Nutrition Therapy in the Adult Hospitalized Patient
Publication Date: March 1, 2016
Last Updated: March 14, 2022
Recommendations
Indications
Specialized nutrition therapy in the form of EN should be initiated promptly in the hospitalized patient who is at high nutritional risk and is unable to maintain volitional oral intake. (Conditional (weak) “We suggest”Low)
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EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy and do not have a contraindication to the delivery of luminal nutrients. (Conditional (weak) “We suggest”Low)
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Specialized nutrition therapy (EN or PN) is not required for hospitalized patients who are at low nutritional risk, appear well nourished, and are expected to resume volitional intake within 5 to 7 days following admission. (Conditional (weak) “We suggest”Very low)
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PN should be reserved for the hospitalized patient under specific circumstances, when EN is not feasible or sufficient enough to provide energy and protein goals. (Conditional (weak) “We suggest”Very low)
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Assessment
Prior to initiation of specialized nutrition therapy (either EN or PN), a determination of nutritional risk should be performed using a validated scoring system such as the Nutritional Risk Score 2002 (NRS-2002) or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient. (Conditional (weak) “We suggest”Very low)
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An additional assessment should be performed prior to initiation of nutrition therapy of factors that may impact the design and delivery of the nutrition regimen. (Conditional (weak) “We suggest”Very low)
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Use of “traditional” nutrition indicators (albumin, pre-albumin, transferrin, and anthropometry) should be avoided. (Conditional (weak) “We suggest”Very low)
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Surrogate markers of infection or inflammation should not be used for nutritional assessment. (Conditional (weak) “We suggest”Very low)
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Caloric requirements should be determined and then be used to set the goal for delivery of nutrition therapy. (Conditional (weak) “We suggest”Very low)
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One of the three strategies should be used to determine caloric requirements:
- Indirect calorimetry
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- Simple weight-based equations
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- Published predictive equations
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Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed. (Conditional (weak) “We suggest”Very low)
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Enteral access
A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient. (Conditional (weak) “We suggest”Very low)
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Radiologic confirmation of placement in the stomach should be carried out prior to feeding (except with the use of electromagnetic transmitter-guided feeding tubes). Repeated periodic radiologic confirmation of correct tube position in the GI tract is not required unless there is concern for tube displacement because of nausea/vomiting, regurgitation, coughing, retching, or overt displacement. (Conditional (weak) “We suggest”Very low)
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Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration. (Strong “We recommend”, )
(moderate-to-high level of evidence)
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Simultaneous aspiration/decompression of the stomach with jejunal feeding may be accomplished by using a dual lumen aspirate/feed nasoenteric tube, a combined percutaneous gastrojejunostomy (GJ) tube, or the use of both gastrostomy and jejunostomy tubes. (Conditional (weak) “We suggest”Very low)
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When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed. (Conditional (weak) “We suggest”Very low)
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A percutaneous enteral access device should be placed, either via the gastric or the jejunal route, if enteral feeding is anticipated to be required for >4-week duration. (Conditional (weak) “We suggest”Very low)
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A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding. (Conditional (weak) “We suggest”Very low)
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For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement. (Conditional (weak) “We suggest”Very low)
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Initiating Enteral Nutrition
In the patient at high nutritional risk unable to maintain volitional intake, EN should be initiated within 24–48 h of admission to the hospital. (Conditional (weak) “We suggest”Low)
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Although early EN should be initiated within 24–48 h of admission, the timing by which to advance to goal is unclear. When tolerated, feeding should be advanced to goal within 48–72 h. (Conditional (weak) “We suggest”Very low)
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With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days. (Conditional (weak) “We suggest”Very low)
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Permissive underfeeding (i.e., hypocaloric feeding) is an acceptable alternative to full feeding and may be considered in three separate patient scenarios:
- Acute Lung Injury/Acute Respiratory Distress Syndrome (ALI/ARDS)
