Approach to Oral and Enteral Nutrition in Adults

Topic 8

Module 8.1

Indications, Contraindications, Complications and Monitoring of EN

Matthias Pirlich

Learning objectives

 To understand the main indications and contraindications for EN;

 To identify patients who might benefit from EN;
 To understand the most important complications of EN;
 To know how to prevent or counteract complications;
 To know how to monitor patients on enteral nutritional support;

Contents

1. What exactly is EN?

2. Indications for EN
2.1 Definition of malnutrition and nutritional risk
2.2 Specific indications for EN according to the ESPEN guidelines 2006
3. Contraindications to EN
4. Gastrointestinal complications of EN
4.1 Diarrhoea
4.2 Nausea and vomiting
4.3 Constipation
5. Aspiration
6. Tube related complications
7. Metabolic complications
8. Monitoring of EN
9. Summary
10. References

Key Messages

 EN is a safe and effective approach to nutritional therapy;

 The main indication for EN is prevention and treatment of malnutrition to improve
outcome;
 The main contraindications are severe disturbances of the gastrointestinal tract
and metabolic instability;
 Most complications of EN are the result of application errors;
 Certain underlying diseases are associated with increased risk of specific
complications;
 Acceptance of EN can be enhanced by adequate monitoring / early recognition of
complications and modification of the type of EN and its application;
 Careful monitoring of EN is especially important in intensive care, in elderly
patients and in patients with neurological impairment.
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1. What exactly is EN?

Enteral nutrition is one form of the so-called “artificial nutrition” and includes both
feeding via nasogastric/enteral or percutaneous (gastric or jejunal) tube and oral
nutritional supplementation. Thus, enteral nutrition comprises all forms of nutritional
support that imply the use of “dietary foods for special medical purposes” as defined in
the European legal regulation of the commission directive 1999/21/EC of 25 March 1999
(1). Enteral nutrition is a safe, effective and generally well tolerated approach of
nutritional therapy in patients with normal functioning gastrointestinal tract.
The main goal of EN is prevention or treatment of malnutrition in order to improve
outcome. This is obvious from a pathophysiological point of view, but there is also strong
evidence from a number of excellent studies which show that malnutrition is an
independent risk factor for poor outcome in terms of morbidity, delayed convalescence
after surgery or trauma, higher readmission rates, increased length of hospital stay,
higher treatment costs, and higher mortality rates (2,3).
In this context it is worth mentioning the editorial accompanying the 2006 ESPEN
guidelines on Enteral Nutrition (4): “Although nutritional support is therapy in most
cases it is exactly what it says – supportive rather than specific treatment of the
underlying disease.”

2. Indications for EN

In general there are two indications for enteral nutrition to maintain or improve
nutritional status irrespective of the underlying disease or clinical setting:
 Anticipated inadequate oral food intake for more than 7 days
 Present or imminent malnutrition

2.1 Definititon of malnutrition and nutritional risk

The term malnutriton can be used both for deficiency and excess of macro- or
micronutrients (1). However, in clinical practice and in the context of enteral nutrition or
other nutritional interventions malnutrition is more specifically used to describe a
nutritional deficit with clinically relevant effects on body composition, organ function and
clinical outcome.
According to the ESPEN guidelines (1) the term nutritional risk is used to describe a state
of malnutrition with impaired outcome. Severe nutritional risk is defined from the
presence of at least one of the following criteria:

 Weight loss > 10 % within 6 months

 BMI < 18.5 kg/m² (< 20 kg/m² in geriatric patients)
 SGA Grade C or NRS ≥ 3
 Serum albumin < 30 g/l (with no evidence of hepatic or renal dysfunction)

