2025 ELSO共识声明：需要体外膜氧合的危重成人患者营养治疗的提供与管理

Methodology

A group of international experts with experience managing the nutritional needs of patients receiving ECMO was convened by the Extracorporeal Life Support Organization (ELSO) to systematically develop consensus-based recommendations for nutrition therapy. Questions of interest were developed

results. This publication reflects the information and expertise available at this time. New information will become available over time, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through this publication.

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by the authors based on those included in guideline recommendations for general critically ill patients with modification specific to the context of patients receiving ECMO. Definitions of terminology used throughout this consensus recommendation document are outlined in Supplementary Table 1, Supplemental Digital Content, https://links.lww.com/ASAIO/B832.

Search

We conducted a systematic review of the literature on nutritional support in critical illness with a focus on patients receiving ECMO support. Search terms were predefined before database searches and adapted appropriately (Supplementary Appendix, Supplemental Digital Content, https://links.lww.com/ASAIO/B832, shows the databases searched and final MEDLINE Ovid SP search). The population of interest was critically ill, adult patients receiving ECMO; the intervention and comparison were any type of medical nutrition therapy and the outcomes of interest were any clinical or nutrition outcome reported in the papers of interest.

Studies were included if they met the following criteria:

1. Of any design (including reviews) but excluding abstracts

2. Published in the English language; and

3. Conducted in critically ill adult patients receiving ECMO (VA or VV) (≥18 years)

4. Reported on any element of medical nutrition therapy (enteral nutrition [EN], parenteral nutrition [PN], oral nutrition).

Quality Assessment

Two authors (D.E.B. and E.J.R.) independently assessed the article (excluding any type of review) quality using the National Institute for Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.$^{9}$ Overall recommendations were discussed to ensure consensus.

Evidence Level and Consensus Voting Process

All recommendations in this guideline are based on data from the available literature and developed by expert consensus. Each recommendation was listed and authors were asked to consider whether they agreed or disagreed (yes or no) with the recommendation based on the literature reviewed using an online blind voting process. If authors disagreed, they were able to provide comments explaining their reasoning, which are listed in Table 1.

Results

There were 331 records identified, with 41 articles included in the development of the consensus recommendations (Figure 1 and Table 1). There were 27 observational studies,$^{10-36}$ 11 review articles,$^{37-47}$ two guidelines,$^{4,5}$ and one proposed model.$^{48}$ No randomized controlled trials were retrieved.

Sixteen consensus-based recommendations were formulated for 10 clinical questions, of which 11 reached “strong consensus” (100%) and 5 “consensus” (87.5%). Where “100%” consensus was not reached, it was due to unclear evidence to inform this or variation in international practice (Table 2).

|Author|Year|Design|Location*|Aim|Number of Patients|Number of VV ECMO vs. VA ECMO| |---|---|---|---|---|---|---| |Al-Dorzi et al.$^{37}$|2020|Review|Saudi Arabia|Summarize the available evidence on the tolerance, safety, and efficacy of EN during the use of ECMO, prone positioning, and infusion of neuromuscular blockers|N/A-review|N/A-review| |Banerjee et al.$^{38}$|2017|Review|USA|To examine the nutritional implications of congestive heart failure, review the nutritional challenges of ECMO and VADs, summarize nutrition support recommendations for the complex cardiac patient, and highlight the importance of an interdisciplinary approach to implementing nutrition screenings and plans in this population|N/A-review|N/A-review| |Bear et al.$^{39}$|2018|Review|UK|To describe the current nutrition practices in patients receiving ECMO, detail research that is currently being undertaken, and list important research questions that require exploration in this field|N/A-review|N/A-review| |Bear et al.$^{32}$|2021|Retrospective analysis of prospectively collected data|UK|To assess skeletal muscle area and density at commencement of W ECMO, their trajectory of change, and to investigate the relationship between skeletal muscle quantity and quality and clinical outcome, nutrition delivery, and physical function|215|VV ECMO = 215 VA ECMO = N/A| |Brisard et al.$^{10}$|2021|Retrospective, observational|France|To assess the nutritional route and impact of nutritional adequacy on the outcome of patients on ECMO. To identify opportunities to improve nutrition therapy during treatment in this specific population|112|VV ECMO = 26 VA ECMO = 86| |Cresci et al.$^{40}$|2012|Review|USA|To review the common challenges that exist with providing optimal nutrition therapy for the cardiothoracic critically ill patient|N/A-review|N/A-review| |D'Alesio et al.$^{41}$|2022|Review|Italy|To gather the current literature on nutrition during ECLS and to provide a summary of potential recommendations considering the following relevant topics: caloric intake in the acute and chronic phases, specific energy expenditure-monitoring tailored for ECLS, type of macronutrients needed, route for nutrition, and considerations for COVID-19 patients supported by ECLS|N/A-review|N/A-review| |Davis et al.$^{42}$|2021|Review|USA|To provide an overview of ECMO and changes in gut physiology during its use, outline the rationale for nutrition support in patients undergoing ECMO, and critically review existing literature for safety, tolerability, and efficacy of EN during ECMO|N/A-review|N/A-review| |De Waele et al.$^{48}$|2015|Prospective, observational|Belgium|To present a method to perform IC and propose a theoretical model for evaluating REE during ECMO. Preliminary experience with this approach in a patient is described|1|VV ECMO = 1 VA ECMO = N/A V ECMO = 3 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECMO = 4 VA ECM|

