Guidelines for the Provision and

Assessment of Nutrition Support Therapy

in the Adult Critically Ill Patient:
SCCM / ASPEN 2009

Stephen A. McClave, MD; Robert G. Martindale, MD, PhD;

Vincent W. Vanek, MD; Mary McCarthy, RN, PhD; Pamela Roberts, MD; Beth Taylor, RD; Juan B. Ochoa, MD; Lena Napolitano, MD; Gail Cresci, RD;

Journal of Parenteral and Enteral Nutrition / Vol. 33,

No. 3, May/June 2009
 Guideline Limitation
Not an absolute requirement
No guarantees to specific benefit in outcome or
survival
Healthcare professional judgement precedes
recommendations
Recommendations are supported by
Review of current literature
Other guidelines
Expert opinion
Clinical practicality.
 Guideline Limitation
Limited by
sample size
patient heterogeneity
variability of disease state and severity of illness
lack of baseline nutrition status
lack of statistical power for analysis
 Grading System Used for These Guidelines

Grade of recommendation
A Supported by at least two level I investigations
B Supported by one level I investigation
C Supported by level II investigations only
D Supported by at least two level III investigations
E Supported by level IV or level V evidence

Level of evidence
I Large, randomized trials with clear-cut results; low risk of false-positive
(alpha) error or false-negative (beta) error
II Small, randomized trials with uncertain results; moderate to high risk of
false-positive (alpha) and/or false-negative (beta) error
III Nonrandomized, contemporaneous controls
IV Nonrandomized, historical controls
V Case series, uncontrolled studies, and expert opinion

Note:
Large studies warranting level I evidence were defined as those with ≥100 patients
or those which fulfilled end point criteria predetermined by power analysis
 Introduction
Traditionally, nutrition goal is to SUPPORT
To preserve lean body mass
To maintain immune function
To avert metabolic complications

Recently, goal is nutrition THERAPY

Attenuate the metabolic response to stress
To prevent oxidative cellular injury
To favorably modulate the immune response
 A1. Initiation of Enteral Feeding
Traditional nutrition assessment tools
(albumin, prealbumin, anthropometry) are
not validated in critical care.
Before initiation of feedings, assess for
weight loss, pre-adm nutrient intake, disease
severity, co-morbidities and GI tract function.
(Grade: E)
Rationale
Traditional protein markers => acute phase
response not representative of overall nutrition
status
 A2. Initiation of Enteral Feeding
Enteral nutrition should be initiated in the
critically ill patient who is unable to maintain
volitional intake. (Grade: C)
Rationale
EN supports the functional integrity of the gut1-2
Maintaining intraepithelial tight junctions, villous
height
Stimulating blood flow
Inducing the release of CCK, gastrin, bombesin and bile
salts
Supports GALT/MALT
Maintaining low gut permeability

1. Lewis SJ. Br Med J. 2001;323:1-5. 2.McClave SA.JPEN J Parenter Enteral Nutr. 2006;30:143-156.
 A3. Initiation of Enteral Feeding
EN is the preferred route of feeding over PN
for the critically ill patient who requires
nutrition support therapy (Grade: B)

Rationale1-7
Reduce
 infectious morbidity
cost of nutrition

1.Kudsk K.Ann Surg. 1992;215:503-513.

5.Gramlich L. Nutrition. 2004;20:843-848.
2.Heyland DK. JPEN J Parenter Enteral Nutr. 2003;27:355-373.
6.Moore FA. Ann Surg. 1992;216:172-183.
3.Braunschweig CL. Am J Clin Nutr. 2001;74:534-542.
7.Peter JV. Crit Care Med. 2005;33:213-220.
4.Simpson F.Intensive Care Med. 2005;31:12-23.
 A4. Initiation of Enteral Feeding
Enteral feeding should be started within the
first 24-48 hours following adm (Grade: C)
Feedings should be advanced toward goal over
the next 48-72 hours (Grade: E)
Rationale.
After resuscitation
Hemodynamically stable
“window of opportunity” =>before hypermetabolic
insult
Success towards goal with feeding protocols : 70%-85%1-2

