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Trauma and critical illness induce profound metabolic and inflammatory responses, thus leading to increased energy and protein requirements. Inadequate nutritional support is associated with poor outcomes, including infections, prolonged mechanical ventilation, and higher mortality. Despite advancements, challenges remain in terms of optimizing nutritional strategies for these vulnerable populations. The aim of this review is to explore the current evidence on nutritional support for trauma and critically ill patients.
Methods
A systematic search of PubMed was conducted, focusing on energy estimation, protein requirements, timing, delivery methods, and monitoring strategies of nutritional support. Particular attention was given to emerging technologies and tailored approaches.
Results
This review highlights the importance of early enteral nutrition (EN) within 24–48 h, prioritizing post-pyloric feeding in cases of gastrointestinal intolerance. Simplified energy calculations (20–30 kcal/kg/day) are recommended when indirect calorimetry is unavailable. Protein needs range from 1.5–2.5 g/kg/day, particularly in hypercatabolic states. Biochemical markers, including CRP and procalcitonin, guide adjustments by contextualizing inflammatory responses. Bioimpedance analysis and exhaled CO2 measurements represent promising advances in dynamic nutritional monitoring, offering noninvasive alternatives to traditional methods. Multidisciplinary collaboration is essential to address unique challenges, such as trauma-induced metabolic dysregulation and complications like refeeding syndrome.
Conclusion
Optimized nutritional support in trauma and critically ill patients requires a combination of evidence-based practices and individualized care. Early initiation, dynamic monitoring, and advanced technologies are key to improving outcomes. Future research should refine predictive models and explore novel interventions such as advanced monitoring technologies to further enhance recovery in these populations.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Trauma and critical illness are leading causes of morbidity and mortality worldwide, affecting diverse populations and placing significant demands on healthcare systems. Both conditions induce profound metabolic and inflammatory responses, leading to hypermetabolism, muscle catabolism, and immune dysfunction. Inadequate nutritional support exacerbates these issues, contributing to poor outcomes such as prolonged mechanical ventilation, higher infection rates, and increased mortality [1, 2].
Over the past decades, advancements in nutritional strategies have improved care for trauma and critically ill patients. Early enteral nutrition (EN), individualized energy and protein prescriptions, and advanced monitoring techniques have emerged as pillars of modern nutritional therapy [3, 4].
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However, significant challenges to translating these strategies into clinical practice persist, particularly in resource-limited settings or complex cases such as gastrointestinal intolerance, hemodynamic instability, or trauma-induced dysregulation [3].
This review aims to synthesize current evidence on nutritional support for trauma and critically ill patients, addressing key topics such as energy estimation, protein requirements, timing, delivery methods, and monitoring strategies. By integrating emerging technologies and tailored approaches, this review seeks to provide practical insights for optimizing nutritional care in these vulnerable populations [4, 5].
Methods
A systematic review of the literature was conducted using the PubMed database to identify studies relevant to nutritional support in trauma and critically ill patients according to the PRISMA statement (https://www.prisma-statement.org/). The search strategy included a combination of Medical Subject Headings (MeSH) terms and free-text keywords such as “nutritional support,” “trauma patients,” “critically ill,” “enteral nutrition,” and “protein requirements,” as shown in Fig. 1.
Inclusion criteria consisted of clinical trials, observational studies, systematic reviews, and guidelines published in English between 1999 and 2023. Studies focusing on energy estimation, protein requirements, timing of nutrition initiation, delivery methods (enteral and parenteral), and monitoring strategies were prioritized.
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Exclusion criteria included studies with low methodological quality, those not directly related to trauma or critical illness, and research conducted in pediatric or neonatal populations.
Relevant data were extracted from selected articles, focusing on findings that addressed key topics such as energy and protein needs, timing and routes of delivery, biochemical monitoring, and emerging technologies. The extracted data were synthesized to provide evidence-based recommendations and highlight knowledge gaps for future research.
Results
Out of 549 articles selected using the filters, 467 were excluded for the reasons outlined in Fig. 1.
The first step in diagnosing malnutrition is identifying patients who are malnourished or at risk of malnutrition. A general clinical assessment should be conducted to evaluate malnutrition in the intensive care unit (ICU), until a specific tool has been definitively validated ([6]; Table 1).