|Author|Year|Design|Location|UK|Of Wird|Location|Number of CV EMCO vs. VA EMCO|Number of V EMCO vs. VA EMCO|Number of V EMCO vs. VA EMCO|Number of V EMCO vs. VA EMCO vs. NA VACO = 19| |---|---|---|---|---|---|---|---|---|---|---| |Hardy et al.$^{14}$|2022 2022 observational|UK|UK|Correlation, the nutrition can be compared to the support to 2022 in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in a length in|||||||

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|Author|Year|Design|Location|UK|Of Wird|Location|Number of CV EMCO vs. VA EMCO|Number of CV EMCO vs. VA EMCO|Number of CV EMCO vs. VA EMCO|Number of CV EMCO vs. VA EMCO vs. NA VACO = 19|Number of CV EMCO vs. VA EMCO vs. NA VACO = 19| |---|---|---|---|---|---|---|---|---|---|---|---| |Hardy et al.$^{14}$|2022 2022 observational|UK|UK|TO VCD-19 patients in the procedure, can care, due to the provision of provision in the provision of a concentration support to be compared to the number of position, the nutrition can care and very $VCD_{MO}$ compared with those who would be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$ compared to be $VCD_{MO}$||||||||

|Author|Year|Design|Location*|Aim|Number of Patients|Number of ECMO vs. VA ECMO| |---|---|---|---|---|---|---| |Park et al.$^{25}$|2020|Retrospective, observational|Korea|To evaluate the relationship between nutritional supply and clinical outcomes in patients undergoing VA ECMO. Additionally, to measure the nutritional status of energy and protein intake and analyzed the reasons why patients on VA ECMO did not receive appropriate amounts of nutrition and the complications that occurred after providing nutritional support to investigate protein catablism during VV ECMO support at a single high-volume center and to assess whether current nutrition recommendations were adequate to achieve nitrogen equilibrium in these patients|41|VV ECMO = N/A VA ECMO = 41| |Pelekhaty et al.$^{26}$|2020|Prospective, observational|USA|To investigate protein catablism during VV ECMO support at a single high-volume center and to assess whether current nutrition recommendations were adequate to achieve nitrogen equilibrium in these patients|16|VV ECMO = 16 VA ECMO = N/A| |Reintam Blaser et al.$^{4}$|2020|Prospective, observational|USA|To investigate the adequacy of current recommendations for protein provision measured by nitrogen equilibrium in adults on VV ECMO.|29|VV ECMO = 29 VA ECMO = N/A review| |Ridley et al.$^{28}$|2015|Prospective, observational|Estonia|To provide evidence-based guidelines for earlyEN during critical illness|N/A-review|VV ECMO = 42 VA ECMO 65| |Scott et al.$^{28}$|2004|Prospective, observational|Australia and New Zealand|To perform a multicenter study in Australia and New Zealand to describe current nutrition delivery practices and to identify barriers to nutrition therapy in patients receiving VV or VA ECMO|107|VV ECMO = 42 VA ECMO = N/A| |Stoppe et al.$^{46}$|2018|Review|Germany|To evaluate the center's experience with early enteral nutrition in adult patients receiving VV ECMO for severe respiratory failure in order to characterize the safety and tolerance of enteral nutrition in this patient population|27|VV ECMO = 27 VA ECMO = N/A| |Tatucu-Babet et al.$^{34}$|2023|Prospective, observational|Australia and New Zealand|To provide an overview on recently published data and highlight specific topics regarding metabolic and nutritional support in patients with ECLS and VAD|N/A-review|N/A-review| |Ulerich et al.