1.Heyland DK. JPEN J Parenter Enteral Nutr. 2003;27:355-373. 2.Marik PE. Crit Care Med. 2001;29:2264-2270.
 A5. Initiation of Enteral Feeding
In hemodynamic compromise, EN is withheld
until the patient is fully resuscitated and/or
stable. (Grade: E)

Rationale1-4
GI dysmotility, sepsis, and hypotension
Subclinical ischemia/reperfusion injury
EN is withheld when MAP <60 mm Hg, esp with
escalating catecholamine
caution to patients on stable low doses of pressor
agents

1.McClave SA. Nut Clin Pract. 2003;18:279-284. 3.Zaloga GP. Nutr Clin Pract. 2003;18:285-293.
2.Melis M. Arch Surg. 2006;141:701-704. 4.Kozar RA. J Surg Res. 2002;104:70-75.
 A6. Initiation of Enteral Feeding
Neither bowel sounds nor passage of
flatus/stool is required for the initiation of EN.
(Grade: B)

Rationale.1-10
GI dysfunction => 30%-70%
Mucosal barrier disruption, altered motility and atrophy
of the mucosa, and reduced mass of GALT
BS are indicative of contractility -> do not necessarily
relate to mucosal integrity, barrier function, or
absorptive capacity.
1.Moore EE. J Trauma. 1986;26:874-881.
2.Chiarelli A. Am J Clin Nutr. 1990;51:1035-1039. 6.Minard G.J Parenter Enteral Nutr. 2000;24:145-149.
3.Eyer SD. J Trauma. 1993;34:639-643. 7.Kompan L.Clin Nutr. 2004;23:527-532.
4.Chuntrasakul C. J Med Assoc Thai. 8.Malhotra A. J Postgrad Med. 2004;50:102-106.
1996;79:21-26. 9.Peck MD. J Trauma. 2004;57:1143-1149.
5.Singh G.J Am Coll Surg. 1998;187:142-146. 10.Dvorak MF. Spine. 2004;29:E175-E180.
 A7. Initiation of Enteral Feeding
Gastric or small bowel feeding is acceptable.
Fed via an enteral tube in the small bowel if at
high risk for aspiration or after showing
intolerance to gastric feeding. (Grade: C)

Withholding enteral feeding for repeated

high gastric residual volumes => sufficient
reason to switch to small bowel feeding.
(Grade: E)

1.Lien HC.Am J Gastroenterol. 2000;95:3439-3443. 2.Heyland DK.Crit Care Med. 2001;29:1495-1501.

 B1. When to Use Parenteral Nutrition
If EN is not feasible within the first 7 days in
ICU, no nutrition support therapy should be
provided. (Grade: C)

PN should be initiated after the first 7 days of

adm in patients whom
previously healthy
no protein-calorie malnutrition
 recent weight
loss of >10%-15%
 actual body weight <90% of ideal body weight

 (Grade: E)

1.Braunschweig CL. Am J Clin Nutr. 2001;74:534-542.

2Heyland DK. JAMA.1998;280:2013-2019 3Sandstrom R. Ann Surg. 1993;217: 185-195.
 B2. When to Use Parenteral Nutrition

Initiate PN immediately after adm and

adequate resuscitation if there is protein-
calorie malnutrition and EN is not feasible
(Grade: C)

1.Heyland DK. JAMA.1998;280:2013-2019. 2.Braunschweig CL. Am J Clin Nutr. 2001;74:534-542

