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New Developments in Clinical Practice Guidelines: Invited Communication
New Developments in Clinical Practice Guidelines: Invited Communication
Kreymann G
Baxter Healthcare, Deerfield, IL, USA
Correspondence to: Dr Georg Kreymann, e-mail: [email protected]
Abstract
During the last four years revised clinical practice guidelines on nutritional support have been published by the major nutritional societies
worldwide. The aim of these guidelines is to promote the safe and effective care of patients who need nutritional support as part of their
overall management. All guidelines are based on the available “best evidence” in order to assist nutrition professionals in making decisions on
the appropriate and cost-effective nutritional practices. Although such guidelines are a useful tool to patient management, they are meant to
support, not replace, the clinical judgment and experience of nutrition professionals.
During the last four years revised clinical practice guidelines have option when it can be easily implemented (post abdominal trauma or
been published by the major nutritional societies: The American elective abdominal surgery).
Society of Enteral and Parenteral Nutrition (ASPEN),1 the European
CCPG: The routine use of small bowel feedings is recommended in
Society for Clinical Nutrition and Metabolism (ESPEN)2–11 and the
units where obtaining small bowel access is feasible.
Canadian Critical Care Clinical Practice Guidelines Committee
(CCPG)12 with latest updates from www.criticalcarenutrition.com. Dosage of enteral feeding
These guidelines agree on most points concerning the nutritional ASPEN: The feedings should be advanced toward the patient’s goal
support of critical ill patients and will be outlined in a short form. Any over the next 48–72 hours. Energy requirements may be calculated
discrepancies will be highlighted. This outline follows the structure by predictive equations or measured by indirect calorimetry.
of the most recent ASPEN guideline.1 Due considerations relating to Efforts to provide > 50%–65% of goal energy should be made in
special diagnoses have not been incorporated in this paper. order to achieve the clinical benefit of EN over the first week of
hospitalisation.
Enteral nutrition
ESPEN: No general amount can be recommended as EN therapy has
Which patient
to be adjusted according to the progression/course of the disease
All: Enteral nutrition (EN) is the preferred form of nutrition support in and to gut tolerance. During the acute and initial phase of critical
the critical ill patient who is unable to maintain volitional intake. illness an exogenous energy supply in excess of 20–25 kcal/kg
ESPEN: It should be given to all patients who are not expected to be BW/day may be associated with a less favourable outcome. During
on a full oral diet within 3 days. recovery (anabolic flow phase), the aim should be to provide 25–30
total kcal/kg BW/day.
Timing of enteral nutrition
• Controversy:
All: EN should be started within the first 24–48 hours following
ASPEN/CCPG: If unable to meet energy requirements (100%
admission.
of target goal energy) after 7–10 days by the enteral route
Route of enteral feeding alone, consider initiating supplemental parenteral nutrition (PN).
All: Either gastric or small bowel feeding is acceptable in the ICU Initiating supplemental PN prior to this 7–10 day period in the
setting. Critically ill patients should be fed via an enteral access patient already receiving EN does not improve outcome and may
tube placed in the small bowel if at high risk for aspiration or be detrimental to the patient.
after showing intolerance to gastric feeding (high gastric residual ESPEN: All patients who do not meet their nutritional needs after
volumes). According to ESPEN, jejunal feeding is likely to be the best 2 days should receive supplemental PN.
ASPEN: In the setting of haemodynamic compromise (patients CCPG: Based on 4 level 1 (A) studies and 17 level 2 (B) studies, we
requiring significant haemodynamic support including high dose recommend that diets supplemented with arginine and other select
catecholamine agents, alone or in combination with large volume nutrients not be used for critically ill patients.
fluid or blood product resuscitation to maintain cellular perfusion),
ALL: Patients with ARDS and severe acute lung injury (ALI)
EN should be withheld until the patient is fully resuscitated
should be placed on an enteral formulation characterised by an
and/or stable.
anti-inflammatory lipid profile (i.e. ω-3 fish oils, borage oil) and
Monitoring tolerance and adequacy antioxidants.
