GLN-004 Nutrition in Critically Ill Population

Document N0
Clinical Practice Guideline CPG-MED-004

Nutrition Support Therapy in Critically Ill Population Version N0
1
Review Date Issue Date Effective Date Validity Date
MAR-APR 2021 25 March 2021 25 April 2021 24 March 2023
 Corporate  Hospital  Multidisciplinary  Departmental
1. Introduction and Background
1.1 ICU and major surgery patients can lose up to 1 kilogram of Lean Body Mass daily
1.2 There was a prospective, multi-institutional study in 201 units from 26 countries. It
included 3390 mechanically ventilated patients who remained in the unit and received
artificial nutrition for at least 96 h. Worldwide the majority of critically ill patients fail
to receive adequate nutritional intake (74% of patients failed to meet ≥ 80% of energy
target). This rate of failure varies across geographic regions. High risk patients are less
likely to be underfed than low risk patients but still experience significant under
feeding. “The prevalence of iatrogenic underfeeding in the nutritionally 'at-risk'
critically ill patient”
1.3 Patient Assessment
1.4 Enteral nutrition
1.5 Nutrition in specific critically ill population
1.6 Total parenteral nutrition
1.7 Enteral nutrition formula composition
2. Important Definitions and Terminologies
2.1 Definition for nutrition support therapy: the provision of enteral nutrition (EN) by
enteral access device and/or parenteral nutrition (PN).
2.2 Definition for standard therapy: provision of intravenous fluids, no EN or PN, and
advancement to oral diet as tolerated.
2.3 Definition for enteral nutrition: nutrition provided through the gastrointestinal tract
via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity.”
2.4 Definition for trophic enteral nutrition: small volume of balanced enteral nutrition
insufficient for nutritional needs of patients (may also be called hypocaloric nutrition
or permissive underfeeding)
2.5 Definition for partial enteral nutrition: enteral nutrition supplemented with either
parenteral nutrition or regular food intake to fulfill nutritional needs of patient
2.6 Definition for cycling: when the PN solution is infused at a higher rate for less than
24 hours, followed by several hours without a PN infusion. Cycling can be initiated
when a patient has been stable on PN for at least one week. Generally the time off PN
is increased and the infusion rate is increased to compensate, so that the total daily
volume of PN is unchanged.
CPG-MED-004 Nutrition Support Therapy in Critically Ill Population Document Version: 1 Page 1 of 27
3. Summary of Clinical Guidelines
3.1 Patient Assessment
3.2 Enteral Nutrition
3.2.1 Indications American College of Gastroenterology (ACG) 2016 clinical guideline for
enteral nutrition therapy in the adult hospitalized patient.
3.2.1.1 Enteral nutrition should be initiated promptly in hospitalized patient at
high nutritional risk (ACG Conditional recommendation, Low-quality
evidence)
3.2.1.2 Enteral nutrition should be used over parenteral nutrition in hospitalized
patients requiring nutrition therapy and not having contraindication to
luminal nutrients (ACG Conditional recommendation, Low-quality
evidence)
3.2.1.3 Consider not using enteral nutrition or parenteral nutrition for
hospitalized patients at low nutritional risk, who appear well-nourished,
and who are expected to resume volitional intake within 5-7 days
following admission (ACG Conditional recommendation, Very low-
quality evidence)
3.2.1.4 For patients at high nutritional risk
3.2.1.5 With functional gastrointestinal tract of sufficient absorptive capacity
and length and partial or total inability to take nutrients orally
3.2.1.6 Who cannot meet nutrition requirements by oral intake
3.2.1.7 Who are malnourished or at risk of becoming malnourished
3.2.2 Contra- 3.2.2.1 Nonoperative mechanical GI obstruction
indications 3.2.2.2 Intractable vomiting/diarrhea refractory to medical management
3.2.2.3 Severe short-bowel syndrome (< 100 cm small bowel remaining)
3.2.2.4 Paralytic ileus
3.2.2.5 Distal high-output fistulas (too distal to bypass with feeding tube)
3.2.2.6 Severe GI bleed
3.2.2.7 Severe GI malabsorption (eg, enteral nutrition failed as evidenced by
progressive deterioration in nutritional status)
3.2.2.8 Inability to gain access to GI tract
3.2.2.9 Need is expected for 5–7 days for malnourished adult patients or 7–9
days if adequately nourished
3.2.2.10 Aggressive intervention not warranted or not desired
3.2.3 Dosing The A.S.P.E.N. guidelines recommend that, in order to derive clinical benefit
from EEN, achievement of greater than 50% to 65% of goal calories during
the first week of hospitalization is desired.
3.2.4 Access device
Figure 2 Enteral Access Decision Tree