 B3. When Indicated, Maximize Efficacy of
Parenteral Nutrition
Allow permissive underfeeding (80% of energy
requirements) initially in PN.(Grade: C)
After stabilization, PN may be increased to meet
energy requirements. (Grade: E)
BMI ≥30, dose of PN follows the same
recommendations given for EN in guideline C5.
(Grade: D)
Rationale.
“Permissive underfeeding” avoids
insulin resistance, infectious morbidity, prolonged
mechanical ventilation and increased hospital length
of stay.1
 B4. When Indicated, Maximize Efficacy of
Parenteral Nutrition
A protocol to promote moderately strict
control of serum glucose should be available
when providing nutrition support therapy.
(Grade: B)
A range of 6-8mmol/L may be most
appropriate. (Grade: E)
Rationale.
Strict glucose control, levels between 4-6 mmol/L
Reduced sepsis, reduced ICU length of stay, and lower
hospital mortality1
More pronounced in surgical than medical ICU patients.2

1. Van den Berghe G. N Engl J Med. 2001;345:1359-1367. 2.Van den Berghe G. N Engl J Med. 2006;354:44946
 B4. When Indicated, Maximize Efficacy of
Parenteral Nutrition
A large level I multicenter European study
suggested
Control of 8 - 10 mmol/L might avoid
hypoglycemia and reduce the mortality
associated with hypoglycemia compared to
tighter control.2
With a paucity of data, the Guidelines Committee
felt that controlling glucose in the range of 6-
8mmol/L was most appropriate at this time.
 B5. When Indicated, Maximize Efficacy of
Parenteral Nutrition
Repeated efforts should be made to initiate EN
while on PN.
As enteral tolerance improves, the amount of PN
is reduced & terminated if ≥60% of target energy
requirements are delivered by EN. (Grade: E)
Rationale.
EN has marked benefits for the critically ill patient
To avoid overfeeding, the amount of calories delivered via
parenteral route should be reduce appropriately to the
increase in the amount of calories delivered enterally.
 C1. Dosing of Enteral Feeding
The target goal of EN
defined by energy requirements
should be determined at the time of initiation of
nutrition support therapy1-4. (Grade: C)
Energy requirements (Grade: E)
Calculated
 Predictive equations (Harris-Benedict, Scholfield,

Ireton-Jones)
 simplistic formulas (25-30 kcal/kg/d)
 used with caution-> less accurate esp obese

Measured
 indirect calorimetry

1.Taylor SJ. Crit Care Med. 1999;27:2525-2531. 3.Artinian V. Chest. 2006;129:960-967.

2.Barr J. Chest. 2004;125:1446-1457. 4.Martin CM. CMAJ.2004;170:197-204.
 C2. Dosing of Enteral Feeding

To achieve clinical benefit of EN, provide

>50%-65% of target goal calories over the first
week of adm. (Grade:C)

Rationale
Impact is dose-dependent
“Trickle” or trophic feeds (10-30 mL/h)
Prevent mucosal atrophy
Insufficient to achieve the desired endpoint from EN
therapy.

1.Taylor SJ. Crit Care Med. 1999;27:2525-2531 2.Ziegler TR. Arch Surg. 1988;123:1313-1319.
 C3 Dosing of Enteral Feeding
If unable to meet 100% of target goal calories
after 7-10 days by EN alone, consider initiating
supplemental PN. (Grade: E)
Initiating supplemental PN prior to 7-10 day
in patients on EN does not improve outcome
and may be detrimental to the patient. (Grade:
C)
Rationale.
After 7-10 days
calories and protein requirement is increased

prevent the deterioration of nutrition status.

