Provision of Nutrition Support Therapy in the Adult Critically Ill Patient

Publication Date: November 16, 2021
Last Updated: March 14, 2022

Summary of Recommendations

No significant difference in clinical outcomes was found between patients with higher vs lower levels of energy intake. We suggest feeding between 12 and 25 kcal/kg (ie, the range of mean energy intakes examined) in the first 7–10 days of ICU stay. (C, M)
620
There was no difference in clinical outcomes in the relatively limited data. Because of a paucity of trials with high-quality evidence, we cannot make a new recommendation at this time beyond the 2016 guideline suggestion for 1.2–2.0 g/kg/day. (C, L)
620
There was no significant difference in clinical outcomes between early exclusive PN and EN during the first week of critical illness. As PN was not found to be superior to EN and no differences in harm were identified, we recommend that either PN or EN is acceptable. (S, H)
620
There was no significant difference in clinical outcomes. Based on findings of no clinically important benefit in providing SPN early in the ICU admission, we recommend not initiating SPN prior to day 7 of ICU admission. (S, H)
620
Owing to limited statistically or clinically significant differences in key outcomes, we suggest that either mixed-oil ILE or 100% SO ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission. (C, L)
620
Because there was only one outcome with a significant difference that was not supported by data covering the other key downstream outcomes, we suggest that either FO- or non–FO-containing ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission. (C, L)
620

Other Questions

  • In adult critically ill patients, do higher nutrition risk scores predict worse outcomes than BMI alone as the indicator of nutrition risk?
    • Our searches yielded no RCTs comparing clinical outcomes based on groups of patients randomized according to either the Nutrition Risk in the Critically Ill (NUTRIC) score or the Nutrition Risk Screening 2002 (NRS2002) tool relative to BMI. The evidence supporting each of these approaches to nutrition assessment to date has been based largely on retrospective observational studies, a level of evidence excluded in this current guideline.
  • In adult critically ill patients, do immune-enhancing nutrients provide better outcomes than standard care?
    • This broad question encompasses differing numbers of nutrients (glutamine; ω-3 fatty acids; individual vitamins, minerals, and trace elements) that are compared at widely variable doses. Because this current guideline was focused on providing answers to foundational practice questions in the general critically ill population, the decision was made to construct a future author panel to deal with this question as its own guideline.
  • In adult critically ill patients, do probiotics provide better outcomes than standard care?
    • The RCTs that were identified by our search strategy reported on a variety of probiotic preparations and doses and did not report consistently on the outcomes included in this guideline.

Recommendation Grading

Overview

Title

Provision of Nutrition Support Therapy in the Adult Critically Ill Patient

Authoring Organization

Publication Month/Year

November 16, 2021

Last Updated Month/Year

July 24, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

Most critically ill patients are unable to provide their own nutrition. In these patients, artificial nutrition is often provided. The purpose of this guideline is to summarize the evidence within nutrition support to guide practitioners in their provision of artificial nutrition to critically ill patients and provide/update recommendations for several foundational questions that are central to the provision of nutrition support for most critically ill adult patients.

Target Patient Population

Critically ill adult patients in surgical or medical ICUs who are unable to maintain volitional oral intake and are supported by PN or EN

Target Provider Population

Clinicians, including dietitians, nurses, nurse practitioners, pharmacists, physicians, and/or physician assistants who provide nutrition care for critically ill adult patient

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital

Intended Users

Dietician nutritionist, health systems pharmacist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D004750 - Enteral Nutrition, D010288 - Parenteral Nutrition

Keywords

enteral nutrition, parenteral nutrition, critically ill

Source Citation

Compher C, Bingham AL, McCall M, Patel J, Rice TW, Braunschweig C, McKeever L. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2021 Nov 16. doi: 10.1002/jpen.2267. Epub ahead of print. PMID: 34784064.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
522
Literature Search Start Date
January 1, 2001
Literature Search End Date
July 15, 2020
Specialties Involved
Critical Care, Internal Medicine General