Table 1
Clinical assessment to assess malnutrition in the ICU
SGA (subjective global assessment)
The SGA includes professional judgment of the severity of the loss of muscle mass and subcutaneous fat
SGA-A → well nourished
SGA-B → suspected or moderately malnourished
SGA-C → severely malnourished
Hospitalized patients
Developed to assess nutritional status and predict clinical outcomes in surgical patients → shown in a systematic review to have a better predictive value than MNA [24], especially for hospital mortality, LOS, complications
MNA (mini nutritional assessment)
MNA-SF (abbreviated)
Anthropometry
General evaluation
Dietary assessment
Subjective assessment
MNA-SF < 11 → risk of malnutrition → full nutritional assessment should be administered
MNA → 17–23.5 significant risk of malnutrition → patients may not present weight loss and low albumin levels, but they are very likely to present a decrease in calorie intake that can be easily reversed with nutritional intervention
MNA < 17 → clear malnutrition → patients usually have weight loss and low albumin levels, requiring a nutritional intervention and an assessment to identify the cause of malnutrition
Mainly elderly population
Developed for assessment and early detection of nutritional status in the elderly population
Reproducible, easy to perform, user friendly, cheap, presents high sensitivity and specificity [25]
Alternative 2: Weight loss (unintentional) > 10% or 5% in the past 3 months, combined with either: 1) BMI < 20 kg/m2 if < 70 years or < 22 if > 70 years or FFMI < 15 and < 17 in women and men, respectively
Alternative 1 or 2 to diagnose malnutrition:
Before diagnosis of malnutrition is considered, it is mandatory to fulfil criteria for being “at risk” of malnutrition by any validated risk screening tools [27]
Validated in hospitalized and outpatient patients
Minimum consensus-based criteria for the diagnosis of malnutrition, applicable regardless of the clinical setting and the etiology of malnutrition
AND/ASPEN criteria
Six items
Two or more present: malnourished
Recent energy intake
Weight loss
Muscle mass depletion
Adipose tissue depletion
Edema
Functional capacity
N/A
Correlation with negative clinical outcomes
Developed by consensus over ESPEN, ASPEN, FELANPE, PENSA
Step 1: use a validated screening tool to ascertain the existence of malnutrition risk
Step 2: assessment for diagnosis of malnutrition and severity
To diagnose malnutrition, a combination of at least one phenotypic (weight loss, low BMI, reduced muscle mass) and one etiological criterium (reduced food intake or assimilation, inflammation) must be present
N/A
N/A
ICU intensive care unit
Nutritional support for trauma and critically ill patients must be tailored to the patient’s clinical phase, as metabolic demands and tolerance can vary significantly. The hyperacute phase focuses on hemodynamic stabilization, during which nutritional interventions are often postponed. In the acute phase, careful initiation of nutritional support is essential to prevent complications such as refeeding syndrome. During the recovery phase, prioritizing higher caloric and protein intake is crucial to meet the demands of healing and rehabilitation. These phases inform the strategies discussed in this review.
Energy expenditure and protein needs in trauma and critically ill patients
An accurate estimation (Table 1) of energy expenditure is essential for effective and optimal nutritional support in trauma and critically ill patients. Indirect calorimetry (IC) remains the gold standard for measuring resting energy expenditure (REE), allowing precise adjustments to caloric intake. However, IC is often unavailable in clinical settings due to cost and resource restrictions [1, 3].
Recent guidelines highlight the limitations of predictive equations, which frequently fail to account for the dynamic and heterogeneous metabolic states in critically ill and trauma patients [4, 7]. As an alternative, simplified caloric estimations, such as 20–25 kcal/kg/day for critically ill patients and 25–30 kcal/kg/day for trauma patients, have emerged as practical and reliable methods when IC is not available [8, 9]. These estimations strike a balance between underfeeding, which exacerbates malnutrition, and overfeeding, which is associated with complications such as hyperglycemia and hepatic steatosis [10].
Protein needs remain particularly elevated in both populations due to severe catabolism. Simplified recommendations suggest protein intake of 1.5–2.5 g/kg/day, depending on the severity of the injury or illness [2, 11]. Early initiation of high-protein enteral nutrition (EN) has demonstrated benefits in reducing nitrogen loss, preserving lean body mass, and promoting wound healing in trauma patients [2, 10].
