Enteral and parenteral feeding protocols

Nutritional support has traditionally been regarded as a means to provide basic energy for cellular homeostasis while amino acids are considered necessary for protein synthesis. However, patients admitted to intensive care units are in a dynamic state between systemic inflammation, immune suppression, and persistent chronic inflammatory states. It often takes weeks or months for the inflammatory states resulting from ICU admission to resolve. Multiple factors including timing of insult, pre-stress co-morbidities will influence the duration of the hyperdynamic inflammatory state. The ability to attenuate the metabolic response to stress has recently been proven in most ICU populations. Obtaining the maximal benefit from this metabolic modulation requires rapid and rather specific nutrient delivery. Evidence suggests that feeding protocols improve the delivery of nutrition to critically ill patients by promoting early initiation and enhanced adequacy of EN. Globally at least six major nutrition societies have published critical care nutrition guidelines over the past 15 years providing some consensus in areas of critical care nutrition. However, worldwide agreement among professional organizations exists for the preference of early enteral nutrition compared to parenteral nutrition in the critically ill patient. Unfortunately, recent multinational, observational studies demonstrate a significant gap between our knowledge and the application of evidence-based nutrition practices. This reveals the complexity of the critical care setting where nutrition therapy varies around the world in different patient populations and diverse intensive care unit (ICU) cultures. This abundance and sometimes discrepancy of information creates confusion and skepticism for the critical care provider who is attempting to apply evidence-based critical care nutrition guidelines. Protocols have become the foundation for hospitals to translate evidenced-based guidelines into bedside application. Protocols can guide a complex decision-making process, closing gaps in knowledge and practice, optimizing the quality of patient care, and promoting cost effectiveness.