Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition

TLDR

As more consistent critical‑care nutrition data become available, precise recommendations will improve, but clinical judgment and close monitoring remain essential. This guideline updates the 2016 ASPEN/SCCM critical‑care nutrition recommendations for five foundational questions in nutrition support. The guideline employed a GRADE‑based systematic review of 36 trials (20,578 participants) to evaluate outcomes for energy and protein dosing, nutrition routes, supplemental PN, and lipid emulsions, and to assess safety by correlating weight‑based intake with hospital mortality. The review found no clinically meaningful differences across energy or protein doses, nutrition routes, supplemental PN, or lipid emulsions, except that fish‑oil emulsions were associated with a modest, uncertain reduction in pneumonia, leading to a revised energy target of 12–25 kcal/kg/day. The guideline was approved by the ASPEN Board of Directors.

Abstract

This guideline updates recommendations from the 2016 American Society for Parenteral and Enteral Nutrition (ASPEN)/Society of Critical Care Medicine (SCCM) critical care nutrition guideline for five foundational questions central to critical care nutrition support.The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose, (2) higher vs lower protein dose, (3) exclusive isocaloric parenteral nutrition (PN) vs enteral nutrition (EN), (4) supplemental PN (SPN) plus EN vs EN alone, (5A) mixed-oil lipid injectable emulsions (ILEs) vs soybean oil, and (5B) fish oil (FO)-containing ILE vs non-FO ILE. To assess safety, weight-based energy intake and protein were plotted against hospital mortality.Between January 1, 2001, and July 15, 2020, 2320 citations were identified and data were abstracted from 36 trials including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Owing to a lack of certainty regarding harm, the energy prescription recommendation was decreased to 12-25 kcal/kg/day.No differences in clinical outcomes were identified among numerous nutrition interventions, including higher energy or protein intake, isocaloric PN or EN, SPN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors.