Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Nutrition support in critically ill patients: Enteral nutrition

David Seres, MD
Section Editors
Polly E Parsons, MD
Timothy O Lipman, MD
Deputy Editor
Geraldine Finlay, MD


Enteral nutrition support refers to the provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids via an intestinal route. The available formulations, components, delivery, and complications of enteral nutrition are reviewed here. The goals, outcomes, indications, contraindications, nutritional requirements, and timing of initiation of enteral nutrition are discussed separately. (See "Nutrition support in critically ill patients: An overview".)


The indications and contraindications for enteral nutrition are described elsewhere. (See "Nutrition support in critically ill patients: An overview", section on 'Patient selection'.)


To initiate enteral nutrition, appropriate access must be obtained and the prescription needs to be determined. The prescription includes the formulation, composition, delivery strategy, and delivery rate [1]. Determination of the presence of gut contractility is subjective and not an absolute requirement prior to initiation. Enteral nutrition is typically not initiated until patients are hemodynamically stable (which includes those on weaning or modest vasopressor support).

Access — Enteral nutrition is most commonly delivered into the stomach (gastric feeding). However, it can also be administered into more distal parts of the alimentary tract (post-pyloric), particularly in those at high risk of aspiration or those intolerant of gastric enteral nutrition.

Gastric — Gastric feeding is typically delivered via an orogastric or nasogastric tube. Such tubes are available in two varieties:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Oct 3, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159.
  2. Sorokin R, Gottlieb JE. Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions. JPEN J Parenter Enteral Nutr 2006; 30:440.
  3. Lee AJ, Eve R, Bennett MJ. Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus. Intensive Care Med 2006; 32:553.
  4. Lord LM, Weiser-Maimone A, Pulhamus M, Sax HC. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN J Parenter Enteral Nutr 1993; 17:271.
  5. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology 2011; 141:742.
  6. Abbott Nutrition products http://abbottnutrition.com/products/index.aspx (Accessed on July 07, 2008).
  7. Nestle Nutrition products http://www.nestle-nutrition.com/Products/Default.aspx (Accessed on July 07, 2008).
  8. Metheny N, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res 1988; 37:165.
  9. Fick TE, van Rooyen W, Eeftinck Schattenkerk M, et al. A nonelemental versus an elemental diet for early postoperative enteral feeding by needle catheter jejunostomy. Clin Nutr 1986; 5:105.
  10. Protein/peptides http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on January 30, 2009).
  11. Seres DS, Ippolito PR. Pilot study evaluating the efficacy, tolerance and safety of a peptide-based enteral formula versus a high protein enteral formula in multiple ICU settings (medical, surgical, cardiothoracic). Clin Nutr 2016.
  12. van den Berg B, Stam H. Metabolic and respiratory effects of enteral nutrition in patients during mechanical ventilation. Intensive Care Med 1988; 14:206.
  13. Singer P, Theilla M, Fisher H, et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med 2006; 34:1033.
  14. Gottschlich MM, Jenkins M, Warden GD, et al. Differential effects of three enteral dietary regimens on selected outcome variables in burn patients. JPEN J Parenter Enteral Nutr 1990; 14:225.
  15. van den Berg B, Bogaard JM, Hop WC. High fat, low carbohydrate, enteral feeding in patients weaning from the ventilator. Intensive Care Med 1994; 20:470.
  16. al-Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients. Intensive Care Med 1989; 15:290.
  17. Mesejo A, Acosta JA, Ortega C, et al. Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients. Clin Nutr 2003; 22:295.
  18. Garrel DR, Razi M, Larivière F, et al. Improved clinical status and length of care with low-fat nutrition support in burn patients. JPEN J Parenter Enteral Nutr 1995; 19:482.
  19. Kreymann KG, Berger MM, Deutz NE, et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006; 25:210.
  20. Weijs PJ, Stapel SN, de Groot SD, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012; 36:60.
  21. Allingstrup MJ, Esmailzadeh N, Wilkens Knudsen A, et al. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr 2012; 31:462.
  22. Clifton GL, Robertson CS, Contant CF. Enteral hyperalimentation in head injury. J Neurosurg 1985; 62:186.
  23. Scheinkestel CD, Kar L, Marshall K, et al. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003; 19:909.
  24. Alexander JW. Immunonutrition: the role of omega-3 fatty acids. Nutrition 1998; 14:627.
  25. Rice TW, Wheeler AP, Thompson BT, et al. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA 2011; 306:1574.
  26. Gadek JE, DeMichele SJ, Karlstad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med 1999; 27:1409.
  27. Pontes-Arruda A, Aragão AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 2006; 34:2325.
  28. Stapleton RD, Martin TR, Weiss NS, et al. A phase II randomized placebo-controlled trial of omega-3 fatty acids for the treatment of acute lung injury. Crit Care Med 2011; 39:1655.
  29. Zhu D, Zhang Y, Li S, et al. Enteral omega-3 fatty acid supplementation in adult patients with acute respiratory distress syndrome: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis. Intensive Care Med 2014; 40:504.
  30. Buchman AL. Glutamine: commercially essential or conditionally essential? A critical appraisal of the human data. Am J Clin Nutr 2001; 74:25.
  31. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27:355.
  32. Glutamine http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  33. Tao KM, Li XQ, Yang LQ, et al. Glutamine supplementation for critically ill adults. Cochrane Database Syst Rev 2014; :CD010050.
  34. Heyland D, Muscedere J, Wischmeyer PE, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368:1489.
  35. Ornithine ketoglutarate (OKG) http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  36. Heyland DK, Novak F. Immunonutrition in the critically ill patient: more harm than good? JPEN J Parenter Enteral Nutr 2001; 25:S51.
