176 O. POSTOPERATIVE MAJOR SURGERY (SICU ADMISSION EXPECTED) O1. Determination of nutrition risk (eg, NRS 2002 or NUTRIC score) should be performed on all postoperative patients in the ICU and that traditional visceral protein levels (serum albumin, prealbumin, and transferrin concentrations) should not be used as markers of nutrition status. O2. EN should be provided when feasible in the postoperative period within 24 hours of surgery, as it results in better outcomes than use of PN or STD. (Very Low) O3. The routine use of an immune-modulating formula (containing both arginine and fish oils) in the SICU is suggested for the postoperative patient who requires EN therapy. (Moderate to Low) O4. Enteral feeding is suggested for many patients in difficult postoperative situations such as prolonged ileus, intestinal anastomosis, OA, and need of vasopressors for hemodynamic support. Each case should be individualized based on perceived safety and clinical judgment. (Low to Very Low) O5. For the patient who has undergone major upper GI surgery and EN is not feasible, PN should be initiated (only if the duration of therapy is anticipated to be ≥7 days). Unless the patient is at high nutrition risk, PN should not be started in the immediate postoperative period but should be delayed for 5–7 days. O6. Upon advancing the diet postoperatively, patients should be allowed solid food as tolerated — clear liquids are not required as the first meal. P. CHRONICALLY CRITICALLY ILL P1. Chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS >21 days) should be managed with aggressive high-protein EN therapy and, when feasible, that a resistance exercise program be used. Q. OBESITY IN CRITICAL ILLNESS Q1. Early EN should start within 24–48 hours of admission to the ICU for obese patients who cannot sustain volitional intake. Q2. Nutrition assessment of the obese ICU patient should focus on biomarkers of metabolic syndrome, an evaluation of comorbidities, and a determination of level of inflammation, in addition to those parameters described for all ICU patients. Q3. Nutrition assessment of the obese ICU patient should focus on evidence of central adiposity, metabolic syndrome, sarcopenia, BMI >40, SIRS, or other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality. Q4. High-protein hypocaloric feeding should be implemented in the care of obese ICU patients to preserve lean body mass, mobilize adipose stores, and minimize the metabolic complications of overfeeding.