Orogastric or nasogastric tube
3.2.4.1 Recommended when initiating enteral nutrition support
3.2.4.2 Feeding tube with distal tip in stomach
3.2.4.3 Appropriate for patients with functional stomach, normal gastric
emptying and no obstruction or fistula
3.2.4.4 Appropriate for short-term access for hospitalized patients
3.2.4.5 Usually placed at bedside
3.2.4.6 Allows for continuous or bolus feeds nasoenteric or postpyloric tube
feeding tube with distal tip past stomach into duodenum or jejunum
3.2.4.7 Use postpyloric or deep jejunal tubes in patients intolerant of gastric
feeds or at high risk of aspiration appropriate for patients with gastric
outlet obstruction, gastroparesis, pancreatitis, or known reflux and
aspiration of gastric contents
3.2.4.8 Appropriate for patients with gastric outlet
obstruction, gastroparesis, pancreatitis, or known reflux and aspiration
of gastric contents
3.2.4.9 Provide naso-enteric feeds continuously, not in bolus form
3.2.4.10 Types of long-term access devices
3.2.4.10.1 percutaneous endoscopic gastrostomy tube
3.2.4.10.2 percutaneous endoscopic jejunostomy tube
3.2.4.10.3 PEG tube with jejunal extension to allow for simultaneous
gastric decompression and jejunal feeding
Consider percutaneous tube via gastric or jejunal route in patients requiring
feeding for > 4 weeks
3.2.5 Timing of Society of Critical Care Medicine/American Society for Parenteral and Enteral
initiation Nutrition (SCCM/ASPEN) 2016 guidelines
3.2.5.1 We recommend that nutrition support therapy in the form of early EN

be initiated within 24–48 hours in the critically ill patient who is unable
to maintain volitional intake.
3.2.5.2 We suggest the use of EN over PN in critically ill patients who require
nutrition support therapy.
3.2.5.3 Based on expert consensus, we suggest that patients who are at low
nutrition risk with normal baseline nutrition status and low disease
severity (eg, NRS 2002 ≤3 or NUTRIC score ≤5) who cannot maintain
volitional intake do not require specialized nutrition therapy over the
first week of hospitalization in the ICU.
3.2.5.4 Based on expert consensus, we suggest that patients who are at high
nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5, without
interleukin 6) or severely malnourished should be advanced toward goal
as quickly as tolerated over 24–48 hours while monitoring for refeeding
syndrome.
3.2.5.5 Efforts to provide >80% of estimated or calculated goal energy and
protein within 48–72 hours should be made to achieve the clinical
benefit of EN over the first week of hospitalization.
3.2.5.6 Specialized nutrition therapy during first week not required in critically
ill patients at low nutrition risk with normal baseline nutrition and
disease severity (NRS 2002 ≤ 3 or NUTRIC score ≤ 5) who cannot
maintain volitional intake
3.2.6 Evaluation of Society of Critical Care Medicine/American Society for Parenteral and Enteral
malnutrition Nutrition (SCCM/ASPEN) 2016 guidelines for provision and assessment of
nutrition support therapy in adult critically ill patients suggest
3.2.6.1 Determining nutrition risk for all patients admitted to intensive care unit
who are anticipated to be undernourished with volitional intake
3.2.6.2 Nutritional Risk Screening (NRS 2002) or NUTRIC score to determine
nutrition status and disease severity
3.2.6.3 Assessing comorbid conditions, function of gastrointestinal tract, and
aspiration risk
Low nutrition risk NUTRIC ❑Withhold exclusive parenteral nutrition for
score ≤ 5 first 7 days after ICU admission.
High nutrition risk NUTRIC ❑Consider initiating parenteral nutrition as
score > 5 or severely soon as possible after ICU admission if enteral
malnourished nutrition not possible.
3.2.7 General energy