$^{47}$ Umezawa Makikado et al.$^{29}$|2015|Review Prospective, observational|USA Spain|To assess the feasibility of measuring EE in patients receiving VA ECMO using a modified indirect calorimetry protocol. Secondary objectives were to report measured EE in patients receiving VA ECMO and to compare values with predictive equation estimates and to control critically ill patients not receiving ECMO|21|VA ECMO = 21 (16 included in EE analysis), VV = N/A N/A review VCMO = N/A VA ECMO = 7| |Visvalingam et al.$^{31}$|2022|Retrospective, observational|Australia|To evaluate the tolerance and safety of EN in a consecutive group of patients receiving VA ECMO|7|VV ECMO = N/A VA ECMO = 7| |Wollersheim et al.$^{30}$|2018|Prospective, observational (protocol, feasibility, and pilot)|Germany|To investigate the association between clinical and biochemical factors predictive of gastrointestinal and liver dysfunction with nutrition adequacy in the first 5 days of ECMO|176|VV ECMO = 57 VA ECMO = 119 VA ECMO = N/A V ECMO = 20| |||||To introduce a new protocol, which allows the measurement of EE in patients with ECLS. Second, to compare the new protocol with the most common equations for the estimation of caloric targets in ARDS patients. Finally, to compare the EE of ARDS patients with VV ECMO to ARDS patients without ECMO, and assess the impact of the VV ECMO blood flow.|40|VA ECMO = N/A V ECMO = 20|

ARDS, Acute Respiratory Distress Syndrome; CHF, Congestive Heart Failure; CPR, Cardiopulmonary Resuscitation; COVID-19, coronavirus disease 2019; ECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation; EEN, early enteral nutrition; EN, enteral nutrition; GI, Gastrointestinal; IC, indirect calorimetry; REE, resting energy expenditure; VA, venoarterial; VAD, ventricular assist device; VF, ventricular Fibrillation; VT, ventricular tachycardia; WV, venovenous.

BEAR ET AL.

Full details of the results, including the narrative informing the recommendations and quality assessment, are in the Supplementary Appendix, Supplemental Digital Content, https://links.lww.com/ASAIO/B832. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flowchart for study selection is in Figure 1.

Quality

Of the 26 studies eligible for quality assessment, 24 (92.3%) were rated as "fair,"$^{10-22,24-28,30-35}$ 1 (3.8%) rated as "good,"$^{23}$ and 1 (3.8%) rated as "poor"$^{29}$ (see Supplementary Appendix, Supplemental Digital Content, https://links.lww.com/ASAIO/B832, for full details).

Clinical Questions With Recommendations

1. Should dietitians be included as part of the critical care multidisciplinary team managing patients receiving ECMO?

We recommended that a dietitian (or clinician with specialist clinical nutrition knowledge) is included as a key member of the critical care multidisciplinary team managing patients receiving ECMO (strong consensus 100%).

$\bullet$ Patients receiving ECMO pose metabolic and nutritional challenges and a dietitian is best placed within the multidisciplinary care team to manage this, including being able to undertake a thorough nutrition assessment.$^{19}$

$\bullet$ In countries where specialist intensive care unit (ICU) dietitors do not practice, an identified nutrition specialist of another profession (e.g., commonly a nursing or medical professional) is recommended.

