BACKGROUND:The delivery of artificial nutrition support during acute illness in patients who are pregnant is complex with considerations for both maternal and foetal health outcomes. However, there is little known about the research available to guide the artificial nutrition support during pregnancy. This scoping review aims to examine the literature related to artificial nutrition support practices during acute illness in pregnancy, to understand current research, identify gaps and inform directions for future research. METHODS:The review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews. A systematic search of five databases (MEDLINE, Embase, CINAHL, Web of Science and the Maternal and Infant Care Database (MIDIRS)) was conducted. Eligible studies involved adult pregnant patients aged 18 or over, hospitalised across a variety of care settings, and receiving artificial nutrition in the form of enteral nutrition or parenteral nutrition. Studies not written in English Language were excluded. Data were extracted on weight, gestation period, type and route of feeding, indication for artificial feeding, energy target and provision, protein target and provision, duration of intervention, micronutrient delivery and supplementation, method of delivery, foetal birthweight and maternal and foetal outcomes. RESULTS:A total of 24 studies were included of which the majority were case reports (n = 12 studies), followed by case series (n = 7), and only one randomised controlled trial (early enteral feeding vs standard care). The most common indication for artificial nutrition support was hyperemesis gravidarum (n = 14 studies) and the most common method was parenteral nutrition (n = 14). There was considerable heterogeneity in reporting of energy and protein targets and delivery, micronutrient supplementation, weight change over pregnancy and maternal and foetal outcomes. CONCLUSIONS:This scoping review highlighted the very limited number of studies regarding artificial nutrition support during pregnancy. Hugh quality research is urgently required to inform guidelines and standardise and optimise management strategies and improve outcomes in this complex patient cohort.

BACKGROUND:Dietary management is essential in gastroparesis, but existing guidelines primarily focus on diabetic gastroparesis, highlighting a lack of evidence-based guidelines for patients with nondiabetic gastroparesis, who experience higher malnutrition and mortality rates. Management is complicated by a suggested bidirectional relationship with eating disorders. OBJECTIVE:To investigate evidence on dietary interventions, patterns, and intake in nondiabetic gastroparesis, including effects on symptoms, nutritional outcomes, quality of life (QoL), and their potential role in disordered eating behaviors. METHODS:A scoping review was conducted using the Joanna Briggs Institute methodology. A comprehensive search was conducted across 8 databases: Embase, MEDLINE, Web of Science Core Collection, Global Health, CINAHL, Scopus, CENTRAL and PsycInfo, alongside gray literature and citation searching. English-language studies from 2008 investigating dietary interventions, patterns, and intake in adults with objectively confirmed nondiabetic gastroparesis (idiopathic, autoimmune-related, postviral, or eating disorder-associated causes) were included. Two reviewers independently screened, extracted data, and synthesized findings using a narrative approach. RESULTS:Of 6212 articles screened by title/abstract, 88 underwent full-text review, and 13 met inclusion criteria. Of these, 7 studies examined dietary interventions, 5 assessed dietary patterns, and 2 reported dietary intake. Two were randomized controlled trials (RCTs) including 16 participants with nondiabetic gastroparesis; the remaining 11 observational studies included 679 participants with confirmed nondiabetic gastroparesis and 752 for whom cause was unspecified or delayed gastric emptying could not be confirmed. All included studies assessed symptom burden; 5 reported nutritional outcomes, and 2 evaluated dietary impact on QoL. No studies explored the role of diet in disordered eating. Considerable variation was observed in dietary management strategies across studies. CONCLUSION:Research on dietary management in nondiabetic gastroparesis is limited, with significant variability in interventions, dietary definitions, and study designs, reflecting lack of standardization across intervention protocols and research methodology. Well-designed trials are needed to clarify the impact of diet on symptoms, nutritional status, and QoL, considering psychosocial effects and potential disordered eating risks.

Suboptimal nutrition provision has been observed during and after the intensive care unit (ICU) stay. Reasons for suboptimal nutrition provision are due to various barriers to intake found across hospitalization and after discharge home. The aim of this narrative review is to provide an overview of the nutrition challenges faced by patients after ICU discharge and in the home, as well as provide suggestions to promote recovery for survivors. Key areas to consider include the role of the patient, caregiver and clinician education, nutrition impact symptoms, the role of communication, and the use of multimodal interventions. Nutrition interventions may be of greatest benefit with longer-term optimization, identifying strategies to overcome barriers and the importance of transition periods as well as a clear follow-up plan.