recommendations 3.2.7.1Protein 1.2-2 g/kg actual body weight/day
3.2.7.2 Fiber 10-20 g fermentable soluble fiber in hemodynamically
stable medical ICU and surgical ICU patients receiving
standard enteral nutrition and who have diarrhea
3.2.7.3 Energy 3.2.7.3.1 Safe starting point for most critically ill patients is
approximately 8 to 10 kcal/kg per day.
3.2.7.3.2 Attempting to achieve a goal of 25 to 30 kcal/kg
of dosing weight per day after one week is reasonable for
most stable patients.
3.2.7.3.3 A goal of 35 kcal/kg per day is an acceptable goal
if weight gain is desired in a relatively stable patient;
weight gain should not be attempted until the patient is
stable and in a lower inflammatory state.
3.2.7.4 Dosing Underweight
weight [BMI] <18.5 kg/m2, use the current weight as the initial
dosing weight.
Normal weight
BMI 18.5 to 24.9 kg/m2 or overweight BMI 25 to 29.9
kg/m2, use the current weight as the initial dosing weight
Obese
BMI ≥30 kg/m2,
dosing weight = IBW + 0.4 (ABW - IBW)
3.2.8 Calculation of 3.2.8.1 Select formula for this patient.
Enteral Nutrition Example: Standard 1.0 kcal/mL formula
Prescription: 3.2.8.2 Determine required kcal/day.
Adult Patient Example: Patient needs 2000 kcal/day
3.2.8.3 Divide total number of kcal required by kcal/mL to determine mL per
day needed.
Example: 2000 kcal needed * 1.0 kcal/mL = 2000 mL/day
3.2.8.4 To determine protein dose, multiply daily formula in mL by grams of
protein/L
Example: 2000 mL/day *44 g/L= 88 g/day protein
3.2.8.5 Assure that this volume of the selected EN formula will provide
adequate micronutrient dosing.
3.2.8.6 Determine required fluid in mL/day. Multiply percent water in formula
times daily formula in mL to determine water contribution of EN.
3.2.8.7 Subtract formula water from total fluid requirements to determine
water flushes.
Example: Patient needs 2200 mL fluid. 2000mL formula *84% water
= 1680 mL water.
2200 mL - 1680 mL= 520 mL additional water.
(Some of which may already be met by IV fluid or medication
dilution.)
3.2.8.8 Determining Administration rate:
Take total mL per day of formula and divide by 24 hours to determine
continuous feeding goal rate.
Example: 2000 ml /24 hours = 83 mL/hour
3.2.9 Amount and Enteral nutrition support during first 7 days of hospitalization:
rate 3.2.9.1 may be in form of trophic feeding in patients at low nutritional risk.
3.2.9.2 may be initiated as trophic feeding and advanced to goal in first 24-48
hours in patients at high nutritional risk
3.2.9.3 10 to 30 mL/hour (for standard enteral formulations), so called "trophic"
feeding, for six days and then incrementally increased to the target rate. It is our
practice to initiate feeds at 25 to 30 percent of estimated goal rate.
3.2.10 Select 3.2.10.1High caloric requirements and/or fluid restriction - Select a more fluid
Appropriate EN restricted, energy dense formula
Formula 3.2.10.2Surgical or trauma patients - Consider use of an immunomodulating
formula
3.2.10.3Persistent diarrhea - Consider use of a mixed fiber-containing formula
3.2.10.4Suspected of malabsorption or lack of response to fiber - Consider a
small-peptide formula
3.2.10.5Renal impairment - Consider use of an electrolyte altered formula
3.2.10.6If none of the above, consider use of a standard formula
3.2.11 Monitoring Society of Critical Care Medicine/American Society for Parenteral and
Enteral Nutrition (SCCM/ASPEN) 2016 guidelines
3.2.11.1Monitoring patients daily for enteral nutrition tolerance and to avoid
terminating enteral nutrition inappropriately suggested
3.2.11.2Avoiding routine use of gastric residual volumes (GRVs) to monitor
patients in intensive care unit receiving enteral nutrition suggested; if
GRVs used, avoiding holding enteral nutrition for GRVs < 500 mL in
absence of other signs of intolerance suggested
3.2.11.3Monitoring protein adequacy by comparing amount of protein
delivered with that prescribed suggested; serum protein markers not
validated for determining protein provision adequacy in critical care
3.2.11.4Consider monitoring serum phosphate and replace phosphate
appropriately
3.2.11.5Avoiding use of traditional nutrition indicators (levels of albumin,
prealbumin, transferrin, retinol-binding protein) or surrogate markers,
which are not validated in critically ill patients
3.2.11.6European Society for Parenteral and Enteral Nutrition (ESPEN) 2009
guidelines recommend monitoring glucose to avoid hyperglycemia (>
10 mmol/L) in critically ill patients (ESPEN Grade B)
3.3 Nutrition in Special Critically Ill Population
3.3.1 Chronic kidney disease patients
KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update
3.3.1.1 In adults with CKD 1-5D or post-transplantation, biomarkers such as PCR, serum albumin, may
be considered complementary tools to assess nutritional status. However, they should not be
interpreted in isolation to assess nutritional status as they are influenced by non-nutritional
factors (OPINION).
3.3.1.2 In adults with CKD 5D on MHD, serum albumin may be used as a predictor of hospitalization
and mortality, with lower levels associated with higher risk (1A).
3.3.1.3 In adults with CKD 1-5D, we suggest that handgrip strength may be used as an indicator of
protein energy status and functional status when baseline data (prior measures) are available for
comparison (2B).
3.3.1.4 In adults with CKD with protein-energy wasting, we suggest a trial of TPN for CKD 1-5
patients (2C) and IDPN (intradialytic parenteral nutrition) for CKD 5D on MHD patients (2C),
to improve and maintain nutritional status if nutritional requirements cannot be met with
existing oral and enteral intake.
Protein restriction
CKD Patients not on Low-protein diet providing 0.55–0.60 g dietary protein/kg body
Dialysis and without weight/day, or Very low-protein diet providing 0.28–0.43 g dietary protein/kg body
Diabetes weight/day with additional keto acid/amino acid analogs to meet protein
requirements (0.55–0.60 g /kg body weight/day)
CKD Patients Not on 0.6 - 0.8 g/kg body weight per day
Dialysis and with
Diabetes
MHD and PD Patients 1.0-1.2 g/kg body weight per day
without Diabetes
Maintenance 1.0-1.2 g/kg body weight per day
Hemodialysis and For patients at risk of hyper- and/or hypoglycemia, higher levels of
Peritoneal Dialysis dietary protein intake may need to be considered to maintain glycemic
Patients with Diabetes control (OPINION).
CRRT or frequent ≥1 g/kg/day (up to 2.5 g/kg/day)
hemodialysis
Energy intake
In adults with CKD 1- 25-35 kcal/kg body weight per day
5D (1C) or post-
transplantation
(OPINION) who are
metabolically stable
Long Chain Omega-3 Polyunsaturated Fatty Acids to reduce triglycerides and LDL cholesterol
CKD 5D on MHD or 1.3-4 g/d LC n-3 PUFA
PD
CKD 3-5 2g/d LC n-3 PUFA
Micronutrients
Consider supplementation with multivitamins, including all the water-soluble
vitamins, and essential trace elements to prevent or treat micronutrient
deficiencies
Folic Acid Supplementation for Folic Acid Deficiency and Insufficiency
CKD 1-5D (2B) or Folate, vitamin B12, and/or B-complex supplement to correct for folate or
post-transplantation vitamin B12 deficiency/ insufficiency based on clinical signs and symptoms
Vitamin C Supplementation
CKD 1-5D or post- Consider supplementation to meet the recommended intake of at least 90
transplantation mg/d for men and 75 mg/d for women (OPINION).
Vitamin D Supplementation for Vitamin D Deficiency and Insufficiency
CKD 1-5D (2C) or Consider prescribing vitamin D supplementation in the form of
post-transplantation cholecalciferol or ergocalciferol to correct 25-hydroxyvitamin D
(OPINION) insufficiency.
CKD 1-5 with Cholecalciferol, ergocalciferol, or other safe and effective 25(OH)D
nephrotic range precursors.
proteinuria,
3.3.2 Acute Kidney Injury
Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition
(SCCM/ASPEN) 2016 guidelines
3.3.2.1 Standard enteral nutrition with 1.2-2 g protein/kg actual body weight/day and 25-30 kcal/kg/day
If significant electrolyte abnormalities develop, consider specialty formulation designed for renal failure
3.3.2.2 Give increased protein (≤ 2.5g/kg/day) in patients receiving frequent hemodialysis or continuous
renal replacement therapy (SCCM/ASPEN Very low-quality evidence)
3.3.2.3 Carbohydrate’s intake 3-5 gm/kg/day
3.3.2.4 Fat intake: 0.8-1 gm/kg body weight
3.3.2.5 Do not restrict protein in patients with renal insufficiency to avoid or delay dialysis
(SCCM/ASPEN Very low-quality evidence)
3.3.3 Pulmonary Failure

