Clinical

When should nutritional support be implemented in a hospitalized patient?


 

Gastric residual volume (GRV) is commonly monitored in patients receiving enteral nutrition. However, the American College of Gastroenterology does not recommend using GRVs to monitor EN feeding because it is a poor marker of clinically meaningful variables, such as gastric emptying, risk of aspiration, and risk of poor outcomes, and increases the risk of tube clogging and inadequate delivery of EN. If GRVs are being monitored, tube feedings should not be withheld because of high GRVs when there are no other signs of intolerance.4 Nausea may be managed by changing a patient from bolus to continuous feedings or by adding promotility agents such as metoclopramide or erythromycin.6

Special considerations in common conditions treated by hospitalists

The principles outlined above are general guidelines that are applicable to most patients requiring nutrition support. We have highlighted special considerations for common conditions in hospitalized patients who require nutritional support below.

Critical Illness

  • Defer enteral nutrition until patient is fully resuscitated and hemodynamically stable.
  • Severely malnourished or high nutritional-risk patients should be advanced toward goals as quickly as can be tolerated over 24-48 hours.
  • Patients with acute respiratory distress syndrome or acute lung injury, or those expected to require mechanical ventilation for more than 72 hours, should receive trophic feeds or full nutrition by enteral route.6

Pancreatitis

  • Oral feeding should be attempted as soon as abdominal pain is decreasing and inflammatory markers are improving.13
  • A regular solid, low-fat diet should be initiated, rather than slowly advancing from a clear liquid diet.13
  • In severe acute pancreatitis, initiation of enteral nutrition within 48 hours of presentation is associated with improved outcomes.13
  • There is no difference in outcomes between gastric and postpyloric feeding.14
  • Initiation of parenteral nutrition may be delayed for up to 5 days to allow for a trial of oral or enteral feeding.13

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