ACG releases new clinical guideline on nutrition therapy for hospitalized adults
The ACG has issued new practice guideline recommendations on nutrition therapy for adult hospitalized patients.
“The target population for these guidelines was the adult hospitalized patient, unable to sustain volitional intake, expected to remain in the hospital for [more than] 3 days,” the guideline committee wrote.
The committee compiled a list of questions and recommendations based on a literature search, and used GRADE methodology to determine the quality of available evidence.
They recommended that enteral nutrition be initiated promptly (within 24 to 48 hours of admission) in patients at high nutritional risk who are unable to maintain volitional oral intake, and enteral nutrition is preferred over parenteral nutrition in those without a contraindication to luminal nutrient delivery who need non-volitional specialized nutrition therapy. Parenteral nutrition “should be reserved for high-risk patients when [enteral nutrition] is not feasible or sufficient enough to meet energy or protein goals,” as the risk–benefit ratio of parenteral nutrition is “much narrower.”
Nutritional risk should be assessed in all patients who may have insufficient volitional intake using a validated scoring system like the Nutritional Risk Score 2002 or the NUTRIC Score, and further assessment of factors that could affect the design and delivery of the nutrition therapy should be performed before the therapy is initiated. Clinicians should avoid using traditional nutrition indicators like albumin, prealbumin, transferrin and anthropometry, as well as surrogate markers of infection or inflammation. Indirect calorimetery, simple weight-based equations or published predictive equations should be used to determine caloric requirements, and protein requirements should be assessed independently and in an ongoing fashion. Patients should also be monitored for risk of aspiration, tolerance and adequacy of feeding.
“A nasogastric or orogastric feeding tube should be used as the initial access device for starting [enteral nutrition] in a hospitalized patient,” the committee wrote, adding that tube placement in the stomach should be radiologically confirmed before feeding. Post-pyloric or deep jejunal feeding is only recommended in patients for whom gastric feeding is not well tolerated or in those with a high risk for aspiration, and percutaneous enteral access devices should be used in patients who require more than 4 weeks of enteral feeding.
The committee strongly recommended that permissive underfeeding is an appropriate temporary alternative for patients with acute lung injury or acute respiratory distress syndrome, and conditionally recommends it as an alternative for patients with obesity or those who received parenteral nutrition during the first week of nutrition therapy.
A standard polymeric formula is recommended for most patients, but an immune-modulating formula with arginine and fish oil is recommended for patients who have undergone major surgery in a surgical ICU.
“Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes,” the committee wrote, adding that “because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.” – by Adam Leitenberger
Disclosure: McClave reports he is a speaker and an advisor for Nestle, Abbott, Covidien and Kimberly Clark, a speaker for Nutricia and has received research support from Nestle. Please see the full guideline for a list of other committee members’ relevant financial disclosures.