Insufficient Enteral Nutrition Research Articles

Growth and Duration of Inflammation Determine Short- and Long-Term Outcome in Very-Low-Birth-Weight Infants Requiring Abdominal Surgery

Necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP) and meconium-related ileus (MI) requiring surgical intervention are associated with a high risk of severe short- and long-term complications in very-low-birth-weight (VLBW) infants including poor growth, cholestasis and neurodevelopmental impairment. This retrospective study aimed to identify risk factors for such complications in a cohort of 55 VLBW preterm infants requiring surgery with enterostomy creation due to NEC, SIP or MI. Long-term follow-up was available for 43 (78%) infants. Multiple regression analyses revealed that the duration of inflammation and longitudinal growth determined the risk of cholestasis and neurodevelopmental outcome at 2 years corrected age independent of the aetiology of the intestinal complication. Direct bilirubin increased by 4.9 μmol/L (95%CI 0.26-9.5), 1.4 μmol/L (95%CI 0.6-2.2) and 0.8 μmol/L (95%CI 0.22-1.13) with every day of elevated (Interleukin-6) IL-6, (C-reactive protein) CrP and parenteral nutrition. The mental development index at 2 years corrected age decreased by 3.8 (95%CI -7.3--0.36), 0.4 (95%CI 0.07-0.80) and 0.3 (95%CI 0.08-0.57) with every day of elevated IL-6 and every 1 point decrease in weight percentile at discharge and 2 years. These data stress the importance of optimal timing for the initial surgery in order to prevent prolonged inflammation and an early reversal of the enterostomy in case of poor growth or insufficient enteral nutrition.

OR26-02 The Effect on Ketogenesis of Withholding Early Parenteral Nutrition in Critically Ill Children, as a Potential Mediator of the Improved Acute Outcome

Introduction: In adults and children, withholding parenteral nutrition (PN) for 1 week in ICU (late PN), hereby accepting macronutrient deficit early during critical illness, as compared with supplementing insufficient enteral nutrition with PN (early PN), accelerates weaning from mechanical ventilation, reduces infections, and shortens ICU stay1,2. We hypothesized that these benefits are in part mediated by fasting-induced ketogenesis. Methods: This is a secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric ICU (PEPaNIC) RCT (N=1440)2. First, for a matched subset of 96 patients with a PICU stay of ≥5 days, daily plasma 3-hydroxybutyrate (3HB) concentrations were determined to identify the time point of maximal effect of late PN versus early PN, if any, on 3HB. Thereafter, for all patients with a plasma sample available on that “maximal effect day” (or last day for shorter stayers), plasma 3HB and insulin concentrations were quantified (N=1142). The independent association between plasma 3HB on that day and outcome was assessed by multivariable Cox proportional hazard analysis for time to live weaning from mechanical ventilation and for time to live PICU discharge and by multivariable logistic regression for incidence of new infection and PICU mortality, adjusted for randomization to late PN versus early PN and baseline risk factors (demographics, diagnosis, illness severity). In a sensitivity analysis, models were further adjusted for key regulators of ketogenesis (plasma insulin, blood glucose, corticosteroids and catecholamines) to assess whether any effect was direct or indirect. Results: In the matched cohort, late PN increased plasma 3HB as compared with early PN (P<0.0001 for PICU-days 1 to 5), with maximal effect observed on PICU day 2. In the 1142 patients, plasma 3HB concentration on that “maximal effect day” was (mean±SEM) 0.19±0.05 mM in early PN patients and 1.17±0.02 mM in late-PN patients (P<0.0001). Adding these plasma 3HB concentrations to the multivariable models, adjusted for baseline risk factors and randomization, showed that higher plasma 3HB concentrations were independently associated with a higher likelihood of early live weaning from mechanical ventilatory support (P=0.0002) and of early live PICU discharge (P=0.004). As the 3HB concentrations replaced the effect of the randomization, this suggested that the 3HB effect statistically explained these effects of the randomization. Further adjustment for key regulators of ketogenesis did not alter these findings. The effect of late PN versus early PN on plasma 3HB did not explain its impact on infections and was not related to mortality. Conclusion: Withholding early PN increased plasma 3HB concentrations in critically ill children, a direct effect that mediated an important part of its beneficial impact on recovery. 1Casaer M. et al, N Engl J Med 20112Fivez T. et al, N Engl J Med 2016

Perioperative Enteral Nutrition After Left Ventricular Assist Device Implantation.