International guidelines for the nutrition management of critically ill adults do not sufficiently cover the unique challenges and considerations of patients receiving extracorporeal membrane oxygenation (ECMO). The aim of the current guideline is to assess the literature informing nutrition provision and practice for patients receiving ECMO and provide clinicians with consensus-based recommendations to inform clinical practice. A group of international experts was convened by the Extracorporeal Life Support Organization (ELSO) to systematically develop consensus-based recommendations for nutrition therapy. Questions of interest were developed by the authors based on those included in guideline recommendations for general critically ill patients on key clinical areas of nutrition provision and practice during critical illness, but specific to the context of patients receiving ECMO. Following question development, a systematic review of the literature was undertaken, recommendations were developed accordingly, and blind voting was undertaken to determine consensus. Study quality was assessed using the National Institute for Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A total of 31 publications informed the recommendations with no randomized controlled trials found. Sixteen consensus-based recommendations were formulated for 10 clinical questions, of which 11 reached "strong consensus" (100%) and five "consensus" (87.5%). A total of 26 studies were eligible for quality assessment with 24 (92.3%) rated "fair," 1 (3.8%) rated "good," and 1 (3.8%) rated "poor." There is limited high-level evidence 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 and will help to guide nutrition practices in this patient group.

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. The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence. 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. 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.

Advances in medical treatment over the recent decades have led to increased rates of survival.1 However, it is well documented that survival from critical illness is complicated by prolonged recovery periods, with persistent and potentially irreversible, physical, functional, and cognitive disability.2 The myriad of features experienced by survivors of critical illness is termed 'Post-Intensive Care Syndrome', and nutrition therapy may play an important role in the prevention and management of this debilitating syndrome.2 The decline in mortality from critical illness has led to difficulties in demonstrating the impact of single interventions to alter this outcome.3 This is particularly true for trials of nutrition therapy undertaken within the intensive care unit (ICU) and may have contributed to the neutral results of several large, randomized controlled trials (RCTs).4-7 Importantly, harm from early enhanced nutrition and particular interventions

BACKGROUND:Noninvasive ventilation (NIV) is increasingly being used in critical care, yet limited evidence exists guiding nutrition practices for patients who are critically ill receiving NIV. This study aimed to describe the nutrition practices and adequacy of nutrition intake among patients who are critically ill receiving NIV. METHODS:This descriptive cohort study included adult patients admitted to critical care who received NIV on ≥3 consecutive days. Prospectively recorded clinical data were retrospectively extracted from electronic medical records and compared between patients who received solely noninvasive ventilation (NIV only) and those who received invasive mechanical ventilation (IMV) and were extubated onto noninvasive ventilation (post-IMV group). RESULTS:Of the 220 patients included (107 NIV only; 113 post-IMV), 142 (64.5%) received exclusive oral nutrition, 66 (30.0%) received artificial nutrition support, and 12 (5.5%) received no nutrition. Enteral nutrition was more prevalent in the post-IMV group (36 [31.9%] vs NIV only 19 [17.8%]; P = 0.01), whereas exclusive oral nutrition was more prevalent in the NIV-only group (86 [80.4%] vs post-IMV 66 [58.4%]; P < 0.001). Most patients who received purely exclusive oral nutrition (n = 152) had inadequate intake (94 [61.8%]). CONCLUSION:Most patients with critically illness receiving NIV received exclusive oral nutrition, which was found to be inadequate in the majority. Patients receiving NIV represent a nutritionally at-risk population, and future studies are needed to understand the barriers to oral intake and the feasibility, safety, and effectiveness of enteral nutrition.

BACKGROUND:Better understanding the impact of dietetic services on nutrition practices seems required as it may represent an opportunity for optimization in post-cardiac surgery patients. The present study aims to evaluate and compare nutrition practices and clinical outcomes in post-cardiac surgery intensive care unit (ICU) patients with and without dietetic services. METHODS:This is a secondary analysis of a multinational prospective observational study in patients (n = 237) with >72 h of post-cardiac surgical ICU stay with and without dietetic services describing nutrition practices and outcomes up to 12 days after ICU admission. RESULTS:Dietetic services were available in 61.5% (8 of 13) ICUs (1.0 ± 0.5 full-time equivalents/10 beds). Enteral nutrition was initiated <48 h from ICU admission in 49.6% and 59.1% of patients at sites with vs without dietetic services, respectively. Parenteral nutrition was started within 118.3 ± 56.5 and 131.5 ± 69.2 h at sites with vs without dietetic services, respectively. Energy target (23.7 ± 4.8 vs 24.6 ± 4.8 kcal/kg body weight/day) and actual supply (10.5 ± 6.7 vs 10.3 ± 6.2 kcal/kg body weight/day) did not differ between the groups. Protein targets (1.4 ± 0.4 vs 1.1 ± 1.3 g/kg body weight/day) and actual protein provision (0.6 ± 0.4 vs 0.4 ± 0.3 g/kg body weight/day) were higher in patients at sites with vs without dietetic services. CONCLUSION:Improvements in medical nutrition therapy practices in patients after cardiac surgery are needed in ICUs with and without dietetic services. Appropriately staffed dietetic services as essential members of the medical care team may be crucial to transfer knowledge on adequate medical nutrition therapy strategies into practice.

