Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.
OBJECTIVE
To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.


METHODS
We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.


RESULTS
We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.


CONCLUSIONS
We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.
Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia. annika.reintam.blaser@ut.ee.|Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland. annika.reintam.blaser@ut.ee.
Annika
A
Reintam Blaser
Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.|Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
Joel
J
Starkopf
Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
Waleed
W
Alhazzani
Services of Adult Intensive Care Medicine and Burns, Lausanne University Hospital, Lausanne, Switzerland.
Mette M
MM
Berger
Department of Intensive Care Medicine, University Hospital Leuven, Louvain, Belgium.
Michael P
MP
Casaer
Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
Adam M
AM
Deane
Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
Sonja
S
Fruhwald
Klinische Abteilung für Herz-Thorax-Gefäßchirurgische Anästhesie & Intensivmedizin, Medizinische Universität Wien, Vienna, Austria.
Michael
M
Hiesmayr
Intensive Care Unit, Hôpital Pasteur 2, University of Nice, Nice, France.
Carole
C
Ichai
Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland.
Stephan M
SM
Jakob
Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín de La Plata, Buenos Aires, Argentina.
Cecilia I
CI
Loudet
Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium.
Manu L N G
ML
Malbrain
Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain.
Juan C
JC
Montejo González
Anesthesiology and Perioperative Care Medicine Department, Hôpital Beaujon APHP, Clichy, France.
Catherine
C
Paugam-Burtz
Department of Surgery/IntensiveCare Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.
Martijn
M
Poeze
Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
Jean-Charles
JC
Preiser
Intensive Care Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.|Anesthesia and Intensive Care Division, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Pierre
P
Singer
Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands.
Arthur R H
AR
van Zanten
Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
Jan
J
De Waele
Department of Intensive Care Medicine, Division of Immunobiology and Transplantation, King's College London, King's College Hospital, London, UK.
Julia
J
Wendon
Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden.
Jan
J
Wernerman
Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK.
Tony
T
Whitehouse
Medical Intensive Care Unit, University Hospital Leuven, Leuven, Belgium.
Alexander
A
Wilmer
Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
Heleen M
HM
Oudemans-van Straaten
D015331:Cohort Studies; D016638:Critical Illness / Q000628:therapy*; D004750:Enteral Nutrition / Q000379:methods* / Q000592:standards*; D019317:Evidence-Based Medicine; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D013997:Time Factors
Abdominal problems; Contraindications; Delay of enteral nutrition; Early enteral nutrition; GI symptoms; Parenteral nutrition