J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Review

Volume 5, Number 1, February 2013, pages 1-11

Enteral Nutrition in Critical Care

**Table 1.** Summary of Recommendations for Enteral Nutrition in Critically Ill Patients
Summary of recommendations for enteral nutrition in critically ill patients	Level of evidence
1. Enteral nutrition is associated with an improvement of nutritional variables, a lower incidence of infections and a reduced length of hospital stay.	A
2. Critically ill patients who cannot be fed orally for a period of more than three days must receive specialized nutritional support.	C
3. Enteral nutrition is preferable to parenteral nutrition.	B
4. Enteral nutrition should be started within the first 24 - 48 hours of admission.	A
5. Enteral nutrition should provide 25 to 30 kcal/kg/day.	C
6. The feedings should be advanced toward goal over the next 48 - 72 hours.	C
7. The enteral nutrition must be deferred until the patient is hemodynamically stable.	C
8. In intensive care unit patients, neither the presence nor absence of bowel sounds and evidence of passage of flatus and stool is required for initiation of enteral nutrition.	B

Table 1. Summary of Recommendations for Enteral Nutrition in Critically Ill Patients

Summary of recommendations for enteral nutrition in critically ill patients

Level of evidence

1. Enteral nutrition is associated with an improvement of nutritional variables, a lower incidence of infections and a reduced length of hospital stay.

2. Critically ill patients who cannot be fed orally for a period of more than three days must receive specialized nutritional support.

3. Enteral nutrition is preferable to parenteral nutrition.

4. Enteral nutrition should be started within the first 24 - 48 hours of admission.

5. Enteral nutrition should provide 25 to 30 kcal/kg/day.

6. The feedings should be advanced toward goal over the next 48 - 72 hours.

7. The enteral nutrition must be deferred until the patient is hemodynamically stable.

8. In intensive care unit patients, neither the presence nor absence of bowel sounds and evidence of passage of flatus and stool is required for initiation of enteral nutrition.

**Table 2.** Contraindications to Enteral Nutrition
Absolute contraindications to enteral nutrition:

1. Diseases associated with ileus: multiple trauma with significant retroperitoneal hematoma and peritonitis
2. Intestinal obstruction
3. Active gastrointestinal hemorrhage
4. Hemodynamic instability: enteral nutrition in an ischemic small bowel can worsen the ischemia and lead to necrosis and bacterial overgrowth

Relative contraindications, use of a mixed nutritional support:

1. Diverticular abscess
2. Early stages of Short bowel syndrome
3. Severe malabsorption
4. Small bowel fistulas, depending on the flow rate and localization
5. Need for early nutritional support and full enteral feeding impossible:
Severely malnourished patients with severe hypercatabolism
Patients in whom an appropriate intestinal approach cannot be carried out or who do not tolerate the full requirements

Table 2. Contraindications to Enteral Nutrition

Absolute contraindications to enteral nutrition:

1. Diseases associated with ileus: multiple trauma with significant retroperitoneal hematoma and peritonitis

2. Intestinal obstruction

3. Active gastrointestinal hemorrhage

4. Hemodynamic instability: enteral nutrition in an ischemic small bowel can worsen the ischemia and lead to necrosis and bacterial overgrowth

Relative contraindications, use of a mixed nutritional support:

1. Diverticular abscess

2. Early stages of Short bowel syndrome

3. Severe malabsorption

4. Small bowel fistulas, depending on the flow rate and localization

5. Need for early nutritional support and full enteral feeding impossible:

Severely malnourished patients with severe hypercatabolism

Patients in whom an appropriate intestinal approach cannot be carried out or who do not tolerate the full requirements

**Table 3.** Complications of Enteral Nutrition
Mechanic

1. Erosion and/or necrosis and/or infection at the contact zones
2. Pharyngeal, esophageal and/or tracheobronchial perforation and stenosis
3. Tracheoesophageal fistula
4. Malpositioning and removal of the probe
5. Obstruction and tethering of the probe
6. Intraperitoneal leakage through osteotomy site
7. Leakage of the formulation
8. Pulmonary aspiration
9. Hemorrhage

Metabolic

1. Hypertonic dehydration
2. Hyperosmolarity
3. Nonketotic hyperosmolar coma
4. Hyper/hypoglycemia
5. Dyselectrolytemia
6. Hyperhydration
7. Dumping syndrome
8. Refeeding syndrome
9. Hypercapnia

Infectious

1. Sinusitis and otitis
2. Aspiration pneumonia
3. Necrotizing peritonitis and enteritis
4. Dietary contamination

Gastrointestinal

1. Increased gastric residual volume
2. Constipation
3. Abdominal fullness and distention
4. Vomiting and regurgitation
5. Diarrhea
6. Hypertransaminasemia, hepatomegaly

Table 3. Complications of Enteral Nutrition

Mechanic

1. Erosion and/or necrosis and/or infection at the contact zones

2. Pharyngeal, esophageal and/or tracheobronchial perforation and stenosis

3. Tracheoesophageal fistula

4. Malpositioning and removal of the probe

5. Obstruction and tethering of the probe

6. Intraperitoneal leakage through osteotomy site

7. Leakage of the formulation

8. Pulmonary aspiration

9. Hemorrhage

Metabolic

1. Hypertonic dehydration

2. Hyperosmolarity

3. Nonketotic hyperosmolar coma

4. Hyper/hypoglycemia

5. Dyselectrolytemia

6. Hyperhydration

7. Dumping syndrome

8. Refeeding syndrome

9. Hypercapnia

Infectious

1. Sinusitis and otitis

2. Aspiration pneumonia

3. Necrotizing peritonitis and enteritis

4. Dietary contamination

Gastrointestinal

1. Increased gastric residual volume

2. Constipation

3. Abdominal fullness and distention

4. Vomiting and regurgitation

5. Diarrhea

6. Hypertransaminasemia, hepatomegaly