174 K2. EN should be used preferentially when providing nutrition therapy in ICU patients with acute and/or chronic liver disease. K3. Standard enteral formulations should be used in ICU patients with acute and chronic liver disease. There is no evidence of further benefit of branched-chain amino acid (BCAA) formulations on coma grade in the ICU patient with encephalopathy who is already receiving first-line therapy with luminal-acting antibiotics and lactulose. L. ACUTE PANCREATITIS L1a. The initial nutrition assessment in acute pancreatitis should evaluate disease severity to direct nutrition therapy. Since disease severity may change quickly, frequent reassessment of feeding tolerance and the need for specialized nutrition therapy is suggested. L1b. Providing specialized nutrition therapy to patients with mild acute pancreatitis is not suggested, instead advancing to an oral diet as tolerated. If an unexpected complication develops or there is failure to advance to oral diet within 7 days, then specialized nutrition therapy should be considered. (Very Low) L1c. Patients with moderate to severe acute pancreatitis should have a naso-/oroenteric tube placed and EN started at a trophic rate and advanced to goal as fluid volume resuscitation is completed (within 24–48 hours of admission). (Very Low) L2. Use of a standard polymeric formula to initiate EN in the patient with severe acute pancreatitis is suggested. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time. (Very Low) L3a. Use of EN over PN is suggested in patients with severe acute pancreatitis who require nutrition therapy. (Low) L3b. EN should be provided to the patient with severe acute pancreatitis by either the gastric or jejunal route, as there is no difference in tolerance or clinical outcomes between these 2 levels of infusion. (Low) L4. In patients with moderate to severe acute pancreatitis who have intolerance to EN, measures should be taken to improve tolerance. L5. The use of probiotics should be considered in patients with severe acute pancreatitis who are receiving early EN. (Low) L6. For the patient with severe acute pancreatitis, when EN is not feasible, use of PN should be considered after 1 week from the onset of the pancreatitis episode. M. SURGICAL SUBSETS Trauma M1a. Similar to other critically ill patients, early enteral feeding with a high-protein polymeric diet should be initiated in the immediate posttrauma period (within 24–48 hours of injury) once the patient is hemodynamically stable. (Very Low)