Stephen A. McClave, MD1, John K. DiBaise, MD, FACG2 , Gerard E. Mullin, MD, FACG3 and Robert G. Martindale, MD, PhD4
1Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA; 2Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA; 3Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; 4Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA.
Am J Gastroenterol advance online publication, 8 March 2016; doi: 10.1038/ajg.2016.28
Correspondence: Stephen A. McClave, MD, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550S, Jackson St, Louisville, Kentucky 40202, USA .
The value of nutrition therapy for the adult hospitalized patient is derived from the outcome bene. ts achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24–48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and .sh oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the .rst week of hospitalization if EN is not suf.cient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.