fiancette M, Clementi E, Lebert C, Renard B, Reignier J. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr. 2010 Mar-Apr;34(2):125-30. doi: 10.1177/0148607109344745. Epub 2009 Oct 27. PMID: 19861528.
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863. Erratum in: JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200. PMID: 26773077.
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National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012 Feb 22;307(8):795-803. doi: 10.1001/jama.2012.137. Epub 2012 Feb 5. PMID: 22307571; PMCID: PMC3743415.
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Arabi YM, Aldawood AS, Haddad SH, Al-Dorzi HM, Tamim HM, Jones G, Mehta S, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Afesh L; PermiT Trial Group. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med. 2015 Jun 18;372(25):2398-408. doi: 10.1056/NEJMoa1502826. Epub 2015 May 20. Erratum in: N Engl J Med. 2015 Sep 24;373(13):1281. PMID: 25992505.
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Arabi YM, Aldawood AS, Al-Dorzi HM, Tamim HM, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Mundekkadan S, Kumar A, Bagshaw SM, Mehta S; PermiT trial group. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med. 2017 Mar 1;195(5):652-662. doi: 10.1164/rccm.201605-1012OC. PMID: 27589411.
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Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Crit Care. 2016 Nov 4;20(1):358. doi: 10.1186/s13054-016-1539-3. PMID: 27814776; PMCID: PMC5097427.
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Allingstrup MJ, Kondrup J, Wiis J, Claudius C, Pedersen UG, Hein-Rasmussen R, Bjerregaard MR, Steensen M, Jensen TH, Lange T, Madsen MB, Møller MH, Perner A. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med. 2017 Nov;43(11):1637-1647. doi: 10.1007/s00134-017-4880-3. Epub 2017 Sep 22. PMID: 28936712.
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Harvey SE, Parrott F, Harrison DA, Bear DE, Segaran E, Beale R, Bellingan G, Leonard R, Mythen MG, Rowan KM; CALORIES Trial Investigators. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014 Oct 30;371(18):1673-84. doi: 10.1056/NEJMoa1409860. Epub 2014 Oct 1. PMID: 25271389.
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Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O’Leary M, Solano T, Peake S; Early PN Investigators of the ANZICS Clinical Trials Group. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013 May 22;309(20):2130-8. doi: 10.1001/jama.2013.5124. PMID: 23689848.
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Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-26. doi: 10.1164/rccm.201407-1317ST. PMID: 25271745.
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Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011 Aug 11;365(6):506-17. doi: 10.1056/NEJMoa1102662. Epub 2011 Jun 29. PMID: 21714640.
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Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, Argaud L, Asehnoune K, Asfar P, Bellec F, Botoc V, Bretagnol A, Bui HN, Canet E, Da Silva D, Darmon M, Das V, Devaquet J, Djibre M, Ganster F, Garrouste-Orgeas M, Gaudry S, Gontier O, Guérin C, Guidet B, Guitton C, Herbrecht JE, Lacherade JC, Letocart P, Martino F, Maxime V, Mercier E, Mira JP, Nseir S, Piton G, Quenot JP, Richecoeur J, Rigaud JP, Robert R, Rolin N, Schwebel C, Sirodot M, Tinturier F, Thévenin D, Giraudeau B, Le Gouge A; NUTRIREA-2 Trial Investigators; Clinical Research in Intensive Care and Sepsis (CRICS) group. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018 Jan 13;391(10116):133-143. doi: 10.1016/S0140-6736(17)32146-3. Epub 2017 Nov 8. PMID: 29128300.
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TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, Bellomo R, Davies A, Deane A, Horowitz M, Hurford S, Lange K, Little L, Mackle D, O’Connor S, Presneill J, Ridley E, Williams P, Young P. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. N Engl J Med. 2018 Nov 8;379(19):1823-1834. doi: 10.1056/NEJMoa1811687. Epub 2018 Oct 22. PMID: 30346225.