The SGA (Subjective Global Assessment) was established by Detsky and coworkers (5)
and relies on the patient´s history regarding weight loss, dietary intake, gastrointestinal
symptoms, functional capacity, and physical signs of malnutrition (loss of subcutaneous
fat or muscle mass, oedema, ascites). The NRS (Nutritional Risk Screening 2002) was
established by Kondrup and coworkers (6) and considers weight loss, food intake, BMI,
disease severity and age. Both scores are useful to identify patients at nutritional risk
who might benefit from enteral nutrition.
The criteria for the definition of nutritional risk in geriatric patients were modified due to
their reduced capacity to recover from nutritional deficits, which therefore require early
intervention (7). The recommended cut-off value for BMI is higher than in younger adults
(< 20 kg/m²), and weight loss of >5 % in 3 months is considered as critical as a weight
loss of >10 % in 6 months.
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2.2. Specific indications for EN according to the ESPEN guidelines

The 2006 ESPEN guidelines on EN have reviewed and analyzed hundreds of

interventional studies to create evidence-based recommendations for the use of EN in
different diseases and clinical settings (8). The following table summarizes the main
indications for EN considering the evidence levels provided by the ESPEN guidelines. The
grades of recommendation are:
 Grade A: Meta-analysis of randomized controlled trials or at least one randomized
controlled trial
 Grade B: At least one well-designed controlled trial without randomization or at least
one other type of well-designed, quasi-experimental study or well-designed non-
experimental descriptive studies such as comparative studies, correlation studies,
case-control studies
 Grade C: Expert opinion and/or clinical experience of respected authorities

Table 1: Specific indications for EN in selected diseases/clinical situations

Disease/Setting Indication Grade

Intensive Care All patients who are not expected to be on a full oral diet C
within 3 days.
Surgery Perioperative: Use nutritional support in patients with severe A
nutritional risk for 10-14 days prior to major surgery even if
surgery has to be delayed.

Initiate nutritional support without delay:

C
- even in patients without obvious undernutriton, if it is
anticipated that the patient will be unable to eat for more
than 7 days.
- in patients who cannot maintain oral intake above 60% of
recommended intake for more than 10 days. C
Organ Before transplantation: In undernutrition, use additional ONS C
transplantation or even TF. Assess nutritonal status regularly while
monitoring patients on the waiting list
After transplantation: Initiate early normal food or EN after
heart, lung, liver, pancreas and kidney transplantation. C

Even after transplantation of the small intestine, nutritional

support can be initiated early, but should be increased very C
carefully.
Non-surgical General: If undernutrition already exists or if it is anticipated C
oncology that the patient will be unable to eat for > 7 days or if intake
is < 60 % of estimated requirement for > 10 days.
In patients with weight loss due to insufficient nutritional
intake. B

Perioperative: Patients with severe nutritional risk benefit

from nutritional support 10-14 days prior to major surgery A
even if surgery has to be delayed.
During radio- or radiochemotherapy: Use intensive dietary
advice and oral nutritional supplements to increase dietary
intake and to prevent therapy-associated weight loss and A
interruption of therapy
During chemotherapy: Routine enteral nutrition is not useful. C
Crohn´s Disease Active disease: Use enteral nutrition as sole therapy for the A
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acute phase mainly when treatment with corticosteroids is not

feasible.
Use combined therapy (EN and drugs) in undernourished
C
patients or in patients with inflammatory stenosis of the
intestine.
Maintenance of remission: Use ONS in case of persistent
intestinal inflammation (steroid dependent patients). B
Ulcerative colitis Active disease: EN is not recommended as treatment of active C
ulcerative colitis unless the patient is malnourished.
Maintenance of remission: EN is not recommended. C
Pancreas Mild acute Pancreatitis: EN is unnecessary if the patient can B
consume normal food after 5-7 days.
EN within 5-7 days has no positive impact on the course of A
the disease and is therefore not recommended.
Tube feed if oral nutrition is not possible due to consistent
pain for more than 5 days. C

Severe necrotising pancreatitis: EN is indicated if possible.