ASPEN: In the ICU setting, evidence of bowel motility (resolution of Probiotics
clinical ileus) is not required in order to initiate EN in the ICU. In the • Controversy:
ICU patient population, neither the presence nor absence of bowel ASPEN: Administration of probiotic agents has been shown to
sounds nor evidence of passage of flatus and stool is required for improve outcome (most consistently by decreasing infection) in
the initiation of enteral feeding.
specific critically ill patient populations involving transplantation,
Patients should be monitored for tolerance of EN (determined by major abdominal surgery, and severe trauma. No
patient complaints of pain and/or distention, physical exam, passage recommendation can currently be made for use of probiotics in
of flatus and stool, abdominal radiographs). Inappropriate cessation the general ICU population due to a lack of consistent outcome
of EN should be avoided. Holding EN for gastric residual volumes effect. It appears that each probiotic species may have different
< 500 mL in the absence of other signs of intolerance should be effects and variable impact on patient outcome, making it
avoided. difficult to make broad categorical recommendations. Similarly,
ESPEN/CCPG: IV administration of metoclopramide or erythromycin no recommendation can currently be made for use of probiotics
should be considered in patients with intolerance to enteral feeding in patients with severe acute necrotising pancreatitis, based on
e.g. with high gastric residuals. the disparity of evidence in the literature and the heterogeneity
of the bacterial strains utilised.
ASPEN/CCPG: Use of enteral feeding protocols increase the likelihood
CCPG: There are insufficient data to make a recommendation
of overall attainment of percentage of goal energy provided and
on the use of prebiotics/probiotics/synbiotics in critically ill
should be implemented.
patients.
ASPEN: Patients placed on EN should be assessed for risk of
Antioxidant vitamins and selenium
aspiration. Steps to reduce risk of aspiration should be employed.
ASPEN/CCPG: A combination of antioxidant vitamins and trace
In all intubated ICU patients receiving EN, the head of the bed
minerals (specifically including selenium) should be provided to all
should be elevated 30°–45°. Use of chlorhexidine mouthwash
critically ill patients receiving specialised nutrition therapy.
twice a day should be considered to reduce risk of ventilator-
associated pneumonia. Blue food colouring and glucose oxidase There are insufficient data to make a recommendation regarding IV/
strips, as surrogate markers for aspiration, should not be used PN selenium supplementation alone, or in combination with other
in the critical care setting. antioxidants, in critically ill patients.
All: The addition of enteral glutamine to an EN regimen (not already ESPEN: A central venous access device is often required to administer
containing supplemental glutamine) should be considered in the high osmolarity PN mixture designed to cover the nutritional
thermally injured, trauma, and mixed ICU patients. needs fully. Peripheral venous access devices may be considered
Soluble fibre for low osmolarity (< 850 mOsmol/L) mixtures designed to cover a
proportion of the nutritional needs and to mitigate negative energy
ASPEN: Soluble fibre may be beneficial for the fully resuscitated,
balance.
haemodynamically stable critically ill patient receiving EN who
develops diarrhoea. Insoluble fibre should be avoided in all critically All-in-on bags
ill patients. Both soluble and insoluble fibre should be avoided in
ESPEN: PN admixtures should be administered as a complete all-
patients at high risk for bowel ischaemia or severe dysmotility.
in-one bag.
CCPG: There are insufficient data to support the routine use of
fibre (pectin or soy polysaccharides) in enteral feeding formulae in Dosing
critically ill patients. ASPEN: In all ICU patients receiving PN, mild permissive underfeeding
should be considered at least initially. Once energy requirements are
Parenteral nutrition
determined, 80% of these requirements should serve as the ultimate
General indication energy goal or dose of parenteral feeding. Eventually, as the patient
ASPEN: A critically ill ICU patient may be an appropriate candidate stabilises, PN may be increased to meet energy requirements. For
for PN under certain circumstances: (i) The patient is well nourished obese patients (BMI ≥ 30), the dose of PN with regard to protein and
prior to admission, but if after 7 days of hospitalisation EN has not energy provision should follow the same recommendations given for
been feasible or target energy goal has not been met consistently EN.
by EN alone, (ii) On admission, the patient is malnourished and
ESPEN: During acute illness, the aim should be to provide energy
EN is not feasible, (iii) A major surgical procedure is planned, the
as close as possible to the measured energy expenditure in order
preoperative assessment indicates that EN is not feasible through
to decrease negative energy balance. In the absence of indirect
the perioperative period, and the patient is malnourished.
