Optimization of energy provision with supplemental parenteral nutrition (SPN) improves the clinical outcome of critically ill patients: a randomized controlled trial

Service of Intensive Care, Geneva University Hospital, Geneva, Switzerland.
The Lancet (Impact Factor: 45.22). 12/2012; 381(9864). DOI: 10.1016/S0140-6736(12)61351-8
Source: PubMed


BACKGROUND: Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS: This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS: We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION: Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING: Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

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    • "Indeed, the largest negative energy balance, that corresponds to cumulated energy delivered minus cumulated resting energy expenditure (REE), observed in the first days after ICU admission results in a negative gap that is not filled thereafter [3,4]. Adapting caloric intakes to REE has long been considered a minor issue in the first days of ICU hospitalization while energy deficit is now correlated with various complications [5,6]. Patients with major energy deficit are reported to have a longer ICU stay, prolonged mechanical ventilation and are more frequently exposed to nosocomial infections [3-8]. "
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    ABSTRACT: Estimation of body composition as fat-free mass (FFM) is subjected to many variations caused by injury and stress conditions in the intensive care unit (ICU). Body cell mass (BCM), the metabolically active part of FFM, is reported to be more specifically correlated to changes in nutritional status. Bedside estimation of BCM could help to provide more valuable markers of nutritional status and may promote understanding of metabolic consequences of energy deficit in the ICU patients. We aimed to quantify BCM, water compartments and FFM by methods usable at the bedside for evaluating the impact of sudden and massive fluid shifts on body composition in ICU patients. We conducted a prospective experimental study over a 6 month-period in a 18-bed ICU. Body composition of 31 consecutive hemodynamically stable patients requiring acute renal replacement therapy for fluid overload (ultrafiltration >=5% body weight) was investigated before and after the hemodialysis session. Intra-(ICW) and extracellular (ECW) water volumes were calculated from the raw values of the low- and high-frequency resistances measured by multi-frequency bioelectrical impedance. BCM was assessed by a calculated method recently developed for ICU patients. FFM was derived from BCM and ECW. Intradialytic weight loss was 3.8 +/- 0.8 kg. Percentage changes of ECW (-7.99 +/- 4.60%) and of ICW (-7.63 +/- 5.11%) were similar, resulting ECW/ICW ratio constant (1.26 +/- 0.20). The fall of FFM (-2.24 +/- 1.56 kg, -4.43 +/- 2.65%) was less pronounced than the decrease of ECW (P < 0.001) or ICW (P < 0.001). Intradialytic variation of BCM was clinically negligible (-0.38 +/- 0.93 kg, -1.56 +/- 3.94 %) and was significantly lesser than FFM (P < 0.001). BCM estimation is less driven by sudden massive fluid shifts than FMM. Assessment of BCM should be preferred to FFM when severe hydration disturbances are present in ICU patients.
    Critical care (London, England) 03/2014; 18(2):R49. DOI:10.1186/cc13794 · 4.48 Impact Factor
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    • "Dans l'état actuel des travaux publiés, il semble préférable de ne pas chercher à compenser trop vite et trop rigoureusement par une parentérale de complément le déficit calorico-azoté observé chez un patient intolérant à la nutrition entérale26. Lorsqu'une NP de complément est administrée, les apports caloriques doivent être ajustés au déficit énergétique (évaluable par calorimétrie indirecte) [50] [51]. "

    Annales francaises d'anesthesie et de reanimation 02/2014; 28(2). DOI:10.1016/j.annfar.2014.01.008 · 0.84 Impact Factor
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    • "In addition, only those patients who were receiving exclusively EN were included. We thereby intended to preclude possible confounding effects of parenteral nutrition (PN) on the amount of nutrition as PN has a treatment effect different and distinct from EN [28-30]. Site characteristics, patients’ baseline demographic and physiologic data, and severity of illness were collected at the time of study enrollment. "
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    ABSTRACT: Current international sepsis guidelines recommend low dose enteral nutrition (EN) for the first week. This contradicts other nutrition guidelines for heterogenous groups of ICU patients. Data on the optimal dose of EN in septic patients are lacking. Our aim was to evaluate the effect of energy and protein amount given by EN on clinical outcomes in a large cohort of critically ill septic patients. We conducted a secondary analysis of pooled data collected prospectively from international nutrition studies. Eligible patients had a diagnosis of sepsis and/or pneumonia and were admitted to the ICU for >= 3 days, mechanically ventilated within 48 hours of ICU admission and only receiving EN. Patients receiving parenteral nutrition were excluded. Data were collected from ICU admission up to a maximum of 12 days. Regression models were used to examine the impact of calorie and protein intake on 60-day mortality and ventilator-free days. Of the 13,630 patients included in the dataset, 2,270 met the study inclusion criteria. Patients received a mean amount of 1,057 kcal/d (14.5 kcal/kg/day) and 49 g protein/day (0.7 g/kg/d) by EN alone. 60-day mortality was 30.5% and patients were mechanically ventilated for median 8.4 days. An increase of 1,000 kcal was associated with reduced 60-day mortality (odds ratio (OR) 0.61; 95% confidence interval (CI) 0.48-0.77, P < 0.001) and more ventilator-free days (2.81 days, 95% CI 0.53-5.08, P = 0.02) as was an increase of 30 g protein per day (OR 0.76; 95% CI 0.65-0.87, P < 0.001 and 1.92 days, 95% CI 0.58-3.27, P = 0.005, respectively). In critically ill septic patients, a calorie and protein delivery closer to recommended amounts by EN in the early phase of ICU stay was associated with a more favorable outcome.
    Critical care (London, England) 02/2014; 18(1):R29. DOI:10.1186/cc13720 · 4.48 Impact Factor
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