Enternal Nutrition for Intubated Patients

most intubated patients should be fed

Benefits of enteral nutrition:
- Maintains gut integrity, preventing bacterial translocation into bloodstream.
- Prevents development of ileus.
- Reduces stress ulceration.
- Prevents malnutrition.
- Avoids the development of starvation ketoacidosis.
Patients should be fed unless there is a legitimate contraindication to feeding:
- GI catastrophe (obstruction, perforation, mesenteric ischemia, major upper GI bleeding)
- (Note: Pancreatitis is not a contraindication to enteral nutrition). (26773077, 29409760)
When in doubt, start feeds at a low level and advance as tolerated.
Absence of bowel sounds isn't a contraindication to feeding. There is little evidentiary support for listening to bowel sounds at all, so this is generally a waste of time.(19966732)

Most intubated patients will initially have an orogastric (OG) tube placed. This can be used for feeding.
A post-pyloric small-bore soft feeding tube may be subsequently placed, for one of the following reasons.
- (1) Post-pyloric feeding can be useful for patients with gastroparesis or vomiting (since it bypasses the stomach).
- (2) A smaller-bore nasal feeding tube is more comfortable and can be left in place longer (e.g., after the patient has been extubated). This may be useful in patients with hepatic encephalopathy or neurologic injury, in whom it is important to maintain gut access following extubation.
The minor drawback of a small-bore tube is that it cannot be used to suction the stomach (e.g., to empty the stomach prior to extubation).

Start with a standard 1 kCal/ml tube feed (e.g. Replete). Target a goal rate of somewhat below ~1 ml/hr/kg. For example, a 77 kg patient would receive ~60 ml/hour. In morbid obesity use the ideal body weight.
In severe renal failure, use a 2 kCal/ml renal tube feed (e.g. Novasource Renal) at a rate of 0.5 cc/kg/hour.
The nutrition team will adjust your orders, but the most important aspect is to provide some enteral nutrition. The precise number of calories doesn't seem to have a huge impact – the key thing is providing a reasonable amount of nutrition.(30346225)

Recent nutrition guidelines recommend against checking gastric residual volume.(26773077, 19861528, 23321763)
Tube feeds shouldn't be held based on elevated gastric residual volumes. Feeding may be continued unless there are clinical signs of feeding intolerance (e.g. abdominal distension/discomfort, emesis).