Skip to main content

Advertisement

Log in

Enteral nutrition in intensive care patients: a practical approach

  • Esicm Statement
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Giner M, Laviano A, Meguid MM, Gleason JR (1996) In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 12: 23–29

    Article  PubMed  CAS  Google Scholar 

  2. Frost P, Bihari D (1997) The route of nutritional support in the critically ill: physiological and economical considerations. Nutrition 13: 58S-63S

    Article  PubMed  CAS  Google Scholar 

  3. Buchman AL, Moukarzel AA et al (1995) Parenteral nutrition is associated with intestinal morphologic and functional changes in humans. JPEN J Par-enter Enteral Nutr 19: 453–460

    Article  CAS  Google Scholar 

  4. Lew JL, Rombeau JL (1993) Effects of enteral nutrients on the critically ill gut. In: Wilmore D, Carpentier Y (ed) Metabolic support of the critically ill patient. Springer, Berlin Heidelberg New York, pp 175–197

    Google Scholar 

  5. Deitch EA, Specian RD, Berg RD (1991) Endotoxin-induced bacterial translocation and mucosal permeability: role of xanthine oxidase, complement activation, and macrophage products. Crit Care Med 19: 785–791

    Article  PubMed  CAS  Google Scholar 

  6. Manning EMC, Shenkin A (1995) Nutritional assessment in the critically ill. Crit Care Clin 11: 603–634

    PubMed  CAS  Google Scholar 

  7. Chioléro R, Gay LJ, Cotting J, Gurtner C, Schutz Y (1992) Assessment of changes in body water by bioimpedance in acutely ill surgical patients. Intensive Care Med 18: 322–326

    Article  PubMed  Google Scholar 

  8. Schlichtig R, Ayres SM (1988) Nutritional assessment of the critically ill. In: Schlichtig R, Ayres S (ed) Nutritional support of the critically ill. Year Book Medical, Chicago, pp 75–95

    Google Scholar 

  9. Shenkin A (1997) Micronutrients. In: Rombeau J, Rolandelli R (ed) Clinical nutrition: enteral and tube feeding. Sauncers, Philadelphia, pp 96–111

    Google Scholar 

  10. Shenkin A (1995) Trace elements and inflammatory response: implications for nutritional support. Nutrition 11: 100–105

    PubMed  CAS  Google Scholar 

  11. Demling RH, DeBiasse MA (1995) Micronutrients in critical illness. Crit Care Clin 11: 651–673

    PubMed  CAS  Google Scholar 

  12. Berger MM, Cavadini C et al (1992) Selenium losses in 10 burned patients. Clin Nutr 11: 75–82

    Article  PubMed  CAS  Google Scholar 

  13. Berger MM, Cavadini C et al (1992) Cutaneous zinc and copper losses in burns. Burns 18: 373–380

    Article  PubMed  CAS  Google Scholar 

  14. Cerra FB, Benitez MR et al (1997) Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. Chest 111: 769–778

    Article  PubMed  CAS  Google Scholar 

  15. MacBurney MM, Russel C, Young LS (1990) Formulas. In: Rombeau J, Cald-well M (ed) Clinical nutrition: enteral tube feeding. Saunders, Philadelphia, pp 149–173

    Google Scholar 

  16. Siperstein MD (1992) Diabetic ketoaci-dosis and hyperosmolar coma. Endocrinol Metab Clin North Am 21: 415–432

    PubMed  CAS  Google Scholar 

  17. Talpers SS, Romberger DJ, Bunce SB, Pingleton SK (1992) Nutritionally associated increased carbon dioxide production. Excess calories vs. high proportion of carbohydrate calories. Chest 102: 551–555

    Article  PubMed  CAS  Google Scholar 

  18. Moore FA, Feliciano DV et al (1992) Early enteral feeding, compared with parenteral, reduces postoperative septic complications. Ann Surg 216:172–183

    Article  PubMed  CAS  Google Scholar 

  19. Scheppach WM, Burghardt W, Bartram P, Kasper H (1990) Addition of dietary fiber to liquid diets: the pros and cons. JPEN J Parenter Enteral Nutr 14: 204–209

    Article  PubMed  CAS  Google Scholar 

  20. Scheppach WM, Bartram H-P (1993) Experimental evidence for and clinical implications of fiber and artificial enteral nutrition. Nutrition 9: 399–405

    PubMed  CAS  Google Scholar 

  21. Compher CH, Seto RW, Lew JI (1997) Dietary fiber and its clinical applications to enteral nutrition. In: Rombeau J, Rolandelli R (ed) Clinical nutrition: enteral and tube feeding. Saunders, Philadelphia, pp 81–95