2. Should patients receiving ECMO support receive a nutrition assessment?

We recommend that a full nutrition assessment, including physical assessment, be performed by a dietitian (or clinician with specialist clinical nutrition knowledge) within 72 hours of admission and weekly thereafter (strong consensus 100%).

$\bullet$ Although a full nutrition assessment, including physical assessment, is an essential component of the nutrition management of any critically ill patient, there is no gold standard,$^{50}$ including in patients receiving ECMO.

$\bullet$ Only one study has investigated malnutrition status on admission to ICU in an ECMO population, where the Subjective Global Assessment was used.$^{12}$ Over 90% of the population studied (N = 86) were considered normally nourished.

$\bullet$ Subjective global assessment or Global Leadership Initiative on Malnutrition (GLIM) criteria are acceptable methods to use$^{50}$,$^{51}$ with consideration of the potential to underestimate nutrition risk or malnutrition status on ICU admission or commencement of ECMO due to factors such as a younger age, altered physiology,$^{39}$ duration of ICU admission before commencing ECMO, and the projected long ICU length of stay in most ECMO patients.

$\bullet$ If a specific tool is not used, factors such as pre-ICU length of stay, projected ICU length of stay, and results from a physical assessment should be considered together.

3. Should all patients receiving ECMO support be considered for medical nutrition therapy?

We recommend all patients are considered for medical nutrition therapy regardless of pre-existing nutrition status due to the metabolic consequences of ECMO, the associated conditions requiring ECMO treatment (critical illness) and the duration of pre-ICU, projected ICU, and hospital length of stay for those who survive (strong consensus 100%).

$\bullet$ A large proportion of patients, especially those where ECMO is commenced as a bridge to transplant/long-term mechanical support, are already malnourished at the time of ECMO initiation due to pre-existing chronic health issues, including chronic heart and/or respiratory failure.$^{46}$ Other considerations include the inflammatory and catabolic impact of ECMO,$^{26,27,52}$ the diseases that lead to a requirement for ECMO therapy, as well as prior and predicted duration of both ICU and hospital stay and the duration of ECMO for patients who survive$^{44}$ which may all exacerbate malnutrition.

* Delaying commencement of medical nutrition therapy (even in patients who are premorbidly well nourished) may further exacerbate complications and aggravate the well-described loss of muscle mass.$^{32,52}$

4. Should all patients receiving ECMO receive early EN?

We recommend early EN is considered for patients receiving ECMO where EN is not contraindicated (strong consensus 100%).

We recommend that delaying or commencing EN at low dose is considered in patients with uncontrolled severe shock with daily review to prevent prolonged underfeeding (strong consensus 100%).

$\bullet$ The use of early EN in patients receiving ECMO is supported in the European Society of Intensive Care Medicine (ESICM) clinical practice guidelines$^{4,5}$ and observational, retrospective studies retrieved in the current search support the safety and feasibility.$^{10,12,15,19,25,28,33}$

$\bullet$ Current data from patients receiving ECMO also indicate some clinical benefit to the provision of early EN with one observational study reporting that early EN, compared with late EN in patients receiving VA ECMO for cardiogenic or obstructive shock was associated with a significantly lower in-hospital and 28 day mortality$^{23}$ and early EN was associated with reduced in-hospital mortality in another (ECMO type not specified).$^{15}$

$\bullet$ Overall, the cumulative current evidence suggests that early EN is feasible and safe in patients receiving ECMO, but dose (energy and protein) restriction should be implemented in the very acute phase and in patients with uncontrolled shock until hemodynamic stability has been achieved.$^{1,3,4,5,3,5}$

$\bullet$ The effects of prolonged underfeeding remain unknown and therefore daily review is strongly recommended in those on an initial restricted feeding regimen.

