Late Parenteral Nutrition Research Articles

Benefits of late parenteral nutrition in critically ill children

Benefits of late parenteral nutrition in critically ill children

Early versus Late Parenteral Nutrition in Critically Ill Children

BackgroundRecent trials have questioned the benefit of early parenteral nutrition in adults. The effect of early parenteral nutrition on clinical outcomes in critically ill children is unclear.MethodsWe conducted a multicenter, randomized, controlled trial involving 1440 critically ill children to investigate whether withholding parenteral nutrition for 1 week (i.e., providing late parenteral nutrition) in the pediatric intensive care unit (ICU) is clinically superior to providing early parenteral nutrition. Fluid loading was similar in the two groups. The two primary end points were new infection acquired during the ICU stay and the adjusted duration of ICU dependency, as assessed by the number of days in the ICU and as time to discharge alive from ICU. For the 723 patients receiving early parenteral nutrition, parenteral nutrition was initiated within 24 hours after ICU admission, whereas for the 717 patients receiving late parenteral nutrition, parenteral nutrition was not provided until the morning of the 8th day in the ICU. In both groups, enteral nutrition was attempted early and intravenous micronutrients were provided.ResultsAlthough mortality was similar in the two groups, the percentage of patients with a new infection was 10.7% in the group receiving late parenteral nutrition, as compared with 18.5% in the group receiving early parenteral nutrition (adjusted odds ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66). The mean (±SE) duration of ICU stay was 6.5±0.4 days in the group receiving late parenteral nutrition, as compared with 9.2±0.8 days in the group receiving early parenteral nutrition; there was also a higher likelihood of an earlier live discharge from the ICU at any time in the late-parenteral-nutrition group (adjusted hazard ratio, 1.23; 95% CI, 1.11 to 1.37). Late parenteral nutrition was associated with a shorter duration of mechanical ventilatory support than was early parenteral nutrition (P=0.001), as well as a smaller proportion of patients receiving renal-replacement therapy (P=0.04) and a shorter duration of hospital stay (P=0.001). Late parenteral nutrition was also associated with lower plasma levels of γ-glutamyltransferase and alkaline phosphatase than was early parenteral nutrition (P=0.001 and P=0.04, respectively), as well as higher levels of bilirubin (P=0.004) and C-reactive protein (P=0.006).ConclusionsIn critically ill children, withholding parenteral nutrition for 1 week in the ICU was clinically superior to providing early parenteral nutrition. (Funded by the Flemish Agency for Innovation through Science and Technology and others; ClinicalTrials.gov number, NCT01536275.)

Effect of Early Parenteral Nutrition on the HPA Axis and on Treatment With Corticosteroids in Intensive Care Patients.

Nutrition can affect the hypothalamus-pituitary-adrenal axis. We hypothesized that early administration of parenteral nutrition (PN) during critical illness reduces plasma ACTH and cortisol concentrations and thereby increases the use of corticosteroids. This is a preplanned substudy of a randomized controlled trial (EPaNIC) that compared early PN with late PN in 4640 critically ill patients. We investigated the effect of early vs late PN on any steroid treatment and on treatment for ≥ 5 days to capture patients with clinical suspicion of adrenal insufficiency, and assessed whether this was related to an effect on septic shock. Also, in a propensity score-matched subgroup (n=174) of patients not receiving steroids, plasma ACTH and (free) cortisol were quantified. Compared with late PN, more patients on early PN received treatment with corticosteroids (26.2% vs 23.8%; P = .05) and with corticosteroids for ≥ 5 days (14.0% vs 11.9%; P = .03). However, plasma ACTH and (free) cortisol concentrations were unaffected and thus could not explain the higher use of corticosteroids with early PN. Instead, more patients developed new septic shock with early PN (17.0%) than with late PN (14.2%) (P = .01). In multivariate logistic regression analysis, new septic shock was an independent determinant for ≥ 5 days steroid treatment (odds ratio, 6.25; 95% confidence interval, 4.93-7.94; P < .0001), statistically explaining the effect of early PN on steroid treatment. Early PN did not affect plasma concentrations of ACTH and (free) cortisol, but increased the incidence of septic shock, which statistically explained why more patients on early PN received corticosteroids.

