Enteral Nutrition

Indications for Enteral Nutrition

1. Any patient on the trauma service who is anticipated to remain unable to take full oral intake on their own for greater than 5-7 days.
2. Any patient who has oral intake with supplementation that is inadequate to meet current nutritional needs (i.e., < 50% of estimated required calories for >3 days.)
3. Any patient with pre-existing malnutrition (>15% involuntary weight loss or pre-injury albumin < 3 g/dl) or categorized as “high nutritional risk” based on a validated nutritional risk scoring system and unable to immediately resume full oral intake. It should be emphasized that for albumin to be useful as a nutrition maker, it should be obtained prior to injury. However, in the combat trauma setting, a pre-injury albumin level is unlikely to be available. Further, albumin measured during acute illness should not be used or followed as a marker of nutrition as it is an acute phase reactant and will markedly decrease during the initial period of critical illness. An initial pre-albumin level is also less useful immediately after injury, but serial pre-albumin levels can be useful during the resolution and recovery phase. If utilized pre-albumin should not be checked more frequently than once weekly.1-4

Absolute Contraindications for Enteral Nutrition

- High risk for non-occlusive bowel necrosis

1. Active shock or ongoing resuscitation
2. Persistent mean arterial pressure (MAP) < 60mmHg
3. Increasing requirement for vasoactive support to maintain MAP>60mmHg

- Generalized peritonitis
- Intestinal obstruction
- Surgical discontinuity of bowel
- Paralytic ileus
- Intractable vomiting/diarrhea refractory to medical management
- Known or suspected mesenteric ischemia
- Major gastrointestinal bleed
- High output uncontrolled fistula 1-3

Relative Contraindications for Enteral Nutrition

- Body temperature < 96 F
- Concern for abdominal compartment syndrome as evidenced by bladder pressure > 25mmHg 1-3