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Dr. Surya Cahyadi Junus

Initiation of Feeding
1. Ventilated patients should receive an orogastric
tube (OGT), nasogastric tube (NGT) .The correct
position of the tube should be confirmed by
auscultation and KUB.
2. Enteral feeding should be initiated within 12-24
hours of admission to ICU, unless the patient is not
hemodynamically stable
Patients with recent abdominal surgeries require prior
discussion with the surgeon before commencing
enteral feeding.
3. Patients receiving enteral feedings should be placed
in the semi-recumbent position with the HOB 30- 45o

Estimated Needs
Estimated energy intake should be
adjusted according to the severity
and type of illness.
Energy requirements may be
calculated either through simplistic
formulas (25-30 kcal/kg/d)

Based on disease condition

Protein needs
For patients with a BMI <30, protein requirements
should be in the range of 1.2-2.0 g/kg actual body
weight per day.
For patients Class I and II patients (BMI 30-40),
protein should be provided in a range 2.1-2.4 g/kg
ideal body weight per day
For patients Class III (BMI 40) protein should 2.5
g/kg ideal body weight per day
Patients receiving hemodialysis or continuous renal
replacement therapy (CRRT) should receive
increased protein, up to a maximum of 2.5 g/kg/d.

Daily protein intake based on disease condition

It is preferred that patients receive continuous
enteral feeding during the acute phase. EN
should start at 20ml/hr, increasing by 10 mL
Q4H, reaching the goal rate as determined by
the Registered Dietitian (RD) within 48-72 hours.
EN tolerance should be monitored:
- pain and/or distention
- physical exam: distended, tense abdomen
- passage of flatus and stool
- abdominal radiographs

Gastric residuals
Gastric residuals should be checked
If GRV 200-500 mL: return residual amount, continue
formula at previous infusion rate, increasing to goal rate
by 10 mL Q4H
consider adding gastric motility agent.
If GRV >500 mL: Clinically examine for signs of
intolerance: abdominal distention, fullness, discomfort, or
presence of emesis. Return 200 mL, discard the
remainder, and hold Tube Feeding for 2 hours. Recheck
residuals after 2 hours, if GRV remains >200 mL: Continue
to hold Tube feeding
Check HOB, patient position,
Consider KUB to rule out ileus/obstruction,
Consider gastric motility agent,
Small bowel feeding by changing to volume restricted
formula or decreasing goal rate or subtitude to total
parenteral nutrition (TPN).

Emesis, abdominal distention

Check HOB/ patient position; consider holding TF

for 2 hours
KUB to rule out ileus/obstruction
gastric motility agent, anti-emetic
small bowel feeding by volume restricted formula
or decreasing goal rate

Diarrhea: >500mL every 8 hours or >3 stools per day for at least 2 consecutive

Warrants further evaluation for etiology

(enteral medications, Clostridium difficile, or
other infectious etiologies).
Persistent diarrhea (where C. difficile has
been excluded) may benefit from the use of
a soluble fiber-containing enteral formula or
the addition of soluble fiber (i.e. Benefiber,