Feeding the ICU Patient

• When the gut works, start enteral feeding early (24–48 h): gastric route first, trophic 10–20 mL/h, then advance.
• Protein ~1.3 g/kg/day (ESPEN 2023; up to 2 g/kg in selected patients); hypocaloric the first week, then 25–30 kcal/kg/day, using indirect calorimetry where available.
• Refeeding risk in starved/alcoholic patients: start low, replace PO₄/K/Mg + thiamine, follow PO₄ daily.
• TPN only when enteral feeding is contraindicated; do not hold feeds for gastric residual volume alone below 500 mL.

Choosing Feeding Route and Starting Feeds

• Hemodynamically stable?
• Any of the following present: high-output fistula · obstruction/active pseudo-obstruction · excessive vomiting/diarrhea · bowel perforation or ischemia?
• Start TPN · reassess routinely for TF eligibility
• Start tube feeding → evaluate route of delivery
• INITIATE GASTRIC FEEDS: for 2 cal/mL product, start at 50 mL q4h · for 1–1.5 cal/mL product, start at 100 mL q4h · increase 50 mL q4–8h until goal is achieved · minimal flush (water or NS) of 30 mL q4h · do not hold feeds for gastric residual volume alone below 500 mL; hold only for distention or emesis
• INITIATE SMALL BOWEL FEEDS: begin at 10–20 mL/hr · advance 10 mL/hr q4–8h until goal is achieved · minimal flush (water or NS) 30 mL q4h · feeding appearing in gastric output → recheck tube position via x-ray
• TF held ×2 or TF goal not achieved for >7 days?
• Start TPN · reassess routinely for TF eligibility
• No nutrition support while hemodynamics are changing and high-dose pressor support is required