Effects of Early and Late Parenteral Nutrition on Clinical Outcomes in Very Low Birth Weight Preterm Infants: A Systematic Review and Meta-analysis

Background: Parenteral Nutrition (PN) provided to the Very Low Birth Weighti¼ˆVLBWi¼‰premature infants should be resulted in gradually development as of the other fetuses following the same gestational age. Even after providing the proven beneficial parenteral nutrition supplements, VLBW infants are often presents with the unfavorable results; the main reason behind it is the decision of the administration of parenteral nutrition, whether it is in early life or later days. Objective: The objective of this study is to explore the effect of early and late parenteral nutrition in the VLBW premature infants. In this study we hypothesize that early parenteral nutrition is associated with comparatively beneficial outcomes. Methods: The PubMed (PubMed Central), Medline, and Google Scholar databases were searched from 1993 to 2013. Methodological quality assessment was based on the PRISMA guidelines. Data analysis were conducted with RevMan 5.3 Results: Ten studies including thirteen trials met our inclusion criteria. The aggregate results of trials showed that early parenteral nutrition was well tolerated by VLBW preterm infants and there was significant reduction in sepsis (RR=0.82, 95% CI=0.69~0.98, P=0.03) Conclusion: Comparison made between the patients provided early and late parenteral nutrition, the development and reduction of clinical disease were significantly lower in the early parenteral nutrition group. The cost-effectiveness of these preparations, however, needs to be further explored. The poor qualities of studies call into a question and robustness of the analysis.

Clinical efficacy of two different parenteral nutrition （PN）method for premature and low birth weight infants

Objective To observe and discuss clinical effect of early parenteral nutrition（PN） born within 24h and late PN within 72h on premature and low birth weight irffants. Methods 68 admitted cases were divided into treatment group（ n = 35 ） and control group（ n = 33 ） with random number table. Treatment group was infused of amino acids（ initial value lg/kg · d） and fat emulsion（ initial value 0. 5-1. 0g/kg · d） born within 24h ,control group was infused of amino acids （ initial value 0.5 g/kg · d） and fat emulsion（ initial value 0. 5-1. 0g/kg · d） born after 72h, during which breast feeding was arranged in terms of suitable situation, and body weight, liver and kidney function, blood lipid, blood glucose, complications were noted and compared between two groups born after 7d. Results （ 1 ） The preterm children born after 7d of physicochemical parameters were significantly improved after birth（ the treatment group t = 2. 169,5. 963,11. 773,5. 920,5. 870,8. 998,2. 076, the control group t = 1. 755,2. 610,9. 255,4. 697,4. 062, 7. 489,2. 042 ,all P 〈 0.05 ）. （2）PN time of treatment group was 8-17d,9-20d in the control group,there was signifi- cant difference between the two groups（ t = 1. 458 ,P 〉 0.05 ）. Two groups of children in hyperlipidemia hyperbilirubinemia,cholestasis,secondary infection, the incidence of complications was no significant difference （x^2 = 0. 215, 0. 235,0. 173,0. 190, all P 〉 0.05 ）. Conclusion Under the premise of initial value of amino acid,fat emulsion were 1 g/kg · d,0.5-1.0g/kg · d, early PN born within 24h compared with latePN born after 72h can better improve nutritional status of premature and low birth weight infants, and clinical safety of two methods are much similar; for premature and low birth weight infants, amino acid and fat emulsion may be considered to intake born within 24h. Key words: Parenteral Nutrition; Total; Body Mass Index; Infant; Premature

Withholding parenteral nutrition during critical illness increases plasma bilirubin but lowers the incidence of biliary sludge

