Artificial Nutrition of the Critically Ill Patient - A Critical Appraisal of the Canadian Guidelines

Apparently, the Canadian Clinical Practice Guidelines mark a change of paradigm as far as nutritional support strategies for critically ill patients are concerned. The recommendation to rather apply enteral and not parenteral nutrition in patients with a functional gastrointestinal tract has to be considered a key issue of these guidelines. The role of parenteral feeding steps down from a standard to a supplementary procedure in cases of insufficient enteral intake. The early placement of a nasojejunal tube (i,e., within 24-48 h after admission) should become a routine procedure in ICU's of tertiary centers. Low volume jejunal feeding (starting with 10-20 ml/h) should be initiated immediately after admission, provided that there are no contraindications, By,feeding the gut" via the enteral route the feeding strategy aims at maintaining intestinal barrier integrity. The enteral infusion rate should then be raised gradually, but should not provide more than 20-25 kcal per kg of body weight (feed the patient"). The question when to start supplementary parenteral nutrition remains a matter of debate. The decision whether or not combined enteral and parenteral nutrition strategies will be commenced depend on the degree of gastrointestinal intolerance to enteral feeds, the severity of preexisting malnutrition, and the level of hypermetabolism.