  37. Arginine containing http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  38. Prebiotics/Probiotics/Synbiotics http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  39. Barraud D, Bollaert PE, Gibot S. Impact of the administration of probiotics on mortality in critically ill adult patients: a meta-analysis of randomized controlled trials. Chest 2013; 143:646.
  40. Besselink MG, van Santvoort HC, Buskens E, et al. [Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial]. Ned Tijdschr Geneeskd 2008; 152:685.
  41. Fiber http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  42. Hart GK, Dobb GJ. Effect of a fecal bulking agent on diarrhea during enteral feeding in the critically ill. JPEN J Parenter Enteral Nutr 1988; 12:465.
  43. Dobb GJ, Towler SC. Diarrhoea during enteral feeding in the critically ill: a comparison of feeds with and without fibre. Intensive Care Med 1990; 16:252.
  44. Heather DJ, Howell L, Montana M, et al. Effect of a bulk-forming cathartic on diarrhea in tube-fed patients. Heart Lung 1991; 20:409.
  45. Schultz AA, Ashby-Hughes B, Taylor R, et al. Effects of pectin on diarrhea in critically ill tube-fed patients receiving antibiotics. Am J Crit Care 2000; 9:403.
  46. Spapen H, Diltoer M, Van Malderen C, et al. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, double-blind, randomized, and controlled trial. Clin Nutr 2001; 20:301.
  47. Rushdi TA, Pichard C, Khater YH. Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin Nutr 2004; 23:1344.
  48. McIvor AC, Meguid MM, Curtas S, et al. Intestinal obstruction from cecal bezoar; a complication of fiber-containing tube feedings. Nutrition 1990; 6:115.
  49. Allingstrup M, Afshari A. Selenium supplementation for critically ill adults. Cochrane Database Syst Rev 2015; :CD003703.
  50. Combined vitamins and trace elements http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 11, 2009).
  51. Beale RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: a systematic review of clinical outcome. Crit Care Med 1999; 27:2799.
  52. Heyland DK, Novak F, Drover JW, et al. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001; 286:944.
  53. Montejo JC, Zarazaga A, López-Martínez J, et al. Immunonutrition in the intensive care unit. A systematic review and consensus statement. Clin Nutr 2003; 22:221.
  54. van Zanten AR, Sztark F, Kaisers UX, et al. High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial. JAMA 2014; 312:514.
  55. Andrews PJ, Avenell A, Noble DW, et al. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. BMJ 2011; 342:d1542.
  56. Continuous vs other methods of administration http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).
  57. Bonten MJ, Gaillard CA, van der Hulst R, et al. Intermittent enteral feeding: the influence on respiratory and digestive tract colonization in mechanically ventilated intensive-care-unit patients. Am J Respir Crit Care Med 1996; 154:394.
  58. Steevens EC, Lipscomb AF, Poole GV, Sacks GS. Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice. Nutr Clin Pract 2002; 17:118.
  59. MacLeod JB, Lefton J, Houghton D, et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma 2007; 63:57.
  60. Ibrahim EH, Mehringer L, Prentice D, et al. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. JPEN J Parenter Enteral Nutr 2002; 26:174.
  61. Rice TW, Mogan S, Hays MA, et al. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011; 39:967.
  62. Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999; 27:2525.
  63. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012; 307:795.
  64. Needham DM, Dinglas VD, Morris PE, et al. Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up. Am J Respir Crit Care Med 2013; 188:567.
  65. Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001; 29:1955.
  66. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005; 33:324.
  67. Montejo JC, Miñambres E, Bordejé L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med 2010; 36:1386.
  68. Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 2013; 309:249.
  69. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units. Crit Care Med 1999; 27:1447.
  70. Luft VC, Beghetto MG, de Mello ED, Polanczyk CA. Role of enteral nutrition in the incidence of diarrhea among hospitalized adult patients. Nutrition 2008; 24:528.
  71. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008; 336:1495.
  72. Scaife CL, Saffle JR, Morris SE. Intestinal obstruction secondary to enteral feedings in burn trauma patients. J Trauma 1999; 47:859.
  73. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323:773.
  74. Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354:1851.
  75. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 1995; 152:1387.
  76. Metheny NA, Clouse RE, Chang YH, et al. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med 2006; 34:1007.
  77. Niël-Weise BS, Gastmeier P, Kola A, et al. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care 2011; 15:R111.
  78. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006; 34:396.
  79. Ho KM, Dobb GJ, Webb SA. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med 2006; 32:639.
  80. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care 2003; 7:R46.
  81. Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. JPEN J Parenter Enteral Nutr 2002; 26:S51.
  82. Gomes CA Jr, Andriolo RB, Bennett C, et al. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev 2015; :CD008096.
  83. Yarmus L, Gilbert C, Lechtzin N, et al. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest 2013; 144:436.
  84. Burgermaster M, Slattery E, Islam N, et al. Regional Comparison of Enteral Nutrition-Related Admission Policies in Skilled Nursing Facilities. Nutr Clin Pract 2016; 31:342.
  85. Mitchell SL, Teno JM, Roy J, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003; 290:73.
  86. Arora G, Rockey D, Gupta S. High In-hospital mortality after percutaneous endoscopic gastrostomy: results of a nationwide population-based study. Clin Gastroenterol Hepatol 2013; 11:1437.
  87. Yavagal DR, Karnad DR, Oak JL. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Crit Care Med 2000; 28:1408.
  88. Motility agents http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 03, 2009).