CRITICAL CARE NUTRITION IN 2026: WHAT THE EVIDENCE REALLY SUPPORTS

Background: Nutritional support is a fundamental component of intensive care, yet optimal timing, energy delivery, protein dosing and route remain debated. Recent guideline revisions and randomized trials challenge traditional assumptions about early full feeding and high protein provision.

Objective: To critically synthesize contemporary evidence and translate the ESPEN 2023 and ASPEN 2022 recommendations into practical, individualized nutritional strategies for critically ill adults.

Evidence and Key Findings: Early enteral nutrition, generally initiated within 48 hours when feasible, remains preferred, but delivery should progress cautiously during the acute phase rather than immediately reaching full targets. Indirect calorimetry is the preferred method for estimating energy expenditure; ESPEN recommends hypocaloric feeding early, followed by progression toward 80–100% of measured expenditure after day three. The NUTRIREA-3 trial found no mortality advantage from standard versus low early calorie delivery in ventilated patients with shock. Protein should also be increased progressively, with ESPEN suggesting approximately 1.3 g/kg/day. The EFFORT Protein trial did not demonstrate an overall benefit from higher protein dosing and raised concerns in patients with acute kidney injury. Enteral versus parenteral feeding decisions should reflect gastrointestinal function, tolerance and individual risk, rather than rigid adherence to one route. Routine intravenous glutamine in unstable patients with multiorgan failure and high-dose antioxidants without established deficiency should be avoided. Safe implementation also requires glycaemic control, electrolyte surveillance, prevention of refeeding syndrome and regular assessment of actual nutritional delivery.

Conclusions: Modern critical care nutrition prioritizes individualized, progressive support over aggressive early targets. Integrating trial evidence with guideline recommendations, physiological monitoring and multidisciplinary reassessment may improve the safety and consistency of bedside practice.