Managing Intolerance based on Critical Care Nutrition Guidelines

u Hold

SUMMARY OF SELECT GUIDELINES

USE OF
PROTOCOLS

Use of enteral feeding protocols increases the overall

percentage of goal calories provided and should be
implemented. Section D3 (Grade C)

GASTRIC
RESIDUALs

Patients should be monitored for tolerance of EN and

inappropriate cessation of EN should be avoided. (Grade:
E) Holding EN for gastric residual volumes <500 mL in
the absence of other signs of intolerance should be
avoided. Section D2 (Grade B)

Are TF gastric
residuals 500 mL?

TF and reassess to determine cause.

If resuming feeding is feasible, consider all measures to

reduce risk of aspiration:
Elevate head of bed (HOB) at 30 45
Prokinetic agents where feasible
Post-pyloric tube placement
Continuous infusion vs. bolus
Reduce rate to previously tolerated level
Chlorhexidine mouthwash twice a day
D4

Yes

D2

NO
u If

The following measures have been shown to reduce risk

of aspiration: Section D4
Elevate the head of bed 30 - 45. (Grade C)

RISK OF
ASPIRATION

Switch to continuous infusion for high risk-patients or

those intolerant to intermittent or bolus gastric feeding.
(Grade D)

Is patient
complaining of pain and/or
distension, or do physical exam or
x-rays indicate intolerance?
D2

Yes

feasible, return residuals < 250 mL3.

u Continue

to advance TF rate towards goal rate or

maintain goal rate.

NO

u Continue standard precautions to reduce risk of aspiration:

Elevate HOB at 30 45
Continue to follow residuals and monitor
D2, D3

Initiate agents to promote motility such as prokinetic

drugs or narcotic antagonists where clinically feasible.
(Grade C)

Consider formula that

contains small peptides
or soluble fiber

Consider post-pyloric tube placement. (Grade C)

Development of diarrhea associated with enteral tube
feedings warrants further evaluation for etiology.

DIARRHEA

Section D6 (Grade: E)

If there is evidence of diarrhea, soluble fiber-containing

or small peptide formulations may be utilized.

Is patient
having diarrhea?
(>300 mL per day or >4 loose
stools/day)2
D6, E4

Section E4 (Grade E)
NO
1

 uidelines summarized from McClave SA, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition
G
Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. 2009;33(3):277316.

Bliss D, Guenter P, Settle RG. Defining And Reporting Diarrhea In Tube-Fed Patients What A Mess! Am J Clin Nutr. 1992;
55: 753-9.

Juve-Udina ME et al. To return or to discard? Randomised trial on gastric residual volume management. Intensive &
Critical Care Nursing 2009;25(5):258-67.

A.S.P.E.N. Enteral Nutrition Practice Recommendations. JPEN. 2009;33 (2):122-167.

 elegge M, Rhodes B, Storm H et al. Malabsorption Index And Its Application To Appropriate Tube Feeding. 25th A.S.P.E.N.
D
Clinical Congress 2001;A0094.

Continue TF as ordered and

continue to monitor stool pattern

Yes

u Address

use of:
Hyperosmolar medications
(e.g. sorbitol)
Antibiotics
Aseptic formula technique4
Culture for C. difficile or
other infectious etiology
E4

u Utilize

Malabsorption Index5

www.NestleHealthScience.us 1-800-422-ASK2 (2752)

All trademarks are owned by Socit des Produits Nestl S.A.,
Vevey, Switzerland or used with permission.
2013 Nestl

NestL
Products

to consider:
u Peptamen

Family

u IMPACT

PEPTIDE 1.5

un
 utrisource

fiber

NEST-10926-0113

Critical Care and Surgery

Nutritional Support Algorithms

Enteral Nutrition Decision and Calculation of Needs based on Critical Care Nutrition Guidelines
SUMMARY OF SELECT GUIDELINES
USE OF
PROTOCOLS

Use of enteral feeding protocols increases the overall percentage of goal calories provided and
should be implemented. Section D3 (Grade C)

ROUTE

EN is the preferred route of feeding over parenternal nutrition (PN) for the critically ill patient who
requires nutrition support therapy. Section A3 (Grade B)

ACCESS

Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be
fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing
intolerance to gastric feeding. Section A7 (Grade C)

STABILITY

In the setting of hemodynamic compromise, EN should be withheld until the patient is fully
resuscitated and/or stable. Section A5 (Grade: E)

HOLD PN

In the patient with no evidence of protein-calorie malnutrition prior to critical illness, use of PN
should be reserved and initiated only after the first 7 days of hospitalization (when EN is not
available). Section B1 (Grade E)

INITIATE PN

If there is evidence of protein-caloric malnutrition on admission and EN is not feasible, it is

appropriate to initiate PN as soon as possible following admission and adequate resuscitation.

