Table 1.
Recommendations and degree of consensus according to the ESPEN SOP.
| Recommendations | Section | Degree of Consensus |
|---|---|---|
| 1. The goal of nutrition therapy is to promote the maintenance of normal body function and the functional recovery of patients. | A. Objectives of clinical nutrition in critically ill patients | Strong consensus (98%) |
| 2. The efficiency of nutrition therapy depends on patient-related factors, the management of injury, the quality of the nutritional prescription and the impact of contributing or harmful factors. | A. Objectives of clinical nutrition in critically ill patients | Strong consensus (100%) |
| 3. The different evolutionary phases of critically ill patients create changes in their metabolic pattern, some of them without anabolism. | B. Critical patient phases | Strong consensus (98%) |
| 4. The design of nutrition therapy is dynamic and should be reassessed at each phase. | B. Critical patient phases | Strong consensus (100%) |
| 5. It would be useful to have a systematic assessment on hand that would help us identify which metabolic phase a critical patient is in. | B. Critical patient phases | Strong consensus (100%) |
| 6. Life support techniques can alter nutritional efficiency in critically ill patients. | B. Critical patient phases | Strong consensus (92%) |
| 7. The calculation of protein and caloric needs should be done on an individual basis and in consideration of co-morbidities, the patient’s usual weight, their BMI and the time of development (including physical therapy). | C. The quality of the nutritional process | Strong consensus (100%) |
| 8. Within each center’s nutritional formulary, there must be a variety of formulas that are sufficient when it comes to meeting the specific needs of critically ill patients at each time point (hyperproteic, with or without fiber, hypercaloric, organ-specific, etc.). | C. The quality of the nutritional process | Consensus (87%) |
| 9. Nutritional history should be included in the critically ill patient’s medical history: number of days without eating, weight loss, previous physical activity, use of “digestive” drugs, etc. | C. The quality of the nutritional process | Strong consensus (100%) |
| 10. Caloric and protein intake calculation should take into account non-nutritional calories (e.g., propofol, citrate, serum) and increases in physiotherapy-related requirements. | C. The quality of the nutritional process | Strong consensus (97%) |
| 11. Prescription does not guarantee that the patient’s requirements are met, so strategies should be implemented in order to ensure that the patient receives the total amount of the prescribed nutrition. | C. The quality of the nutritional process | Strong consensus (100%) |
| 12. The enteral route is the route of choice in critically ill patients. Given the difficulty of achieving the prescribed requirements by the enteral route, and after optimizing tolerance, the parenteral route (complementary or total) should be considered. | C. The quality of the nutritional process | Strong consensus (92%) |
| 13. In patients receiving an oral diet, monitoring of intake is recommended in order to identify patients in need of supplementation. | C. The quality of the nutritional process | Strong consensus (95%) |
| 14. A diverse menu choice that increases patient satisfaction with food can help increase their intake and thus help improve nutritional status. | C. The quality of the nutritional process | Agreement in favor (72% in first round; 85.7% after review of the text) |
| 15. Critically ill patients are at nutritional risk, which is aggravated if there is prior malnutrition. | D. Safety in prescribing medical nutrition therapy | Strong consensus (100%) |
| 16. Inadequate administration of nutrients can lead to metabolic complications in critically ill patients (nutritrauma). Prevention is essential, especially in the early stages of nutrition therapy. | D. Safety in prescribing medical nutrition therapy | Strong consensus (100%) |
| 17. Monitoring of physical, digestive or metabolic complications is essential, continuous and should be integrated into routine clinical practice. | D. Safety in prescribing medical nutrition therapy | Strong consensus (95%) |
| 18. Tissue hypoperfusion markers should be included in the assessment at the beginning of enteral nutrition in critically ill patients. | D. Safety in prescribing medical nutrition therapy | Consensus (87%) |
| 19. Medical nutrition therapy should not be initiated until critically ill patients are in a state of stabilized shock. | D. Safety in prescribing medical nutrition therapy | Strong consensus (97%) |
| 20. The transition between nutrient access routes (PN, EN, ON) is a complex time that should follow protocol and be monitored in a specific manner. | D. Safety in prescribing medical nutrition therapy | Strong consensus (97%) |