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Timing of nutritional support
The timing of nutritional support plays a pivotal role in patient outcomes. Early initiation of EN within the first 24–48 h after injury or ICU admission has been consistently associated with reduced sepsis rates, shorter ICU stays, and lower mortality [5, 12, 13]. Trauma patients undergoing resuscitation and critically ill patients with refractory shock require individualized timing based on hemodynamic stability to prevent exacerbating organ dysfunction [8, 14, 15].
Route of administration
The selection of the appropriate delivery method for nutritional support in trauma and critically ill patients depends on gastrointestinal function, metabolic needs, and the patient’s clinical condition and hemodynamic status. Enteral nutrition (EN) is the preferred approach whenever feasible due to its physiological benefits, which include maintaining gut integrity, reducing bacterial translocation, and minimizing infectious complications [4, 16].
Enteral nutrition can be administered via several routes, with nasogastric or orogastric feeding being most common for patients with intact gastric motility. These methods are simple, cost effective, and generally well tolerated. However, in trauma patients with a basilar skull fracture, an orogastric tube is preferred over a nasogastric tube to avoid complications such as intracranial placement through a disrupted cribriform plate [4, 9]. For patients with gastric dysmotility, aspiration risk, or severe trauma, post-pyloric feeding may be required. Feeding tubes can be advanced beyond the stomach and into the jejunum via nasojejunal or gastrojejunostomy routes, ensuring reliable nutrient delivery while reducing the complications associated with delayed gastric emptying [9].
Monitoring of gastric residual volumes (GRVs) is commonly employed to assess tolerance to EN, but its routine use remains controversial. Recent evidence suggests that clinical signs such as vomiting, abdominal distension, or diarrhea are more reliable indicators of intolerance than strict GRV thresholds [4, 16].
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When EN is not feasible due to conditions such as bowel ischemia, ileus, or perforation, total parenteral nutrition (TPN) becomes necessary [4, 5]. Administration of TPN requires a central venous catheter (CVC) to safely deliver hyperosmolar nutrient solutions. Peripheral administration may be considered for short-term or less concentrated solutions, but central access is preferred for prolonged TPN to reduce the risk of vein irritation and ensure adequate nutrient delivery [4].
Total parenteral nutrition requires meticulous monitoring to prevent metabolic complications including hyperglycemia, hypertriglyceridemia, and liver dysfunction [10]. Additionally, the risk of catheter-related bloodstream infections necessitates strict aseptic techniques during catheter insertion and regular care to minimize infections.
In cases where EN alone is insufficient to meet the patient’s caloric requirements, a combined approach of EN and TPN can be used to optimize nutritional delivery while awaiting recovery of gastrointestinal function. This hybrid strategy ensures that energy and protein needs are met without over-relying on TPN, which may have a higher risk of complications [4, 17].
Tolerance to nutritional support
Ensuring tolerance to nutritional support is a critical aspect of care in trauma and critically ill patients, as intolerance can significantly compromise the delivery of adequate nutrition and increase the risk of complications. The approaches to managing tolerance differ depending on whether the patient is receiving enteral nutrition (EN) or total parenteral nutrition (TPN).
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Enteral nutrition
Trauma patients, particularly those with abdominal or thoracic injuries, frequently experience delayed gastric emptying and gastrointestinal dysmotility due to their severe inflammatory and metabolic responses. In such cases, strategies like post-pyloric feeding via nasojejunal tubes or the use of prokinetic agents such as metoclopramide or erythromycin are effective for enhancing gastric motility and ensuring safe and adequate nutrient delivery. For patients unable to tolerate gastric feeding, jejunal feeding routes provide a reliable alternative for reducing the risk of aspiration and improving tolerance [9, 18, 19].
Monitoring clinical signs of intolerance, such as vomiting, abdominal distension, or diarrhea, remains a cornerstone of EN management. Evidence suggests that GRVs, traditionally used to assess feeding tolerance, are less reliable and should not be the sole parameter for decision-making. Current guidelines recommend focusing on clinical signs over strict GRV thresholds, as this approach minimizes unnecessary feeding interruptions and delays in achieving nutritional goals [4, 16]. Additionally, protocols to address interruptions caused by factors like sedation, prone positioning, or medical procedures can help ensure continuity of feeding and better overall tolerance [19].