Cholestatic liver dysfunction (CLD) and biliary sludge often occur during critical illness and are allegedly aggravated by parenteral nutrition (PN). Delaying initiation of PN beyond day 7 in the intensive care unit (ICU) (late PN) accelerated recovery as compared with early initiation of PN (early PN). However, the impact of nutritional strategy on biliary sludge and CLD has not been fully characterized. This was a preplanned subanalysis of a large randomized controlled trial of early PN versus late PN (n = 4,640). In all patients plasma bilirubin (daily) and liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], gamma-glutamyl transpeptidase [GGT], alkaline phosphatase [ALP], twice weekly; n = 3,216) were quantified. In a random predefined subset of patients, plasma bile acids (BAs) were also quantified at baseline and on days 3, 5, and last ICU-day (n = 280). Biliary sludge was ultrasonographically evaluated on ICU-day 5 (n = 776). From day 1 after randomization until the end of the 7-day intervention window, bilirubin was higher in the late PN than in the early PN group (P < 0.001). In the late PN group, as soon as PN was started on day 8 bilirubin fell and the two groups became comparable. Maximum levels of GGT, ALP, and ALT were lower in the late PN group (P < 0.01). Glycine/taurine-conjugated primary BAs increased over time in ICU (P < 0.01), similarly for the two groups. Fewer patients in the late PN than in the early PN group developed biliary sludge on day 5 (37% versus 45%; P = 0.04). Tolerating substantial caloric deficit by withholding PN until day 8 of critical illness increased plasma bilirubin but reduced the occurrence of biliary sludge and lowered GGT, ALP, and ALT. These results suggest that hyperbilirubinemia during critical illness does not necessarily reflect cholestasis and instead may be an adaptive response that is suppressed by early PN.

Impact of Early Parenteral Nutrition on Muscle and Adipose Tissue Compartments During Critical Illness*

The goal of enhanced nutrition in critically ill patients is to improve outcome by reducing lean tissue wasting. However, such effect has not been proven. This study aimed to assess the effect of early administration of parenteral nutrition on muscle volume and composition by repeated quantitative CT. A preplanned substudy of a randomized controlled trial (Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients [EPaNIC]), which compared early initiation of parenteral nutrition when enteral nutrition was insufficient (early parenteral nutrition) with tolerating a pronounced nutritional deficit for 1 week in ICU (late parenteral nutrition). Late parenteral nutrition prevented infections and accelerated recovery. University hospital. Fifteen EPaNIC study neurosurgical patients requiring prescheduled repeated follow-up CT scans and six healthy volunteers matched for age, gender, and body mass index. Repeated abdominal and femoral quantitative CT images were obtained in a standardized manner on median ICU day 2 (interquartile range, 2-3) and day 9 (interquartile range, 8-10). Intramuscular, subcutaneous, and visceral fat compartments were delineated manually. Muscle and adipose tissue volume and composition were quantified using standard Hounsfield Unit ranges. Critical illness evoked substantial loss of femoral muscle volume in 1 week's time, irrespective of the nutritional regimen. Early parenteral nutrition reduced the quality of the muscle tissue, as reflected by the attenuation, revealing increased intramuscular water/lipid content. Early parenteral nutrition also increased the volume of adipose tissue islets within the femoral muscle compartment. These changes in skeletal muscle quality correlated with caloric intake. In the abdominal muscle compartments, changes were similar, albeit smaller. Femoral and abdominal subcutaneous adipose tissue compartments were unaffected by disease and nutritional strategy. Early parenteral nutrition did not prevent the pronounced wasting of skeletal muscle observed over the first week of critical illness. Furthermore, early parenteral nutrition increased the amount of adipose tissue within the muscle compartments.

Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: a subanalysis of the EPaNIC trial