1.Chiarelli AG. Minerva Anestesiol. 1996;62:1-7.138. 4Herndon DN. JBurn Care Rehabil. 1989;10:309-313.
2.Bauer P. Intensive Care Med. 2000;26:893-900.139. 5Braunschweig CL. Am J Clin Nutr.2001;74:534-542.
3.Herndon DN. J Trauma. 1987;27:195-204.140 6Sandstrom R. Ann Surg. 1993;217:185-195
 C4. Dosing of Enteral Feeding
Add modular protein supplements (enteral
formulations have high non-protein
calorie:nitrogen ratio)
Patients with BMI <30, protein requirements :
 1.2-2.0 g/kg /d
Higher in burn or multi-trauma patients.
(Grade: E)
Rationale.
Protein => most important macronutrient for
Wound healing
Supporting immune function,
Maintaining lean body mass.
 C5 Dosing of Enteral Feeding
Obese patient
 permissive underfeeding or hypocaloric feeding with EN
BMI >30
Do not exceed 60%-70% of target energy requirements
11-14 kcal/ kg actual body weight per day
22-25 kcal/kg ideal body weight per day
Protein
BMI 30-40: ≥2.0 g/kg ideal body weight per day
BMI ≥ 40: ≥2.5 g/kg ideal body weight per day
(Grade: D)
 C5 Dosing of Enteral Feeding
Rationale.
Achieve weight loss with 60%-70% of caloric
goal
Increase insulin sensitivity
Improve nursing care
Reduce risk of co-morbidities.
Protein 2.0-2.5 g/kg ideal body weight/day
Approximate protein requirements
Neutral nitrogen balance
Adequate wound healing1.

1Choban PS Nutr Clin Pract. 2005;20:480-487. 2Elamin EM. Curr Opin Crit Care. 2005;11:300-303.
 D1 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Bowel motility (resolution of clinical ileus) is
not required in order to initiate EN. (Grade: E)
Rationale.
EN
Safe prior to the emergence of overt evidence of enteric
function (BS, passing flatus and stool)
EN promotes gut motility.
Haemodynamically stable -> appropriate to feed
through mild to moderate ileus.1

Martindale RG. Curr Opin Crit Care. 2006;12:290-294

1
 D2 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Time period that a patient is NBM (Grade: C)
Prior to, during, immediately following the time of
diagnostic tests or procedures
Prevent inadequate delivery of nutrients and
prolonged periods of ileus.
Ileus may be propagated by NBM
Rationale.
Healthcare providers tend to under-order calories1,
Receive approximately 80% of what is ordered.
Under-ordering and inadequate delivery => receiving
only 50% of target goal calories.

1McClave SA. Crit Care Med. 1999;27:1252-1256.

 D2 Monitoring Tolerance and Adequacy of Enteral
Nutrition

Withholding EN for GRV <500 mL in the

absence of other signs of intolerance should
be avoided. (Grade: B)
Rationale
GRV do not correlate well with
 incidence of pneumonia.1-3
 measures of gastric emptying.4-6
 incidence of regurgitation and aspiration.7

1
Pinilla JC,JPEN J. 2001;25:81-86.
2
Montejo JC.Intensive Care Med. 2009.
5
Landzinski J. JPEN J. 2008; 32:45-50.
3
Taylor SJ. Crit Care Med. 1999;27:2525-2531.
6
Cohen J.Clin Nutr. 2000;19:233-236.
7
 D2 Monitoring Tolerance and Adequacy of
Enteral Nutrition
4 level II studies1,3-4,7
Raising GRV cutoff value from 50-150 mL to 250-500 mL
 No
increase risk for regurgitation, aspiration or
pneumonia.
Decreasing GRV cutoff value
 Does not protect from these complications,
 Leads to inappropriate cessation

GRV in the range of 200-500 mL

lead to the implementation of measures to reduce risk of
aspiration,
Automatic cessation of feeding should not occur for
GRV<500 mL in the absence of other signs of intolerance.8