EN should be supplemented by parenteral nutrition if needed. A

In severe acute pancreatitis with complications tube feeding C

can be performed successfully.
Chronic pancreatitis: 10-15 % of all patients require ONS,
tube feeding is indicated in approximately 5 %. C
Liver disease Liver cirrhosis: Use ONS or TF (even in presence of A
oesophageal varices) if caloric requirements cannot be met
through oral intake.
PEG placement is not recommended.
C
Renal disease Chronic renal failure: Consider EN when oral feeding is not C
possible; when oral intake is insufficient overnight TF might
be indicated.
Haemodialysis therapy (HD): Use EN when normal nutrition is
not possible due to intercurrent catabolic acute conditions. C
Consider TF when oral intake is inadequate and in
unconscious patients.
Infectious HIV: Start nutritional therapy when weight loss or loss of A
Disease body cell mass has occurred (>5% in 3 months) or BMI is C
<18,5 kg/m².
Diarrhea and/or malabsorption are not contraindications for
EN (A positive effect on nutritional status will not be A
prevented: PN has similar effects, EN has a positive impact on
stool frequency and consistency).
Chronic Heart EN is recommended to stop or reverse weight loss in cardiac C
Failure cachexia, but not in prophylaxis of cardiac cachexia.
COPD Evidence of beneficial effects of EN in COPD patients is B
limited. In combination with exercise and anabolic
pharmacotherapy it might improve nutritional status and
function.
ONS - oral nutritional supplement; TF - tube feeding

It has to be mentioned that this table gives only a rough overview on selected indications
for EN. More detailed recommendations on further clinical situations and the modes of
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application including routes for enteral feeding and choice of formulae are given in the
full text of the ESPEN guidelines (published in the April 2006 edition of Clinical Nutrition
and on-line via www.espen.org).
Note: Especially in geriatrics a variety of specific indications exists, because this group of
patients carries the highest risk for malnutrition. This broad topic is treated in detail in
the LLL-module “nutritional therapy in elderly patients”.
A specifically difficult clinical situation is the nutritional support of incurable patients. The
consensus (expert opinion level) of the ESPEN “non-surgical oncology” working group is,
that cancer patients with incurable disease should receive “enteral nutrition in order to
minimize weight loss as long as the patient consents and the dying phase has not yet
started”. When the end of life is very close, prevention or treatment of malnutrition is no
longer an indication for EN. In this situation most patients only require minimal amounts
of food and little water to reduce thirst and hunger. This helps to avoid dehydration and
states of confusion.
The situation becomes even more complex when the patient is not able to give consent
or when it is uncertain whether tube feeding will be beneficial and the prognosis of the
underlying condition is uncertain. The ethical and legal aspects of such situations have
been extensively discussed by Körner and colleagues (9).

3. Contraindications to EN

Contraindications to EN encompass the clinical situations where there is insufficient

gastrointestinal function, or severe metabolic and circulatory instability (10), and in
particular:
Gastrointestinal
 Intestinal obstruction / ileus
 Intestinal ischaemia
 Severe peritonitis
 Nausea / vomiting
 Malassimilation

Metabolic
 Diabetic ketoacidosis
 Diabetic coma
 Hepatic coma

Circulatory
 Severe acute cardiac insufficiency
 Shock of any origin


Nausea and malassimilation are not strict contraindications, and EN might be possible
when the underlying condition is adequately treated or specific formulae are applied.
General contraindications for endoscopic tube placement are discussed in the LLL-module
8.3 “Techniques of EN”. According to the ESPEN guidelines PEG placement is not
recommended in patients with liver cirrhosis or in those on chronic ambulatory peritoneal
dialysis due to the increased risk of peritonitis and other complications. In patients with
advanced cirrhosis, however, oesophageal varices are not associated with increased risk
of bleeding, and thus, nasogastric tube feeding is possible (11).

4. Gastrointestinal complications of EN

Enteral nutrition is a safe, effective and generally well-tolerated approach to nutritional

therapy in patients with a normally functioning gastrointestinal tract. Interruption of
enteral nutrition is frequently related to gastrointestinal complications however. It is
important to understand, that most complications are the result of application errors.
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Complications of EN can be divided into those of gastrointestinal, tube related and

metabolic origin.

Complications of enteral nutrition

Problem Frequency

 Compliance 10-40 %
 Tube malposition / displacement up to 50 %
 Nausea / Vomiting 10-15 %
 Diarrhoea 25-50 %
 Infections rare
 Severe metabolic complications very rare
 Aspiration ?