Total parenteral nutrition
Total parenteral nutrition tolerance issues are primarily related to metabolic and infectious complications. Hyperglycemia, hypertriglyceridemia, and liver dysfunction are common challenges, requiring regular monitoring and timely adjustments to nutrient composition or infusion rates [14, 20]. Refeeding syndrome is a critical concern, especially in malnourished patients transitioning to TPN. To mitigate this risk, caloric intake should be increased gradually, with close monitoring of electrolytes such as phosphate, potassium, and magnesium to prevent life-threatening imbalances [21].
Infection control is another key consideration for TPN, as catheter-related bloodstream infections pose significant risks. Adherence to strict aseptic techniques during catheter insertion and maintenance, as well as routine monitoring for early signs of infection, is essential to reduce these complications [1, 22].
By addressing these challenges and tailoring interventions to each patient’s specific clinical needs, both EN and TPN can be optimized to maximize their benefits while minimizing associated risks.
Biochemical markers and metabolic monitoring
Trauma and critically ill patients often exhibit profound alterations in biochemical markers due to systemic inflammation and metabolic stress. Visceral proteins such as albumin, prealbumin, and transferrin are traditionally used to assess nutritional status. However, during acute inflammatory phases, these markers are significantly influenced by systemic inflammation and may not reliably reflect malnutrition [4, 11]. C‑reactive protein (CRP) and procalcitonin (PCT) provide insights into inflammation, helping differentiate nutritional deficits from inflammatory changes in visceral protein levels [8, 23].
Electrolyte imbalances, including hypophosphatemia, hypokalemia, and hypomagnesemia, are common in trauma patients with significant fluid shifts or blood loss as well as in critically ill patients initiating refeeding after prolonged fasting. These imbalances are hallmark features of refeeding syndrome and require meticulous monitoring during initiation of nutritional support to prevent life-threatening complications [7, 21]. Glycemic control is another cornerstone of metabolic monitoring. Hyperglycemia, often observed in patients receiving TPN, is associated with an increased infection risk, impaired wound healing, and higher mortality rates [18].
Specialized nutritional strategies
Immunonutrition
Trauma patients, especially those with severe injuries such as major fractures, burns, or polytrauma, often exhibit a heightened inflammatory response that makes them particularly suitable for immunonutrition strategies. Formulations enriched with omega‑3 fatty acids, arginine, and glutamine have demonstrated benefits in modulating this hyperinflammation, reducing oxidative stress, and supporting immune responses. These supplements are critical for promoting wound healing and improving clinical outcomes in trauma patients [1, 23].
Antioxidants and micronutrients
Supplementation with antioxidants such as vitamin C, selenium, and zinc is increasingly recognized for its role in reducing oxidative stress and supporting immune function, particularly in critically ill patients with prolonged illness or extensive tissue damage ([1, 11, 20]; Table 2).
100–200 mg/day; 200–500 mg/day for chronic oxidative stress
Vitamin E
> 11.5 µmol/L, > 4.95 mg/mL
Lipid-soluble antioxidant, immune function
Low serum levels in critically ill patients
≥ 15 mg/day α‑tocopherol per 1500 kcal
≥ 9 mg/day α‑tocopherol
High-protein diets
Tailored formulations with increased protein content are essential for counteracting catabolism, promoting wound healing, and maintaining lean body mass. Protein intake recommendations range from 1.5–2.5 g/kg/day, depending on the severity of the injury or illness [2, 20, 22].
Emerging technologies and advanced monitoring tools
Advanced technologies are transforming nutritional monitoring in trauma and critically ill patients. Bioimpedance analysis (BIA) is a noninvasive method gaining traction for assessing body composition and tracking changes in lean mass and fluid status over time [18]. Exhaled CO2 analysis shows promise as an alternative to indirect calorimetry for estimating energy expenditure, particularly in unstable patients for whom traditional methods may not be feasible [17].
Multidisciplinary approach
A coordinated multidisciplinary approach is essential for successful implementation and monitoring of nutritional support. Collaboration among intensivists, general surgeons, trauma surgeons, dietitians, nurses, and pharmacists ensures that nutritional strategies are dynamically adjusted to the patient’s evolving clinical condition [18]. Regular interdisciplinary discussions address challenges such as feeding intolerance, refeeding complications, and the need for specialized formulations [21].