8
McClave SA. JPEN J. 2002;26(6 Suppl):S80-S85.
 D3 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Feeding protocols increases the percentage of
goal calories provided and should be
implemented. (Grade: C)
Rationale.
Use of ICU or nurse-driven protocols
Define goal infusion rate
designate more rapid startups
Specific orders for handling GRV, frequency of
flushes, and conditions under which feeding
may be adjusted or stopped.1-6
1Taylor SJ. Crit Care Med. 1999;27:2525-2531. 4Martin CM. CMAJ.2004;170:197-204
2Kozar RA. J Surg Res. 2002;104:70-75 5Adam S.Intensive Care Med. 1997;23:261-266.
 D4 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Patients on EN should be assessed for risk of
aspiration. (Grade: E)
Steps to reduce risk of aspiration should be
employed. (Grade: E)
High-risk patients & those intolerant to gastric feeding,
delivery should be continuous infusion. (Grade: D)
Prokinetic drugs (metoclopramide and erythromycin)
or narcotic antagonists (naloxone ) should be initiated
where clinically feasible. (Grade: C)
Diverting the level of feeding by post-pyloric tube
placement should be considered. (Grade: C)
 D4 Monitoring Tolerance and Adequacy of Enteral
Nutrition
Rationale.
Patients at increased risk for aspiration1
use of a nasoenteric tube
Patient position
poor oral health
use of bolus intermittent feedings.
Pneumonia and bacterial colonization of the
upper respiratory tree
aspiration of contaminated oropharyngeal secretions >>
aspiration of contaminated gastric contents.2-4

1
McClave . JPEN J 2002;26(6 Suppl):S80-S85 Bonten MJ. Chest.1994;105:878-884.
3

2
Torres A.Am Rev Respir Dis. 1993;148:352-357. Pingleton SK. Am J Med. 1986;80:827-832
4
 D5 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Blue food coloring and glucose oxidase strips, as
markers for aspiration, should not be used.
(Grade: E)
Rationale.
Traditional monitors for aspiration are ineffective.
Blue food coloring was associated with mitochondrial
toxicity and patient death.1
Glucose oxidase strips (glucose content in tracheal
secretions is solely related to aspiration of glucose-
containing formulation) has been shown to be invalid with
poor sensitivity/specificity.2

1Maloney JP.JPEN J. 2002;26(6 Suppl):S34-S41.. 2Metheny NA. Chest. 1997;111:724-731

 D6 Monitoring Tolerance and Adequacy of
Enteral Nutrition
Diarrhea associated with enteral feedings
warrants further evaluation for etiology.
(Grade: E)
Rationale.
Excessive intake of hyperosmolar medications
Use of broad spectrum antibiotics
Clostridium difficile pseudomembranous colitis
Other infectious etiologies
Mostly mild and self-limiting.1

1Kenneally C.Chest. 2007;132:418-424. 2Maroo S. Gastroenterology. 2006;130:1311-1316.

E1. Selection of Appropriate Enteral Formulation

Immune-modulating enteral formulations

Used for appropriate patient
Major elective surgery, trauma, burns, head and neck
cancer and critically ill patients on mechanical
ventilation,
Caution in severe sepsis.
For surgical ICU patients, Grade: A
For medical ICU patients, Grade: B
Do not meet criteria for IMEF
 will
not change outcome.
 added cost
 E1. Selection of Appropriate Enteral Formulation
Rationale.
Arginine:
In severe sepsis, arginine may be converted to NO
=> hemodynamic instability + higher mortality.
Contradictory studies
Upon review of this controversy the Guidelines
Committee feels
Arginine is safe enough to use in mild to moderate
sepsis, but caution in severe sepsis.

1Bower RH. Crit Care Med.1995;23:436-449. 3Bertolini G. Intensive Care Med. 2003;29:834-840
2Dent DL. Crit Care Med. 2003;30:A17. 4Luiking YC. e-SPEN. 2006;1:14-15.
E1. Selection of Appropriate Enteral Formulation

ω-3 fatty acids eicosapentaenoic acid (EPA) and

docosohexaenoic acid (DHA) in fish oils
reduces systemic inflammation via
Displacement ω-6 fatty acids from the cell membranes of
immune cells
Down-regulate nuclear factor-kappa B (NFkB),
intracellular adhesion molecule 1 (ICAM-1), and E-
selectin => decreases neutrophil attachment &
transepithelial migration
Stabilize myocardium (lowers arrhythmias), decrease
ARDS, and reduce the likelihood of sepsis.1-4

1Calo L. J Am Coll Cardiol. 2005;45:1723-1728. 3Singer P.Crit Care Med. 2006;34:1033-1038.