CALORIES

Energy requirements may be calculated by simplistic formulas (25-30 kcal/kg/d), predictive

equations or with indirect calorimetry. Section C1 (Grade E)

PROTEIN

In patients with body mass index (BMI) <30, protein requirements should be in the range of 1.2-2.0 g/
kg actual body weight (ABW), (NPC:N ratio 70:1 100:1), and may likely be even higher in burn or
multi-trauma patients. Section C4 (Grade E)
Patients receiving hemodialysis or continuous renal replacement therapy (CRRT) should receive
increased protein, up to a maximum of 2.5g/kg/d. Protein should not be restricted in patients with
renal insufficiency as a means to avoid or delay initiation of dialysis therapy. Section I2 (Grade C)

OBESITY
immune
modulating

Admission to ICU Expected stay > 23 days

Is patient
able to
eat?

NO

Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine,

nucleic acid, omega-3 fatty acids, and antioxidants) should be used for the appropriate patient
population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on
mechanical ventilation), being cautious in patients with severe sepsis. Section E1 Grade A: SICU;
Grade B: MICU

GLUTAMINE

The addition of enteral glutamine to an EN regimen (not already containing supplemental glutamine)
should be considered in burn, trauma and mixed ICU patients. The glutamine powder, mixed with
water, should be given in divided doses to provide 0.3 0.5 g/kg/d. Section F3 (Grade B)

FIBER

Soluble fiber may be beneficial for the fully resuscitated, hemodynamically stable critically ill patient
receiving EN who develops diarrhea. Insoluble fiber should be avoided in all critically ill patients.
Both soluble and insoluble fiber should be avoided in patients at high risk for bowel ischemia or
severe dysmotility. Section F4 (Grade C)

Is patient
hemodynamically
stable?
u MAP 65 mm

YES

Hg*2

A5

Is EN
contraindicated?

3,4

NO

YES

u diffuse

peritonitis u obstruction
u ischemia u <100 cm remaining
jejunum u inability to
gain access u severe
GI bleed

oral diet

YES
NO

Initiate PN

Monitor for
refeeding syndrome

CALCULATION OF CALORIE
AND PROTEIN NEEDS
calories contributed by propofol

if BMI <30

u 25 30 kcal/kg
u 1.2 2.0 g protein/kg ABW

if BMI >30

u 22 25
u 2.0 g

if BMI >40

u 22 25 kcal/kg IBW
u 1114 kcal/kg ABW
u 2.5 g protein/kg IBW

C1, C4

Level of Evidence:
I Large, randomized trials
with clear-cut results
II Small, randomized trials
with uncertain results
III Non-randomized,
contemporaneous controls
IV Non-randomized, historical
controls
V Case series, uncontrolled
studies, and expert opinion

Does patient
have pre-existing
malnutrition?**
B2

NO

u Consider

Grade of Recommendation
supported by:
A At least two Level I
investigations
B One Level I investigation
C Level II investigations only
D At least two Level III
investigations
E Level IV or Level V evidence

YES

A3

Do Not Feed

Section B2 (Grade C)

For all classes of obesity where BMI is >30, the goal of the EN regimen should not exceed 60-70% of
target energy requirements or 22-25 kcal/kg ideal body weight). Protein should be provided in a
range of 2.0 g/kg (BMI 31-40) to 2.5 g/kg (BMI >40) ideal body weight (IBW). Section C5 (Grade D)

C5

C5

kcal/kg IBW
protein/kg IBW

SELECT EN FORMULA
u Evaluate

Place enteral
feeding tube
u EN

is the preferred
route of feeding over PN
A3, A7

NestL
Formulas

to consider:
u Impact

Family

YES

NO

Does use of
EN become possible
within 7 days?
B1, B2

ADDITIONAL
NUTRITIONAL
INTERVENTIONS
to consider:
u Arginaid

E1

u Peptamen Family

u GLUTASOLVE

u Vivonex

u BENEPROTEIN C4,

Family

E1, F3

need for adjunctive therapy

* Mean Arterial Pressure ** >10% unintentional loss of usual body weight (UBW) in the past 6 months.
1
Guidelines summarized from McClave SA, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:
Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. 2009;33(3):277316.
2
Dellinger RP, Levy M, Carlet JM et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008. Int Care Med.
2008;34:17-60.
3
Marian M et al. Overview of Enteral Nutrition. In: Gottschlich MM ed. The A.S.P.E.N. Nutrition Support Core Curriculum. 189-191.
4
Scolapio JS. A Review of the Trends in the Use of Enteral and Parenteral Nutrition Support. J Clin Gastroenterol 2004;38:403-407.

u nUTRIsource

FIBER F4

F3