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Review
. 2011;15(6):234.
doi: 10.1186/cc10430. Epub 2011 Nov 30.

Clinical review: Optimizing enteral nutrition for critically ill patients--a simple data-driven formula

Refaat A Hegazi  1 , Paul E Wischmeyer
Affiliations
Review

Clinical review: Optimizing enteral nutrition for critically ill patients--a simple data-driven formula

Refaat A Hegazi et al. Crit Care. 2011.

Abstract

In modern critical care, the paradigm of 'therapeutic nutrition' is replacing traditional 'supportive nutrition'. Standard enteral formulas meet basic macro- and micronutrient needs; therapeutic enteral formulas meet these basic needs and also contain specific pharmaconutrients that may attenuate hyperinflammatory responses, enhance the immune responses to infection, or improve gastrointestinal tolerance. Choosing the right enteral feeding formula may positively affect a patient's outcome; targeted use of therapeutic formulas can reduce the incidence of infectious complications, shorten lengths of stay in the ICU and in the hospital, and lower risk for mortality. In this paper, we review principles of how to feed (enteral, parenteral, or both) and when to feed (early versus delayed start) patients who are critically ill. We discuss what to feed these patients in the context of specific pharmaconutrients in specialized feeding formulations, that is, arginine, glutamine, antioxidants, certain ω-3 and ω-6 fatty acids, hydrolyzed proteins, and medium-chain triglycerides. We summarize current expert guidelines for nutrition in patients with critical illness, and we present specific clinical evidence on the use of enteral formulas supplemented with anti-inflammatory or immune-modulating nutrients, and gastrointestinal tolerance-promoting nutritional formulas. Finally, we introduce an algorithm to help bedside clinicians make data-driven feeding decisions for patients with critical illness.

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Figures

Figure 1
Figure 1
Specific dietary fatty acids, eicosapentaenoic acid (EPA) and gamma linolenic acid (GLA), limit excessive inflammation by competing with enzymes involved in conversion of membrane-derived arachidonic acid (AA) to proinflammatory mediators. As a result, alternative mediators, which are less inflammatory, are produced. PGE, prostaglandin.
Figure 2
Figure 2
Formulas containing eicosapentaenoic acid (EPA) and gamma linolenic acid (GLA) moderate uncontrolled inflammation, while formulas with arginine lessen immune suppression. With feeding of these specific pharmaconutrients, complications of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and sepsis or surgery, burns, and trauma can be prevented or blunted, thereby lessening adverse outcomes. MODS, multiple organ dysfunction syndrome.
Figure 3
Figure 3
For ICU patients, this algorithm guides how, when, and what feeding formulation to select in order to improve outcomes. It highlights targeted use of anti-inflammatory and immune-modulating formulas, as well as tolerance-promoting formulas. ALI, acute lung injury; AOX, anti-oxidants; ARDS, acute respiratory distress syndrome; ARG, arginine; BMI, body mass index; GI, gastrointestinal; GLN, glutamine; IV, intravenous; ω-3, omega-3 fatty acids.
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