2Gadek JE.Crit Care Med. 1999;27:1409-1420. 4Pontes-Arruda A.Crit Care Med. 2006;34:23252333.
 E1. Selection of Appropriate Enteral Formulation

Glutamine

conditionally essential amino acid

antioxidant defenses, immune function, production
of heat shock proteins and nitrogen retention.
Trophic influence on intestinal epithelium and
maintenance of gut integrity.
given
 enterally
0.3-0.5g/kg/d
 Parenterally 0.5 g/kg/d

. Jones C. Nutrition. 1999;15:108-115. 3 . Garrel DR.Crit Care Med. 2003;31:2444-2449.

2. Hall JC. Intensive Care Med. 2003;29:1710-1716 4.Houdijk AP. Lancet. 1998;352:772-776.
E2. Selection of Appropriate Enteral Formulation

To receive optimal therapeutic benefit from

immune-modulating formulations, at least
50%-65% of goal energy requirements should
be delivered. (Grade: C)

Rationale.
The benefit is a dose-dependent effect1-2

1Bower RH. Crit Care Med.1995;23:436-449. 2 Atkinson S. Crit CareMed. 1998;26:1164-1172.

E3. Selection of Appropriate Enteral Formulation

If diarrhea, utilise soluble fiber containing

small peptide formulations(Grade: E)

Rationale.
Current large prospective trials are not available to
make this a strong recommendation.1

Edes TE.. Am J Med. 1990;88:91-93.

1
 F1. Adjunctive Therapy
Probiotic agents improve outcome in specific patients
(transplant, major abdominal surgery and severe
trauma).
No recommendation for general ICU population & pts
with severe acute necrotizing pancreatitis (Grade: C)
Rationale.
Probiotics
microorganisms of human origin,
safe
stable in the presence of gastric acid and bile salts
administered in adequate amounts confer a health benefit to
the host.
 F1. Adjunctive Therapy

The most consistent beneficial effect

reduction in infectious morbidity in critically ill
patients involving transplantation1-2, major
abdominal surgery 3, trauma.4-5

The Guidelines Committee felt that

Most studies are grade B recommendation but
Downgrade to a grade C recommendation because
heterogeneity in ICU populations, difference in
bacterial strains and variability in dosing
1
Rayes N. Am J Transplant. 2005;5:125-130.
2
Rayes N. Transplantation. 2002;74:123-127. 4
Kotzampassi K. World J Surg. 2006;30:1848-1855.
3
Rayes N. Ann Surg. 2007;246:36-41. 5
Spindler-VA. JPEN J . 2007;31:119-126.
 F2. Adjunctive Therapy

Soluble fiber may be beneficial for the fully

resuscitated, hemodynamically stable critically ill
patient receiving EN who develops diarrhea.
Insoluble fiber should be avoided in all critically ill
patients.
Both soluble and insoluble fiber should be avoided
in patients at high risk for bowel ischemia or severe
dysmotility. (Grade: C)

1. Spapen H. Clin Nutr. 2001;20:301-305. 3. Scaife CL. J Trauma. 1999;47:859-863.

2. Dobb GJ Intensive Care Med. 1990;16:252-255. 4. McIvor AC, Nutrition. 1990;6:115-117
 H1. Pulmonary Failure

Special high-lipid low-carbohydrate

formulations (reduce CO2 production) are
not recommended for routine use in ICU
patients with acute respiratory failure.
(Grade: E)
Rationale.
Lack of consensus
Contradictory studies
Avoid total caloric provision that exceeds
energy requirements, as CO2 production
increases with lipogenesis
1.al-Saady NM. Intensive Care Med: 1989;15:290-295.
. 1-3

2.Barale F. Agressologie. 1990;31:77-79. 3.Radrizzani D. Clin Nutr. 1998;17:7-10

 H2. Pulmonary Failure
Fluid-restricted caloric dense formulations
should be considered for patients with acute
respiratory failure. (Grade: E)
Rationale.
Fluid accumulation and pulmonary edema are
common with poor clinical outcomes.
A fluid-restricted calorically dense nutrient
formulation (1.5-2.0 kcal/mL).1