Background: The EFFORT Protein trial assessed the effect of high vs usual dosing of protein in adult ICU patients with organ failure. This study provides a probabilistic interpretation and evaluates heterogeneity in treatment effects (HTE). Methods: We analysed 60-day all-cause mortality and time to discharge alive from hospital using Bayesian models with weakly informative priors. HTE on mortality was assessed according to disease severity (Sequential Organ Failure Assessment [SOFA] score), acute kidney injury, and serum creatinine values at baseline. Results: The absolute difference in mortality was 2.5% points (95% credible interval-6.9 to 12.4), with a 72% posterior probability of harm associated with high protein treatment. For time to discharge alive from hospital, the hazard ratio was 0.91 (95% credible interval 0.80 to 1.04) with a 92% probability of harm for the high-dose protein group compared with the usual-dose protein group. There were 97% and 95% probabilities of positive interactions between the high protein intervention and serum creatinine and SOFA score at randomisation, respectively. Specifically, there was a potentially relatively higher mortality of high protein doses with higher baseline serum creatinine or SOFA scores. Conclusions: We found moderate to high probabilities of harm with high protein doses compared with usual protein in ICU patients for the primary and secondary outcomes. We found suggestions of heterogeneity in treatment effects with worse outcomes in participants randomised to high protein doses with renal dysfunction or acute kidney injury and greater illness severity at baseline.

Micronutrient (MN) status alterations (both depletion and deficiency) are associated with several complications and worse outcomes in critically ill patients. On the other side of the spectrum, improving MN status has been shown to be a potential co-adjuvant therapy. This review aims to collect existing data to better guide research in the critical care setting. This narrative review was conducted by the European Society of Intensive Care Medicine Feeding, Rehabilitation, Endocrinology, and Metabolism MN group. The primary objective was to identify studies focusing on individual MNs in critically ill patients, selecting the MNs that appear to be most relevant and most frequently investigated in the last decade: A, B1, B2, B3, B6, folate, C, D, E, copper, iron, selenium, zinc, and carnitine. Given the limited number of interventional studies for most MNs, observational studies were included. For each selected MN, the review summarizes the main form and functions, special needs and risk factors, optimal treatment strategies, pharmacological dosing, and clinical implications all specific to critically ill patients. A rigorous rebalancing of research strategies and priorities is needed to improve clinical practice. An important finding is that high-dose monotherapy of MNs is not recommended. Basal daily needs must be provided, with higher doses in diseases with known higher needs, and identified deficiencies treated. Finally, the review provides a list of ongoing trials on MNs in critically ill patients and identifies a priority list of future research topics.

OBJECTIVES: Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein. DESIGN: A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial. SETTING: Eighty-five adult ICUs across 16 countries. PATIENTS: Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m(2) (n = 425). INTERVENTIONS: In the primary study, patients were randomized into a high-dose (>= 2.2 g/kg/d) or usual-dose protein group (<= 1.2 g/kg/d). MEASUREMENTS AND MAIN RESULTS: Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m(2). After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58-1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, -5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups. CONCLUSIONS: In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.

BACKGROUND:Surviving critical illness leads to prolonged physical and functional recovery with both nutritional and physical rehabilitation interventions for prevention and treatment being investigated. Nutritional status and adequacy may influence outcome, but no consensus on which nutritional-related variables should be measured and reported in clinical trials exists. OBJECTIVES:This study aimed to undertake a systematic review investigating the reporting of nutritional screening, nutritional status, and nutritional intake/delivery in randomized controlled trials (RCTs) evaluating nutritional and/or physical rehabilitation on physical and functional recovery during and following critical illness. METHODS:Five electronic databases (MEDLINE, Web of Science, EMBASE, CINAHL, and Cochrane) were searched (last update 9 August, 2023). Search terms included both free text and standardized indexed terms. Studies included were RCTs assessing nutritional and/or physical interventions either during or following intensive care unit (ICU) admission in adults (18 y or older) with critical illness, and who required invasive mechanical ventilation for any duration during ICU admission. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool for RCTs and descriptive data synthesis was performed and presented as counts (%). n t RESULTS: In total, 123 RCTs (30 nutritional, 87 physical function, and 6 combined) were included. Further, ≥1 nutritional variable was measured and/or reported in 99 (80%) of the studies including BMI (n = 69), body weight (n = 57), nutritional status (n = 11), nutritional risk (n = 10), energy delivery (n = 41), protein delivery (n = 35), handgrip strength (n = 40), and other nutritional-related muscle variables (n = 41). Only 3 studies were considered to have low risk of bias in all categories. CONCLUSIONS:Few RCTs of physical rehabilitation measure and report nutritional or related variables. Future studies should measure and report specific nutritional factors that could impact physical and functional recovery to support interpretation where studies do not show benefit. This protocol was preregistered at PROSPERO as CRD42022315122.