Figure 1: Complications of enteral nutrition

4.1 Diarrhoea

Diarrhoea is a fairly common gastrointestinal complication of EN. There is a wide range of

prevalence data for diarrhoea in the literature which is most likely explained by the
different definitions used. The most common definition of diarrhoea is: stool mass > 200
g/24 h, or a frequency of more than 3 liquid stools per day. The prevalence of EN related
diarrhoea is estimated to be 25 % on general wards and up to 60 % in ICU patients.
Reasons for diarrhoea include intolerance of bolus application or a high delivery rate,
high osmolality, bacterial contamination or inappropriate temperature of the formula diet.

Reasons for diarrhoea during enteral

nutrition

 Bolus application
 High delivery rate
 High osmolality
 Bacterial contamination of the formula diet
 Formula diet is too cold
 Gastrointestinal infections
 Malabsorption

Figure 2: Reasons for diarrhoea during enteral nutrition

The ideal temperature of the formula is 20 to 25 °C. Furthermore, a number of

medications (i.e. macrolides, antacids, atropine, metoclopramide etc.) can cause
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diarrhoea. Before intolerance of EN is considered, one must also exclude gastrointestinal

infections and disturbances of nutrient absorption (e.g. due to milk protein allergy,
exocrine pancreatic insufficiency or lactose intolerance,).

The work-up for diarrhoea occurring during EN should include the following issues:

 When bolus application has initially been performed switch to continuous application
using an electronic pump system. Continuous application of EN is generally better
tolerated than bolus application, even if the latter appears to be more physiologic.
 Decrease the delivery rate (sometimes it is effective to decrease the delivery rate
only for one or two days and than increase the rate to the initial level). The maximum
tolerated delivery rate does usually not exceed 120 ml/h which is equivalent to the
physiologic flux into the duodenum.
 Avoid bacterial contamination of the formula diet: change the drip line daily; review
the manufacturers’ guidelines for the use of the formula; when open systems are
used, the formula diet should be delivered within 6 to 10 hours; feeds should not
made up in advance
 Review patients’ prescriptions regarding diarrhoea-inducing drugs
 Exclude gastrointestinal infections (stool culture including screening for Clostridium
difficile toxin)
 If malabsorption is suspected change to low molecular diets
 If diarrhoea persists change to a soluble fibre-containing EN formula

4.2 Nausea and vomiting

Many patients who receive enteral nutrition suffer from diseases which are themselves
associated with a high risk of nausea and vomiting (e.g. cancer of the upper GI tract).
Furthermore antineoplastic therapy (i.e. radio- or chemotherapy) is a strong trigger for
nausea and vomiting and consequently requires antiemetic therapy before EN is initiated.

Reasons for impaired gastric

emptying during EN
 Pre-existing diseases:
 Diabetes mellitus
 Vagotomy
 Systemic scleroderma
 Myopathies
 Acute disease related:
 Pain and stress
 Pancreatitis
 Spinal cord injury
 Extensive trauma, abdominal surgery, burn injuries
 Medication:
 Opioids
 Anticholinergics
 Erythromycin

Figure 3: Reasons for impaired gastric emptying during EN

In some cancer patients nausea might be so dominant that EN becomes impossible and
total parenteral nutrition must be considered.
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Delayed gastric emptying is the most common cause of nausea related to tube feeding
and this may be aggravated by pain, ascites, immobilisation, sedatives, antibiotics etc.
In ventilated patients a high PEEP might induce vomiting (with the risk of aspiration). In
some patients after initiating EN abdominal distension and nausea might occur only
transiently.

The work-up of nausea/vomiting occurring during EN should include the following

issues:
 In case of cancer / antineoplastic therapy: initiate adequate antiemetic / analgesic
therapy
 Exclude bowel obstruction (auscultation, x-ray abdomen)
 Review patients’ prescriptions regarding nausea-inducing drugs
 If delayed gastric emptying is considered: reduce delivery rate, try prokinetic drugs

4.3 Constipation

Constipation is a rare gastrointestinal complication of EN. Decreased fluid intake, the use
of high energy dense formulae and lack of dietary fibre are possible reasons for
constipation associated with EN. Furthermore, immobilisation and decreased bowel
motility (as a result of sedatives or opioids) may contribute to constipation.