Objective:We assessed what predicts nutritional adequacy at day 14 following implantation of left ventricular assist device (LVAD).Method:We retrospectively reviewed the cases of 97 adult patients who underwent LVAD implantation at our institution from June 2011 to June 2016. We divided the patients into two groups based on the administered enteral nutrition (EN) calories on post-operative day (POD) 14: the EN calories of group SEN (sufficient enteral nutrition) were >80% of their total target calories, or the EN calories of group IEN (insufficient enteral nutrition) were <80% of their total target calories. We compared the two groups in terms of the perioperative factors within 1 week after surgery.Results:Groups SEN and IEN consisted of 53 and 44 patients, respectively. The mean doses of adrenaline and noradrenaline, mean central venous pressure (CVP), duration of nitric oxide administration, and mean residual gastric volume during 1 week after surgery in group SEN were significantly lower than those in group IEN (P < .05). In multivariate analysis, higher CVP during 1 week after surgery was identified as an independent risk factor for delayed EN on POD14 (odds ratio, 1.40; 95% confidence interval, 1.11-1.66; P = .0037). Total bilirubin, occurrence of acute kidney injury, and mixed venous blood saturation during 1 week after surgery were not significant predictors for EN on POD14.Conclusions:Increased CVP within 1 week after LVAD implantation was an independent factor for reduced EN feeding.

Parenteral nutrition in the critically ill.

Feeding guidelines have recommended early, full nutritional support in critically ill patients to prevent hypercatabolism and muscle weakness. Early enteral nutrition was suggested to be superior to early parenteral nutrition. When enteral nutrition fails to meet nutritional target, it was recommended to administer supplemental parenteral nutrition, albeit with a varying starting point. Sufficient amounts of amino acids were recommended, with addition of glutamine in subgroups. Recently, several large randomized controlled trials (RCTs) have yielded important new insights. This review summarizes recent evidence with regard to the indication, timing, and dosing of parenteral nutrition in critically ill patients. One large RCT revealed no difference between early enteral nutrition and early parenteral nutrition. Two large multicenter RCTs showed harm by early supplementation of insufficient enteral nutrition with parenteral nutrition, which could be explained by feeding-induced suppression of autophagy. Several RCTs found either no benefit or harm with a higher amino acid or caloric intake, as well as harm by administration of glutamine. Although unanswered questions remain, current evidence supports accepting low macronutrient intake during the acute phase of critical illness and does not support use of early parenteral nutrition. The timing when parenteral nutrition can be initiated safely and effectively is unclear.

Changes in Neonatal Microbiota Distribution Influenced by the Environment of the Neonatal Intensive Care Unit in the First Month of Life

Commensal bacterial colonization is crucial for human health, and the early neonatal period is important for the establishment of microbial populations. However, studies on the developmental patterns of microbiota in early life, particularly in those exposed to the environment of the neonatal intensive care unit (NICU), are limited. Using a 16S ribosomal RNA polymerase chain reaction assay, this study aimed to evaluate the changes in the levels of representative microbiota in healthy term infants and infants who were admitted to the NICU during the first month of life. Compared with term infants, the NICU group showed lower levels of Bifidobacterium in the early days after birth but achieved the same levels as those of term infants after day 30 of probiotics use. In addition, we found that the presence of Staphylococcus aureus, including methicillin-resistant S. aureus, from fecal samples was not associated with disturbances in Bifidobacterium during the neonatal period. Clinical factors such as the mode of delivery, antibiotic therapy, and intubation for mechanical ventilation could change the neonatal distribution of microbiota, but the most important factor was insufficient enteral nutrition. This group, which had experienced poor general conditions and/or underwent surgery early in the neonatal period, showed are markable decrease in Bifidobacterium level at day 30. In conclusion, infants in the NICU developed similar microbiota composition as in the healthy term infants group in 1 month afterbirth; however, insufficient enteral nutrition could lead to disintegration of the microbiota distribution.