2025 ELSO CONSENSUS STATEMENT

![graph TD\n A1[Records identified from: Databases(n = 1128)] --> A2[Records screened(n = 1006)]\n A1 --> A7[Records removed before screening: Duplicate records removed(n = 122)]\n A2 --> A3[Reports sought for retrieval(n = 80)]\n A2 --> A8[Records excluded(n = 926)]\n A3 --> A4[Reports assessed for eligibility(n = 80)]\n A3 --> A11[Reports not retrieved(n = 0)]\n A4 --> A5[Included in review(n = 41)]\n A4 --> A12[Reports excluded: Wrong patient population(n = 31)Wrong study design(n = 8)Abstract only(n = 3)Not in English(n=2)Wrong intervention(n=2)Wrong setting(n=1)]\n A6[Records identified from: Authors records(n=5)Citation searching(n = 1)] --> A9[Reports sought for retrieval(n = 6)]\n A9 --> A10[Reports not retrieved(n=0)]\n A9 --> A13[Reports assessed for eligibility(n = 6)]\n A13 --> A14[Reports excluded(n=0)]\n](1/parseimages/figure7f3179e9ae3d4695858c4ca6c8db2109_0_1.png) 5. How should gastrointestinal intolerance be managed in patients receiving ECMO?

We recommend the use of prokinetics for delayed gastric emptying, defined using gastric residual volume (GRV) cutoffs locally, but not less than 250 ml 4 hourly (consensus 87.5%).

We recommend regular review of laxative dose so as not to achieve excessive stool output >1 L/day (strong consensus 100%).

We recommend the use of postpyloric feeding tubes or, in the absence of a postpyloric feeding tube insertion service, PN, for persistent delayed gastric emptying refractory to prokinetics (strong consensus 100%).

$\bullet$ Enteral feeding intolerance (EFI) is frequently cited as a complication in patients receiving ECMO, with the most commonly reported reasons defining EFI being elevated GRVs, diarrhea, ileus, and bowel ischemia.$^{10,12-16,19,25,28,33,35}$Elevated GRVs are reported to be a major barrier to achieving target energy and protein delivery for those receiving ECMO.$^{14,19}$

$\bullet$ There is no standardized approach for the management of delayed gastric emptying in the general critically ill population; however, guidelines recommend the use of prokinetics, including metoclopramide or erythromycin.$^{1}$

$\bullet$ An alternative approach to the management of delayed gastric emptying is postpyloric feeding.$^{19}$ However, the logistical issues associated with placement of postpyloric feeding tubes, especially if radiological or endoscopic guidance is required, must be considered. Bedside approaches to the placement of feeding tubes may be timelier,$^{54}$ although this technique is not available in every institution.

$\bullet$ PN (supplemental or total) use is an acceptable alternative to EN in centers without ready access to postpyloric feeding tubes$^{12,28}$ and is supported in the recent American Society for Parenteral and Enteral Nutrition (ASPEN) guideline update.$^{2}$

$\bullet$ Switching to a more concentrated feed to reduce the volume of delivery is not recommended, as this has been shown to increase the prevalence of Gastrointestinal dysfunction rather than improve it.$^{55}$

$\bullet$ Lazatives are recommended to achieve stool output of no more than 1 L with a balance between prevention of ileus and the adverse consequences of high stool output including fluid and electrolyte deficiencies.

6. Under what circumstances should PN be used in patients receiving ECMO?

We recommend that the ICU length of stay (LOS) before commencing ECMO is considered when deciding on the use of PN and that PN be considered following 72 hours of intolerance to EN or where enteral access cannot be achieved (strong consensus 100%).

$\bullet$ No studies have compared EN and PN in patients receiving any type of ECMO or investigated the timing of commencing PN in patients not tolerating EN. However, observational studies report using PN, either alone or in combination with EN, in 2–30% of patients$^{10,12,14,16,19,20,33}$ and one study reports using PN alone on 111 study days (7%) and EN combined with PN on 52 study days (3%).$^{28}$ In patients receiving ECMO and either not tolerating full EN, having contraindications to EN or not having EN access, the use of PN (as a sole source of nutrition or as a supplement to EN; SPN) should be initiated on a