The work-up of constipation occurring during EN should include the following issues:
 Review patients’ EN prescription
 Increase fluid intake, reduce density of formula or switch to fibre-containing formulae
 Exclude bowel obstruction (auscultation, x-ray abdomen)
 If these steps fail consider stool softener (e.g. lactulose) or bowel stimulants

5. Aspiration

Aspiration is the most critical complication of EN and may result in pneumonia and
sepsis. Patients with neurological impairment, decreased level of consciousness or with
diminished gag reflexes are at high risk of aspiration. Further risk factors are:
postoperative or drug induced delayed gastric emptying, high GI reflux, supine position
or incompetent lower oesophageal sphincter.

Problems of enteral nutrition during

1929 days in ICU patients
Adam S, Batson S; Intensive Care Med 1997; 23: 261-266

Problem days

 Gastric reflux 191

 Nausea / Vomiting 112
 Meteorism 62
 Pain 20
 GI-Bleeding 17
 Diarrhoea 16
 Tube malposition 37
 Tube occlusion 12

Figure 4: Problems of enteral nutrition in ICU patients (12)

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In ICU patients periodic measurement of gastric reflux is recommended (interruption of

infusion for several hours, gastric drainage). If the reflux is higher than 200 ml/ 6 h or 1 l
/ day the delivery rate must be reduced or EN terminated. Although recommended by
some authors the use of prokinetics in the prevention of aspiration has not been proven.

In order to prevent aspiration in high risk patients the following issues should be
considered:
 Measure gastric reflux, adjust the delivery rate (prolong delivery period)
 Prefer a semi-recumbent position (30-45°)
 Prefer nasojejunal instead of nasogastric tube feeding

6. Tube related complications

A primary tube malposition can be diagnosed by adequate post-placement monitoring

and requires immediate correction. In patients with neurological impairment, decreased
level of consciousness or diminished gag reflexes it is not sufficient to monitor correct
tube placement by auscultation of insufflated air. The auscultation method can fail even
in the hands of well experienced staff and some fatal cases have been reported where
erroneous infusion of large amounts of formula diet into the lungs was not recognised by
the patient (who might not even cough) nor by the staff. Therefore radiological control of
tube position is recommended.
In patients with nasopharyngeal or facial injuries transnasal tube placement is
contraindicated. In contrast, oesophageal varices are not associated with an increased
risk of bleeding complications and, thus, nasogastric tube feeding can be used even in
advanced cirrhosis.
Other tube related complications such as necrosis or ulceration of the nasopharyngeal,
oesophageal, gastric or duodenal mucosa became very rare after introduction of the
modern fine-bore tubes. These are made from polyurethane or silicon. They are filiform
(7 to 8 Ch, maximum 12 Ch), soft, flexible and can be used for weeks. However, even
with these modern and convenient fine-bore tubes, tolerance of nasogastric tubes is
usually limited.

Complications of percutaneous
endoscopic gastrostomy (PEG)

 Pain 5-7 %
 Local wound infection 15 %
 Sepsis <1%
 Perforation / peritonitis < 0.5 %
 Buried bumper rare

Local wound infection Pressure ulcer

Figure 5: Complications of PEG

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When long term EN (> 4 weeks) is anticipated, insertion of gastrostomy tube should be
considered (13).
Local wound infections are the most common complication of percutaneous
gastrostomies.
The infection rate can be reduced by pre-interventional use of antibiotics (30 min before
PEG insertion using a 3rd generation cephalosporine or a broad spectrum penicillin). This
is recommended especially in patients with impaired immune function or malignant
disease.
A frequent complication of all kinds of feeding tubes is tube obstruction. This can be
avoided by adequate flushing with water (40 ml or more) before and after feeding or
whenever an interruption of feeding is necessary. When fine-bore tubes are used flushing
should be performed every 4 to 6 hours even during feeding. However, clogging might
also occur due to precipitates of administered medication. Application of warm water,
sodium bicarbonate or pancreatic enzymes is not always successful in dislodging the
blockage, and, therefore, tube replacement might be necessary.