| 21. Before starting oral nutrition, the patient’s clinical condition must be adequate to test for dysphagia. | D. Safety in prescribing medical nutrition therapy | Strong consensus (21% in first round; 95% after review of the text) |
| 22. Referral to other care services is a time of risk in which the continuity of medical nutrition therapy must be ensured. | D. Safety in prescribing medical nutrition therapy | Strong consensus (90%) |
| 23. During the anabolic phase, protein contribution should be increased and combined with a rehabilitation program that promotes nutrient transformation to lean mass. | E. Determinants of food transformation into lean mass | Strong consensus (100%) |
| 24. The use of high-quality proteins (digestibility, amino acid composition, etc.) favors nutritional efficiency. | E. Determinants of food transformation into lean mass | Favorable Agreement (66%) |
| 25. It is critical to assess muscle dysfunction (MRC/MRC-SS, ICU mobility score, etc.) to categorize ICU patients based on their rehabilitation needs. | E. Determinants of food transformation into lean mass | Consensus (87%) |
| 26. Critical patient rehabilitation must be a process integrated into their care, and it should follow protocol and be progressive and based on objectives. | E. Determinants of food transformation into lean mass | Strong consensus (97%) |
| 27. Muscle and functional recovery of critically ill patients exceeds their ICU stay (and most likely their hospital stay), so continued medical nutrition therapy and rehabilitation outside the ICU is necessary. | E. Determinants of food transformation into lean mass | Strong consensus (100%) |
| 28. Rehabilitation sessions range from passive treatment to the recovery of maximum function in the patient. | E. Determinants of food transformation into lean mass | Consensus (86%) |
| 29. Physiotherapy sessions should increase in intensity in accordance with the patient’s tolerance at each time point. Rest is an essential part of the rehabilitation strategy. | E. Determinants of food transformation into lean mass | Consensus (58% in first round; 76.2% after review of the text) |
| 30. Devices that facilitate recovery of lean mass, e.g., cycloergometers, standing frames, walking slings, etc., must be incorporated. | E. Determinants of food transformation into lean mass | Agreement in favor (69%) |
| 31. Currently, we do not have tools that would allow us to adequately calculate nutritional efficiency in critically ill patients. | F. Is it possible to monitor nutritional efficiency? | Strong consensus (94%) |
| 32. In the absence of a key indicator of nutritional efficiency, close monitoring of the nutritional process should be performed to optimize its results. | F. Is it possible to monitor nutritional efficiency? | Strong consensus (94%) |
| 33. Imaging techniques could play a very important future role in the monitoring of muscle quantity and functional quality. | F. Is it possible to monitor nutritional efficiency? | Strong consensus (94%) |
| 34. Medical nutrition therapy is a care process that has an impact on patient prognosis. | G. Key elements in transforming a care process | Strong consensus (91%) |
| 35. Medical nutrition therapy in critically ill patients is, by necessity, multidisciplinary and requires the dedication of intensivists, nutritionists, endocrinologists, nurses, physiotherapists, physiatrists, speech therapists, hospital pharmacists, etc., integrated into the team and with experience in managing this type of patient. | G. Key elements in transforming a care process | Strong consensus (95.2%) |
| 36. It is necessary that we go beyond following protocols. To this end, the following aspects are critical: 1. The formation and motivation of the multidisciplinary team involved in the process. 2. Having a simplified version of the protocol and a definition of process indicators on hand. | G. Key elements in transforming a care process | Strong consensus (95.2%) |
| 37. It is necessary to identify leaders who promote training, evaluation, analysis and feedback as essential parts of the process. | G. Key elements in transforming a care process | Strong consensus (100%) |
| 38. Each unit must have a reference person that coordinates this process. This figure must be recognized by managers. | G. Key elements in transforming a care process | Consensus (81%) |
| 39. Adapting protocols to different formats or models of care aids their implementation. | G. Key elements in transforming a care process | Consensus (82%) |
| 40. Training through clinical practice is a useful tool that benefits from different strategies: daily checklists, weekly multidisciplinary sessions and periodic safety rounds | G. Key elements in transforming a care process | Strong consensus (100%) |