Parenteral nutrition: never say never.

This review emphasizes the benefits of parenteral nutrition (PN) in critically ill patients, when prescribed for relevant indications, in adequate quantities, and in due time.Critically ill patients are at risk of energy deficit during their ICU stay, a condition which leads to unfavorable outcomes, due to hypercatabolism secondary to the stress response and the difficulty to optimize feeding. Indirect calorimetry is recommended to define the energy target, since no single predictive equation accurately estimates energy expenditure. Energy metabolism is intimately associated with protein metabolism. Recent evidence calls for adequate protein provision, but there is no accurate method to estimate the protein requirements, and recommendations are probably suboptimal. Enteral nutrition (EN) is the preferred route of feeding, but gastrointestinal intolerance limits its efficacy and PN allows for full coverage of energy needs.Seven recent articles concerning PN for critically ill patients were identified and carefully reviewed for the clinical and scientific relevance of their conclusions. One article addressed the unfavorable effects of early PN, although this result should be more correctly regarded as a consequence of glucose load and hypercaloric feeding. The six other articles were either in favor of PN or concluded that there was no difference in the outcome compared with EN. Hypercaloric feeding was not observed in these studies. Hypocaloric feeding led to unfavorable outcomes. This further demonstrates the beneficial effects of an early and adequate feeding with full EN, or in case of failure of EN with exclusive or supplemental PN.EN is the first choice for critically ill patients, but difficulties providing optimal nutrition through exclusive EN are frequently encountered. In cases of insufficient EN, individualized supplemental PN should be administered to reduce the infection rate and the duration of mechanical ventilation. PN is a safe therapeutic option as long as sufficient attention is given to avoid hypercaloric feeding.

The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study

Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN. In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeeding during three-month study period. Decisions regarding EN were made and substantiated by the doctors. No feeding protocol was in use. The EN rate was assessed daily and considered insufficient if less than 50 kcal/h was administered and the rate had not increase in the previous 12 hour period. Eighty-seven patients were screened for 707 patient-days. Nurses documented 141 instances of insufficient EN in 49 patients (56.7% of all study subjects). EN was not initiated in 61% of these cases, EN was stopped in 14%, EN decreased in 2% and insufficient EN was not increased in 23%. EN was not initiated primarily due to surgical reasons. EN was not increased due to clinical instability. EN was decreased or stopped primarily due to high gastric residual volumes (GRV). The study served as step one in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol. The main reasons for insufficient EN in intensive care patients include recent GI surgery, shock and large GRV. EN is commonly withheld for several days after GI surgery, whereas in shock there was a prohibition on increasing EN towards the target. Insufficient EN is highly prevalent; the incidence of EN should be reduced by training and the acceptance of more liberal EN policies.

Parenteral nutrition in the intensive care unit: cautious use improves outcome.

Critical illness is characterised by nutritional and metabolic disorders, resulting in increased muscle catabolism, fat-free mass loss, and hyperglycaemia. The objective of the nutritional support is to limit fat-free mass loss, which has negative consequences on clinical outcome and recovery. Early enteral nutrition is recommended by current guidelines as the first choice feeding route in ICU patients. However, enteral nutrition alone is frequently associated with insufficient coverage of the energy requirements, and subsequently energy deficit is correlated to worsened clinical outcome. Controlled trials have demonstrated that, in case of failure or contraindications to full enteral nutrition, parenteral nutrition administration on top of insufficient enteral nutrition within the first four days after admission could improve the clinical outcome, and may attenuate fat-free mass loss. Parenteral nutrition is cautious if all-in-one solutions are used, glycaemia controlled, and overnutrition avoided. Conversely, the systematic use of parenteral nutrition in the ICU patients without clear indication is not recommended during the first 48 hours. Specific methods, such as thigh ultra-sound imaging, 3rd lumbar vertebra-targeted computerised tomography and bioimpedance electrical analysis, may be helpful in the future to monitor fat-free mass during the ICU stay. Clinical studies are warranted to demonstrate whether an optimal nutritional management during the ICU stay promotes muscle mass and function, the recovery after critical illness and reduces the overall costs.

Development and current use of parenteral nutrition in critical care - an opinion paper.

Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

ABSTRACT 94

Background and aims: Nutritional support may improve outcome during Pediatric Intensive Care Unit (PICU) stay, but guidelines are limited and based on consensus rather than evidence. Aims: We aimed to study current practice in nutritional management of PICUs worldwide. Methods: An online questionnaire, composed of 59 questions, was distributed to members of the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The IRB waived the need for informed consent. Results: We analysed 189 questionnaires accounting for 89000 admissions in 156 PICUs covering 52 countries. A nutritional protocol and nutrition support team (NST) are present in respectively 52% and 57% of PICUs. Presence of a NST is associated with number of beds and admissions. Energy requirements are based on various equations and few PICUs use indirect calorimetry (14%). Lipid targets range from < 1.5 to > 3.5 g/kg/day, protein targets from 0.9 to 3 g/kg/day. Glucose administration during the first 24 hours varies from <2 to >10 mg/kg/min. Enteral nutrition (EN), preferably by gastric tube (68–88%), is started within 24 hours after admission in 60% of the PICUs. In 55% of the PICUs parenteral nutrition (PN) is started within 48 hours in patients intolerable to EN. Insufficient EN, providing < 50% or < 80% of target calories, is respectively supplemented with PN in 48% and 24% of PICUs. Conclusions: Nutritional practices, in terms of requirements, timing and route, are highly variable in PICUs worldwide. Even the limited available guidelines are not consistently followed. The potential impact on outcome warrants uniform evidence based guidelines with consistent implementation.

Impact of Early Parenteral Nutrition on Metabolism and Kidney Injury

A poor nutritional state and a caloric deficit associate with increased morbidity and mortality, but a recent multicenter, randomized controlled trial found that early parenteral nutrition to supplement insufficient enteral nutrition increases morbidity in the intensive care unit, including prolonging the duration of renal replacement therapy, compared with withholding parenteral nutrition for 1 week. Whether early versus late parenteral nutrition impacts the incidence and recovery of AKI is unknown. Here, we report a prespecified analysis from this trial, the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) study. The timing of parenteral nutrition did not affect the incidence of AKI, but early initiation seemed to slow renal recovery in patients with stage 2 AKI. Early parenteral nutrition did not affect the time course of creatinine and creatinine clearance but did increase plasma urea, urea/creatinine ratio, and nitrogen excretion beginning on the first day of amino acid infusion. In the group that received late parenteral nutrition, infusing amino acids after the first week also increased ureagenesis. During the first 2 weeks, ureagenesis resulted in net waste of 63% of the extra nitrogen intake from early parenteral nutrition. In conclusion, early parenteral nutrition does not seem to impact AKI incidence, although it may delay recovery in patients with stage 2 AKI. Substantial catabolism of the extra amino acids, which leads to higher levels of plasma urea, might explain the prolonged duration of renal replacement therapy observed with early parenteral nutrition.

Early Versus Late Parenteral Nutrition in Critically Ill Adults

A b s t r ac t Background Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. Methods In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia. Results Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P = 0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P = 0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P = 0.008) and a lower incidence of cholestasis (P<0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P = 0.006), a median reduction of 3 days in the duration of renalreplacement therapy (P = 0.008), and a mean reduction in health care costs of €1,110 (about $1,600) (P = 0.04). Conclusions Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem program of the Flemish government and others; EPaNIC ClinicalTrials.gov number, NCT00512122.)

Does artificial nutrition improve outcome of critical illness?

Nutritional support is generally considered an essential component in the management of critically ill patients. The existing guidelines advocate early enteral nutrition, with the optimal timing for the addition of parenteral nutrition to insufficient enteral feeding being the subject of transatlantic controversy. The unphysiologic intervention of artificial nutrition in critically ill patients, however, may evoke complications and side effects. Besides the classically described complications, suppression of autophagy, potentially important for cellular repair and organ recovery, was elucidated only recently. The question whether artificial nutrition in critical illness improves or worsens outcome as compared with starvation has so far not been adequately addressed. This paper provides a critical analysis of the existing literature on ICU nutrition, highlighting important methodological shortcomings of many trials and meta-analyses and underlining the urgent need for high-quality research in this field. Recent adequately designed randomized controlled trials suggest that trophic enteral feeding during the first week of critical illness is as good as full enteral feeding and that early addition of parenteral nutrition to insufficient enteral nutrition does not provide any benefit and worsens morbidity.