    Google Scholar 

  22. Kinsella JE, Lokesh B (1990) Dietary lipids, eicosanoids and the immune system. Crit Care Med 18: S94-S113

    Article  PubMed  CAS  Google Scholar 

  23. Gottschlich MM (1992) Selection of optimal lipid sources in enteral and parenteral nutrition. Nutr Clin Pract 7: 152–165

    Article  PubMed  CAS  Google Scholar 

  24. Bower RH, Cerra FB et al (1995) Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 23: 436–449

    Article  PubMed  CAS  Google Scholar 

  25. Koretz RL (1995) The impact of immunonutrition. Gastroenterology 109: 1713–1714

    Article  PubMed  CAS  Google Scholar 

  26. Gottschlich MM, Shronts EP, Hutchins AM (1997) Defined formula diets. In: Rombeau J, Rolandelli R (ed) Clinical nutrition: enteral and tube feeding. Saunders, Philadelphia, pp 207–239

    Google Scholar 

  27. Dubin S, McKee K, Battish S (1994) Essential amino acid profile affects the evaluation of enteral feeding products. J Am Diet Assoc 94: 884–887

    Article  PubMed  CAS  Google Scholar 

  28. Ziegler F, Nitenberg G, Coudray-Lucas C, Lasser P, Giboudeau J, Cynober L (1998) Pharmacokinetic assessment of an oligopeptide-based enteral formula in abdominal surgery patients. Am J Clin Nutr 67:124–128

    PubMed  CAS  Google Scholar 

  29. Cerra FB (1994) Effects of manipulating dietary constituents on the incidence of infection in critically ill patients. Sem Respir Infect 9: 232–239

    CAS  Google Scholar 

  30. Bone RC (1996) Sir Isaac Newton, sepsis, SIRS and CARS. Crit Care Med 24:1125–1128

    Article  PubMed  CAS  Google Scholar 

  31. Braga M, Vignali A, Gianotti L, Cestari A, Profili V, DiCarlo V (1996) Immune and nutritional effects of early enteral nutrition after major abdominal operations. Eur J Surg 162:105–112

    PubMed  CAS  Google Scholar 

  32. Braga M, Gianotti L et al (1996) Gut function and immune and inflammatory responses in patients perioperatively fed with supplemented enteral formulas. Arch Surg 131: 1257–1265

    PubMed  CAS  Google Scholar 

  33. Brown RO, Hunt H, Mowatt-Larsen CA, Wojtysiak SL, Henningfield MF, Kudsk KA (1994) Comparison of specialized and standard enteral formulas in trauma patients. Pharmacotherapy 14:314–320

    PubMed  CAS  Google Scholar 

  34. Daly JM, Lieberman MD et al (1992) Enteral nutrition with supplemental ar-ginine, RNA, and omega-3 fatty acids in patients after operation: immunolo-gic, metabolic, and clinical outcome. Surgery 112: 56–67

    PubMed  CAS  Google Scholar 

  35. Daly JM, Reynolds J et al (1988) Immune and metabolic effects of arginine in the surgical patients. Ann Surg 208: 512–522

    Article  PubMed  CAS  Google Scholar 

  36. Kemen M, Senkal M et al (1995) Early postoperative enteral nutrition with arginine-ω-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact®. Crit Care Med 23: 652–659

    Article  PubMed  CAS  Google Scholar 

  37. O’Riordain MG, Fearon KCH et al (1994) Glutamine-supplemented total parenteral nutrition enhances T-lymphocyte response in surgical patients undergoint colorectal resection. Ann Surg 220: 212–221

    Article  PubMed  Google Scholar 

  38. Heyland DK, Cook DJ, Guyatt GH (1994) Does the formulation of enteral feeding products influence infectious morbidity and mortality rates in the critically ill patient? A critical review of the evidence. Crit Care Med 22: 1192–1202

    Article  PubMed  CAS  Google Scholar 

  39. Beale R, Bryg DI (1997) Clinical effects of immunonutrition on intensive care patients: a meta-analysis (abstract). Intensive Care Med 23: S128

  40. Hall JC, Keel K, McCauley R (1996) Glutamine. Br J Surg 83: 305–312

    Article  PubMed  CAS  Google Scholar 

  41. Neu J, Shenoy V, Chakrabati MC (1996) Glutamine nutrition and metabolism: where do we go from here? FASEB J 10: 829–837

    PubMed  CAS  Google Scholar 

  42. Calder PC (1994) Glutamine and the immune system. Clin Nutr 13: 2–8

    Article  PubMed  CAS  Google Scholar 

  43. Spittler A, Winkler S et al (1995) Influence of glutamine on the phenotype and function of human monocytes. Blood 86:1564–1569

    PubMed  CAS  Google Scholar 

  44. Zapata-Sirvent RL, Hansbrough JF, Ohara MM, Rice-Asaro M, Nyhan WL (1994) Bacterial translocation in burned mice after administration of various diets including fiber- and glutamine-enriched enteral formulas. Crit Care Med 22: 690–696

