ESPEN guidelines and GUIDELINE ARTICLE

Question 1

Def

Answer 1

Question 2

Def

Answer 2

Question 3

Clinical question 1: Who should benefit from medical nutrition?
Who should be considered for medical nutrition therapy?

Question 4

3.2. Clinical question 2: How to assess malnutrition?

Answer 4

A general clinical assessment should be performed to assess
malnutrition in the ICU, until a specific tool has been validated.
Remark:
General clinical assessment could include anamnesis, report
of unintentional weight loss or decrease in physical performance
before ICU admission, physical examination, general
assessment of body composition, and muscle mass and strength,
if possible.
Grade of recommendation: GPP e strong consensus (100%
agreement)

Question 5

3.4. Clinical question 4: When should nutrition therapy be initiated
and which route should be used?

Recommendations 3-8

Answer 5

Recommendation 8
To avoid overfeeding, early full EN and PN shall not be used in
critically ill patients but shall be prescribed within three to
seven days.
Grade of recommend

Question 6

CI to enteral feeds?

Answer 6

We endorse contraindications as defined in ESICM guidelines
[15] and suggest withholding EN in critically ill patients with uncontrolled
shock, uncontrolled hypoxemia and acidosis, uncontrolled
upper GI bleeding, gastric aspirate >500 ml/6 h, bowel
ischemia, bowel obstruction, abdominal compartment and high-output fistula without distal feeding access.

Question 7

3.5. Clinical question 5: In adult critically ill patients, does
intermittent EN have an advantage over continuously administered
EN?

Answer 7

Continuous rather than bolus EN should be used.
Grade of recommendation: B e strong consensus (95%
agreement)

Question 8

: In adult critically ill patients, does
postpyloric EN compared to gastric EN improve outcome (reduce
mortality, reduce infections) ?

What are problems regarding post pyloric feeding ?

Answer 8

As postpyloric tube placement requires expertise, is
commonly associated with some time delay, and is considered less
physiologic compared to gastric EN, the routine use of the postpyloric
route is currently not justified. Moreover, postpyloric
feeding could possibly be harmful in cases of GI motility problems
distal to the stomach.

Question 9

Clinical question 7: In adult critically ill patients, does the
administration of prokinetics improve outcome (reduce mortality,
reduce infections)?

What is best prokinetic ?

Answer 9

In critically ill patients with gastric feeding intolerance,
intravenous erythromycin should be used as a first line prokinetic
therapy.
Grade of recommendation: B e strong consensus (100%
agreement)
Alternatively, intravenous metoclopramide or a combination
of metoclopramide and erythromycin can be used as a prokinetic
therapy.
Grade of recommendation: 0 e strong cons

Question 10

When should enteral feeding be delayed ?

Answer 10

. We suggest that
enteral feeding should be delayed when GRV is >500 mL/6 h.

Question 11

Clinical question 8: How to define the energy expenditure (EE)?

Answer 11

In critically ill mechanically ventilated patients, EE should be
determined by using indirect calorimetry.
Grade of recommendation: B e strong consensus (95%
agreement)
Statement 2
If calorimetry is not available, using VO2 (oxygen consumption)
from pulmonary arterial catheter or VCO2 (carbon dioxide
production) derived from the ventilator will give a better evaluation
on EE than predictive equations.
Consensus (82% agreemen
VO2 or VCO2 measurements, use of simple
weight-based equations (such as 20e25 kcal/kg/d) [1,2,41]: the
simplest option may be preferred

Question 12

Clinical question 9: In critically ill patients for whom caloric
needs are measured using indirect calorimetry or estimated using
predictive equations, should isocaloric or hypocaloric nutrition be
used?

Answer 12

If predictive equations are used to estimate the energy need,
hypocaloric nutrition (below 70% estimated needs) should be
preferred over isocaloric nutrition for the first week of ICU stay.
Grade of recom

Question 13

3.10. Clinical question 10: When should we apply/implement
supplemental PN?

Answer 13

Recommendation 20
In patients who do not tolerate full dose EN during the first
week in the ICU, the safety and benefits of initiating PN should
be weighed on a case-by-case basis.
Grade of recommendation: GPP e strong consensus (96%
agreement)
Recommendation 21
PN should not be started until all strategies to maximize EN
tolerance have been attempted.
Grade of recommendation: GPP e strong consensus (95%
agreement)
Commentary to recommendations 20 and 21

Question 14

3.11. Clinical question 11: In adult critically ill patients, does high
protein intake compared to low protein intake improve outcome
(reduce mortality, reduce infections)?