7. Metabolic complications

Compared to parenteral nutrition EN is a more physiologic approach to nutritional support

which is reflected by a lower frequency and severity of metabolic complications.
However, disturbances of the hydration status might occur, if treatment focuses only on
caloric intake and fluid balance is ignored. Overhydration and dehydration are usually
accompanied by hyponatraemia and hypernatraemia, respectively, and are treated by
fluid restriction or additional fluid supplements. A severe form of dehydration is called the
“tube-feeding syndrome”, where a hyperosmolaric formula diet causes diarrhoea and
intestinal fluid losses, acidosis, and impairment of renal function. Such disturbances can
be avoided when adequate monitoring of EN is performed.

The Refeeding Syndrome

Schnitker Ma, Mattman PF, Bliss TL. A clinical study of malnutrition in

Japanese prisoners of war. Ann Intern Med 1951; 35: 69-96.

First described in Far East

prisoners of war after the
second world war.

Starting to eat again after a

period of prolonged
starvation seemed to
precipitate cardicac failure.

Figure 6: The refeeding syndrome

A further metabolic complication is the “refeeding syndrome”, which is the potentially

life-threatening result of rapid and excessive food intake in severely malnourished
subjects. It was first clearly described in Far East prisoners after the second world war
(14).
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The refeeding syndrome is associated with hypophosphataemia, hypokalaemia,

hypomagnesaemia, thiamine deficiency and fluid retention and can ultimately result in
cardiac arrhythmias and congestive cardiac failure. Milder forms of the refeeding
syndrome are probably not so uncommon and may be identified by hypophosphataemia.

Refeeding Syndrome - Findings

 Hypophosphataemia
 Hypokalaemia
 Hypomagnesaemia
 Thiamine (and other vitamin) deficiency
 Fluid retention
Neuromuscular dysfunction
Hypoventilation
Lactic acidosis
Cardiac arrhythmia
Congestive heart failure

Figure 7: Refeeding syndrome - findings and consequences

Patient groups with increased risk for the refeeding syndrome are: patients with severe
chronic malnutrition, undernourished children, those with anorexia nervosa, chronic
alcoholics and after prolonged fasting (hunger strikers). In order to prevent the refeeding
syndrome in patients at risk it is important to perform close monitoring of vital functions,
fluid balance, plasma and urinary electrolytes, heart rate, ventilatory function and blood
gases. Before onset of nutritional support electrolyte and fluid deficiencies must be
corrected. Nutritional support has to be started with reduced amount of energy (less than
50 % of planned energy intake, about 500-1000 kcal/day) while the patient’s needs for
fluid and electrolytes should be infused separately.

Refeeding Syndrome - prevention

 Identify patients at risk

 Start nutritional support with < 50 % of
calculated energy
 Monitor phosphorus, K, Na, Cl, Mg
 Supplement Vitamins (B1, B6, B12 etc.)
and electrolytes as mandatory

Figure 8: Refeeding syndrome: prevention

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Energy intake is gradually increased over a week until daily nutritional requirements are
met. Additional potassium and phosphate should be given intravenously to prevent
deficiency (15, 16).

8. Monitoring of EN

It is important to monitor EN for two reasons: 1. to monitor the patient’s progress if

enteral feeding is to be successful and adequate for the patient’s needs; and 2. to
recognize possible (metabolic) complications early.
It is important to mention that in many clinical situations monitoring of nutrition cannot
be separated from monitoring of other medical interventions (e.g. fluid balance in
necrotizing pancreatitis with renal failure). The following recommendations can only be
used for rough orientation and should be adjusted to the patient’s individual needs.