Recommendation

|We recommended that a dietitian is included as a key member of the critical care multidisciplinary team managing patients receiving ECMO|Agreement (%)|Personal Comments/Rationale for Disagreement| |---|---|---| |We recommend that a full nutrition assessment, including physical assessment, be performed by a dietitian (or clinician with specialist clinical nutrition knowledge) within 72 hours of admission and weekly thereafter|100|n/a| |We recommend all patients are considered for medical nutrition therapy regardless of pre-existing nutrition status due to the metabolic consequences of ECMO, the associated conditions requiring ECMO treatment (critical illness), and the duration of pre-ICU, projected ICU, and hospital LOS for those who survive|100|n/a| |We recommend early EN is considered for patients receiving ECMO, where EN is not contraindicated|100|n/a| |We recommend that delaying or commencing EN at low dose is considered in patients with uncontrolled severe shock with daily review to prevent prolonged underfeeding|100|n/a| |We recommend the use of prokinetics for delayed gastric emptying, defined using GRV cutoffs locally, but not less than 250 ml 4 hourly|87.5|The cutoffs used can be controversial| |We recommend regular review of laxative dose so as not to achieve excessive stool output >1/L/day|100|n/a| |We recommend the use of postpyloric feeding tubes or PN in the absence of a postpyloric feeding tube insertion service for persistent delayed gastric emptying refractory to prokinetics|100|n/a| |We recommend that the ICU LOS before commencing ECMO is considered when deciding on the use of PN and that PN be considered following 72 hours of intolerance to EN or where enteral access cannot be achieved|100|n/a| |We recommend monitoring of triglyceride levels and visual inspection of the membrane oxygenator for clotting when receiving PN and to consider lipid-free PN if concerns arise|87.5|There is no current ICU guideline supporting the use of lipid-free parenteral nutrition| |In the absence of a standardized, validated protocol for the use of IC in patients receiving ECMO, a weight-based formula (25 kcal/kg/BW/day) should be used to calculate energy targets for simplicity|100|n/a| |We recommend aiming for <70% of estimated or measured energy targets for the first 3 days of ECMO, with a progressive increase to target after this and avoiding prolonged underfeeding|87.5|The cutoff seems to be chosen randomly; I would prefer this not to be set in metrics in the absence of evidence| |We recommend aiming for <70% of protein targets for the first 3 days of ECMO and progressively increasing to target after this, avoiding prolonged underfeeding|87.5|There is limited evidence on the timing for reaching 100% of the target protein dose in critically ill and ECMO patients. It is inevitable that protein underfeeding will occur over the first 72 hours if we are intentionally hypocalorically underfeeding. However, based on limited evidence, I don't think that intentionally aiming for <70% protein targets can be confidently recommended. If 100% protein targets can be achieved alongside hypocaloric feeding (i.e., using a low kcal/high protein formulation), then this should not be discouraged information), then this should not be discouraged if we agree that there is a higher protein need in CRRT because of loss by the filter, we can expect the same to happen in ECMO n/a| |We recommend aiming for a protein dose of no more than 1.3 g/kg/day, especially in those patients with acute kidney injury or high severity of illness at admission|87.5|If we agree that there is a higher protein need in CRRT because of loss by the filter, we can expect the same to happen in ECMO n/a| |We recommend that monitoring of medical nutrition therapy for patients receiving ECMO should be under guidance of a critical care dietitian or other clinician with specialist clinical nutrition knowledge. Monitoring should include nutrition status, refeeding syndrome, energy and protein balance, metabolic tolerance (e.g., blood glucose levels and insulin requirements), and gastrointestinal tolerance (measurement of GRVs and abdominal pathology)|100|n/a| |We recommend if oral intake is between 50 and 75% of target energy and protein for 72 hours, despite maximal oral nutrition therapy strategies, that escalation to EN (alone or as a supplement to oral intake) be strongly considered to prevent further nutrition decline|100|n/a|

The strength of consensus was based on that included in the European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines$^{1}$; strong consensus (agreement of >90% of participants), consensus (agreement of >75%–90% of participants), majority agreement (≥50%–75% of participants), no consensus (agreement of <50% of the participants).

CRRT, continuous renal replacement therapy; ECMO, extracorporeal membrane oxygenation; EN, enteral nutrition; GRV, gastric residual volume; ICU, intensive care unit; LOS, length of stay; PN, parenteral nutrition.

