172 F. ADJUNCTIVE THERAPY F1. A fermentable soluble fiber additive (eg, fructooligosac- charides [FOS], inulin) should be considered for routine use in all hemodynamically stable MICU/SICU patients placed on a standard enteral formulation. Ten to 20 g of a fermentable soluble fiber supplement should be given in divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea. F2. While the use of studied probiotics species and strains appears to be safe in general ICU patients, they should be used only for select medical and surgical patient populations for which RCTs have documented safety and outcome benefit. The routine use of probiotics across the general population of ICU patients cannot be recommended at this time. (Low) F3. A combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients should be provided to those patients who require specialized nutrition therapy. (Low) F4. Supplemental enteral glutamine should not be added to an EN regimen routinely in critically ill patients. (Moderate) G. WHEN TO USE PARENTERAL NUTRITION G1. In the patient at low nutrition risk (eg, NRS 2002 ≤3 or NUTRIC score ≤5), exclusive PN should be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible. (Very Low) G2. In the patient determined to be at high nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5) or severely malnourished, when EN is not feasible, exclusive PN should be initiated as soon as possible following ICU admission. G3. In patients at either low or high nutrition risk, use of supplemental PN should be considered after 7–10 days if unable to meet >60% of energy and protein requirements by the enteral route alone. Initiating supplemental PN prior to this 7- to 10-day period in critically ill patients on some EN does not improve outcomes and may be detrimental to the patient. (Moderate) H. WHEN INDICATED, MAXIMIZE EFFICACY OF PN H1. The use of protocols and nutrition support teams are recommended to help incorporate strategies to maximize efficacy and reduce associated risk of PN. H2. Hypocaloric PN dosing (≤20 kcal/kg/d or 80% of estimated energy needs) with adequate protein (≥1.2 g protein/kg/d) should be considered in appropriate patients (high risk or severely malnourished) requiring PN—initially over the first week of hospitalization in the ICU. (Low) H3a. Withhold or limit SO-based IVFE during the first week following initiation of PN in the critically ill patient to a maximum of 100 g/wk (often divided into 2 doses/wk) if there is concern for essential fatty acid deficiency. (Very Low) H3b. Alternative IVFEs may provide outcome benefit over soy-based IVFEs; a recommendation cannot be made at this time due to lack of availability of these products in the United States. When these alternative IVFEs (SMOF [soybean oil, MCT, olive oil, and fish oil emulsion], MCT, OO,