Table 1 Reasons to start and delay early enteral nutrition

Recommendation 1: Start early enteral nutrition in all critically ill patients within 48 h, preferably within 24 h when there is no reason to delay enteral nutrition (see the following recommendations).

Early enteral nutrition is associated with lower risk of infections and preserves the gut function, immunity, and absorptive capacity.

Recommendation 2: Delay early enteral nutrition in case of enteral obstruction.

Feeding proximal of an obstruction will lead to blow-out or perforation.

Recommendation 3: Delay early enteral nutrition in case of compromised splanchnic circulation such as uncontrolled shock, overt bowel ischemia, abdominal compartment syndrome, and during intra-abdominal hypertension when feeding increases abdominal pressures.

Absorption of nutrients demands energy and oxygen. In states of low flow or ischemia, forcing feeding into the ischemic gut may aggravate ischemia and lead to necrosis or perforation.

Recommendation 4: Delay early enteral nutrition in case of high-output fistula that cannot be bypassed.

Enteral feeding will be spilled into the peritoneal space or increase the fistula production.

Recommendation 5: Delay early enteral nutrition in case of active gastrointestinal bleeding.

Enteral feeding will limit the visualization of the upper gastrointestinal tract during endoscopy.

Recommendation 6: Delay early enteral nutrition in case of high gastrointestinal residual volume (> 500 mL per 6 h).

This threshold is associated with poor gastric emptying and may increase the risk of aspiration. Prokinetics and postpyloric feeding can circumvent this problem.