Patients who are critically ill can develop so-called intensive-care unit acquired weakness, which delays rehabilitation. Reduced muscle mass, quality, or both might have a role. The Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) trial (registered with ClinicalTrials.gov, number NCT00512122) showed that tolerating macronutrient deficit for 1 week in intensive-care units (late parenteral nutrition [PN]) accelerated recovery compared with early PN. The role of weakness was unclear. Our aim was to assess whether late PN and early PN differentially affect muscle weakness and autophagic quality control of myofibres. In this prospectively planned subanalysis of the EPaNIC trial, weakness (MRC sum score) was assessed in 600 awake, cooperative patients. Skeletal muscle biopsies, harvested from 122 patients 8 days after randomisation and from 20 matched healthy controls, were studied for autophagy and atrophy. We determined the significance of differences with Mann-Whitney U, Median, Kruskal-Wallis, or χ(2) (exact) tests, as appropriate. With late PN, 105 (34%) of 305 patients had weakness on first assessment (median day 9 post-randomisation) compared with 127 (43%) of 295 patients given early PN (absolute difference -9%, 95% CI -16 to -1; p=0·030). Weakness recovered faster with late PN than with early PN (p=0·021). Myofibre cross-sectional area was less and density was lower in critically ill patients than in healthy controls, similarly with early PN and late PN. The LC3 (microtubule-associated protein light chain 3) II to LC3I ratio, related to autophagosome formation, was higher in patients given late PN than early PN (p=0·026), reaching values almost double those in the healthy control group (p=0·0016), and coinciding with less ubiquitin staining (p=0·019). A higher LC3II to LC3I ratio was independently associated with less weakness (p=0·047). Expression of mRNA encoding contractile myofibrillary proteins was lower and E3-ligase expression higher in muscle biopsies from patients than in control participants (p≤0·0006), but was unaffected by nutrition. Tolerating a substantial macronutrient deficit early during critical illness did not affect muscle wasting, but allowed more efficient activation of autophagic quality control of myofibres and reduced weakness. UZ Leuven, Research Foundation-Flanders, the Flemish Government, and the European Research Council.

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.

Withholding parenteral nutrition during the first week of critical illness increases plasma bilirubin but lowers the incidence of cholestasis and gallbladder sludge

Cholestatic liver dysfunction (CLD) during critical illness, defined by hyperbilirubinemia, often occurs and is associated with poor outcome. Parenteral nutrition (PN) is assumed to aggravate CLD. However, hyperbilirubinemia more frequently occurred when the start of PN was delayed until day 8 in the ICU (late PN) [1]. Late PN accelerated recovery as compared with early initiation of PN.

Impact of early versus late parenteral nutrition on morphological and molecular markers of atrophy and autophagy in skeletal muscle of critically ill patients

Muscle weakness of critical illness is associated with prolonged dependency on ventilatory support and delayed rehabilitation. Muscle wasting related to poor nutrition has long been considered a major determinant, whereas the importance of myofiber integrity only recently emerged [1-4]. We hypothesized that nutrient restriction early during illness aggravates atrophy while preserving myofiber integrity by activating the crucial cellular quality control pathway autophagy. The latter could be important to preserve muscle function.

Gluttony in the Intensive Care Unit

Gluttony in the Intensive Care Unit

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.)

Early versus late parenteral nutrition in the adult ICU: feeding the patient or our conscience?

Background: Critical illness increases the risk of malnutrition, which can increase infections, prolong mechanical ventilation, delay recovery, and increase mortality. While enteral nutrition (EN) is considered optimal, this is not always an option. Furthermore, algorithms for parenteral nutrition (PN) vary significantly, and it is unclear whether early initiation or delay of parenteral feeding is preferable. Objective: This study compares intensive care unit (ICU) duration of stay in adults randomized to early initiation of PN (within 48 hr of ICU admission) vs delayed (at eight days or later after ICU admission), as consistent with European and North American guidelines, respectively. Design and setting: This multicentre parallel-group randomized controlled trial was carried out from August 2007 to November 2010 and involved seven Belgian ICUs. The trial was powered at [ 80% to detect a one-day between-group change of stay in the ICU and powered at 70% to detect a 3% change in mortality. The study was supported by an unrestricted and unconditional grant from Baxter Healthcare. Patients: Inclusion criteria included patients older than 18 yr who were admitted to the ICU and had a nutritional risk screening (NRS) score of C 3 (scale of 1-7; where C 3 indicates nutritional risk). Exclusion criteria included patients with a do not resuscitate order, short bowel syndrome, absence of central venous access, a body mass index (BMI) 17, the ability to tolerate oral nutrition or a predetermined nutritional regimen, and those with lung ventilation at home; patients in a diabetic coma or enrolled in other studies were also excluded. Intervention: Eight thousand, seven hundred three patients were screened, and 4,640 of those were randomized in blocks of ten via sequentially numbered envelopes. Two thousand three hundred twelve patients were assigned to early PN initiation, and 2,328 patients were assigned to late PN initiation. Patients received enteral feeding by unit protocol, if appropriate. In addition, early PN patients received an intravenous solution of 20% glucose to achieve 400 kCal day on day one, 800 kCal day on day two, and 100% of the caloric goal by day three. Patients were weaned from PN when enteral nutrition met [ 80% of caloric goals. The late PN initiation group received an intravenous solution of 5% glucose (equal in volume to the early initiation group and adequate to maintain hydration). If EN did not meet caloric goals by day seven, then PN was initiated on day eight. Both groups were maintained semirecumbant (unless contraindicated); they received prokinetic agents, had duodenal feeding tubes, and received early parenteral trace elements, minerals, and vitamins. J. P. Kerrie, MD Department of Medicine, University of British Columbia, Vancouver, BC, Canada