Answer 14

During critical illness, 1.3 g/kg protein equivalents per day
can be delivered progressively
Grade of recommendation: 0 e strong consensus (91%
agreement)

Question 15

Clinical question 12: What are the optimal combinations of
carbohydrates and fat during EN and PN?

Answer 15

Recommendation 23
The amount of glucose (PN) or carbohydrates (EN) administered
to ICU patients should not exceed 5 mg/kg/min.
Grade of recommendation: GPP e strong consensus (100%
agreement)
Recommendation 24
The administration of intravenous lipid emulsions should be
generally a part of PN
Intravenous lipid (including non-nutritional lipid sources)
should not exceed 1.5 g lipids/kg/day and should be adapted to
individual tolerance.
Grade of recommendation: GPP e strong consensus (100%
agreement)

Question 16

Clinical question 13: Should we use additional enteral/
parenteral glutamine (GLN) in the ICU

Answer 16

In unstable and complex ICU patients, particularly in those
suffering from liver and renal failure, parenteral GLN -dipeptide
shall not be administered.
Grade of recommendation: A e strong consensus (92.31%
agreement)

Question 17

4. Clinical question 14: Should we use enteral/parenteral EPA/
   DHA?

Answer 17

Question 18

Clinical question 15: Should we use parenteral micronutrients
and antioxidants in critically ill patients?

Answer 18

To enable substrate metabolism, micronutrients (i.e. trace
elements and vitamins) should be provided daily with PN.
Grade of recommendation: B e strong consensus (100%
agreement)
Antioxidants as high dose monotherapy should not be
administered without proven deficiency.
Grade of recommendation: B e strong consensus (96%
agreement)

Question 19

Clinical question 16: Should additional vitamin D be used in
critically ill patients?

Answer 19

Question 20

EN should be delayed? ci ?

Answer 20

Question 21

Low dose EN should be administered?

Answer 21

in patients receiving therapeutic hypothermia and
increasing the dose after rewarming;
in patients with intra-abdominal hypertension without
abdominal compartment syndrome, whereas temporary
reduction or discontinuation of EN should be considered
when intra-abdominal pressure values further increase
under EN; and
in patients with acute liver failure when acute, immediately
life-threatening metabolic derangements are
controlled with or without liver support strategies, independent
on grade of encephalopathy

Question 22

Low dose EN ? Indications ?

Answer 22

Question 23

Early EN ? Indications or safe ?

Answer 23

Question 24

Non intubated patients ?

Answer 24

In non-intubated patients not reaching the energy target
with an oral diet, oral nutritional supplements should be
considered first and then EN.
Grade of recommendation: GPP e strong consensus (96%
agreement)

Question 25

3.19. Clinical question 19: In adult critically ill patients with sepsis,
does EN compared to no nutrition improve outcome (reduce
mortality, reduce infections)?
3.19.1. Clinical question 20: In adult critically ill patients with
sepsis, does EN compared to PN improve outcome (reduce mortality,
reduce infections)?

Answer 25

Question 26

3.20. Clinical question 21: Critically ill patients with surgical
complications after abdominal or esophageal surgery

Answer 26

Question 27

Clinical question 22: How should head trauma patients be
fed?

Answer 27

Question 28

Clinical question 23: How should obese patients be fed?

Answer 28

Question 29

3.23. Clinical question 24: How should nutrition therapy be
monitored during the ICU stay?

Answer 29

therapy in the ICU are:
a) To assure that optimal nutritional support is planned and
provided as prescribed regarding energy, protein and
micronutrient targets,
b) To prevent or detect any possible complication,
c) To monitor response to feeding and detect refeeding, and
d) to detect micronutrient deficiencies in patient categories at
risk.

Question 30

3.24. Clinical question 25: Which laboratory parameters should be
monitored?

Glucose

Answer 30

Question 31

Electrolytes ?

Answer 31

Question 32

Def refeeding syndrome ?

Answer 32

Refeeding syndrome can be defined as the potentially fatal shifts
in fluids and electrolytes that may occur in malnourished patients
receiving artificial refeeding

Question 33

Recommended macronutrient requirements for use in ICU
Energy
Protein
Glucose
Fat

Answer 33

Question 34

Effects refeeding syndrome?

Answer 34

Severe hypophosphataemia (whole body depletion).
Fluid balance abnormalities (acute overload/depletion).
Hypokalaemia.
Hypomagnesaemia.
Altered glucose metabolism.
Vitamin deficiency.
Cardiac failure, pulmonary oedema and dysrhythmias.
Risk of death.

Question 35

At risk ?

Answer 35