1. Barale F. Agressologie. 1990;31:77-79.

 H3. Pulmonary Failure
Serum phosphate levels should be monitored
and replaced appropriately when needed.
(Grade: E)
Rationale.
Phosphate is essential for the synthesis ATP and
2,3-DPG, both are critical for normal
diaphragmatic contractility and pulmonary
function.
Length of stay and duration of mechanical
ventilation are increased in patients who become
hypophosphataemic.1-2
1. Chassard D. Crit Care Med. 1994;22:248-251. 2. Mizock BA. Care Clin. 2000;16:319-336.
 I1. Renal Failure
Patients with ARF should be placed on
standard enteral formulations.
If there is electrolyte abnormalities, a
specialty formulation designed for renal
failure may be considered. (Grade: E)
Rationale.
ARF is seldom an isolated organ failure
Specialty formulations with certain lower electrolytes
(PO42-, K+) may be beneficial.1-3

1.Marin A. Curr Opin Clin Nutr Metab Care. 2001;4:219-225.

3.Bozfakioglu S.NephroDial Transpt. 2001;16(suppl 6):21-22.
2.Cano N. Clin Nutr. 2006;25:295-310.
 I1. Renal Failure
Patients on CRRT should receive increased
protein, up to a maximum of 2.5 g/kg/d. Protein
should not be restricted in patients as a means
to avoid or delay initiation of dialysis therapy.
(Grade: C)
Rationale.
An approximate 10-15g/d of amino acid will be lost
during CRRT.
Providing <1 g/kg/d of protein may result in more
nitrogen deficits for patients on CRRT.
Patients on CRRT should receive 1.5-2.0 g/kg/d.1-3
1.Scheinkestel CD.Nutrition. 2003;19:909-916.
2.Wooley JA. Nutr Clin Pract. 2005;20:176-191. 3.Bellomo R. Int J Artif Organs. 2002;25:261-268.
 J1. Hepatic Failure

Traditional assessment tools is less accurate

in cirrhosis and hepatic failure.(Grade: E)

Rationale.
Energy needs are variable
Difficult to predict by simple equations
Best determined by indirect calorimetry.1-9

5.Aranda-Michel J.Curr Gastroenterol Rep. 2001;3:362-370.

1.Plauth M. Clin Nutr. 2006;25:285-294. 6. Sanchez AJ. Liver Transpl. 2006;12:1310-1316.
2.Henkel AS. Clin Pract Gastroenterol Hepatol.2006;3:202-209. 7.Plevak DJ.Mayo Clin Proc. 1994;69:225-230.
3.Campillo B.Gastroenterol Clin Biol. 2006;30:1137-1143. 8.Kondrup J.Clin Nutr. 2003;22:415-421.
4 Florez DA. Semin Gastrointest Dis. 2002;13:169-178 . 9.Schutz T. ClinNutr. 2004;23:975-982.
 J2. Hepatic Failure

EN without protein restriction is preferred for

acute/chronic liver disease. (Grade: E)

Rationale.
Protein should not be restricted as a management
strategy to reduce risk of developing hepatic
encephalopathy1-2
Protein requirements is the same as for the general
ICU patient.