Early Versus Late Parenteral Nutrition in Very Low Birthweight Neonates : A Retrospective Study from Oman

The aim of this study was to compare the biochemical parameters, weight gain, osteopenia and phosphate supplementation in very low birth weight (VLBW) neonates receiving early versus late parenteral nutrition (EPN versus LPN). A RETROSPECTIVE STUDY WAS UNDERTAKEN IN THE LEVEL III NEONATAL INTENSIVE CARE UNIT AT SULTAN QABOOS UNIVERSITY HOSPITAL, OMAN: from January 2007 to October 2008 (LPN group, n = 47) and from January 2009 to June 2010 (EPN group, n = 44). Demographic data, anthropometric and laboratory parameters were extracted from the electronic record system. The mean age of PN initiation was LPN = 47.3 hours versus EPN = 14.3 hours. Biochemical parameters analysed during the first week of life revealed a reduction in hypernatraemia (12.7% versus 6.8%) and non-oliguric hyperkalemia (12.7% versus 6.8%) in EPN, with no significant differences in acidosis and urea levels between the two groups. Hyperglycemia >12 mmol/L in <1000g was higher in EPN. Nutritional parameters in 81 babies who survived/stayed in the unit up to a corrected gestational age (CGA) of 34 weeks (40 in LPN and 41 in EPN), revealed a reduction in metabolic bone disease (osteopenia of prematurity [OOP], 17.5% versus 7.3%) and the need for phosphate supplementation (22.5% versus 7.3%) in the EPN group. There was no increase in acidosis or cholestasis. No difference was noted in albumin levels, time to full feeds, time to regain birthweight and mean weight gain per day till 34 weeks corrected CGA. EPN in VLBW newborns is well tolerated and reduces hypernatraemia, non-oliguric hyperkalemia, OOP and the need for phosphate supplementation.

Early versus late Parenteral Nutrition in Critically Ill Adults

Early versus late Parenteral Nutrition in Critically Ill Adults

Early versus late parenteral nutrition in ICU patients: cost analysis of the EPaNIC trial

IntroductionThe EPaNIC randomized controlled multicentre trial showed that postponing initiation of parenteral nutrition (PN) in ICU-patients to beyond the first week (Late-PN) enhanced recovery, as compared with Early-PN. This was mediated by fewer infections, accelerated recovery from organ failure and reduced duration of hospitalization. Now, the trial's preplanned cost analysis (N = 4640) from the Belgian healthcare payers' perspective is reported.MethodsCost data were retrieved from individual patient invoices. Undiscounted total healthcare costs were calculated for the index hospital stay. A cost tree based on acquisition of new infections and on prolonged length-of-stay was constructed. Contribution of 8 cost categories to total hospitalization costs was analyzed. The origin of drug costs was clarified in detail through the Anatomical Therapeutic Chemical (ATC) classification system. The potential impact of Early-PN on total hospitalization costs in other healthcare systems was explored in a sensitivity analysis.ResultsICU-patients developing new infection (24.4%) were responsible for 42.7% of total costs, while ICU-patients staying beyond one week (24.3%) accounted for 43.3% of total costs. Pharmacy-related costs represented 30% of total hospitalization costs and were increased by Early-PN (+608.00 EUR/patient, p = 0.01). Notably, costs for ATC-J (anti-infective agents) (+227.00 EUR/patient, p = 0.02) and ATC-B (comprising PN) (+220.00 EUR/patient, p = 0.006) drugs were increased by Early-PN. Sensitivity analysis revealed a mean total cost increase of 1,210.00 EUR/patient (p = 0.02) by Early-PN, when incorporating the full PN costs.ConclusionsThe increased costs by Early-PN were mainly pharmacy-related and explained by higher expenditures for PN and anti-infective agents. The use of Early-PN in critically ill patients can thus not be recommended for both clinical (no benefit) and cost-related reasons.Trial registrationClinicalTrials.gov NCT00512122.

