171 D3b. Use of a volume-based feeding protocol or a top-down multistrategy protocol should be considered. D4. Patients receiving EN should be assessed for risk of aspiration and steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed. D4a. Divert the level of feeding by postpyloric enteral access device placement in patients deemed to be at high risk for aspiration (see also section B5). (Moderate to High) D4b. For high-risk patients or those shown to be intolerant to bolus gastric EN, delivery of EN should be switched to continuous infusion. D4c. In patients at high risk of aspiration, agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), should be initiated where clinically feasible. (Low) D4d. Nursing directives to reduce risk of aspiration and VAP should be employed. In all intubated ICU patients receiving EN, the head of the bed should be elevated 30°–45° and use of chlorhexidine mouthwash twice a day should be considered. D5. Neither blue food coloring nor any coloring agent should be used as a marker for aspiration of EN. Glucose oxidase strips should not be used as surrogate markers for aspiration in the critical care setting. D6. EN should not be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment. E. SELECTION OF APPROPRIATE ENTERAL FORMULATION E1. Use a standard polymeric formula when initiating EN in the ICU setting. Avoid the routine use of all specialty formulas in critically ill patients in the MICU and disease- specific formulas in the SICU. E2. Immune-modulating enteral formulations (arginine with other agents, including eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], glutamine, and nucleic acid) should not be used routinely in the MICU. Consideration for these formulations should be reserved for patients with TBI and perioperative patients in the SICU (see sections O and M). (Very Low) E3. The routine use of an enteral formulation characterized by an anti-inflammatory lipid profile (eg, omega-3 FOs, borage oil) and antioxidants in patients with ARDS and severe ALI, cannot be recommended at this time, given conflicting data. (Low to Very Low) E4a. A commercial mixed fiber formula should not be used routinely in the adult critically ill patient prophylactically to promote bowel regularity or prevent diarrhea. (Low) E4b. Use a commercial, mixed fiber-containing formulation if there is evidence of persistent diarrhea. Avoid both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. We suggest considering use of small peptide formulations in the patient with persistent diarrhea, with suspected malabsorption or lack of response to fiber.