Expert consensus‑based clinical practice guidelines for nutritional support in the intensive care unit: the French Intensive Care Society (SRLF) and the French-Speaking Group of Pediatric Emergency Physicians and Intensivists (GFRUP)
SRLF/SFAR · 2025 · France
Source and licence
- Authors
- Jean Reignier, Benedicte Gaillard-Le Roux, Pierre François Dequin et al.
- Title
- Expert consensus‑based clinical practice guidelines for nutritional support in the intensive care unit: the French Intensive Care Society (SRLF) and the French-Speaking Group of Pediatric Emergency Physicians and Intensivists (GFRUP)
- Journal
- Annals of Intensive Care, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC12263543
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Results and guidelines
- The experts identified 24 PICO questions leading to 34 and 29 recommendations for adults and children, respectively. For adults, the level of evidence was high (GRADE 1) for three recommendations, moderate (GRADE 2) for 12 recommendations, and very low (expert opinion), for 19 recommendations. The corresponding numbers for children were one, five, and 23. Strong agreement by the panel of experts was achieved for all recommendations.
Guidelines for adults
- R1The experts suggest early initiation of nutritional support in critically ill adults, within 48 h after intensive care unit (ICU) admission.
- R2In critically ill adults, either enteral nutrition (EN) or parenteral nutrition (PN) can be used within the first week after ICU admission.Grade 1+, strong agreement
- R3Given the lack of data on patient outcomes, the experts cannot recommend using a specific equation instead of the standard method for estimating energy needs in critically ill adults (Kcal/kg/d adjusted for body-mass index).
- R4Although reliable for assessing energy expenditure, indirect calorimetry (IC) should probably not be used routinely at the bedside with the goal of improving outcomes of critically ill adults.Grade 2-, strong agreement
- R5.1A low energy supply of 6–8 kcal/kg/d (adjusted for BMI) should probably be administered during the first ICU week in mechanically ventilated patients, instead of the standard energy supply of 20–25 kcal/kg/d (adjusted for BMI).Grade 2+, strong agreement
- R5.2The experts suggest changing to a standard energy supply (20–30 kcal/kg/d, adjusted for BMI) at the end of the first ICU week.
- R6In critically ill adults who are receiving standard energy supplies and have hypophosphatemia (< 0.65 mmol/L), the energy intake should probably be reduced to 20 kcal/h (480 kcal/day) for two days, then increased progressively.Grade 2+, strong agreement
- R8Supplemental parenteral nutrition (supplemental PN) should probably not be given before day 7 after ICU admission in critically ill adults who are unable to meet their nutritional needs with oral or enteral nutrition.Grade 2-, strong agreement
- R9Energy- and/or protein-enriched solutions should probably not be used in critically ill adults.Grade 2-, strong agreement
- R10.1The experts suggest the enteral or parenteral administration of micronutrient supplements in critically ill adults with insufficient micronutrient intakes (e.g., due to fasting, parenteral nutrition, or prolonged enteral nutrition < 1500 kcal/d) or with increased losses due to renal replacement therapy (RRT).
- R11The experts suggest reserving postpyloric feeding for critically ill adults with enteral nutrition intolerance refractory to appropriate management.
- R12The experts suggest that gastrostomy should not be used routinely instead of orogastric or nasogastric tubes for prolonged EN in critically ill adults.
- R13Continuous enteral nutrition should probably be preferred over bolus enteral nutrition in critically ill adults.Grade 2+, strong agreement
- R14In critically ill adults, enteral nutrition should probably be continued until extubation, with no pre-extubation fasting period.Grade 2+, strong agreement
- R15The experts suggest either gradual or immediate achievement of the energy target, with monitoring of phosphatemia and digestive tolerance in critically ill adults receiving enteral nutrition.
- R16Gastric residual volume (GRV) should probably not be monitored routinely with the goal of assessing enteral nutrition intolerance or preventing nosocomial pneumonia in critically ill adults.Grade 2-, strong agreement
- R17.1For critically ill adults with persistent enteral nutrition intolerance despite adequate symptomatic treatment, the experts suggest decreasing the enteral nutrition delivery rate for a predefined period of a few hours rather than stopping enteral nutrition.
- R17.2The experts suggest that causes of EN intolerance should be investigated before administering symptomatic treatment.
- R18.1Prokinetic agents should probably be used to decrease vomiting in critically ill adults with enteral nutrition intolerance.Grade 2+, strong agreement
- R19.1In patients on mechanical ventilation who are receiving enteral nutrition and require prone positioning, the experts suggest continuing enteral nutrition during the prone periods.
- R19.2The experts suggest that the nutritional protocol for patients managed with prone positioning should include prophylactic prokinetic agents and elevated head-of-bed position, to improve enteral nutrition tolerance.
- R20.1The experts suggest the use of fiber-containing enteral nutrition products in critically ill adult patients with diarrhea.
- R20.2There is insufficient evidence to recommend the routine use of fiber-containing enteral nutrition products to prevent diarrhea or other digestive complications in critically ill adults.
- R22.1In critically ill adults with acute pancreatitis and persistent organ failure, enteral nutrition should probably be initiated within the first week following ICU admission.Grade 2+, strong agreement
- R22.2In critically ill adults with acute pancreatitis and persistent organ failure, enteral nutrition should be preferred over parenteral nutrition.Grade 1+, strong agreement
- R22.3In critically ill adults with acute pancreatitis and persistent organ failure, initial nasojejunal tube feeding should probably not be prioritized over nasogastric tube feeding.Grade 2-, strong agreement
- R23.1The experts suggest oral feeding with monitoring of swallowing for critically ill adults receiving noninvasive ventilation or high-flow nasal oxygen.
- R23.2There is no evidence to recommend additional enteral nutrition or parenteral nutrition for critically ill adult patients receiving noninvasive ventilation or high-flow nasal oxygen during the first ICU week.
- R24The experts suggest that a comprehensive nutritional and physical assessment be conducted before ICU discharge to develop a personalized nutritional and physical rehabilitation program designed to promote functional recovery.
Abstract
The objective of this work was to develop guidelines for nutritional support in critically ill adults and children (excluding neonates and burn patients) unable to maintain an adequate oral intake. We aimed to provide up-to-date recommendations based on high-level evidence including the results of recent landmark randomized controlled trials. Experts from the French Intensive Care Society (SRLF), the French Society of Clinical Nutrition and Metabolism (SFNCM), and the French-Speaking Group of Pediatric Emergency Physicians and Intensivists (GFRUP) used the GRADE methodology to develop the guidelines. Twenty-four Patient Intervention Comparator Outcome (PICO) questions were identified, resulting in 34 adult and 29 pediatric recommendations. Of the 34 recommendations for adults, three were based on high-level evidence, 12 on moderate-level evidence, and 19 on expert opinion. The corresponding numbers for the 29 pediatric recommendations were one, five, and 23. All recommendations achieved strong agreement among the experts. These guidelines emphasize the importance of individualized nutritional support strategies that incorporate recent high-quality evidence to optimize the outcomes of critically ill patients.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Results and guidelines
- Guidelines for adults
- Guidelines for children
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