Optimization of enteral nutrition delivery in critically ill patients treated with mechanical ventilation

Abstract

Nutritional support is a cornerstone of the care of critically ill patients treated with invasive mechanical ventilation. Guidelines recommend to start nutrition as soon as possible after admission in the intensive care unit and to use the enteral route. However, many critically ill patients experience poor tolerance to early enteral nutrition (EN), which has been ascribed to gastroparesis with increased gastric volume, gastroesophageal reflux, regurgitation or vomiting and subsequent increased risk of aspiration and ventilator-associated pneumonia. Management of intolerance to EN has been reported as a leading cause of hypocaloric feeding. However, both definition and management of gastrointestinal intolerance to enteral feeding should be revisited. Regurgitation and vomiting do not seem to be a leading cause of significant complications including ventilator-associated pneumonia. Thus, prevention of vomiting should not significantly impede the delivery of EN. Monitoring of gastric residual volume should not be routinely performed. In case of vomiting, prokinetic drugs should be administered in first-line before any reduction in the rate of EN delivery. Prophylactic treatment with prokinetic drugs should be promoted in patients at high risk of vomiting. Predetermined protocol on EN delivery should be implemented in all intensive care units with the aim to achieve nutritional goals in most of the patients treated with mechanical ventilation. Because of numerous uncertainties, further studies are required in the field of artificial nutrition in the critically ill patients.