3.3.3.1 Patients with ARDS/ acute lung injury and those with duration of mechanical ventilation≥ 72
hours can receive either trophic or full nutrition by EN
3.3.3.2 Fluid-restricted, energy-dense EN formulations should be considered, especially in a state of
volume over-load.
3.3.3.3 Serum phosphate concentrations should be monitored closely and phosphate replaced when
needed.
3.3.4 Trauma, burn and surgery
Energy requirements 25 kcal/usual body wt/day
Protein intake 1.5 to 2.0 g/kg/d, with the higher range to promote nitrogen equilibrium, or at
least to minimize nitrogen deficit.
Obese patients with a body mass index of >30: 2 g/kg of ideal body weight
per day.
In patients with large surface area burns: 3-4 gm /kg/day
Carbohydrate 120 g/d
Fats EN formulas with high concentrations of omega-3 polyunsaturated fatty acids
is recommended.
Fluids and electrolytes Burns: 4 mL of lactated Ringer’s for each kilogram of body weight times the
TBSA.
One-half of this total amount is administered in the first eight hours after the
burn. The remaining amount is administered over the subsequent 16 hours,
followed by maintenance fluids.
Urine output: 0.3-0.5 ml/kg/hour
Vitamins and minerals
Glutamine Parenteral glutamine: 0.35-0.5 gm/kg/day is suggested

Arginine 8-30 gm/day
Antioxidants and trace Combination of vitamins and trace elements is recommended.
elements Initiate enteral nutrition within 4-6 hours of injury
3.3.5 Hepatic patients
3.3.5.1 Consider using dry weight or usual weight instead of actual weight to predict energy and protein
requirement due to complications of hepatic failure.
3.3.5.2 Enteral nutrition is preferred in critically ill patients with acute or chronic liver disease.
3.3.5.3 Consider standard enteral formulations
3.3.5.4 Avoid severe protein restriction 60 gm/day is reasonable
3.3.5.5 There is no evidence of further benefit of branched-chain amino acid formulations on coma grade
in ICU patients with encephalopathy who is receiving first- line therapy with luminal-acting antibiotics
and lactulose.
3.3.6 Traumatic brain injury
3.3.6.1 Early enteral feeding should be initiated in the immediate post-trauma period (within 24-48 hours
of injury) once the patient is hemodynamically stable.
3.3.6.2 Use arginine-containing immune-modulating formulations (arginine, glutamine prebiotic fiber
and omega-3 fatty acids) or EPS/DHA supplement with standard enteral formula in patients with
TBI, it can accelerate recover
3.3.7 Open abdomen
3.3.7.1 Early EN (24-48 hours post injury) is recommended in absence of a bowel injury.
3.3.7.2 Provide additional 15-30 gm of protein per liter of exudate loss for patients with open abdomen,
energy needs are same for other ICU patients
3.3.8 Sepsis
3.3.8.1 Patients must receive EN within 24-48 hours of making the diagnosis of sepsis/ septic shock after
the patient is hemodynamically stable.
3.3.8.2 In patients whom early enteral feeding is not feasible, initiate IV glucose and advance enteral
feeding as tolerated in first 7 days
3.3.8.3 Exclusive PN or supplemental PN in conjunction with EN early in the acute phase of sepsis or
septic shock is not recommended regardless patients’ degree of nutritional risk.
3.3.8.4 Trophic feeding “10-20 kcal/hour or up to 500 kcal/day for the initial phases of sepsis, advancing
as tolerated after 24-48 hours to > 80% of target energy goal over the first week
3.3.8.5 Protein: 1.2-2 gm/kg/day
3.3.8.6 Do not use omega-3 fatty acids, IV selenium, glutamine and arginine
3.3.8.7 nitiating enteral nutrition with caution in patients with vasopressor with-drawl.
3.3.9 Chronically critically ill patients
Patients with persistent organ dysfunction requiring ICU LOS> 21 days, should be managed with high-
protein EN therapy and a resistance exercise program should be used
3.3.10 Obesity
3.3.10.1 Consider enteral nutrition therapy within 24-48 hours of intensive care unit (ICU)
admission if volitional intake not sustained
3.3.10.2 To identify high risk patients, consider assessment of central adiposity, metabolic
syndrome, sarcopenia, body mass index > 40, systemic inflammatory response syndrome, or
other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and
mortality
3.3.10.3 Consider giving supplemental thiamine prior to dextrose-containing IV fluids or nutrition
therapy in patients with history of bariatric surgery
3.3.10.4 Consider evaluating and treating micronutrient deficiencies, such as calcium, thiamin,
vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, and trace minerals, such as iron,
selenium, zinc, and copper
Energy 11-14 kcal/kg actual body weight/day for patients with body mass index (BMI) of
requirements 30-50
22-25 kcal/kg ideal body weight/day for patients with BMI > 50
Protein 2 g/kg ideal body weight/day for patients with BMI 30-40
2.5 g/kg ideal body weight/day for patients with BMI ≥ 40
Monitoring Assess for worsening hyperglycemia, hyperlipidemia, hypercapnia, fluid overload,
hepatic fat accumulation in patients receiving enteral nutrition
3.3.11 Surgical intensive care unit (ICU) admission
European Society of Intensive Care Medicine (ESICM) 2017 guideline and European Society of Clinical
Nutrition and Metabolism (ESPEN) 2019 guideline recommendations on early enteral nutrition in
critically ill patients after surgery
3.3.11.1 Consider early (< 48 hours) enteral nutrition in critically ill adult patients
3.3.11.1.1 after gastrointestinal surgery (ESICM Level 2, Grade C; ESPEN Grade B)
3.3.11.1.2 after abdominal aortic surgery (ESICM Level 2, Grade D; ESPEN Grade B
3.3.11.1.3 with abdominal trauma when gastrointestinal tract continuity confirmed/restored (ESICM
Level 2, Grade D; ESPEN Grade B)
3.3.11.1.4 with open abdomen (ESICM Level 2, Grade D; ESPEN Grade B)
3.3.11.2 Consider delay in enteral nutrition in critically ill patients with high-output intestinal fistula if
reliable refeeding access distal to fistula not achievable (ESICM Level 2, Grade D)
3.3.11.3 In patients having major upper gastrointestinal surgery and who cannot tolerate enteral
nutrition, consider parenteral nutrition if anticipated duration ≥ 7 days; delay parenteral
nutrition for 5-7 days unless patient is at high nutrition risk
3.3.11.4 Clear liquids not required as first meal in postoperative patients, who may eat solid food as
tolerated
3.3.12 Acute pancreatitis
3.3.12.1 Avoiding specialized nutrition for patients with mild acute pancreatitis and provide oral diet
as tolerated; if complication develops or failure to advance to oral diet within 7 days,
consider specialized nutrition therapy
3.3.12.2 Moderate-to-severe acute pancreatitis, consider placing naso- or oro-enteric tube and
initiating trophic enteral nutrition within 24-48 hours of admission
3.3.12.3 Severe acute pancreatitis, consider standard polymeric formula when initiating enteral
nutrition
3.3.12.4 Consider antibiotics in patients with severe acute pancreatitis receiving early enteral nutrition
(SCCM/ASPEN Low-quality evidence)
3.3.12.5 Consider parenteral nutrition 1 week after onset of severe acute pancreatitis when enteral
nutrition not possible
3.3.13 Enteral Nutrition in Pediatric Patients
3.3.13.1 Clinical indications for enteral nutrition in pediatric patients
3.3.13.2 Contraindications to EN
3.3.13.2.1 Absolute contraindications include problems with the gastrointestinal function, such as
paralytic or mechanical ileus, and intestinal obstruction or perforation.
3.3.13.2.2 Relative contraindications include intestinal dysmotility, necrotizing enterocolitis, toxic
megacolon, diffuse peritonitis, gastrointestinal bleeding, and high-output enteric fistula
3.3.13.3 Feeding volume according to bolus and continuous feedings
3.3.13.4 Types and methods of EN: classification by enteral access
3.3.13.5 European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism,
endocrine and nutrition section position statement and clinical recommendations
3.3.13.5.1 The assessment of nutritional status is recommended in critically ill children at admission and throughout their
PICU admission
3.3.13.5.2 It is recommended to perform anthropometric measurements on admission and regularly during admission, and to
express these measurements in z-scores, including weight, height/length mid upper arm circumference and head
circumference in young children
3.3.13.5.3 It is recommended to commence early enteral nutrition within 24 h of admission unless contraindicated
3.3.13.5.4 It is recommended to increase enteral nutrition in a stepwise fashion until goal for delivery is achieved using a
feeding protocol or guideline
3.3.13.5.5 Early enteral nutrition is recommended in children who are stable on ECLS (extracorporeal life support)
3.3.13.5.6 Early enteral nutrition is recommended in children who are stable on pharmaceutical haemodynamic support
3.3.13.5.7 Early enteral nutrition is recommended in children after cardiac surgery
3.3.13.5.8 In the acute phase, energy intake provided to critically ill children should not exceed resting energy expenditure
3.3.13.5.9 After the acute phase, energy intake provided to critically ill children should account for energy debt, physical
activity, rehabilitation and growth
3.3.13.5.10 Schofield equation (for age and gender and using an accurate weight) is recommended to estimate resting energy
expenditure
3.3.13.5.11 Parenteral glucose provision should be sufficient to avoid hypoglycemia but not excessive to prevent
hyperglycemia
3.3.13.5.12 When parenteral nutrition is used, composite lipid emulsions, with or without fish oil, should be considered as
the first-choice treatment
3.3.13.5.13 For critically ill infants and children on enteral nutrition a minimum enteral protein intake of 1.5 g/kg/d can be
considered to avoid negative protein balance
3.3.13.5.14 Polymeric feeds should be considered as the first choice for enteral nutrition in most critically ill children, unless
there are contraindication
3.3.13.5.15 Peptide-based formulations may be considered to improve tolerance and progression of enteral feeding in children
for whom polymeric formulations are poorly tolerated or contra-indicated
3.3.13.5.16 There is no evidence to suggest that either continuous or intermittent/bolus feeds are superior in delivering gastric
feeds in critically ill children
3.3.13.5.17 Post-pyloric feeding can be considered for critically ill children at high risk of aspiration or requiring frequent
fasting for surgery or procedures
3.3.13.5.18 Routine measurement of GRV in critically ill children is not recommended
3.3.13.5.19 There is insufficient evidence to support the use of prokinetics in critically ill children to improve gastric emptying
and feed tolerance
3.3.13.5.20 Withholding parenteral nutrition for up to one week can be considered in critically ill term neonates and children,
independent of nutritional status, while providing micronutrients
3.3.13.5.21 Enteral feeding protocols are recommended for high-risk populations to improve nutritional intake and reduce
adverse events
3.3.13.6 Accurate calculation of energy requirements