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McNelly AS, Bear DE, Connolly BA, Arbane G, Allum L, Tarbhai A, Cooper JA, Hopkins PA, Wise MP, Brealey D, Rooney K, Cupitt J, Carr B, Koelfat K, Damink SO, Atherton PJ, Hart N, Montgomery HE, Puthucheary ZA. Effect of Intermittent or Continuous Feed on Muscle Wasting in Critical Illness: A Phase 2 Clinical Trial. Chest. 2020 Jul;158(1):183-194. doi: 10.1016/j.chest.2020.03.045. Epub 2020 Apr 2. PMID: 32247714.
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Doig GS, Simpson F, Heighes PT, Bellomo R, Chesher D, Caterson ID, Reade MC, Harrigan PW; Refeeding Syndrome Trial Investigators Group. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med. 2015 Dec;3(12):943-52. doi: 10.1016/S2213-2600(15)00418-X. Epub 2015 Nov 18. PMID: 26597128.
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Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC, van Zanten ARH, Oczkowski S, Szczeklik W, Bischoff SC. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 Feb;38(1):48-79. doi: 10.1016/j.clnu.2018.08.037. Epub 2018 Sep 29. PMID: 30348463.
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Duan JY, Zheng WH, Zhou H, Xu Y, Huang HB. Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis. Crit Care. 2021 Feb 27;25(1):88. doi: 10.1186/s13054-021-03508-6. PMID: 33639997; PMCID: PMC7913168.
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Early Enteral Nutrition in Patients Undergoing Sustained Neuromuscular Blockade: A Propensity-Matched Analysis Using a Nationwide Inpatient Database. Crit Care Med. 2019 Aug;47(8):1072-1080. doi: 10.1097/CCM.0000000000003812. PMID: 31306255.
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Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, Garcia Gigorro R, Terceros Almanza LJ, Sanchez Izquierdo JA, Montejo Gonzalez JC. Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):250-5. doi: 10.1177/0148607114553232. Epub 2014 Oct 1. PMID: 25274497.
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Savio RD, Parasuraman R, Lovesly D, Shankar B, Ranganathan L, Ramakrishnan N, Venkataraman R. Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position. J Intensive Care Soc. 2021 Feb;22(1):41-46. doi: 10.1177/1751143719900100. Epub 2020 Jan 14. PMID: 33643431; PMCID: PMC7890761.
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Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;2015(8):CD008875. doi: 10.1002/14651858.CD008875.pub2. PMID: 26241698; PMCID: PMC6516803.
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Sams VG, Lawson CM, Humphrey CL, Brantley SL, Schumacher LM, Karlstad MD, Norwood JE, Jungwirth JA, Conley CP, Kurek S, Barlow PB, Daley BJ. Effect of rotational therapy on aspiration risk of enteral feeds. Nutr Clin Pract. 2012 Dec;27(6):808-11. doi: 10.1177/0884533612462897. Epub 2012 Oct 19. PMID: 23087262.
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Lee, ZY., Yap, C.S.L., Hasan, M.S. et al. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Crit Care 25, 260 (2021). https://doi.org/10.1186/s13054-021-03693-4
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Porter C, Cohen NH. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results. J Am Diet Assoc. 1996 Jan;96(1):49-57. doi: 10.1016/S0002-8223(96)00014-4. PMID: 8537570.
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Wang Z, Ding W, Fang Q, Zhang L, Liu X, Tang Z. Effects of not monitoring gastric residual volume in intensive care patients: A meta-analysis. Int J Nurs Stud. 2019 Mar;91:86-93. doi: 10.1016/j.ijnurstu.2018.11.005. Epub 2019 Jan 3. PMID: 30677592.
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Heffernan, A.J., Talekar, C., Henain, M. et al. Comparison of continuous versus intermittent enteral feeding in critically ill patients: a systematic review and meta-analysis. Crit Care 26, 325 (2022). https://doi.org/10.1186/s13054-022-04140-8
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Here are some topics on ICU Nutrition that I have covered in the past.
Nutrition in COVID Patients: CLICK HERE.
Enteral Nutrition and mortality: CLICK HERE.
ASPEN Guidelines for Enteral Nutrition: CLICK HERE.
Which day to start enteral nutrition: 1 or 4? CLICK HERE.
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