    Article  PubMed  CAS  Google Scholar 

  45. Wells CL, Jechorek RP, Erlandsen SL, Lavin PL, Cerra FB (1990) The effects of dietary glutamine and dietary RNA on ileal flora, ileal histology and bacterial translocation in mice. Nutrition 6: S70-S75

    Google Scholar 

  46. Gianotti V, Alexander JW, Gennari R, Pyles T, Babcock GF (1995) Oral glutamine decreases bacterial translocation and improves survival in experimental gut-origin sepsis. JPEN J Parenter Enteral Nutr 19: 69–74

    Article  PubMed  CAS  Google Scholar 

  47. Jensen GL, Miller RH, Talabiska DG, Fish J, Gianferante L (1997) A double-blind, randomized study of glutamine-enriched compared with standard pep-tide-based feeding in critically ill patients. Am J Clin Nutr 64: 615–621

    Google Scholar 

  48. Ziegler TR, Young LS et al (1992) Clinical and metabolic efficacy of glutamine-supplemented parenteral nutrition after bone marrow transplantation. Ann Intern Med 116: 821–828

    PubMed  CAS  Google Scholar 

  49. Griffiths RD, Jones C, Palmer TEA (1997) Six-month outcome of critically ill patients given glutamine-supplemented parenteral nutrition. Nutrition 13:295–302

    PubMed  CAS  Google Scholar 

  50. Braga M, Gianotti L, Vignali A, Cestari A, Bisagni P, Di Carlo V (1998) Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet. Crit Care Med 26: 24–30

    Article  PubMed  CAS  Google Scholar 

  51. Le Bricon T, Coudray-Lucas C et al (1997) Ornithine alpha-ketoglutarate metabolism after enteral administration in burn patients: bolus compared with continuous infusion. Am J Clin Nutr 65: 512–518

    PubMed  Google Scholar 

  52. Hammarqvist F, Wernerman J, Ali R, Vinnars E (1990) Effects of an amino acid solution enriched with either branched-chain amino acids or ornithine-alpha-ketoglutarate on the postoperative intracellular amino acid concentration of skeletal muscle. Br J Surg 77: 214–218

    Article  PubMed  CAS  Google Scholar 

  53. Blok WL, Katan MB, ven der Meer JW (1996) Modulation of inflammation and cytokine production by dietary (n-3) fatty acis. J Nutr 126:1515–1533

    PubMed  CAS  Google Scholar 

  54. Endres S, Ghorbani R et al (1989) The effects of dietary supplementation with ω−3 polyunsaturated fatty acids on the synthesis of interleukin-1 and tumor necrosis factor. N Engl J Med 320:265–271

    PubMed  CAS  Google Scholar 

  55. Anderton A (1993) Bacterial contamination of enteral feeds and feeding systems. Clin Nutr 12: S16-S32

    Google Scholar 

  56. Dentinger B, Faucher KJ, Ostrom SM, Schmidl MK (1995) Controlling bacterial contamination of an enteral formula through the use of a unique closed system: contamination, enteral formulas, closed system. Nutrition 11: 747–750

    PubMed  CAS  Google Scholar 

  57. Crawford DHG, Shepherd RW, Halliday JW, Cooksley GWGE, Golding SD, Cheng WSC (1994) Body composition in nonalcoholic cirrhosis: the effect of disease etiology and severity on nutritional compartments. Gastroenterology 106:1611–1617

    PubMed  CAS  Google Scholar 

  58. Cano N, Fernandez JP, Lacombe P, Lamkester M, Pascal S, Defayolle M (1987) Statistical selection of nutritional parameters in hemodialyzed patients. Kidney Int 32: S178-S180

    Google Scholar 

  59. Elwyn DH, Parikh HC, Shoemaker WC (1968) Amino acid movements between gut, liver, and periphery in unanesthetized dogs. Am J Physiol 215:1260–1275

    PubMed  CAS  Google Scholar 

  60. Garibotto G, Deferrari G, Robaudo C, Saffioti S, Salvidio G, Paoletti E (1987) Effect of amino acid ingestion on blood amino acid profile in patients with chronic failure. Am J Clin Nutr 46: 949–954

    PubMed  CAS  Google Scholar 

  61. McClave SA, Greene LM et al (1997) Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr 21:14–20

    Article  PubMed  CAS  Google Scholar 

  62. Plauth M, Merli M, Kondrup J, Weimann A, Ferenci P, Miiller MJ (1997) ESPEN guidelines for nutrition in liver disease and transplantation. Clin Nutr 16: 43–55

    Article  PubMed  CAS  Google Scholar 

  63. Alp Ikizler T, Hakim RM (1996) Nutrition in end-stage renal disease. Kidney Int 50: 343–357

    Article  Google Scholar 

  64. Klein S, Kinney J et al (1997) Nutrition support in clinical practice: review of published data and recommendations for future research directions. JPEN J Parenter Enteral Nutr 21:133–156