BackgroundPre-existing malnutrition in critically ill patients is associated with adverse clinical outcomes. Malnutrition can be diagnosed with the Global Leadership Initiative on Malnutrition using parameters such as weight loss, muscle wasting and body mass index. International critical care nutrition guidelines recommend high protein treatment to improve clinical outcomes in critically ill patients diagnosed with pre-existing malnutrition. However, this recommendation is based on expert opinion.Research QuestionsIn critically ill patients, what is the association between pre-existing malnutrition and time to discharge alive (TTDA), and does high protein treatment modify this association?Study Design and MethodsThis was a multicenter randomized controlled trial involving 16 countries designed to investigate the effects of high vs. usual protein treatment in 1301 critically ill patients. The primary outcome was TTDA. Multivariable regression was used to identify if pre-existing malnutrition was associated with TTDA, and if protein delivery modified their association.ResultsThe prevalence of pre-existing malnutrition was 43.8%, and the cumulative incidence of live hospital discharge by day 60 was 41.2% vs. 52.9% in the groups with and without pre-existing malnutrition, respectively. The average protein delivery in the high vs. usual treatment groups was 1.6 vs. 0.9 g/kg/day. Pre-existing malnutrition was independently associated with slower TTDA (Adj HR 0.81, 95% CI 0.67-0.98). However, high protein treatment in patients with and without pre-existing malnutrition was not associated with TTDA (Adj HR 0.84, 95% CI 0.63-1.11; and 0.97, 95% CI 0.77-1.21, respectively). Furthermore, no effect modification was observed (ratio of Adj HR 0.84, 95% CI 0.58-1.20).InterpretationMalnutrition was associated with slower TTDA, but high protein treatment did not modify the association. These findings challenge current international critical care nutrition guidelines.

Purpose of review Critical care nutrition guidelines recommend provision of higher protein doses than recommended in health. These recommendations have been predominately based on lower quality evidence and physiological rationale that greater protein doses may attenuate the significant muscle loss observed in critically ill patients. This review discusses the mechanistic action of protein in the critically ill, details results from recent trials on health outcomes, discusses considerations for interpretation of trial results, and provides an overview of future directions. Recent findings Two recent large clinical trials have investigated different protein doses and the effect on clinical outcome. Important findings revealed potential harm in certain sub-groups of patients. This harm must be balanced with the potential for beneficial effects on muscle mass and physical function given that two recent systematic reviews with meta-analyses demonstrated attenuation of muscle loss with higher protein doses. Utilizing biological markers such as urea: creatinine ratio or urea levels may prove useful in monitoring harm from higher protein doses. Summary Future research should focus on prospectively investigating biological signatures of harm as well as taking into the consideration elements that will likely enhance the effectiveness of protein dose.

Gastrointestinal (GI) dysfunction is common in critically ill patients and associated with poor outcomes. There is a lack of standardised methods for daily monitoring of GI function. COSMOGI aimed to develop a Core Outcome Set (COS) for daily monitoring of GI function to improve consistency and comparability in future studies in critically ill patients. A modified Delphi consensus process engaging healthcare providers, clinical researchers, and patient representatives was performed. A systematic review identified existing parameters to monitor GI function, informing the development of potential outcomes. In Stage 1, participants rated outcomes (i.e., variables used for daily monitoring). In Stage 2, they refined and agreed on the definitions for the selected outcomes. The COS was ratified through consensus meetings. 368 individuals registered for the Delphi process. 285 participants (77.4 www.comet-initiative.org ) on 27.03.2023 (number 2609) and was an ESICM-endorsed research project.