2025 ELSO CONSENSUS STATEMENT

case-by-case. Important considerations are the nutrition status of the patient assessed within 3 days of commencing ECMO, the duration of ICU stay before commencing ECMO, the predicted ECMO and subsequent ICU LOS, and the anticipated time to commence EN.

$\bullet$ This recommendation should be used in line with recommendation 7 regarding the assessment of nutrition risk in ECMO patients.

We recommend monitoring of triglyceride levels and visual inspection of the membrane oxygenator for clotting when receiving PN and to consider lipid-free PN if concerns arise (consensus 87.5%).

$\bullet$ The potential for lipid infiltration into the oxygenator and resultant circuit failure or increased risk of membrane thrombus formation need to be considered.$^{56}$

$\bullet$ Recommendations from one group of authors suggest that intravenous lipid administration should not exceed 10 ml/kg to reduce the risks involved$^{56}$ and others suggest that a cutoff value of 3 mmol/L for plasma triglycerides should be used to inform decisions for lipid-free PN based on their local practice.$^{39}$

$\bullet$ While strong recommendations are impossible to provide in the context of limited evidence, it is reasonable to suggest monitoring the oxygenator and measuring triglyceride levels twice weekly in patients receiving ECMO and PN and to limit intravenous lipid provision (including propofol) where the circuit is thought to be a risk. In this instance, lipid-free PN may be considered with provision of weekly lipids and daily fat-soluble vitamin administration to prevent the development of essential fatty acid deficiency.

7. How should energy targets be calculated in patients receiving ECMO and what dose should be achieved?

In the absence of a standardized, validated protocol for the use of indirect calorimetry (IC) in patients receiving ECMO, a weight-based formula (25 kcal/kg/BW/day) should be used to calculate energy targets for simplicity (strong consensus 100%).

$\bullet$ IC is considered the gold standard for measuring energy expenditure (EE) in critically ill patients.$^{1,2}$ However, gas exchange occurring within the extracorporeal circuit may limit its feasibility and accuracy in patients receiving ECMO.$^{39}$

$\bullet$ To date, four techniques have been described to measure EE in ECMO patients,$^{22,24,30,34,48}$ each with limitations (full details specified in the Supplementary Appendix, Supplemental Digital Content, https://links.lww.com/ASAIO/B832).

$\bullet$ Most studies of clinical practice in ECMO describe the main equation used to be 25 kcal/kg/BW/day.$^{14,19,20,29,32}$ However, as observed in the general critically ill population, measured EE using IC of individuals receiving ECMO varies daily when expressed in kcal/kg/BW/day.$^{30,34,48}$ This suggests that EE may potentially depend on factors such as underlying disease, ECMO duration, gas flow, and lung functionality; however, these assumptions require confirmation in larger studies.

$\bullet$ Given the lack of adequate evidence to inform the optimal energy dose for ECMO patients, applying general ICU nutrition guidelines $^{1,2}$ to estimate energy targets is a practical approach; however, use of clinical judgement and expertise in clinical nutrition is paramount.

We recommend aiming for <70% of estimated or measured energy targets for the first 3 days of ECMO, with a progressive increase to target after this and avoiding prolonged underfeed- ing (consensus 87.5%).

* Achieving <70% of estimated energy targets in the subjective "acute" or "early phase" of critical illness with progressive increase in rate appears reasonable, which requires regular monitoring to prevent prolonged underfeeding.

$\bullet$ Extracorporeal membrane oxygenation patients often experience prolonged ICU stays and significant catabolism, underscoring the importance of regular, monitoring to ensure adequate nutrition and the avoidance of prolonged underfeeding.

$\bullet$ Higher energy targets may be appropriate for mobile patients or those of mechanical ventilation,$^{39}$ although no studies currently exist exploring measured EE in ambulatory ECMO patients.

8. How should protein targets be calculated in patients receiving ECMO and what dose should be achieved?

We recommend aiming for a protein dose of no more than 1.3 g/kg/day, especially in those patients with acute kidney injury or high severity of illness at admission (consensus 87.5%).

