Nutrition and metabolic support

Nutritional risk and early enteral nutrition

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Screen risk (mNUTRIC), start enteral feeding within 24-48 h when resuscitated, and know when to delay.

Definition
Every ICU patient staying > 48 h is at risk of malnutrition. Early EN (within 48 h) is recommended over early PN or delayed EN when oral intake is not possible.

At the bedside

  1. 1

    Assess risk

    mNUTRIC ≥ 5 (age, APACHE II, SOFA, comorbidities, days in hospital before ICU) or clinical malnutrition (weight loss, low BMI, sarcopenia, reduced intake) = high risk.

  2. 2

    Oral first

    If able to eat, oral diet; add oral supplements if intake insufficient.

  3. 3

    Start EN within 48 h

    ≤ 48 h

    Via nasogastric tube (confirm position by X-ray or pH); start low (10-20 mL/h) and advance over 3-7 days.

  4. 4

    Delay EN when

    Uncontrolled shock, escalating vasopressors, uncontrolled life-threatening hypoxaemia or acidosis, active upper GI bleeding, overt bowel ischaemia, high-output fistula without distal access, abdominal compartment syndrome, GRV > 500 mL/6 h.

  5. 5

    Shock

    Start low-dose (trophic) EN once shock controlled on stable or decreasing vasopressor doses; NUTRIREA-2 showed more bowel ischaemia with full early EN in shock.

  6. 6

    Prone, ECMO, TTM, NMB

    EN is not contraindicated - continue at low dose with monitoring.

Modified NUTRIC score (no IL-6)

VariableRangePoints
Age< 50 / 50-74 / ≥ 750 / 1 / 2
APACHE II< 15 / 15-19 / 20-27 / ≥ 280 / 1 / 2 / 3
SOFA< 6 / 6-9 / ≥ 100 / 1 / 2
Comorbidities0-1 / ≥ 20 / 1
Days hospital to ICU admission0 / ≥ 10 / 1

mNUTRIC 0-9; ≥ 5 = high nutritional risk.

Red flag · call your senior now
Abdominal distension, rising lactate and vasopressor requirements on EN: suspect non-occlusive bowel ischaemia - stop feeds and investigate.
Pitfall
Keeping patients nil by mouth for days 'until stable' without a reason.
Pitfall
Blind tube placement without position confirmation.
Pearl
Bowel sounds and flatus are not required to start EN.

References

  1. 1

    Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38:48-79.

  2. 2

    Compher C, Bingham AL, McCall M, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2022;46:12-41.

  3. 3

    Rahman A, Hasan RM, Agarwala R, et al. Identifying critically-ill patients who will benefit most from nutritional therapy: further validation of the 'modified NUTRIC' nutritional risk assessment tool. Clin Nutr 2016;35:158-62.

  4. 4

    Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011;15:R268.

  5. 5

    Reignier J, Boisrame-Helms J, Brisard L, et al. Enteral versus parenteral early nutrition in ventilated adults with shock (NUTRIREA-2). Lancet 2018;391:133-43.

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