Background Delivering higher doses of protein to mechanically ventilated critically ill patients did not improve patient outcomes and may have caused harm. Longitudinal urea measurements could provide additional information about the treatment effect of higher protein doses. We hypothesised that higher urea values over time could explain the potential harmful treatment effects of higher doses of protein. Methods We conducted a reanalysis of a randomised controlled trial of higher protein doses in critical illness (EFFORT Protein). We applied Bayesian joint models to estimate the strength of association of urea with 30-day survival and understand the treatment effect of higher protein doses. Results Of the 1301 patients included in EFFORT Protein, 1277 were included in this analysis. There were 344 deaths at 30 days post-randomisation. By day 6, median urea was 2.1 mmol/L higher in the high protein group (95% CI 1.1–3.2), increasing to 3.0 mmol/L (95% CI 1.3–4.7) by day 12. A twofold rise in urea was associated with an increased risk of death at 30 days (hazard ratio 1.34, 95% credible interval 1.21–1.48), following adjustment of baseline characteristics including age, illness severity, renal replacement therapy, and presence of AKI. This association persisted over the duration of 30-day follow-up and in models adjusting for evolution of organ failure over time. Conclusions The increased risk of death in patients randomised to a higher protein dose in the EFFORT Protein trial was estimated to be mediated by increased urea cycle activity, of which serum urea is a biological signature. Serum urea should be taken into consideration when initiating and continuing protein delivery in critically ill patients. ClinicalTrials.gov Identifier : NCT03160547 (2017-05-17).

Bioenergetic failure caused by impaired utilisation of glucose and fatty acids contributes to organ dysfunction across multiple tissues in critical illness. Ketone bodies may form an alternative substrate source, but the feasibility and safety of inducing a ketogenic state in physiologically unstable patients is not known. Twenty-nine mechanically ventilated adults with multi-organ failure managed on intensive care units were randomised (Ketogenic n = 14, Control n = 15) into a two-centre pilot open-label trial of ketogenic versus standard enteral feeding. The primary endpoints were assessment of feasibility and safety, recruitment and retention rates and achievement of ketosis and glucose control. Ketogenic feeding was feasible, safe, well tolerated and resulted in ketosis in all patients in the intervention group, with a refusal rate of 4.1% and 82.8% retention. Patients who received ketogenic feeding had fewer hypoglycaemic events (0.0% vs. 1.6%), required less exogenous international units of insulin (0 (Interquartile range 0-16) vs.78 (Interquartile range 0-412) but had slightly more daily episodes of diarrhoea (53.5% vs. 42.9%) over the trial period. Ketogenic feeding was feasible and may be an intervention for addressing bioenergetic failure in critically ill patients. Clinical Trials.gov registration: NCT04101071.

Intermittent (or bolus) feeding regimens in critically ill patients have been of increasing interest to clinicians and scientists. Changes in amino acid, fat and carbohydrate metabolites over time might yet deliver other benefits (e.g. modulation of the circadian rhythm and sleep, and impacts on ghrelin secretion, insulin resistance and autophagy). We set out to characterise these changes in metabolite concentration. The Intermittent versus Continuous Feeding in Critically Ill paitents study (NCT02358512) was an eight-centre single-blinded randomised controlled trial. Patients were randomised to received a continuous (control arm) or intermittent (6x/day, intervention arm) enteral feeding regimen. Blood samples were taken on trial days 1, 7 and 10 immediately before and 30 min after intermittent feeds, and at equivalent timepoints in the control arm. A pre-planned targeted metabolomic analysis was performend using Nuclear Resonance Spectroscopy. Five hundred and ninety four samples were analysed from 75 patients. A total of 24 amino acid-, 19 lipid based-, and 44 small molecule metabolite features. Across the main two axes of variation (40–60% and 6–8% of variance), no broad patterns distinguished between intermittent or continuous feeding arms, across intra-day sampling times or over the 10 days from initial ICU admission. Logfold decreases in abundance were seen in metabolites related to amino acids (Glutamine − 0.682; Alanine − 0.594), ketone body metabolism (Acetone − 0.64; 3-Hydroxybutyric Acid − 0.632; Acetonacetic Acid − 0.586), fatty acid (carnitine − 0.509) and carbohydrate metabolism ( Maltose − 0.510; Citric Acid − 0.485). 2–3 Butanediol, a by-product of sugar-fermenting microbial metabolism also decreased (− 0.489). No correlation was seen with change in quadriceps muscle mass for any of the 20 metabolites varying with time (all p > 0.05). Increasing severity of organ failure was related to increasing ketone body metabolism (3 Hydroxybutyric Acid-1 and − 3; p = 0.056 and p = 0.014), carnitine deficiency ( p = 0.002) and alanine abundancy ( p − 0.005). A 6-times a day intermittent feeding regimen did not alter metabolite patterns across time compared to continuous feeding in critically ill patients, either within a 24 h period or across 10 days of intervention. Future research on intermittent feeding regimens should focus on clinical process benefits, or extended gut rest and fasting.