The review identified several critical aspects of nutritional support in trauma and critically ill patients, including energy estimation, protein requirements, timing, delivery methods, and monitoring strategies. These findings are synthesized and summarized in Table 3, which provides a concise overview of the key nutritional recommendations tailored to these populations.
Table 3
Nutritional recommendations for trauma and critically ill patients
Key aspect
Recommendation
Justification
Energy needs
Hyperacute phase: no nutrition during resuscitation
Acute phase: 20–25 kcal/kg/day
Recovery phase: 25–30 kcal/kg/day
During resuscitation, focus on hemodynamic stability. Energy needs increase as the patient transitions to recovery
Protein requirements
1.5–2.5 g/kg/day, tailored to metabolic state and injury severity
High protein intake supports catabolism mitigation, wound healing, and lean mass preservation during recovery
Enteral nutrition (EN)
Start EN within 24–48 h after stabilization, preferably via nasogastric or post-pyloric feeding, depending on tolerance
EN maintains gut integrity, reduces bacterial translocation, and lowers infection risk. Post-pyloric feeding bypasses gastric dysfunction
Parenteral nutrition (TPN)
Avoid TPN in the hyperacute phase. In the acute phase, use only when EN is not feasible; combine EN and TPN in recovery, if needed
TPN ensures caloric delivery but carries risks such as hyperglycemia, infections, and liver dysfunction
Route of administration
Start with EN as soon as stable, using post-pyloric feeding if needed
EN preserves gut integrity and reduces infection risk. Post-pyloric feeding is advised for gastric dysfunction or aspiration risk
Monitoring strategies
Combine clinical assessment with advanced tools like indirect calorimetry and bioimpedance analysis when available
Electrolyte monitoring (phosphate, magnesium, potassium) is crucial during refeeding or metabolic stress phases
Emerging tools such as indirect calorimetry and bioimpedance analysis complement clinical assessments of tolerance
Electrolyte monitoring prevents complications such as refeeding syndrome and ensures safe nutritional delivery, especially in high-risk patients
Specialized strategies
Immunonutrition and antioxidants are recommended in the post-acute and recovery phases for burns, polytrauma, and sepsis
These strategies modulate inflammation, oxidative stress, and promote recovery, especially in patients with severe injuries
Conclusion
Optimizing nutritional support for trauma and critically ill patients remains a cornerstone of improving outcomes in these vulnerable populations. A tailored approach that integrates evidence-based practices, individualized care, and dynamic monitoring is essential to address the complex metabolic and inflammatory challenges unique to these patients.
Early enteral nutrition (EN) should be prioritized whenever feasible, as it preserves gut integrity and reduces complications, while total parenteral nutrition (TPN) remains a valuable alternative for patients unable to tolerate EN. Emerging technologies, such as bioimpedance analysis and exhaled CO2 measurements, offer promising avenues for enhancing nutritional monitoring and personalizing interventions. Moreover, strategies like immunonutrition and antioxidant supplementation provide additional tools to modulate the inflammatory response and support recovery.
Multidisciplinary collaboration is crucial to ensure that nutritional strategies are continuously adapted to the patient’s evolving clinical status. The involvement of intensivists, trauma surgeons, dietitians, and other healthcare professionals fosters a comprehensive approach to care, addressing challenges such as feeding intolerance, metabolic complications, and refeeding syndrome.
Despite advancements, several barriers to implementing nutritional strategies remain, including limited access to indirect calorimetry and advanced monitoring tools in many clinical settings. These challenges are particularly pronounced in resource-limited environments, in which simplified protocols and pragmatic approaches are essential for effective care.
Looking forward, future research should focus on refining predictive models for energy expenditure and protein needs, validating the efficacy of emerging monitoring tools, and exploring innovative nutritional interventions. Large-scale clinical trials are needed to better define the role of immunonutrition, antioxidants, and high-protein diets in trauma and critically ill patients. By bridging these knowledge gaps, the field can continue to advance toward more effective and personalized nutritional support, ultimately enhancing patient recovery and survival.
Conflict of interest
A.-M. González-Castillo, L. Picazo, E. Manzo, F. Marcucci, and R. Latifi declare that they have no competing interests. R. Latifi is a member of the Editorial Board in European Surgery and recuses himself from every editorial procedure of this submission including peer-review and academic decisions.
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