Monitoring of enteral nutrition

 Feed administration daily

 Fluid balance daily
 Laboratory tests
 Na, K, Glucose initially daily
 P, Ca, Urea, Creatinine, initially twice/week
ALT, Blood count
 Nutritional status weekly/every 2nd week
 Weight, albumin,
Bioimpedance analysis
 Functional status weekly
 Hand grip strength

Figure 9: Monitoring of EN

Monitoring of EN should consider the following issues:

 Feed administration: Check delivery rates at intervals to ensure even flow. Aspirate
periodically to check stomach emptying; if necessary measure gastric reflux.
 Fluid balance: Fluid balance charts must be strictly maintained throughout enteral
feeding. Check hydration status clinically; in patients with diarrhoea, fever or other
nonphysiological fluid losses assess urinary output daily.
 Laboratory tests: Electrolytes and glucose should initially be monitored daily, with
serum urea, calcium, magnesium and phosphate levels twice weekly until feeding is
well established. Keep in mind that many cancer patients have insulin resistance and
might develop diabetes mellitus under EN. Serum albumin should be measured
initially and then at weekly intervals.
 Nutritional status: weigh patient daily until feeding is well established, then weigh
patient weekly. If available perform analysis of body composition by bioelectrical
impedance analysis or by anthropometry every second week. A good functional
outcome measure of tube feeding is hand grip strength which can easily be performed
every week.

9. Summary

In this module indications and contraindications for enteral nutrition with special respect
to selected diagnoses and clinical situations are highlighted. In addition diagnosis and
treatment of gastrointestinal, tube-related and metabolic complications of EN are
discussed. Most complications of EN are the result of application errors and can be
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avoided by an adequate approach and appropriate monitoring. The recommendations are

based on the published ESPEN guidelines on enteral nutrition.

10. References

(1) Lochs H, Allison SP, Meier R, Pirlich M, Kondrup J, Schneider St, van den Berghe G,
Pichard C. Introductory to the ESPEN Guidelines on enteral nutrition: terminology,
definitions and general topics. Clin Nutr 2006; 25: 180-186.
(2) Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related
malnutrition. Clin Nutr 2008; 27: 5-15.
(3) Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based
approach to treatment. CAB international 2003.
(4) Lochs H, Pichard C, Allison SP. Evidence supports nutritional support. Clin Nutr 2006;
25: 177-179.
(5) Detsky AS, McLaughlin JR Baker JP, Johnston N, Whittaker S, Mendelson RA,
Jeejeebhoy KN. What is subjective global assessment of nutritional status? JPEN J
Parenter Enteral Nutr 1987; 11: 8-13.
(6) Kondrup J, Allison SP, Elia M et al. ESPEN guidelines for nutrition screening 2002 Clin
Nutr 2003; 22: 415-421.
(7) Volkert D, Berner YN, Berry E et al. ESPEN guidelines on enteral nutrition: geriatrics.
Clin Nutr 2006; 25: 330-360.
(8) Valentini L, Schütz T, Allison S, Howard P, Pichard C, Lochs H (eds.). ESPEN
guidelines on Enteral Nutrition. Clin Nutr 2006; 25: 177-360.
(9) Körner U, Bondolfi A, Nühler E et al. Ethical and legal aspects of enteral nutrition .
Clin Nutr 2006; 25: 196-202.
(10) American Gastroenterological Association Medical Position Statement: Guidelines
for the use of enteral nutrition. Gastroenterology 1995; 108: 180.
(11) DeLedinghen V, Beau P, Mannant PR, et al. Early feeding or enteral nutrition in
patients with cirrhosis after bleeding from esophageal varices ? A randomized
controlled study. Dig. Dis Sci 1997; 42: 536-541.
(12) Adam S, Batson S: A study of problems associated with the delivery of enteral
feed in critically ill patients in five ICUs in the UK. Intensive Care Med 1997; 23: 261-
266.
(13) Löser C, ASchl G, Hebuterne X et al. ESPEN guidelines on artifical enteral nutrition
– Percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005; 24: 848-861.
(14) Schnitker M, Mattman PF, Bliss TL. A clinical study of malnutrition in Japanese
prisoners of war. Ann Intern Med 1951; 35: 69-96.
(15) Marinella MA. The refeeding syndrome and hypophosphataemia. Nutr Rev 2003;
61: 320.
(16) Maier-Dobersberger T, Lochs H. Enteral supplementation of phosphate does not
prevent hypophosphataemia during refeeding of cachectic patients. JPEN 1994; 18:
182.

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