    Article  PubMed  CAS  Google Scholar 

  65. American Society for Parenteral and Enteral Nutrition (1993) Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 17: 1SA-51SA

    Article  Google Scholar 

  66. Heyland D, Cook DJ, Winder B, Brylowski L, Van de Mark H, Guyatt G (1995) Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med 23:1055–1060

    Article  PubMed  CAS  Google Scholar 

  67. Dive A, Moulart M, Jonard P, Jamart J, Mahieu P (1994) Gastroduodenal motility in mechanically ventilated critically ill patients: a manometric study. Crit Care Med 22: 441–447

    Article  PubMed  CAS  Google Scholar 

  68. Weekes E, Elia M (1996) Observations on the patterns of 24-hour energy expenditure changes in body composition and gastric emptying in head-injured patients receiving nasogastric tube feeding. JPEN J Parenter Enteral Nutr 20: 31–37

    Article  PubMed  CAS  Google Scholar 

  69. Zaloga GP, Black KW, Prielipp P (1992) Effect of rate of enteral nutrient supply on gut mass. JPEN J Parenter Enteral Nutr 16: 39–42

    Article  PubMed  CAS  Google Scholar 

  70. Kudsk KA, Croce MA et al (1991) Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 215:503–513

    Article  Google Scholar 

  71. Patrick PG, Marulendra S, Kirby DF, DeLegge MH (1997) Endoscopic nasogasric-jejunal feeding tube placement in critically ill patients. Gastrointest Endosc 45: 72–76

    Article  PubMed  CAS  Google Scholar 

  72. Ott DJ, Mattox HE, Gelfand DW, Chen MY, Wu WC (1991) Enteral feeding tubes: placement by using fluoroscopy and endoscopy. AJR Am J Roentgenol 157:769–771

    PubMed  CAS  Google Scholar 

  73. Stark SP, Sharpe JN, Larson GM (1991) Endoscopically placed nasoenteral feeding tubes. Indications and technique. Ann Surg 57: 203–205

    CAS  Google Scholar 

  74. DeLegge MH, Duckworth PF Jr, McHenry L Jr, Foxx-Orenstein A, Craig RM, Kirby DF (1995) Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial. JPEN J Parenter Enteral Nutr 19: 239–243

    Article  PubMed  CAS  Google Scholar 

  75. Breach CL, Saldanha LG (1988) Tube feedings: a survey of compliance to procedures and complications. Nutr Clin Pract 3: 230–234

    Article  PubMed  CAS  Google Scholar 

  76. Burdon JT, Morton AM, Conway SP (1995) Accidental intravenous administration of enteral feeds by a patient with cystic fibrosis. Clin Nutr 14: 313–315

    Article  PubMed  CAS  Google Scholar 

  77. Butters M, Campos AC, Meguid MM (1992) High frequency-low morbidity mechanical complications of tube feeding: a prospective study. Clin Nutr 11: 87–92

    Article  PubMed  CAS  Google Scholar 

  78. Spapen HD, Duinslaeger L, Diltoer M, Gillet R, Bossuyt A, Huyghens LP (1995) Gastric emptying in critically ill patients is accelerated by adding cisapride to a standard enteral feeding protocol: results of a prospective, randomized, controlled trial. Crit Care Med 23: 481–485

    Article  PubMed  CAS  Google Scholar 

  79. Frost P, Edwards N, Bihari D (1997) Gastric emptying in the critically ill -the way forward? Intensive Care Med 23: 243–245

    Article  PubMed  CAS  Google Scholar 

  80. Bleichner G, Bléhaut H, Mentec H, Moyse D (1997) Saccharomyces boular-dii prevents diarrhea in critically ill tube-fed patients. Intensive Care Med 23: 517–523

    Article  PubMed  CAS  Google Scholar 

  81. Koretz RL (1995) Nutritional supplementation in the ICU. How critical is nutrition for the critically ill? Am J Respir Crit Care Med 151: 570–573

    PubMed  CAS  Google Scholar 

  82. Koretz RL (1994) Feeding controversies. In: Zaloga G (ed) Nutrition in critical care. Mosby, St Louis, pp 283–296

    Google Scholar 

Download references

Author information

Authors

Consortia

Additional information

Reprint requests to the European Society of Intensive Care Medicine, 40 Ave Joseph Wybran, B-1070 Brussels, Belgium E-mail esicm@pophost.eunet.be

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jolliet, P., Pichard, C., Biolo, G. et al. Enteral nutrition in intensive care patients: a practical approach. Intensive Care Med 24, 848–859 (1998). https://doi.org/10.1007/s001340050677

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s001340050677

Key words

Navigation