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    MDCalc>Guidelines/ACG/Nutrition
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    Nutrition Therapy in the Adult Hospitalized Patient (beta)

    Official guideline from American College of Gastroenterology.

    Summary by Shawn Shah, MD
    Strength of Recommendation
    Strong
    Moderate
    Conditional
    Weak
    Level of Evidence
    High
    Moderate-high
    Low
    Very low

    Indications and Assessment

    Indications
    1. In hospitalized patients at high nutritional risk and unable to maintain adequate PO, should start early EN
    2. EN preferred over PN in hospitalized patients who need specialized nutrition and have no contraindications to EN (e.g. mechanical obstruction, ischemic bowel)
    3. In hospitalized patients at low nutritional risk, appear well-nourished, and expected to resume oral intake in 5-7 days, PN/EN not required
    4. Should only use PN in high nutritional risk patients where EN not feasible or sufficient to meet energy/protein goals
    Assessment
    1. Before starting EN/PN, should evaluate nutritional risk with validated scoring system (NRS-2002, NUTRIC Score) in admitted patients with anticipated insufficient intake
    2. Should assess additional patient factors (e.g. comorbities, GI tract function, aspiration risk) that may impact design/delivery of nutrition plan
    3. Should avoid using albumin, pre-albumin, transferrin, and anthropometry to indicate nutritional status
    4. Should not use surrogate markers of infection/inflammation for nutritional assessment
    5. Should determine caloric needs to help set delivery goals
    6. Determine caloric needs by indirect calorimetry (gold standard), simple weight-based equations (e.g. 25-30 kcal/kg/day) or published predictive equations
    7. Should calculate protein need independent of caloric need (~1.5-2.0 g/kg/day) and should do ongoing assessment of protein provision

    Enteral Feeding

    Access
    1. Should use either NGT (often easier) or OGT for initial access to start EN
    2. Should confirm gastric tube placement by x-ray (unless electromagnetic transmitter-guided tube); repeated confirmation not required unless concern for tube displacement
    3. Should convert to post-pyloric feeds if high aspiration risk or poor tolerance of gastric feeds
    4. Aspiration/decompression of stomach with jejunal feeds may be done with dual lumen nasoenteric tube, perc GJ tube, or both G and J tubes
    5. Should place J tube if chronic pancreatitis or gastroparesis (need for long term access)
    6. Should place PEG/PEJ if anticipate >4 weeks EN
    7. Should preferentially place PEG in antrum for ease of conversion to a GJ tube if G feeding not tolerated
    8. Should secure perc enteral tubes in patients at high risk for tube displacement (e.g. delirium, dementia)
    Initiation
    1. Should initiate EN within 24-48 hours of admission if high nutritional risk
    2. Timing for advancing to goal is unclear; recommend advance to goal within 48-72 hours if tolerating
    3. If reduced tolerance, should advance to goal by 5-7 days
    4. Permissive underfeeding is acceptable if ALI/ARDS
    5. Permissive underfeeding is acceptable if BMI >30 kg/m²
    6. Permissive underfeeding is acceptable if on PN for 1st week of nutrition
    7. Should use standard polymeric or high-protein EN formula routinely in hospitalized patients requiring EN
    8. In patients who had major surgery and are in SICU, should use immune-modulating EN formula with arginine and omega-3 fish oil (reduced infection and LOS but not mortality)
    9. Should not routinely use immune-modulating EN formula in MICU
    Monitoring
    1. Should monitor EN patients daily with physical exam → check BS, distension, volume status, etc.
    2. Should monitor percent of goal calories/protein delivered, follow cumulative calorie deficit, and watch for inappropriate stopping of feeds
    3. If patient is high risk for refeeding syndrome (BMI <20 kg/m² or prolonged NPO), should increase feeding to goal slowly over 3-4 days and monitor electrolytes and volume status
    4. Should use EN feeding protocols in hospitalized patients needing nutritional therapy
    5. Should use validated EN feeding protocols, e.g. volume-based or multi-strategy top-down protocol
    6. Should not routinely use gastric residual volumes to monitor EN (poor marker of gastric volume/emptying)
    7. Should assess patients on EN for aspiration risk (increased risk if age >70, altered mental status, etc)
    8. If at high risk for aspiration, should use a prokinetic agent
    9. If at high risk for aspiration, should divert feeding to lower in GI tract
    10. If at high risk for aspiration, should switch to continuous infusion
    11. If at high risk for aspiration, should use chlorhexidine mouthwash BID
    12. If diarrhea develops on EN (common), should pursue work-up and initiate therapy (often self-limited, but can cause electrolyte imbalance, skin breakdown, wound contamination)
    13. If diarrhea on EN, should supplement EN with soluble fiber
    14. If diarrhea on EN, should switch to a mixed soluble/insoluble fiber
    15. If diarrhea on EN, should start small peptide/MCT oil formula
    Complications
    1. Should clean percutaneous enteral access site daily with mild soap and water and maintain correct positioning of external bolster
    2. Should clean percutaneous enteral access site daily with mild soap and water and maintain correct positioning of external bolster
    3. If clogged tube not improving with water flushes, should use solution of a nonenteric-coated pancreatic enzyme dissolved in sodium bicarbonate solution (or carbonated soft drink); should avoid papain (meat tenderizer)
    4. If still unsuccessful, should consider mechanical de-clogging (e.g. cytology brush, wire stylet) before exchanging tube
    5. If tube dislodges within 7-10 days of placement, patient should return ASAP to the GI or IR suite for replacement through same tract
    6. If tube dislodges >7-10 days, a tube should be placed blindly ASAP through tract (and should confirm on x-ray before feeding if any question of inappropriate location)
    7. If deterioration, breakdown, increasing leakage or enlarging stoma of the percutaneous site, should work up to determine etiology and management
    8. Should not use larger tube to manage leaking from enlarging stoma
    9. Should replace percutaneous tube (non-urgent but timely) if signs of fungal colonization with compromised structural integrity

    Parenteral Nutrition

    Parenteral Nutrition
    1. If patient at low nutritional risk on admission and early EN not feasible, should withhold PN for 1st week of hospitalization (no difference in outcomes including LOS, mortality)
    2. If patient at high nutritional risk on admission and EN not feasible, should start PN ASAP
    3. If on EN for >7-10 days and not meeting >60% of energy and/or protein needs, should consider supplemental PN
    4. In patients receiving PN, should consider permissive underfeeding (80% of energy needs, full protein) for the 1st 7-10 days, then increase to goal thereafter if long-term PN required
    5. Should not use peripheral PN (high risk of phlebitis, loss of venous access, generally inadequate nutritional therapy)
    6. If EN being initiated while on PN, PN should be carefully tapered as EN tolerance improves to avoid overfeeding
    7. Should stop PN when EN provides >60% of goal energy/protein

    End-of-Life

    End-of-Life
    1. Decision to place a PEG tube in end-of-life situation should be based on patient autonomy and family wishes (nutrition therapy may not change clinical outcome)
    2. PEG placement should be based on patient/family goals, regardless of prognosis, even if only benefit is improved QOL for family, easier medication delivery, or to facilitate transfer out of hospital
    3. Clinicians are not obligated to provide nutrition therapy at end of life if felt unwarranted
    4. In end-stage malignancy, nutrition therapy (if requested) should be delivered through enteral route
    5. In end-stage malignancy, PN may cause harm and should be discouraged
    6. If ethical concern, clinicians should excuse themselves and transfer care to a qualified provider
    What do the icons mean?  score-icon-strongscore-icon-high
    Research PaperMcClave SA, Dibaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient. Am J Gastroenterol. 2016;111(3):315-34.