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Recommendations Summary

CI: Initiation of Enteral Nutrition 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Initiation of Enteral Nutrition

    If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), then the Registered Dietitian (RD) should recommend that EN be started within 24 to 48 hours following injury or admission to the intensive care unit (ICU) (early EN). Research indicates that EEN is associated with a reduction in infectious complications in critically ill, adult patients. The impact of EEN on mortality and length of stay (LOS) is unclear.  

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      A series of case studies have indicated that jejunally fed EN administered to patients with inadequate mesenteric perfusion may be associated with hypoxia and might promote the development of small bowel hypoxia and necrosis (Rai et al, 1996; Lawlor et al, 1998; and Melis et al, 2006). Enteral nutrition should be withheld in hypotensive patients with a mean arterial pressure (MAP) of <60mmHg and/or receiving escalating doses of pharmacologic agents (e.g., epinephrine, norephinephrine, dopamine, etc.) to maintain hemodynamic stability (McClave et al, 2009).

    • Conditions of Application

      • Appropriate enteral access
      • Patient and/or family concurrence with enteral nutrition
      • Ability to determine contraindications (e.g., hemodynamic instability, bowel obstruction, high output fistula, or severe ileus)
      • Benefits of early initiation of EN (EEN) may be lost if there is a delay 
      • Potential for reduced EN delivery if formula is repeatedly stopped or held. 
         

    • Potential Costs Associated with Application

      No obvious costs are associated with the application of this recommendation.

    • Recommendation Narrative

      A total of 15 studies were included in the evidence analysis for this recomendation:

      • Four positive quality meta-analyses (Doig et al, 2009; Doig et al, 2011; Heyland et al, 2003; and Marik and Zaloga, 2001)
      • Three positive quality retrospective cohort studies (Dissanaike et al, 2008; and Khalid et al, 2010)
      • Seven neutral quality RCTs (Eyer et al, 1993; Grahm et al, 1989; Ibrahim et al, 2002; Kompan et al, 1999; Kudsk,  1996; Singh et al, 1998; and Taylor et al, 1999)
      • One neutral quality systematic review (Lewis et al, 2001).

      Mortality 

      • Twelve studies provide evidence that the impact of EEN on mortality in adult, critically ill patients is inconsistent 
      • Evidence is based on the following studies: Dissanaike et al, 2008; Doig et al; 2008; Doig et al, 2009; Doig et al, 2011; Eyer et al, 1993; Heyland et al, 2003; Ibrahim et al, 2002; Khalid et al, 2010; Lewis et al, 2001; Marik and Zaloga, 2001; Singh et al, 1998; and Taylor et al, 1999.

      Infectious Complications

      • Twelve studies provide evidence that in fluid-resuscitated, critically ill adult patients, EEN reduces infectious complications  
      • Evidence is based on the following studies: Dissanaike et al, 2008; Doig et al, 2009; Doig et al, 2011; Eyer et al, 1993; Grahm et al, 1989; Heyland et al, 2003; Ibrahim et al, 2002; Kudsk et al,  1996; Lewis et al, 2001; Marik and Zaloga, 2001; Singh et al, 1998; and Taylor et al, 1999. 

      Hospital Length Stay

      • Thirteen studies provide evidence that the impact of EEN on LOS in adult, critically ill patients is inconsistent 
      • Evidence is based on the following studies: Dissanaike et al, 2008; Doig et al, 2008; Eyer et al, 1993; Grahm et al, 1989; Heyland et al, 2003; Ibrahim et al, 2002; Khalid et al, 2010; Kompan et al, 1999; Kudsk et al,  1996; Lewis et al, 2001; Marik and Zaloga, 2001; Singh et al, 1998; and Taylor et al, 1999. 

    • Recommendation Strength Rationale

      • Grade I evidence is available for the conclusion statement regarding the impact of early vs. late initiation of EN on infectious in critically ill adult patients
      • Grade II evidence is available for the conclusion statements regarding the impact of early vs. late initiation of EN in critically ill adult patients on:
        • Mortality 
        • LOS.

    • Minority Opinions

      None.