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- Obesity with BMI>30
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- Placement on PN over the first week of nutrition therapy
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A standard polymeric formula or a high-protein standard formula should be used routinely in the hospitalized patient requiring EN. (Conditional (weak) “We suggest”Very low)
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An immune-modulating formula containing arginine and omega-3 fish oil should be used for patients who have had major surgery and are in a surgical ICU setting. (Conditional (weak) “We suggest”Very low)
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An immune-modulating formula containing arginine and omega-3 fish oil should not be used routinely in patients in a medical ICU. (Conditional (weak) “We suggest”Very low)
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Monitoring tolerance and adequacy of EN
Hospitalized patients on EN should be monitored daily by physical exam. (Conditional (weak) “We suggest”Very low)
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Patients on EN should be monitored for adequacy of provision of EN as a percent of target goal calories, cumulative caloric deficit, and inappropriate cessation of EN. (Conditional (weak) “We suggest”Very low)
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In the patient at high risk for refeeding syndrome, feeding should be ramped up slowly to goal over 3 to 4 days, while carefully monitoring electrolytes and volume status. (Conditional (weak) “We suggest”Very low)
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Enteral feeding protocols should be used in hospitalized patients in need of nutrition therapy. (Strong “We recommend”Moderate)
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A validated protocol should be used, such as a volume-based feeding protocol or a multi-strategy (bundled) top-down protocol. (Conditional (weak) “We suggest”Very low)
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Gastric residual volume (GRV) should not be used routinely as a monitor in hospitalized patients on EN. (Conditional (weak) “We suggest”Very low)
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Patients on EN should be assessed for risk of aspiration. (Conditional (weak) “We suggest”Very low)
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For patients determined to be at high risk, the following steps should be taken to proactively reduce that risk:
- Use a prokinetic agent
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- Divert the level of feeding lower in the GI tract
(moderate-to-high level of evidence)
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- Switch to continuous infusion
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- Use chlorhexidine mouthwash twice daily
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For the patient receiving EN who develops diarrhea, an evaluation should be initiated to identify an etiology and direct management. (Conditional (weak) “We suggest”Very low)
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The patient receiving EN who develops diarrhea should be managed by one of the three strategies:
- Use of fermentable soluble fiber as an adjunctive supplement to a standard EN formula
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- Switching to a commercial mixed fiber
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- Initiating a small peptide/MCT oil formula
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Complications of enteral access
The percutaneous enteral access site should be monitored by cleaning daily with mild soap and water and maintaining correct positioning of the external bolster. (Conditional (weak) “We suggest”Very low)
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Prevention of tube clogging is important to successful EN and may be achieved by frequent water flushes delivered every shift and each time medications are given. (Conditional (weak) “We suggest”Very low)
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When a clogged tube is encountered and the use of water flushes is unsuccessful at clearing, a de-clogging solution comprising a nonenteric-coated pancreatic enzyme tablet dissolved in a sodium bicarbonate solution should be used. (Conditional (weak) “We suggest”Very low)
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If still unsuccessful, a mechanical de-clogging device should be considered prior to exchanging the tube for a new one. (Conditional (weak) “We suggest”Very low)
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A patient who inadvertently dislodges a recently placed percutaneous gastrostomy tube (<7–10-day old) should be brought back immediately to the endoscopy or radiology suite and a new tube placed endoscopically or radiologically through the same site on the abdominal wall. (Conditional (weak) “We suggest”Very low)
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If a percutaneous gastrostomy tube becomes dislodged that has been in place long enough for a partially formed tract to develop (>7–10 days), a tube of similar diameter should be placed blindly as expeditiously as possible to maintain patency and prevent closure of the tube tract. In this latter circumstance, radiologic confirmation should be carried out prior to feeding if there is any question of inappropriate location of the tube. (Conditional (weak) “We suggest”Very low)
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For a patient with deterioration, breakdown, increased drainage/leakage, or enlarging stoma around the percutaneous tube site, an evaluation should be performed to determine etiology and appropriate management. (Conditional (weak) “We suggest”Very low)
