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ARTICLE IN PRESS
Clinical Nutrition (2006) 25, 210–223
http://intl.elsevierhealth.com/journals/clnu
ESPEN GUIDELINES
ESPEN Guidelines on Enteral Nutrition:
Intensive care$
a, b c d e
K.G. Kreymann , M.M. Berger , N.E.P. Deutz , M. Hiesmayr , P. Jolliet ,
f g h i
G. Kazandjiev , G. Nitenberg , G. van den Berghe , J. Wernerman,
DGEM:$$C.Ebner, W. Hartl, C. Heymann, C. Spies
aDepartment of Intensive Care Medicine, University Hospital Eppendorf, Hamburg, Germany
bSoins Intensifs Chirurgicaux et Centre des Bruˆles, Centre Hospitalier Universitaire Vaudois (CHUV)-BH
08.660, Lausanne, Switzerland
cDepartment of Surgery, Maastricht University, Maastricht, The Netherlands
dDepartment of Anaesthesiology and Intensive Care, Medical University of Vienna, Vienna, Austria
e
Department of Intensive Care, University Hospital Geneva, Geneva, Switzerland
f
Department of Anaesthesiology and Intensive Care, Military Medical University, Sofia, Bulgaria
gDepartment of Anaesthesia, Intensive Care and Infectious Diseases, Institut Gustave-Roussy,
Villejuif, France
h
Department of Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, Belgium
i
Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge,
Stockholm, Sweden
Received 20 January 2006; accepted 20 January 2006
KEYWORDS Summary Enteral nutrition (EN) via tube feeding is, today, the preferred way of
Guideline; feeding the critically ill patient and an important means of counteracting for the
Clinical practice; catabolic state induced by severe diseases. These guidelines are intended to give
Evidence-based; evidence-based recommendations for the use of EN in patients who have a
Enteral nutrition; complicated course during their ICU stay, focusing particularly on those who develop
Tube feeding; a severe inflammatory response, i.e. patients who have failure of at least one organ
Oral nutritional sup- during their ICU stay.
plements; These guidelines were developed by an interdisciplinary expert group in
Parenteral nutrition; accordance with officially accepted standards and are based on all relevant publica-
Immune-modulating tions since 1985. They were discussed and accepted in a consensus conference.
nutrition; ENshouldbegiventoallICUpatientswhoarenotexpectedtobetakingafulloral
diet within three days. It should have begun during the first 24h using a standard
$ 69 70
For further information on methodology see Schu¨tz et al. For further information on definition of terms see Lochs et al.
Corresponding author. Tel.: +4940428037010; fax: +4940428037020.
E-mail address: kreymann@uke.uni-hamburg.de (K.G. Kreymann).
$$The authors of the DGEM (German Society for Nutritional Medicine) guidelines on enteral nutrition in intensive care are
acknowledged for their contribution to this article.
0261-5614/$-see front matter & 2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2006.01.021
ARTICLE IN PRESS
ESPEN Guidelines on Enteral Nutrition 211
Intensive care; high-protein formula. During the acute and initial phases of critical illness an
Undernutrition; exogenous energy supply in excess of 20–25kcal/kg BW/day should be avoided,
Malnutrition; whereas, during recovery, the aim should be to provide values of 25–30 totalkcal/
Catabolism; kgBW/day.Supplementaryparenteralnutrition remains a reserve tool and should be
Prognosis; given only to those patients who do not reach their target nutrient intake on EN
Outcome alone.
There is no general indication for immune-modulating formulae in patients with
severe illness or sepsis and an APACHE II Score 415. Glutamine should be
supplemented in patients suffering from burns or trauma.
The full version of this article is available at www.espen.org.
&2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.
Summary of statements: Intensive care
Subject Recommendations Grade69 Number
Indications All patients who are not expected to be on a full oral C1
diet within 3 days should receive enteral nutrition
(EN).
Application There are no data showing improvement in relevant 2
outcome parameters using early EN in critically ill
patients.
Nevertheless, the expert committee recommends C2
that haemodynamically stable critically ill patients
whohaveafunctioning gastrointestinal tract should
befedearly (o24h)using an appropriate amount of
feed.
No general amount can be recommended as EN 3
therapy has to be adjusted to the progression/
course of the disease and to gut tolerance.
Exogenous energy supply:
during the acute and initial phase of critical C3
illness: in excess of 20–25kcal/kg BW/day may be
associated with a less favourable outcome.
during the anabolic recovery phase, the aim C3
should be to provide 25–30kcal/kg BW/day.
Patients with a severe undernutrition should receive C9
EN up 25–30 totalkcal/kg BW/day. If these target
values are not reached supplementary parenteral
nutrition should be given.
Consider i.v. administration of metoclopramide or C6
erythromycin in patients with intolerance to enteral
feeding (e.g. with high gastric residuals).
Route Use EN in patients who can be fed via the enteral C7
route.
There is no significant difference in the efficacy of C4
jejunal versus gastric feeding in critically ill
patients.
Avoid additional parenteral nutrition in patients who A8
tolerate EN and can be fed approximately to the
target values.
ARTICLE IN PRESS
212 K.G. Kreymann et al.
Use supplemental parenteral nutrition in patients C8
whocannotbefedsufficiently via the enteral route.
Consider careful parenteral nutrition in patients C8
intolerant to EN at a level equal to but not
exceeding the nutritional needs of the patient.
