170 B3. In the majority of MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN. B4a. The level of infusion should be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastric EN. (Moderate to High) B4b. In most critically ill patients, it is acceptable to initiate EN in the stomach. B5. In the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support. C. DOSING OF ENTERAL NUTRITION C1. Patients who are at low nutrition risk with normal baseline nutritional status and low disease severity (eg, NRS 2002 ≤3 or NUTRIC score ≤5) who cannot maintain volitional intake do not require specialized nutrition therapy over the first week of hospitalization in the ICU. C2. Either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) and those expected to have a duration of mechanical ventilation ≥72 hours, as these 2 strategies of feeding have similar patient outcomes over the first week of hospitalization. (High) C3. Patients who are at high nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5, without interleukin 6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24–48 hours while monitoring for refeeding syndrome. Efforts to provide >80% of estimated or calculated goal energy and protein within 48–72 hours should be made to achieve the clinical benefit of EN over the first week of hospitalization. C4. Sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.2–2.0 g/kg actual body weight per day and may likely be even higher in burn or multitrauma patients (see sections M and P). (Very Low) D. MONITORING TOLERANCE AND ADEQUACY OF ENTERAL NUTRITION D1. Patients should be monitored daily for tolerance of EN. Inappropriate cessation of EN should be avoided. Ordering a feeding status of nil per os (NPO) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery. D2a. GRVs should not be used as part of routine care to monitor ICU patients receiving EN. D2b. For those ICUs where GRVs are still utilized, holding EN for GRVs <500 mL in the absence of other signs of intolerance (see section D1) should be avoided. (Low) D3a. Enteral feeding protocols should be designed and implemented to increase the overall percentage of goal calories provided. (Moderate to High)