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Placement of a larger tube should not be used to manage leakage caused by an enlarging stoma around the percutaneous access device. (Conditional (weak) “We suggest”Very low)
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A percutaneous enteral access device that shows signs of fungal colonization with material deterioration and compromised structural integrity should be replaced in a non-urgent but timely manner. (Conditional (weak) “We suggest”Very low)
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Parenteral nutrition
If early EN is not feasible and the patient is at low nutritional risk upon admission, no specialized nutrition therapy should be provided and PN should be withheld for the first week of hospitalization. (Conditional (weak) “We suggest”Very low)
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If a patient is at high nutritional risk on admission to the hospital and EN is not feasible, PN should be initiated as soon as possible. (Strong “We recommend”Moderate)
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Supplemental PN should be considered for the patient already on enteral tube feeding only after 7 to 10 days, when unable to meet >60% of energy and/or protein requirements by the enteral route alone. Initiating supplemental PN prior to this 7–10-day period in those patients already receiving EN does not improve outcomes and may be detrimental to the patient. (Strong “We recommend”Moderate)
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In hospitalized patients receiving PN, mild permissive underfeeding (delivery 80% of energy requirements with full protein provision) should be considered initially for the first 7 to 10 days. Following this first week (if long-term PN is required), energy provision should be increased to meet energy goals. (Conditional (weak) “We suggest”Low)
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Peripheral PN (PPN) should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy. (Conditional (weak) “We suggest”Very low)
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Careful transition feeding should be used in the patient on PN, for whom EN is now being initiated. As tolerance to EN improves and volume of delivery increases, PN should be tapered to avoid overfeeding. (Conditional (weak) “We suggest”Very low)
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PN should be stopped when the EN provides >60% of energy and protein goals. (Conditional (weak) “We suggest”Very low)
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End-of-Life
The decision to place a gastrostomy tube in an end-of-life situation should be determined by patient autonomy and the wishes of that patient and their family, even though the nutrition therapy may do little to change traditional clinical outcomes. (Conditional (weak) “We suggest”Very low)
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Regardless of prognosis, placement of a gastrostomy device should be based on whether achieving enteral access and initiating EN successfully meet the goals of the patient and/or their family. Percutaneous gastrostomy placement should be considered even if the only benefit is to provide improvement in the quality of life for the family, increased ease of providing nutrition, hydration, and medications, or to facilitate transfer out of the hospital setting to a facility closer to home. (Conditional (weak) “We suggest”Very low)
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The clinician is not obligated to provide hydration and nutrition therapy in end-of-life situations. The decision to initiate nutrition therapy is no different than the decision to stop therapy once it has started (thus, clinicians are not obligated to provide therapy that is unwarranted). (Conditional (weak) “We suggest”Very low)
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If requested, nutrition therapy in end-stage malignancy should be provided by the enteral route. (Conditional (weak) “We suggest”Very low)
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Use of PN in this setting may cause net harm and should be highly or aggressively discouraged. (Conditional (weak) “We suggest”Very low)
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The clinician who has ethical concerns of his own in a difficult end-of-life situation should excuse himself from the case, as long as he can transfer care to an equally qualified and willing health-care provider. (Conditional (weak) “We suggest”Very low)
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Recommendation Grading
Overview
Title
Nutrition Therapy in the Adult Hospitalized Patient
Authoring Organization
American College of Gastroenterology
Publication Month/Year
March 1, 2016
Last Updated Month/Year
June 1, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
It provides recommendations regarding nutrition therapy in the adult hospitalized patients compiled by the group of experts on the guideline committee
Target Patient Population
Adult hospitalized patient, unable to sustain volitional intake, expected to remain in the hospital for >3 days
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D000066888 - Diet, Food, and Nutrition, D004750 - Enteral Nutrition, D044623 - Nutrition Therapy, D009751 - Nutritional Requirements, D018529 - Nutritional Support, D010288 - Parenteral Nutrition
Keywords
nutrition, nutritionist, enteral nutrition, parenteral nutrition, GI endoscopy
Source Citation
McClave, Stephen A MD; DiBaise, John K MD, FACG; Mullin, Gerard E MD, FACG; Martindale, Robert G MD, PhD. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient, American Journal of Gastroenterology: March 2016 - Volume 111 - Issue 3 - p 315-334 doi: 10.1038/ajg.2016.28