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Recommendations Summary

CI: Enteral Nutrition Energy Delivery 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: Enteral Nutrition Energy Delivery

    If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus),  the Registered Dietitian (RD) should make sure that at least 60% of of the total estimated energy requirement, as determined by the nutrition assessment, is actually delivered to the patient within the first week of hospitalization. Research indicates that in critically ill adult patients receiving EN only,  an average of at least 60% of EN energy actually received is associated with fewer infectious complications. The impact of a specific threshold of EN energy delivery on mortality, hospital length of stay (LOS), and days on mechanical ventilation is unclear, due to inconsistent results. There were no studies evaluating impact on cost of medical care.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      • Feeding medical ICU patients more than 70% of goal intake in the first five days of ICU stay is associated with a lower chance of being discharged alive or breathing spontaneously when discharged from the ICU (Dickerson et al, 2002)
      • Providing surgical patients with obesity more than 70% of goal intake over a seven-day period is associated with a longer LOS and more days of antibiotics (Dickerson et al, 2002)

      • 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

      • These recommendations are limited to critically ill patients in the early phase of ICU admission
      • Ability to determine contraindications (e.g., hemodynamic instability, bowel obstruction, high output fistula, or severe ileus)
      • Efforts to provide greater than 50% to 65% of goal calories should be made in order to achieve the clinical benefit of EN over the first week of hospitalization (McClave et al, 2009)
      • Early EN is reportedly well tolerated by ICU patients. The following are guidelines for avoiding intestinal hypoxia and bowel necrosis (Rai et al, 1996; Lawlor et al, 1998; and Melis et al, 2006):
        • Feeding into the small bowel
        • Administering feedings in patients adequately resuscitated and when mean arterial pressure can be sustained at at least 70mmHg
        • Use of iso-osmolar formulations
        • Advancement of feedings when tolerance demonstrated.

    • Potential Costs Associated with Application

      • Early EN in ICU patients may require small bowel feeding tube placement, specifically in patients who are intolerant of gastric feedings or those who are at high risk for aspiration. Small bowel placement of feeding tubes requires the skill and time of a clinician at the bedside, endoscopic placement by a gastroenterologist or placement under fluoroscopy.
      • The complications or undesireable outcomes (increased LOS, increased infectious complications, more days of mechanical ventilation) associated with inappropriate (under- or over-feeding) EN feeding in ICU patients, affect the cost of hospitalization.

    • Recommendation Narrative

      A total of five studies were included in the evidence analysis for this recommendation.

      • Two positive quality randomized controlled trials (RCT) (Arabi et al, 2011; and Taylor et al, 1999)
      • Two positive quality retrospective cohort studies (Dickerson et al, 2002; and Faisy et al, 2009)
      • One positive quality nonrandomized controlled study (Heyland et al, 2010).

      Background

      • Actual attainment of full goal nutrient delivery by EN feedings in the first week of ICU admission is unusual
      • Most EN feedings were initiated within one week of ICU admission.

      Mortality

      • Four studies provide evidence that it is unknown whether a specific threshold of EN actually delivered within the first week of hospitalization affects mortality in critically ill adult patients, because the evidence is inconsistent  
        • Evidence is based on the following studies: Arabi et al, 2011; Dickerson et al, 2002; Faisy et al, 2009; and Taylor et al, 1999.

      Infectious Complications

      • Three studies provide evidence that actual delivery of >60% of EN goal within the first week of hospitalization is associated with fewer infectious complications in critically ill adult patients  
        • Evidence is based on the following studies: Arabi et al, 2011; Dickerson et al, 2002; and Taylor et al, 1999.

      Hospital Length of Stay (LOS)

      • Five studies provide evidence that it is unknown whether a specific threshold of EN actually delivered within the first week of hospitalization affects LOS in critically ill adult patients is unknown, because the evidence is inconsistent
        • Evidence is based on the following studies: Arabi et al, 2011; Dickerson et al, 2002; Faisy et al, 2009; Heyland et al, 2010; and Taylor et al, 1999. 

      Days on Mechanical Ventilation

      • Three studies provide evidence that it is unknown whether a specific threshold of EN actually delivered within the first week of hospitalization affects days on mechanical ventilation in critically ill adult patients is unknown, because the evidence is inconsistent
        • Evidence is based on the following studies: Arabi et al, 2011; Dickerson et al, 2002; and Heyland et al, 2010.

      Cost of Medical Care 

      • There were no studies that looked at cost of medical care in relation to EN delivery in critically ill adult patients.   

    • Recommendation Strength Rationale

      • Patient populations were not homogenous across all studies. Patient populations included ICU patients with obesity; non-obese, trauma, surgical and medical patients.
      • Confounding clinical variables, such as inadequate glycemic control or other sources of calories (IV dextrose or lipid-based sedatives) were not documented in all studies and can impact outcomes
      • Grade II evidence is available for the following conclusion statements regarding the average amount of EN intake actually delivered within the first week of hospitalization in critically ill adult patients and its association with:  
        • Mortality
        • Infectious complications
        • LOS 
      • Grade III evidence is available for the conclusion statement regarding the average amount of EN intake actually delivered within the first week of hospitalization and its association with days on mechanical ventilation in critically ill adult patients
      • Grade V evidence is available for the conclusion statement regarding the average amount of EN actually delivered within the first week of hospitalization and its association with cost of medical care in critically ill adult patients.

       

    • Minority Opinions

      None.