Nutrition management in critically ill surgical patients: a clinical practice guideline appraisal and synthesis

Critically ill surgical patients are particularly vulnerable to inadequate nutritional intake due to surgery, trauma, treatment-related interruptions, and hypermetabolic stress. Clinical practice guidelines (CPGs) are important for guiding nutritional management in this population, but specific recommendations remain limited. Therefore, this systematic review aimed to evaluate the methodological quality of CPGs related to nutritional management in critically ill surgical patients and to synthesize their recommendations.

Comprehensive bibliographic searches were conducted across six literature databases and ten guideline repositories to identify CPGs published between January 2005 and November 2025. Professional society websites and relevant grey literature sources were also searched. Data on guideline characteristics and development methodology were extracted. The methodological quality of included guidelines was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II), and the quality of recommendations using the AGREE-Recommendation Excellence (AGREE-REX). Recommendations relevant to nutritional management in critically ill surgical patients were then synthesized narratively.

A total of 17 CPGs were included, comprising 12 critical care CPGs, one surgical CPG, one obesity-specific CPG, and three disease-specific CPGs. Substantial variability was observed across the six AGREE II domains, with mean overall quality ratings ranging from 3.75 ± 0.96 to 6.25 ± 0.50. The AGREE-REX overall scores ranged from 48.15% to 75.93%. In terms of whether the appraisers would recommend the CPGs and their recommendations for use, one CPG was rated as "No" in both AGREE II and AGREE-REX assessments, and the remaining were rated as either "Yes" or "Yes, with modifications." Guideline recommendations were summarized into general nutritional recommendations for critically ill surgical patients and subgroup-specific recommendations. The former covered general principles, nutrition screening and assessment, preoperative and postoperative nutrition, nutritional monitoring, and management of feeding intolerance. The latter addressed 12 conditions, including gastrointestinal surgery and injury, organ transplantation, bariatric surgery, acute pancreatitis, neurocritical illness, cardiac critical illness, burns, trauma, sepsis, respiratory dysfunction, hepatic dysfunction, and renal dysfunction.

This systematic review suggests that nutritional therapy for critically ill surgical patients should be tailored based on the type of surgery, stage of critical illness, comorbidities, and individual characteristics. These findings provide evidence-based guidance for clinical practice and highlight the need for dedicated guidelines for this population.

CRD420251076919.