1.Plauth M. Clin Nutr. 2006;25:285-294 2.Florez DA. Semin Gastrointest Dis. 2002;13:169-178.
 J3. Hepatic Failure
Use standard enteral formulations in
acute/chronic liver disease.
Branched chain amino acid formulations (BCAA)
is reserved for encephalopathic patient refractory
to standard treatment (antibiotics, lactulose).
(Grade: C)
Rationale.
No evidence to suggest that a BCAA formulation improves
outcomes compared to standard formulations.
In hepatic encephalopathy refractory to usual therapy,
BCAA formulations may improve coma grade compared to
standard formulations.1-6
1.Plauth M,.lin Nutr. 2006;25:285-294. 4.Marchesini G. Gastroenterology. 2003;124:1792-1801.
2.Horst D.Hepatology. 1984;4:279-287. 5.Muto Y. Clin Gastroenterol Hepatol. 2005;3:705-713.
6.Sato S. Hepatol Res.2005;31:232-240.
 K1. Acute Pancreatitis

Severity of acute pancreatitis should be evaluated

on admission (Grade: E)
Patients with severe acute pancreatitis should have
a nasoenteric tube and EN initiated as soon as fluid
resuscitation is complete. (Grade: C)
Rationale.
EN reduces infectious morbidity, hospital length of
stay, need for surgical intervention, multiple organ
failure and mortality

1.Windsor AC. Gut. 1998;42:431-435.

2.Kalfarentzos F. Br J Surg.1997;84:1665-1669. 7.Louie BE.Can J Surg. 2005;48:298-306.
3.McClave SA.JPEN J Parenter Enteral Nutr. 1997;21:14-20. 8.Petrov MS.Dig Surg. 2006;23:336-344.
4.Oláh A. Nutrition. 2002;18:259-262. 9.Eckerwall GE.Ann Surg. 2006;244:959-967.
5.Abou-Assi S.Am J Gastroenterol. 2002;97:2255-2262. 10. Casas M. Eur J Surg.2000;166:383-387.
6.Gupta R. Pancreatology. 2003;3:406-413 11.Pupelis G. Nutrition. 2001;17:91-94.
 K2. Acute Pancreatitis
• Patients with mild to moderate acute
pancreatitis do not require nutrition support
therapy unless (Grade: C)
a complication develops
failure to advance to oral diet within 7 days
Rationale.
Mild to moderate pancreatitis
Low rate of complications & mortality rate
 81% chance of advancing to oral diet within 7 days.1-3
Providing nutrition therapy will not change outcome

2.Wilson C. J Surg. 1990;77:1260-1264.

1.Sax HC. Am J Surg. 1987;153:117-124.
 K3. Acute Pancreatitis

Patients with severe acute pancreatitis may be

fed enterally by the gastric or jejunal route.
(Grade: C)

Rationale.
2 level II trials
no significant differences between the 2 levels of EN
infusion within the GI tract. 1-2

1.Eatock FC.Am J Gastroenterol. 2005;100:432-439. 2.Kumar A. J Clin Gastroenterol. 2006;40:431-434.

 K4. Acute Pancreatitis
Enhance tolerance to EN in patients with severe
acute pancreatitis by:
Minimizing the period of ileus . (Grade: D)
More distal placement of EN in the GI tract.
(Grade: C)
Content of the EN:
 smallpeptides
 medium-chain triglycerides

a nearly fat-free elemental formulation. (Grade: E)

Switching from bolus to continuous infusion.
(Grade: C)
 K5. Acute Pancreatitis

When EN is not feasible in patients with

severe acute pancreatitis, PN should be
considered. (Grade: C)

PN should not be initiated until > 5 days of

hospitalization. (Grade: E)

1.Sax HC. Am J Surg. 1987;153:117-124. 2.Xian-Li H. Clin Nutr Suppl. 2004;1:43-47.

 L1. Nutrition Therapy in End-of-Life Situations
Nutrition therapy is not obligatory in futile care or
end-of-life situations.
The decision to provide nutrition therapy should
be based on effective patient/family
communication, realistic goals, and respect for
patient autonomy. (Grade: E)
Rationale.
Dehydration and starvation are well tolerated with min
symptoms
EN or PN has not been shown to improve outcome.
Nonetheless, cultural, ethnic, religious, or individual
patient issues may in some circumstances necessitate
delivery of nutrition support therapy.1-2
1.DeLegge MH. Gastrointest Endosc. 2005;62:952-959. 2.Van der Riet P. J Law Med.2006;14:182-198.
Thank You