Timing of the initiation of parenteral nutrition in critically ill adults

BackgroundCritical illness in hospitalized patients induces anorexia: aninability to eat suitably, predisposing to nutritional deficit,weakness, infections, increased duration of mechanicalventilation, delayed recovery and death [1]. To date,whether artificial nutritional support improves outcomesfor critically ill patients is unclear. Enteral nutrition isassociated with fewer complications than parenteral nutri-tion, and is less expensive [2], but enteral nutrition alonedoes not often achieve caloric targets. Combining paren-teral and enteral nutrition could prevent nutritional deficit.However, this strategy may carry the risk of overfeeding,which has been associated with complications such as liverdysfunction [3]. Current clinical practice guidelines fornutritional support in critically ill patients are largely basedon expert opinion, and differ substantially across conti-nents, in particular about the timing to start parenteralnutrition. The European Society of Parenteral and EnteralNutrition (ESPEN) recommends the commencement ofparenteral nutrition within 2 days after admission to theintensive care unit (ICU) for patients who cannot be ade-quately fed enterally [4], while the American and Canadianguidelines recommend early initiation of enteral nutrition,but suggest starting parenteral nutrition after a week inpatients who are not malnourished at baseline [5].SummaryCasaer and coworkers [6] in a randomized, multicenter trial,comparedanearlytoalateinitiationofparenteralnutritioninadults admitted to the ICU who were not malnourished atbaseline [body-mass index (BMI) of C17] in order to sup-plement insufficient enteral nutrition. The primary endpoints were the number of days spent in ICU (for survivorsand non-survivors), and the time to discharge from the ICU.In 2,312 patients, parenteral nutrition was initiated within48 h after ICU admission, whereas in 2,328 patients, it wasnot initiated before the eighth day from admission. ThemedianstayintheICUwas1 dayshorterinthelate-initiationgroup than in the early-initiation group (3 vs. 4 days,respectively, P = 0.02), which was reflected in a relativeincrease of 6.3% of the likelihood of earlier discharge alivefrom the ICU [hazard ratio 1.06, 95% confidence interval(CI), 1.00–1.13, P = 0.04]. Considering the secondary out-comes, patients in the late-initiation group had fewer healthassistance related infections (22.8 vs. 26.2%, P = 0.008), alowerincidenceofcholestasis(32.6vs.38.4%,P\0.001),areduction in the proportion of patients requiring more than2 days of mechanical ventilation (36.3 vs. 40.2%,P = 0.006), a median reduction of 3 days in the duration ofrenal replacement therapy (7 vs. 10 days, P = 0.008) and areduction in mean health care costs of €1,110 as comparedwith the early-initiation group (€16863 vs. €17973,P = 0.04). The safety outcomes (in-hospital mortality rates,survival at 90 days, rates of nutrition-related complications)weresimilarinthetwogroups,buthypoglycaemiawasmorecommon in the late-initiation group patients (3.5 vs. 1.9%,P = 0.001). Although enteral nutrition was initiated if pos-sible in the majority of patients, the post hoc subgroupanalyses including patients for whom early enteral nutritionwas contraindicated showed the same results.

Early versus Late Parenteral Nutrition in Critically Ill Adults

Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia. Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P=0.008) and a lower incidence of cholestasis (P<0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P=0.006), a median reduction of 3 days in the duration of renal-replacement therapy (P=0.008), and a mean reduction in health care costs of €1,110 (about $1,600) (P=0.04). Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem program of the Flemish government and others; EPaNIC ClinicalTrials.gov number, NCT00512122.).

