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Table 3 Guideline recommendations for strategies to improve EN delivery [1, 2, 13, 14]

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

StrategyEvidenced-based feeding protocolGRV (minimum 500 ml cut-off)Appropriate and timely use of prokinetics for EN intolerancePost-pyloric tubes for EN intolerance
ASPEN/SCCM (2016)Use an EN protocol (designed and implemented to increase the overall percentage of goal energy delivered) (quality: moderate to high)Do not use GRVs as part of routine care to monitor ICU patients on EN
If GRVs are used, use 500ml cut-off (quality: low)
Use metoclopramide or erythromycin where indicated (quality: low)Nil
Canadian Clinical Practice Guidelines (2015)Use an EN protocol (that details strategies to improve delivery of EN) (based on 2 level 2 studies and 3 cluster RCTsa)Use GRV of 250–500 ml every 4–6 h (based on 3 level 2 studiesa)Use metoclopramide where indicated (based on 1 level 1 study and 5 level 2 studiesa)Use post-pyloric tubes for patients at high risk for intolerance to EN or aspiration (based on 16 level 2 studiesa)
ESPEN (2019)NilEN should only be delayed when GRV is > 500 ml/6 h (grade 0b)Use IV erythromycin as a first line therapy (grade of recommendation Bb) or use IV metaclopramide or combination therapy (grade 0b)
Alternatively, combination therapy (IV metoclopramide and erythromycin) (grade 0b)
Use post-pyloric feeding for EN intolerance not resolved with prokinetics (grade Bb)
  1. ASPEN/SCCM American Society of Parenteral and Enteral Nutrition/Society of Critical Care Medicine, EC expert consensus, EN enteral nutrition, ESICM European Society of Intensive Care Medicine, ESPEN European Society of Parenteral and Enteral Nutrition, GRV gastric residual volume, ICU intensive care unit, IV intravenous therapy
  2. aCanadian 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 forementioned characteristics was unfulfilled
  3. bESPEN grade of recommendation: A = at least one high-quality meta-analysis, systematic review, or RCT; B = 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)