3.3.13.6.1 Equation to estimate BMR (kcal/day) of PICU patient
3.3.13.6.2 Suggested energy and macronutrient contribution during the different phases of
critical illness
3.3.13.6.3 Protein requirements for critically ill children
3.3.13.6.4 Carbohydrates 4 kcal/kg

3.3.13.6.5 Fat 9 kcal/kg
3.3.13.6.6 Daily Fluid requirements
Body weight Daily fluid requirements
< 10 kg 100/kg
10-20 kg 1000 +50 ml/kg for each kg > 10 kg
>20 kg 1500 ml+ 20 ml/kg for each kg > 20 kg
3.3.13.6.7 Recommendations regarding glucose infusion
3.4 Total Parenteral Nutrition
3.4.1 Indications 3.4.1.1 Nonfunctioning gastrointestinal (GI) tract (such as GI fistula or short
bowel syndrome)
3.4.1.2 Severe Crohn disease
3.4.1.3 Radiation enteritis
3.4.1.4 Chronic pseudo-obstruction
3.4.1.5 Provide no nutrition support if early enteral nutrition not available or
feasible in first 7 days
3.4.1.6 Parenteral nutrition indicated after first 7 days of hospitalization (when
enteral nutrition not available or feasible) for previously healthy critically ill
adults with no evidence of protein-calorie malnutrition
3.4.1.7 Start parenteral nutrition after ICU admission and if enteral nutrition not
feasible and patient has evidence of protein-calorie malnutrition defined as
3.4.1.7.1 Recent weight loss of < 10%-15% body weight
3.4.1.7.2 Actual body weight < 90% of ideal body weight
3.4.1.8 Consider supplemental parenteral nutrition if unable to meet energy
requirements (100% of target goal calories) after 7-10 days by enteral route
3.4.1.9 Acute pancreatitis: Do not start until > 5 days after hospital admission
when enteral nutrition not feasible
3.4.1.10 Surgical patients: patients having major upper gastrointestinal (GI)
surgery when enteral nutrition not feasible
3.4.1.11Start parenteral nutrition 5-7 days preoperatively in malnourished
patients and continue postoperatively
3.4.1.12 Delay starting parenteral nutrition for 5-7 days postoperatively
3.4.1.13 Only start parenteral nutrition if expected duration of parenteral
nutrition ≥ 7 days
3.4.1.14 Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine
and American Society for Parenteral and Enteral Nutrition:
3.4.1.14.1we do not recommend the initiation of PN within 24 hours of
PICU admission
3.4.1.14.2 For children tolerating EN, we suggest stepwise
advancement of nutrient delivery via the enteral route and delaying
commencement of PN.
3.4.1.14.3 we do not recommend the use of immunonutrition in
critically ill children
TPN: Total parenteral nutrition
SPN: Supplemental parenteral nutrition
3.4.2 3.4.2.1 Functioning gastrointestinal tract and enteral or oral nutrition possible
Contraindications
3.4.2.2 Hemodynamic instability
3.4.2.3 Serum glucose ≥ 300 mg/dl
3.4.3 Energy 3.4.3.1 Calorie’s requirement: 25 to 30 kcal/kg/day (use dry or usual body
Requirements in weight)
ICU Obese patients:
3.4.3.1.1 BMI of 30 to 50 kg/m2: 11 to 14 kcal/kg/day (use actual body
weight)
3.4.3.1.2 BMI >50 kg/m2: 22 to 25 kcal/kg/day
3.4.3.2 Fluid: 30 to 40 mL/kg
3.4.3.3 Carbohydrate: 45% to 65% of total calories, maximum rate: 7
mg/kg/minute
3.4.3.4 Fat: 10% to 35% of total calories
3.4.3.5 Protein:
Sepsis: 1.2 to 2 g/kg/day
Burn 1.5 to 2 g/kg/day
patients
(severe)
Renal Acute (severely malnourished or hypercatabolic): 1.2 to 2
failure g/kg/day
Chronic, with dialysis: 1 to 1.2 g/kg/day
Chronic, without dialysis: 0.6 to 0.8 g/kg/day
CRRT or frequent hemodialysis: ≥1 g/kg/day (up to 2.5
g/kg/day)
3.4.4 Monitoring 3.4.4.1 At baseline and daily: Weight; intake and output
3.4.4.2 At baseline and weekly: CBC with differential; PT/INR, PTT; serum
triglycerides (upon initiation also measure on day 1); transferrin or
prealbumin; ALT/AST, alkaline phosphatase, total bilirubin)
3.4.4.3 At baseline and 1 to 2 times per week in stable patients/daily in
critically-ill patients: Electrolytes (upon initiation, 3 times daily); BUN,
creatinine; serum glucose (upon initiation, 3 times daily)
3.4.4.4 As needed: Capillary glucose (in critically ill patients, measure 3 times
daily until consistently <150 mg/dL); nitrogen balance.
3.4.5 Smofkabiven 3.4.5.1 Dose: 20 – 40 mL/kg /day
dosing and In obese patients, use ideal body weight
administration Infusion rate Dosing recommendation
Smofkabiven Central 2 ml/kg/hr 13-31 ml/kg/day
Infusion period: 14- Maximum dose: 35
24 hours ml/kg/day
Smofkabiven peripheral 20-40 ml/kg/day
Maximum dose: 40
ml/kg/day
Bag size 1206 ml 1448 ml 1904 ml

