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Table 1 Key recommendations in clinical practice guidelines [1, 2, 13, 14]

From: Nutrition therapy in critical illness: a review of the literature for clinicians

GuidelineBasis of recommendationEnergy requirementsProtein requirementsCommencement of ENaCommencement of PN
ASPEN/SCCM (2016)Observational studies, RCTs, and consensus opinion from topic expertsUse IC (quality: very low)
In the absence of IC use 25–30 kcal/kg/day (EC)
Obesity: hypocaloric nutrition, 65-70% measured requirements by IC. If no IC, BMI 30–50 = 11–14 kcal/kg ABW/day; BMI > 50 = 22–25 kcal/kg IBW/day (EC)
1.2–2 g/kg/day (quality: very low)
Obesity: high protein, BMI 30–40 = 2.0 g/kg IBW/day; BMI ≥ 40 = up to 2.5 g/kg IBW/day (EC)
Early EN (24–48 h) (quality: very low)
Patients at low nutrition risk, well-nourished, and/or with low disease severity do not require specialised nutrition therapy over the first week in ICU (EC)
Patients at high nutrition risk or severely malnourished, EN should advance to goal as quickly as tolerated over 24–48 h in (while monitoring for refeeding) (quality: very low)
Exclusive PN (when oral intake or EN contraindicated) for patients at low nutrition risk, withhold for the first 7 days (quality: very low)
For patients at high nutrition risk or severely malnourished start PN as soon as possible (EC)
Supplemental PNb should be considered after 7–10 days if unable to meet > 60% of energy and protein requirements by EN (quality: moderate)
Canadian Clinical Practice Guidelines (2015)RCTs and consensus opinion from topic expertsNilNilEarly EN (within 24–48 h) (based on 16 level 2 studiesc)Exclusive PN (when oral intake or EN contraindicated) should be considered early in nutritionally high-risk patients (based on 6 level 2 studiesc)
For patients who are not malnourished, are tolerating some EN, or when PN is indicated for <10 days, low dose PN should be considered (based on 4 level 2 studiesc)
Supplemental PNb should be assessed on case-by-case basis (based on 1 level 1 study and 7 level 2 studiesc)
ESICM clinical practice guidelines (2017)Observational studies, RCTs, and consensus opinion from topic expertsNilNilEarly EN should be prescribed rather than delaying EN (low-quality evidence)Nil
ESPEN (2019)Observational studies, RCTs, and consensus opinion from topic expertsUse IC (grade Bd)
In the absence of IC use VO2 or VCO2 predictive equations (grade 0d)
Obesity: if no IC, 20–25 kcal/kg ABW/day (grade 0d)
1.3 g/kg/day delivered progressively (grade 0d)
Obesity: 1.3 g/kg ABW/day (grade 0d)
Early EN (within 48 h) (grade Ad)
Hypocaloric nutrition (< 70% of EE) in the early acute phase (ICU day 1–3) (grade Bd)
If using IC—isocaloric nutrition (80–100% EE) can be progressively implemented after day 3 (grade 0d)
If using predictive equations—hypocaloric nutrition (< 70% of EE) for the first week (grade Bd)
Exclusive PN (when oral intake or EN contraindicated) within 3–7 days (grade Bd)
For severely malnourished patients, consider early and progressive PN (grade 0d)
Supplemental PNb should be considered on a case-by-case basis (grade 0d)
  1. ABW adjusted body weight, ASPEN/SCCM American Society of Parenteral and Enteral Nutrition/Society of Critical Care Medicine, EC expert consensus, EE energy expenditure, EN enteral nutrition, ESICM European Society of Intensive Care Medicine, ESPEN European Society of Parenteral and Enteral Nutrition, IC indirect calorimetry, IBW ideal body weight, PN parenteral nutrition, RCTs randomised controlled trials, VO2 oxygen consumption, VCO2 carbon dioxide production
  2. aCommencement of EN in haemodynamically stable patients who are unable to maintain oral intake
  3. bSupplemental PN—when all nutritional requirements are unable to be met by EN (i.e. due to intolerance, fasting)
  4. cCanadian Clinical Practice Guidelines, level of bias for included RCTs: Level 1 = randomisation was concealed, outcome adjudication was blinded, and an intention to treat analysis was performed. Level 2 = if any one of the level 1 characteristics were unfulfilled
  5. dESPEN grade of recommendation: A = at least one high-quality meta-analysis, systematic review, or RCT; B = based on a body of evidence from well-conducted observational studies; 0 = case studies, expert opinion, or evidence extrapolated from high-quality systematic reviews or observational studies (recommendation refers to ‘can be aimed for’ rather than best practice)