Type of formula Whole protein formulae are appropriate in most C5
patients because no clinical advantage of peptide-
based formulae could be shown.
Immune-modulating formulae (formulae enriched
with arginine, nucleotides and x-3 fatty acids) are
superior to standard enteral formulae:
in elective upper GI surgical patients (see A 10.1
guidelines surgery).
in patients with a mild sepsis (APACHE IIo15). B 10.2
in patients with severe sepsis, however, B 10.2
immune-modulating formulae may be harmful and
are therefore not recommended.
in patients with trauma (see guidelines surgery) A 10.3
in patients with ARDS (formulae containing o-3 B 10.5
fatty acids and antioxidants).
No recommendation for immune-modulating 10.4
formulae can be given for burned patients due to
insufficient data.
In burned patients trace elements (Cu, Se and Zn) A 10.4
should be supplemented in a higher than standard
dose.
ICU patients with very severe illness who do not B 10.6
tolerate more than 700ml enteral formulae per day
should not receive an immune-modulating formula
enriched with arginine, nucleotides and o-3 fatty
acids.
Glutamine should be added to standard enteral
formula in
burned patients A 12.1
trauma patients A 12.1
There are not sufficient data to support glutamine 12.2
supplementation in surgical or heterogenous
critically ill patients.
Grade: Grade of recommendation; Number: refers to statement number within the text.
Preliminary remarks ered in review articles vary widely in terms of
diagnosis, severity of disease, metabolic derange-
Patients ments, therapeutic procedures, and gastrointest-
inal function.
Amajormethodological problem in this chapter are Overlap with other chapters concerning
the terms ‘‘ICU patients’’ and ‘‘critically ill’’ as they patients in need of intensive care (surgery,
do not refer to homogenous populations. Patients trauma and transplant patients) is therefore in-
included in original trials as well as those consid- evitable.
ARTICLE IN PRESS
ESPEN Guidelines on Enteral Nutrition 213
In order to minimise overlap, only trials that met Owingtoincreasedsubstrate metabolism, under-
the following criteria were evaluated: nutrition is more likely to develop in critical illness
than in uncomplicated starvation or in less acute
The severity of disease could be deduced from illness. A Scandinavian study1 showed that patients
the available data. onglucosetreatmentonly(250–300g)overaperiod
The patients included in the study could not be of 14 days, had a 10 times higher mortality rate
explicitly assigned to categories discussed in than patients on continuous total parenteral nutri-
other chapters (e.g. patients undergoing elec- tion.
tive surgery). These data imply that, with an inadequate oral
The patients were not routinely managed in intake, undernutrition is likely to develop within
ICUs for a short term. 8–12 days following surgery. However, most of the
trials studying early EN in various patient groups
The recommendations are thus focused on (see below) have compared a regimen of early EN
patients who develop an intense inflammatory with standard care and oral intake or with late EN
response with failure of at least one organ or after 4–6 days. As most of these studies have shown
patients with an acute illness necessitating support a positive effect of early EN, we have come to the
of their organ function during their ICU stay. conclusion that all patients who are not expected
The results were then classified into the follow- be on an full oral diet within three days should
ing categories: surgical, medical, trauma, trans- receive nutritional support.
plant, burns and sepsis.
2. Is early EN (o24–48h after admission to
Terminology ICU) superior to delayed EN in the critically
As oral intake is almost always impossible in these ill?
patients, in this chapter the term ‘‘EN’’ is confined There are no data showing improvement in
to tube feeding exclusively without regard to any relevant outcome parameters using early EN in
kind of oral nutritional supplement. critically ill patients. The expert committee,
however favours the view that critically ill
Outcome measures patients, who are haemodynamically stable
and have a functioning gastrointestinal tract,
ICU mortality, 28-day mortality and hospital mortal- should be fed early (o24h), if possible, using an
ity as well as length of stay in ICU or hospital were appropriate amount of feed (C).
listed as primary outcome measures. Data on long- Comment: Only one study evaluating early EN was
term survival would have been useful but were, performed specifically in critically ill patients.2
unfortunately, not given in any of the studies. As Most studies were performed after trauma or
post-ICU mortality is high, 6-month mortality was abdominal surgery and these were summarised in
also considered a relevant outcome measure. 2 meta-analyses3,4 and 2 systematic reviews.5,6
The rate of septic complications was listed as a
secondary outcome measure. Particular emphasis
was placed on identifying nutrition-related compli- Meta-analyses and reviews
cations, e.g. infections, when such information was A meta-analysis of 15 randomised controlled trials4
available. evaluated the effects of early EN in adult patients
after surgery, trauma, head injury, burns or suffer-
ing from acute medical conditions. Early EN was
Indications for and implementation of associated with a significant reduction in infectious
enteral nutrition (EN) complications and length of stay. Owing to the
heterogeneity between the studies however, the
1. When is EN indicated in ICU patients? results of this meta-analysis have to be interpreted
with caution.
Zaloga,6 in a systematic review of 19 studies of
All patients who are not expected to be on a full early EN, found a positive effect of early EN on
oral diet within 3 days should receive EN (C). survival rate in one study. In 15 trials a positive
Comment:Studiesinvestigating the maximum time impact on length of treatment, the rate of septic
ICUpatients can survive without nutritional support and other complications, and on other secondary
would be considered unethical and are therefore parameters was found. They concluded that there
not available. waslevel 1 evidence to support the use of early EN.
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