Enteral nutrition in septic shock: A pathophysiologic conundrum

Septic shock is a public health burden and defined as a subset of sepsis whereby abnormalities in microcirculatory and cellular metabolism manifest as acute circulatory failure. At the level of the gut, septic shock impairs epithelial barrier function (EBF), and the gut initiates proinflammatory responses contributing to multiple organ dysfunction syndrome. The timing and dose of enteral nutrition (EN) in septic shock remains a conundrum. On the one hand, early EN preserves EBF. On the other hand, serious gastrointestinal complications such as bowel necrosis may limit EN initiation in septic shock. We (1) describe the pathophysiologic conundrum septic shock poses for EN initiation, (2) outline guideline-based recommendations for EN in septic shock, (3) identify the role of parenteral nutrition in septic shock, and (4) identify and appraise postguideline literature on the timing, dose, and titration of EN in septic shock.