Kcal 800 1000 1300
Osmolarity 850 850 850
g/AA 38 46 60
g/Lipids 34 41 54
g/ Gluocse 85 103 135
3.4.5.2 Electrolyte content of Smofkabiven PERIPHERAL and delivery
recommendation of ESPEN
Sodium 30/1803 36/225 48/300
Potassium 23/180 28/225 36/300
Magnesium 3.8/6 4.6/7.5 3/10
Calcium 1.9/6 2.3/7.5 3/10
Phosphate 9.9/18 11.9/22.5 15.6/30
3.4.5.3 Electrolyte content of Smofkabiven CENTRAL and delivery
recommendation of ESPEN
Sodium 40/150 60/225 80/300
Potassium 30/150 45/225 60/300
Magnesium 5/5 7.5/7.5 10/10
Calcium 2.5/5 3.8/7.5 5/10
Phosphate 12/15 19/22.5 25/30
3.4.6 Pediatric
parenteral
nutrition
calculation
3.4.7 Example of
pediatric total
parenteral
nutrition (PN)
orders
3.4.8 Example of a
step-wise
approach to
cycling parenteral
nutrition
3.5 Formula Composition
Product Index K.cal CHO Protein Fat Na K Fiber Water

Name g g g mg mg g g
Ensure 200 ml 300 40.4 12.5 9.84 184 320 - 154.86
plus 1.5 k.cal gm gm gm mg mg gm
kcal/ml
Resource plus 237 ml 365 53.6 13 gm 10.7 239 356 - 181.54
1.5 k.cal gm mg mg gm
k.cal/ml
Vital 200 ml 300 36.8 13.5 11 gm 338 400 0
1.5 kcal gm gm mg mg
kcal/ml
Glucerna SR 200 ml 186 17.3 9.3 gm 6.76 178 312 - 170
0.93 k.cal gm Gm mg mg gm
k.cal/ml
Nepro HP 220 ml 401 32.43 17.82 21.49 154 233 2.77 161
1.8 kcal gm gm mg mg gm gm
kcal/ml
Nepro LP 220 ml 401 40.77 9.94 21.34 176 251 2.77 162
1.8 kcal gm gm gm mg mg gm gm
kcal/ml
Novasource renal 237 ml 475 43.8 21.6 23.7 223 194 0 170
2 kcal gm gm gm mg mg gm
kcal/ml
Protein
Peptamen powder 430 gm 441 55 gm 18.5 18 gm 365 580 0 0
Per 100 Kcal gm mg mg
gm
Ensure max 330 ml 150 6 gm 30 gm 1.5 420 2 gm
protein Kcal gm mg
Prosource 45 ml 40 0 gm 11 gm 0 20 10
kcal mg mg
Argiment 42.75 160 11 gm 10 gm 0 gm 20 50 3 gm 0
gm kcal mg mg
4. References
4.1 McClave, Stephen A., 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 (ASPEN)." Journal
of Parenteral and Enteral Nutrition 40.2 (2016): 159-211.
4.2 KDIGO clinical practice guideline on acute kidney injury (Kidney Inter Suppl 2012
Mar;2(1):1 PDF), commentary can be found in Am J Kidney Dis 2013 May;61(5):649)
4.3 DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record
No. T909144, Nutrition in Critically Ill Patients; [updated 2018 Dec 02, cited Saudi
Arbaia]. Available from https://www.dynamed.com/topics/dmp~AN~T909144.
Registration and login required.
4.4 SCCM Surviving Sepsis Campaign 2016 international guideline on management of severe
sepsis and septic shock (Intensive Care Med 2017 Mar;43(3):304
4.5 European Society of Intensive Care Medicine (ESICM) clinical practice guideline on early
enteral nutrition in critically ill patients
4.6 da Silva, Joshua SV, et al. "ASPEN consensus recommendations for refeeding syndrome."
Nutrition in Clinical Practice 35.2 (2020): 178-195.
4.7 Bankhead R, Boullata J, Brantley S, et al. ASPEN Enteral Nutrition Practice
Recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):122-167
4.8 DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No.
T360973, Enteral Nutrition Support in Adults; [updated 2018 Nov 30, cited Saudi Arabia].
Available from https://www.dynamed.com/topics/dmp~AN~T360973. Registration and
login required
4.9 Pitta, Marina Regueira, et al. "Tutorial on Diarrhea and Enteral Nutrition: A
Comprehensive Step‐By‐Step Approach." Journal of Parenteral and Enteral
Nutrition 43.8 (2019): 1008-1019
4.10Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit
the most from nutrition therapy: the development and initial validation of a novel risk
assessment tool. Critical Care. 2011;15(6):R268. 2 Rahman A, Hasan RM, Agarwala R,
Martin C, Day AG, Heyland DK. Identifying critically-ill patients who will benefit most from
nutritional therapy: Further validation of the "modified NUTRIC" nutritional risk assessment
tool. Clin Nutr. 2015. [Epub ahead of print]
4.11https://www.criticalcarenutrition.com/resources/nutric-score
4.12Mueller CM, ed. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd edition.
Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2012.
4.13SmofKabiven (total parenteral nutrition) [produt monograph]. Richmond Hill, Ontario,
Canada: Fresenius Kabi Canada; August 2015.
4.14McClave, S. A., Taylor, B. E., Martindale, R., Warren, M. M., Johnson, D. R.,
Braunschweig, C., ... & Gervasio, J. M. (2016). 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
(ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
4.15DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No.
T113862, Nutrition in Critically Ill Patients, [cited 2020 June 21]. Available from
https://www.dynamed.com/management/nutrition-in-critically-ill-patients/ Registration
and login required.
4.16Total Parenteral Nutrition. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.
Riverwoods, IL. Available at:
https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/362822?cesid=1KG4G0Cou
my&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dtotal%2520parenteral%2520nut
rition%26t%3Dname%26va%3Dtotal%2520parenteral%2520nutrition#mop. Accessed
June, 21 2020.
4.17Heyland DK, Dhaliwal R, Wang M, Day AG. The prevalence of iatrogenic underfeeding
in the nutritionally 'at-risk' critically ill patient: Results of an international, multicenter,
prospective study. Clin Nutr. 2015 Aug;34(4):659-66. doi: 10.1016/j.clnu.2014.07.008.
Epub 2014 Jul 19. PMID: 25086472.
4.18Yi DY. Enteral Nutrition in Pediatric Patients. Pediatr Gastroenterol Hepatol Nutr.
2018;21(1):12-19. doi:10.5223/pghn.2018.21.1.12
4.19Tume LN, Valla FV, Joosten K, et al. Nutritional support for children during critical
illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism,
endocrine and nutrition section position statement and clinical recommendations.
Intensive Care Med. 2020;46(3):411-425. doi:10.1007/s00134-019-05922-5
4.20Ardila Gómez IJ, González CB, Martínez Palacio PA, et al. Nutritional Support of the
Critically Ill Pediatric Patient: Foundations and Controversies. Clinical Medicine Insights:
Trauma and Intensive Medicine. January 2017. doi:10.1177/1179560317701108
4.21Mehta, Nilesh M., et al. "Guidelines for the provision and assessment of nutrition support
therapy in the pediatric critically ill patient: Society of Critical Care Medicine and
American Society for Parenteral and Enteral Nutrition." Journal of Parenteral and Enteral
Nutrition 41.5 (2017): 706-742.
4.22Robert D Baker, MD, PhDSusan S Baker, MD, PhDJessica Briggs, RDGeorgina Bojczuk,
RD, CSP (2020). Parenteral nutrition in infants and children. Kathleen J Motil, MD, PhD.
UpToDate. Retrieved April 12, 2021, from
https://www.uptodate.com/contents/parenteral-nutrition-in-infants-and-
children/contributors.
5. Document Ownership and Review Responsibility
SN0 Position (s) Department
1 Clinical Pharmacist Pharmacy
2 ICU Consultant ICU
6. History of Past Versions

VN0 Effective Date Validity Date Status
N/A N/A N/A N/A
7. Approval of the Clinical Guideline / Pathway / Protocol # CPG-MED-004
Initiated by
Dr. Sara Youssef
Clinical Pharmacist Signature & Date
Reviewed by
Dr. Lulu Ibrahim Eljerwan
Acting – Chief of Pharmacy Signature & Date

Dr. Ali Fawzy
ICU Head of Department Signature & Date
Recommended by
Dr. Shahera Elattafy
Chief Nursing Officer Signature & Date

Dr. Ahmed Al Solami
Chief Medical Officer Signature & Date

Dr. Hussein Reyad
QPS Manager Signature & Date
Approved by
Dr. Ahmed Eissa
Regional Chief Executive Officer Signature & Date

GLN-004 Nutrition in Critically Ill Population

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GLN-004 Nutrition in Critically Ill Population

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Clinical Practice Guideline CPG-MED-004

 Corporate  Hospital  Multidisciplinary  Departmental

1. Introduction and Background

2. Important Definitions and Terminologies

3.1 Patient Assessment

Figure 2 Enteral Access Decision Tree

3.2.5.1 We recommend that nutrition support therapy in the form of early EN

3.2.7 General energy

3.3.3 Pulmonary Failure

Glutamine Parenteral glutamine: 0.35-0.5 gm/kg/day is suggested

3.3.5 Hepatic patients

3.3.13.3 Feeding volume according to bolus and continuous feedings

3.3.13.6 Accurate calculation of energy requirements

3.3.13.6.3 Protein requirements for critically ill children

3.3.13.6.4 Carbohydrates 4 kcal/kg

Bag size 1206 ml 1448 ml 1904 ml

Product Index K.cal CHO Protein Fat Na K Fiber Water

6. History of Past Versions

Clinical Pharmacist Signature & Date

Acting – Chief of Pharmacy Signature & Date

ICU Head of Department Signature & Date

Chief Nursing Officer Signature & Date

Chief Medical Officer Signature & Date

QPS Manager Signature & Date

Regional Chief Executive Officer Signature & Date

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