* The optimal dose of protein to provide in critically ill patients is unknown and this includes patients receiving ECMO. Nitrogen balance studies performed in ECMO patients suggest that protein requirements in both obese and nonobese patients may be higher than the current recommendations.$^{27,57}$

$\bullet$ The protein recommendation for general critically ill patients in international guidelines ranges between 1.2 and 2.5 g/kg/day based on their individual needs,$^{1}$ but recent data suggest that amounts above 1.3 g/kg/day may be harmful in patients with high severity of illness and Acute Kidney Injury (AKI).$^{58}$

$\bullet$ Given that no randomised controlled trial (RCT) data exist for protein delivery in patients receiving ECMO and the recent results of the EFFORT Protein Trial,$^{58}$ the target for protein delivery should be as per current guideline recommendations (1.3 g/kg/day)$^{1}$ and probably lower in those patients with development of acute kidney injury and more severe illness, particularly in the acute phase of illness.

We recommend aiming for <70% of protein targets for the first 3 days of ECMO and progressively increasing to target after this, avoiding prolonged underfeeding (consensus 87.5%).

$\bullet$ Reaching protein targets in patients receiving ECMO can be difficult, particularly if energy provision is reduced to account for propofol, and underfeeding is common.$^{19,28}$

* The optimal timing of reaching the target protein dose is unknown, but given recommendations for hypocaloric

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feeding early in critical illness, underdosing protein will be inevitable.

$\bullet$ Effort should be made to avoid prolonged protein under-feeding due to the risk of muscle wasting, the unknown effect on long-term outcome, and the known association between increased muscle wasting and worse clinical outcome in critical illness.

9. How should medical nutrition therapy be monitored in patients receiving ECMO?

We recommend that monitoring of medical nutrition therapy for patients receiving ECMO should be under guidance of a critical care dietian or other clinician with specialist clinical nutrition knowledge. Monitoring should include nutrition status, refeeding syndrome, energy and protein balance, metabolic tolerance (e.g., blood glucose levels and insulin requirements), and gastrointestinal tolerance (measurement of GRVs and abdominal pathology) (strong consensus 100%).

$\bullet$ There are no studies investigating the effectiveness of monitoring the provision and tolerance of medical nutrition therapy in any group of critically ill adults on outcome.

$\bullet$ As an accompaniment to the European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines for medical nutrition therapy in the ICU, a position paper providing recommendations for monitoring medical nutrition therapy and metabolism is available.$^{59}$ Recommendations from this position paper have been considered in the recommendations provided here with caveats for the ECMO population made as per the clinical expertise of this guidelines group.

10. How should nonventilated patients receiving ECMO be managed?

We recommend if oral intake is between 50 and 75% of target energy and protein for 72 hours, despite maximal oral nutrition therapy strategies, that escalation to EN (alone or as a supplement to oral intake) be strongly considered to prevent further nutrition decline (strong consensus 100%).

$\bullet$ Awake patients, especially if not mobile or feeling nauseous, can have reduced appetite, difficulty in positioning for eating, and the use of high flow oxygen can dry the oral mucosa, making chewing and swallowing difficult. They may also be less tolerant of nasogastric tubes. These factors mean that malnutrition can quickly develop.

$\bullet$ Evidence from the general critically ill population informs of some of the anticipated issues with oral intake during critical illness and recovery$^{60-62}$ and underscores the need for careful consideration for the continued requirement of EN while oral nutrition is established.

Conclusions

There are limited high-level data to inform nutrition practice in adult patients receiving ECMO. However, these consensus recommendations have been developed using the available observational data, relevant studies of nutrition in general critically ill patients and the clinical expertise of those working

in high-volume ECMO centers to guide nutrition practices with the aim of improving both short and long-term patient outcomes. The importance of individualized nutrition assessment, treatment, and ongoing monitoring is imperative in this patient cohort. It is recommended that there is a recognized member of the multiprofessional team with nutrition expertise (e.g., ideally a dietitian or other professional with an interest or additional training in critical care nutrition) who can lead the nutrition service for these patients. These recommendations are based on the best available evidence at the time of writing, but clearly highlight the need for more focused nutrition research in this patient group.

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