ICU Map

ICU Enteral Nutrition & Feeding Escalation

From nutritional risk stratification and early enteral nutrition to feeding intolerance management and parenteral escalation.

RecognizeAssessDecideDifferentialInterveneReassess
Critical Illness Requiring Nutritional Support (>48h Inability to Eat)
Assessment StepAssess nutritional risk: Calculate NUTRIC score or NRS-2002Explore Topic
High nutritional risk (e.g., modified NUTRIC score) identifies patients needing closer nutrition assessment, but it does not prove benefit from rapid delivery of full calorie or high-protein targets.
Clinical ActionInitiate Early Enteral Nutrition (EEN) within 24–48 hours of ICU admission
Start gastric enteral feeding when feasible, often at a trophic/low rate, and advance progressively while avoiding early overfeeding. Use indirect calorimetry when available; protein dosing should be individualized rather than routinely escalated to very high targets, particularly in severe AKI/high organ failure after EFFORT Protein and TARGET Protein.
Decision PointMonitor feeding tolerance: Do NOT routinely hold feeds for GRV < 500 mL
ASPEN/SCCM guidelines recommend against holding enteral nutrition for Gastric Residual Volumes (GRV) < 500 mL in the absence of other signs of intolerance (vomiting, abdominal distension, severe pain).
Differential Branches (2)
1Branch
Reassessment / LoopTolerating Enteral Feeds: Advance to goal rate & maintain glycemic targets
Target blood glucose 140–180 mg/dL with IV insulin protocol. Monitor serum phosphate/potassium/magnesium daily to detect and treat refeeding syndrome.
2Branch
Clinical ActionFeeding Intolerance Present (Vomiting, Distension, GRV > 500 mL)
1. Add IV prokinetic: Metoclopramide 10 mg IV q6h and/or Erythromycin 250 mg IV q8h; 2. Place post-pyloric feeding tube under electromagnetic/endoscopic guidance; 3. Reduce narcotics where feasible.
Clinical ActionIf <60% of goal calories achieved by Day 7: Initiate Supplemental Parenteral Nutrition
Initiate central line Total/Supplemental Parenteral Nutrition (TPN) with dedicated lipid/amino acid formulations to bridge protein-calorie deficit in high-risk patients.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Refeeding Syndrome — acute profound hypophosphatemia (<1.0–1.5 mg/dL), hypokalemia, and hypomagnesemia occurring 24–72h after initiating feeds in malnourished patients; causes acute diaphragmatic failure, ventricular arrhythmias, and death. Check baseline electrolytes and replace aggressively.
  • High-dose vasopressor shock with increasing lactate and abdominal pain on enteral feeds — hold enteral feeding immediately to prevent non-occlusive mesenteric ischemia (NOMI) during acute hemodynamic instability.

Related Bedside Clinical Problems (25)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Acute Hypercapnia & Ventilatory Failure

Triaging rising PaCO2: distinguishing acute uncompensated acidemia from chronic compensation, identifying central vs pump vs dead-space failure, and titrating noninvasive ventilation.

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Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

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Linked Deep-Dive Topics (6)

Reference Knowledge
Critical Illness Nutrition & Metabolismgi-hepatic

Phased energy and protein delivery, early enteral nutrition when safe, indirect calorimetry, refeeding prevention, feeding-intolerance troubleshooting, and individualized parenteral nutrition timing.

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Severe Acute Pancreatitisgi-hepatic

Revised Atlanta severity staging, goal-directed fluid resuscitation informed by WATERFALL, oral/enteral nutrition as tolerated, antibiotic avoidance in sterile necrosis, and the PANTER step-up approach.

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Acute Liver Failure (ALF)gi-hepatic

Hyperammonemia, cytotoxic cerebral edema, balanced coagulopathy, N-acetylcysteine, 3% saline neuroprotection, CRRT ammonia clearance, and King's College transplant criteria.

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Burns & Major Burn Critical Carespecial-critical-care

Inhalation injury management, endpoint-driven fluid resuscitation, avoidance of fluid creep, bedside escharotomy, and hypermetabolic catabolism support.

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Shock: Foundational Critical Care Frameworkcardiovascular

Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.

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Invasive Mechanical Ventilationrespiratory

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

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