Early use of supplemental parenteral nutrition in critically ill patients: Results of an international multicenter observational study*

To evaluate the effect of using supplemental parenteral nutrition compared to early enteral nutrition alone on nutritional and clinical outcomes. A multicenter, observational study. Two hundred twenty-six intensive care units from 29 Countries. Mechanically ventilated critically ill adult patients that remained in the intensive care unit for >72 hrs and received early enteral nutrition within 48 hrs from admission. Data were collected on patient characteristics and daily nutrition practices for up to 12 days. Patient outcomes were recorded after 60 days. We compared the outcomes of patients who received early enteral nutrition alone, early enteral nutrition + early parenteral nutrition, and early enteral nutrition + late parenteral nutrition (after 48 hrs of admission). Cox regression analyses were conducted to determine the effect of feeding strategy, adjusted for other confounding variables, on time to being discharged alive from hospital. A total of 2,920 patients were included in this study; 2562 (87.7%) in the early enteral nutrition group, 188 (6.4%) in the early parenteral nutrition group, and 170 (5.8%) in the late parenteral nutrition group. Adequacy of calories and protein was highest in the early parenteral nutrition group (81.2% and 80.1%, respectively) and lowest in the early enteral nutrition group (63.4% and 59.3%) (p < .0001). The 60-day mortality rate was 27.8% in the early enteral nutrition group, 34.6% in the early parenteral nutrition group, and 35.3% in the late parenteral nutrition group (p = .02). The rate of patients discharged alive from hospital was slower in the group that received early parenteral nutrition (unadjusted hazard ratio 0.75, 95% confidence interval 0.59-0.96) and late parenteral nutrition (hazard ratio 0.64, 95% confidence interval 0.51-0.81) (p = .0003) compared to early enteral nutrition. These findings persisted after adjusting for known confounders. The supplemental use of parenteral nutrition may improve provision of calories and protein but is not associated with any clinical benefit.

Late initiation of parenteral nutrition reduced length of intensive care unit stay

Source Citation Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-17. 21714640

Early or Late Parenteral Nutrition in Critically Ill Adults

To the Editor: Casaer et al. (Aug. 11 issue)1 provide evidence that early supplemental parenteral nutrition appeared to be inferior to withholding parenteral nutrition until day 8 of the intensive care unit (ICU) stay. However, we think that some limitations of the study should be addressed. Half the patients included were extubated at day 2 and discharged from the ICU at day 4, when they were already receiving two thirds of the caloric demand as oral feeding; this casts doubt on the indication for parenteral nutrition and the correct application of the European Society of Parenteral and Enteral Nutrition guidelines.2 A total of 60% of the study patients underwent cardiac surgery, for which artificial nutritional support is rarely indicated. Initiation of an oral diet after successful extubation is the standard of care. Patients with the strongest indication for nutritional support3 (body-mass index [BMI, the weight in kilograms divided by the square of the height in meters], <17) were excluded from the study. In addition, by neglecting stepwise increases in parenteral nutrition,4 hyperalimentation during stress metabolism with an energy goal up to 32 kcal per kilogram of body weight per day may have been achieved as early as day 3. Concomitant intensive insulin therapy necessarily masked metabolic consequences such as severe hyperglycemia. In our mind, better selection of patients may have indeed shown the benefits of supplemental parenteral nutrition. Thomas W. Felbinger, M.D., Ph.D.