calorimetry, ICU patients should receive 25 kcal/kg/day increasing
ESPEN: All patients who are not expected to be on normal to the energy target over the next 2–3 days.
nutrition within 3 days should receive PN within 24– 48 h, if EN is
contraindicated or if patients cannot tolerate EN. CCPG: In critically ill patients who are not malnourished, are tolerating
some EN, or when PN is indicated for short term use (< 10 days), low
Patients without malnutrition
dose PN should be considered. There are insufficient data to make
• Controversy:
recommendations about the use of low dose PN in the following
ASPEN: If early EN is not feasible or available the first 7 days
patients: those requiring PN for long term (> 10 days), obese critically
following admission to the ICU, no nutrition support therapy (i.e.
ill patients, and malnourished critically ill patients. Practitioners will
standard therapy) should be provided. In the patient who was
have to weigh the safety and benefits of low dose PN on an individual
previously healthy prior to critical illness with no evidence of
protein-energy malnutrition, use of PN should be reserved and case-by-case basis in these latter patient populations.
initiated only after the first 7 days of hospitalisation (when EN is Parenteral nutrition supplementary to enteral nutrition
not available).
ESPEN: In patients who tolerate EN and can be fed • Controversy:
approximately to the target energy values no additional PN ASPEN: A critically ill ICU patient may be an appropriate
should be given. In patients who cannot be fed sufficient candidate for PN under certain circumstances:
enterally the deficit should be supplemented parenterally.
In patients intolerant to EN, PN may be proposed at a level (i) The patient is well nourished prior to admission, but after
equal to but not exceeding the nutritional needs of the patient. 7 days of hospitalisation, EN has not been feasible or target
Overfeeding should be avoided. energy goal has not been met consistently by EN alone.
Patients with malnutrition ESPEN: All patients receiving less than their targeted enteral
ASPEN: If there is evidence of protein-energy malnutrition on feeding after 2 days should be considered for supplementary
admission and EN is not feasible, it is appropriate to initiate PN as PN.
soon as possible following admission and adequate resuscitation. CCPG: We recommend that PN not be started at the same time
ESPEN: Patients with a severe undernutrition should receive EN up as enteral nutrition. In the patient who is not tolerating adequate
25–30 total kcal/kg BW/day. If these target energy values are not enteral nutrition, there are insufficient data to put forward a
reached, supplementary PN should be given. recommendation about when PN should be initiated.
Carbohydrates Micronutrients
ESPEN: The minimal amount of carbohydrate required is about All: All PN prescriptions should include a daily dose of multivitamins
2 g/kg of glucose per day. and of trace elements.
ASPEN: A protocol should be in place to promote moderately strict ASPEN: In patients stabilised on PN, periodically repeated efforts
control of serum glucose when providing nutrition support therapy. should be made to initiate EN. As tolerance improves and the volume
A range of 6– 8 mg/dL may be most appropriate. of EN energy delivered increases, the amount of PN energy supplied
should be reduced. PN should not be terminated until ≥ 60% of target
ESPEN: Hyperglycaemia (glucose > 10 mmol/L) contributes to death
energy requirements are being delivered by the enteral route.
in the critically ill patient and should also be avoided to prevent
infectious complications. Reductions and increases in mortality rates
References
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ESPEN: Lipid emulsions should be an integral part of PN for energy 12. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for
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The tolerance of mixed LCT/MCT lipid emulsions in standard use
is sufficiently documented. Several studies have shown specific
clinical advantages over soybean LCT alone but require confirmation
by prospective controlled studies. Olive oil-based PN is well tolerated
in critically ill patients. Addition of EPA and DHA to lipid emulsions
has demonstrable effects on cell membranes and inflammatory
processes. Fish oil-enriched lipid emulsions probably decrease
length of stay in critically ill patients. Intravenous lipid emulsions
(LCT, MCT or mixed emulsions) can be administered safely at a rate
of 0.7 g/kg up to 1.5 g/kg over 12–24 h.
Amino acids
Glutamine (parenteral)