Indicaciones no quirúrgicas de la nutrición parenteral periférica

Peripheral Parenteral Nutrition, defined as a mixture of micronutrients, vitamins and minerals with lower osmolarity of 800 mOsm/L, it avoids the risk of the central catheter. It has traditionally been used in postoperative patients, but really medical conditions can also benefit from it either as complementary, or as the only one source of nutrients, since a high number of patients require less caloric intake than previously believed. Evaluation of the use of peripheral parenteral nutrition in non postoperative hospitalized patients, reasons for its prescription and duration. 368 patients who required peripheral parenteral nutrition were studied by the Nutrition Support Unit for 54 months, in a Tertiary Hospital of 1,560 beds, from all, specialties excluding postoperative patients. The study include the mechanisms that led to its use in all its forms: the only one nutritional support or complementing insufficient Enteral Nutrition or Oral Diet. Oncology and Critical Care were the most prescribed pathologies, followed by Pancreatitis, Inflammatory Bowel Disease and HIV and a miscellany of clinical pathologies. Gastrointestinal pathology (pain, diarrhea or vomiting) was the most frequent cause, both in critically ill as in non-critical patients. Although enteral route is preferred and raised primarily in most patients studied, there are many causes that might impair or nullify it. Peripheral parenteral nutrition is an alternative when caloric intake is impossible or insufficient or refused by the patient, as it minimizes the complications of the central catheter.

Nutrition and clinical outcome in intensive care patients

In the setting of ICU, the characteristics of patients have changed during the last decade. Patients are older, frequently overweight or obese, present with more chronic diseases and undernutrition. These conditions are characterized by reduced muscle mass and vulnerable homeostasis. This review sustains the hypothesis that an early and optimal nutritional support, combining enteral and parenteral nutrition, could improve the clinical outcome of ICU patients. The combination of stress and undernutrition observed in the ICUs is associated with negative energy balance, which leads to lean body mass loss. Catabolism of lean body mass has been repeatedly associated with a worsening of the clinical outcome, increased length of hospital stay, recovery and healthcare costs. Early enteral nutrition is the recommended feeding route in ICU patients, but it is often unable to fully cover the nutritional needs. Parenteral nutrition is recommended if enteral nutrition is not feasible. It is hypothesized that supplemental parenteral nutrition, together with insufficient enteral nutrition, could optimize the nutritional therapy by preventing the onset of early energy deficiency, and thus, could allow to reduce the side-effects of undernutrition and promote better chances of recovery after the ICU stay.

Enteral and parenteral nutrition for critically ill patients: A logical combination to optimize nutritional support

Malnutrition is a common and serious problem in intensive care units. Negative energy balance has been associated with increased morbidity and mortality in critically ill patients. The increased incidence of complications attributable to malnutrition correlates with increased length of hospital stay and overall health care costs. Although early enteral nutrition is the preferred method of feeding critically ill patients, enteral nutrition alone often fails to supply adequate calories and nutrients to critically ill patients, who are frequently hypermetabolic. Supplementation of insufficient enteral nutrition with parenteral nutrition may optimize nutritional support and avert negative energy balance in critically ill patients, thereby improving outcomes.

Paradigm of early parenteral nutrition support in combination with insufficient enteral nutrition

Several observational studies have pointed out the negative effects of an energy deficit in long-staying ICU patients. Morbidity as well as mortality seem to be linked to such an energy deficit, which is often built up during the first week of stay. A combination of enteral and parenteral nutrition may be a strategy to avoid the development of an energy deficit. A cumulated energy deficit is demonstrated to be connected to an increased infectious morbidity. The question is whether or not addition of parenteral nutrition to the enteral nutrition may prevent such morbidity. So far there is only one prospective randomized blinded clinical trial comparing enteral nutrition only to a combination of enteral and parenteral nutrition. This study was inconclusive for outcome, but demonstrated an effect upon length of hospital stay. This field of intensive care medicine is clearly lacking prospective randomized trials. The diversity of opinions is broad, ranging from questioning the use of any nonvolutional nutrition to the use of a combination of enteral and parenteral nutrition to obtain full coverage of the energy needed early on during ICU stay. The arguments for the latter view are summarized in this review.

Ernährung des Intensivpatienten - Strategien zu Planung und Umsetzung

Adequate nutrition of the critically ill patient is a cornerstone of intensive care medicine. While the enteral route should be used whenever possible, parenteral supplementation of insufficient enteral nutrition has been shown to be beneficial and is not considered to be lethal anymore. The daily energy supply should not exceed 20-30 kcal/kgBW in the acute phase of the illness. Vitamins and trace elements should be supplied daily to avoid any deficiency.