Beyond Early Initiation: Predictors of Successful Early Enteral Nutrition Advancement in Critically Ill Patients

Background/Objectives: Early enteral nutrition (EN) initiation and progressive EN advancement are critical components of nutritional care in critically ill patients; however, not all patients achieve successful early EN advancement in real-world intensive care unit (ICU) settings. We investigated clinical predictors of early EN initiation and successful early EN advancement at ICU admission in a retrospective cohort study at a single tertiary academic medical center in South Korea. Methods: A total of 2112 critically ill adults receiving EN between January 2020 and December 2024 were included. Successful early EN advancement was defined as EN initiation within 48 h of ICU admission, followed by progressive advancement without any reduction or discontinuation during the subsequent seven days. Using a two-stage multivariable logistic regression approach, we identified predictors of each outcome. Results: Among the total cohort, 722 patients (34.2%) achieved early EN initiation, of whom 449 (62.2%) subsequently achieved successful early EN advancement, representing 21.3% of the total cohort. Male sex (adjusted odds ratio [aOR] 0.87, 95% CI 0.78-0.96), higher admission lactate (aOR 0.85, 95% CI 0.74-0.96), prior surgery (aOR 0.81, 95% CI 0.70-0.93), and higher APACHE II score (aOR 0.88, 95% CI 0.79-0.99) were identified as significant negative predictors (all p < 0.05). Admission-time variables (male sex, elevated lactate, prior surgery, and higher APACHE II scores) effectively identify patients at risk of early EN failure. Conclusions: Reflecting distinct predictor profiles between ICU types, the preliminary nomogram can guide tailored nutritional strategies, although prospective external validation remains essential before clinical implementation.