Individualizing post-ICU nutrition: from guideline intent to bedside practice.

Precision nutrition in critical illness: a phase-specific framework from acute feeding to post-ICU recovery

An operational framework with bedside indicators for early acute illness, stabilization/prolonged ICU care, and post-ICU recovery is proposed, which contextualizes existing recommendations and requires prospective validation.

Optimizing nutritional care across the continuum from intensive care to recovery: an expert opinion review.

INTRODUCTION Survivorship after critical illness is frequently complicated by muscle wasting and gastrointestinal (GI) dysfunction, driving prolonged functional impairment. Nutrition is a modifiable determinant across the intensive care unit (ICU)-to-home continuum, yet delivery is commonly limited by feeding intolerance and fragmented transitions of care. AREAS COVERED This expert opinion review synthesizes evidence identified via a narrative search of MEDLINE/PubMed and key guideline/reference screening, focusing on GI dysfunction as a barrier to enteral nutrition (EN) in the ICU, phase-adapted energy and protein provision, and strategies to restore intake during ward recovery and after discharge, including high-energy, protein-dense oral nutritional supplements (ONS). EXPERT OPINION Nutrition should be delivered as a structured pathway rather than a single ICU intervention. Early EN with proactive, symptom-targeted management of GI dysfunction, coupled with stepwise protein escalation aligned to metabolic phase and organ function, may help reduce avoidable deficits. The early post-ICU period is an anabolic 'window of opportunity' that warrants intake monitoring, deliberate tapering of tube feeds only once oral intake is reliable, and routine post-discharge ONS for patients at nutritional risk. Research should prioritize pragmatic trials of phase-specific targets and transition-of-care models.

Key principles for rehabilitation of critically ill patients with obesity.

PURPOSE Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery. METHODS The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence. RESULTS Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals. CONCLUSION Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.

Feeding or Failing? Rethinking Nutrition Therapy in Pediatric Critical Care

Malnutrition, whether pre-existing or acquired in the ICU, is common in critically ill children. This narrative review synthesizes current evidence on nutritional assessment and therapy, highlighting how illness phase, underlying disease, and medical interventions influence energy expenditure and nutrient requirements. International guidelines recommend comprehensive nutritional assessment and early initiation of enteral nutrition (EN) for all patients admitted to the Pediatric ICU. However, EN is frequently underutilized or insufficient to meet metabolic demands and sometimes contraindicated. Barriers to delivery persist, and parenteral nutrition (PN) may be required when EN is not feasible or adequate. Nutrition plays a crucial yet complex role in the care of critically ill children. Optimizing individualized nutrition strategies, including timely EN and appropriate PN use, is essential to improve clinical outcomes, support recovery, and enhance long-term rehabilitation, while highlighting the need for improved implementation and future research.

Providing appropriate response-contingent phase-specific nutrition therapy in critical illness.

PURPOSE OF REVIEW The pathogenesis of critical illness drives a dynamic cascade of clinical, metabolic, and immunologic abnormalities through the course of disease. Recent randomized trials show that early full-dose feeding for critically ill patients is ineffective and potentially harmful compared to trophic feeding. The aim of this review is to propose a response-contingent phase-specific strategy of nutrition therapy appropriate for this patient population. RECENT FINDINGS Barriers to delivering effective nutritional therapy exist, ranging from bioenergetic failure related to mitochondrial dysfunction and gastrointestinal dysmotility with feeding intolerance, to microbial dysbiosis and impaired substrate utilization characterized by inefficient energy production and futile substrate cycling. Emerging concepts are helping to design more appropriate regimens, including estimation of potential benefit from nutritional therapy based on disease severity, risk of net harm, and determination of the stage of enteral nutrition responsiveness, which can be conceptualized as the capacity for achieving phase-specific goals within the constraints of physiologic state, metabolic capacity, safety, and feasibility. SUMMARY Calibrating goals, dosage, monitoring strategies, and expectations from nutritional therapy is required to overcome barriers imposed by the underlying pathophysiology and to optimize support, as these complex patients transition through the acute phase of critical illness towards recovery and rehabilitation.

OF ICU-ACQUIRED WEAKNESS IN CRITICALLY ILL PATIENTS: EVIDENCE, LIMITATIONS