Article

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

ABSTRACT

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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    • "This patient group can usually return to volitional oral intake quickly and do not often require artificial nutrition due to their short duration of ICU stay; thus, it would seem there may be a low likelihood of benefit from supplemental PN in this population . Another RCT investigating supplemental PN from admission to ICU versus usual care found that the supplemental PN group received more energy (28 kcal/ kg per day versus 20 kcal/kg per day) and had fewer nosocomial infections compared with the usual care group (27 % versus 38 %, respectively), but only on days 9–28 of ICU admission[14]. This finding may be explained by the positive effect of adequately delivered nutrition on immunity later in the ICU stay, which is also a biologically plausible explanation. "
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    ABSTRACT: Background: Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed "supplemental parenteral nutrition"), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill. Methods/design: This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first). Discussion: This trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial. Trial registration: NCT01847534 (First registered 5 February 2013, last updated 14 October 2015).
    Full-text · Article · Dec 2015 · Trials
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    • "The potential for overfeeding is certainly a concern with PN, while enteral feeding has generally been plagued by not reaching the prescribed energy targets. Indeed the energy delivery by the enteral route is generally lower than the prescribed target [1]: only 2 trials succeeded in delivering the prescribed target in the intervention groups: the TICACOS [8] and SPN [7] trials. The gap between prescription and delivery exposes the patient to the risk of an important energy deficit: this is probably tolerable for a few days in young [32] and obese patients [28], but not in elderly, frail patients. "
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    ABSTRACT: Background & aims: Energy targets are a matter of debate for intensive care (ICU) patients. As the guidelines have evolved, energy targets have been reduced, while the protein intake objectives have increased. The impact of these changes remains largely unknown. This quality study aimed at investigating the clinical impact of these changes in patients with an ICU stay >3 days. Methods: Observational cohort study over two 3 months periods (A, B), with distinct prevailing nutrition recommendations in patients admitted consecutively to a multidisciplinary ICU. Inclusion criterion: ICU stay >3 days. Recorded variables: severity scores, energy target and delivery, protein delivery, feeding route, length of stay (ICU, hospital) and hospital outcome. Data as mean, SD and IQR. Results: The analysis included 389 patients, and 3920 observation days. Except for patient age (A versus B: 57.8 and 62.3 years; p = 0.010) and NRS (4.3 vs 3.9 respectively p = 0.002), the cohorts were similar. Compared to A, the mean prescribed energy target decreased by 125 kcal (1947 kcal/d vs. 1822 kcal*day(-1) respectively), resulting in lower energy delivery (1353 kcal*day(-1) vs. 1238 kcal*day(-1); p < 0.0001), and reduced protein delivery (81 g*day(-1) vs. 65 g*day(-1): p < 0.0001). These differences were associated in survivors with prolonged mechanical ventilation (5.0 days vs. 6.7 days; p = 0.004), extended ICU stay (8.5 vs. 9.9 days; p = 0.0036), and longer hospital stay (23.4 vs. 26.4 days respectively; p = 0.028). Mortality was unchanged. Conclusions: A linear reduction in energy target recommendation without changing the feed composition led to an unplanned and significant reduction in protein delivery, which was associated with a prolonged duration of ventilation and an extended hospital stay.
    Full-text · Article · Dec 2015 · Clinical nutrition (Edinburgh, Scotland)
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    • "The results were complicated by some degree of overfeeding due to additional non-nutritional energy (glucose for drugs, lipids in propofol for sedation) observed in the study group, and mild underfeeding in the control group. Heidegger et al. reported a significant reduction of the rate of late nosocomial infections for patients who were given supplemental PN to meet energy targets determined by indirect calorimetry, while there were no differences in the mortality or the length of stay in ICU [30]. This study conveys a very practical message from the clinical point of view (i.e. "
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    ABSTRACT: Background & aims: We hypothesize that an optimal and simultaneous provision of energy and protein is favorable to clinical outcome of the critically ill patients. Methods: We conducted a review of the literature, obtained via electronic databases and focused on the metabolic alterations during critical illness, the estimation of energy and protein requirements, as well as the impact of their administration. Results: Critically ill patients undergo severe metabolic stress during which time a great amount of energy and protein is utilized in a variety of reactions essential for survival. Energy provision for critically ill patients has drawn attention given its association with morbidity, survival and long-term recovery, but protein provision is not sufficiently taken into account as a critical component of nutrition support that influences clinical outcome. Measurement of energy expenditure is done by indirect calorimetry, but protein status cannot be measured with a bedside technology at present. Conclusions: Recent studies suggest the importance of optimal and combined provision of energy and protein to optimize clinical outcome. Clinical randomized controlled studies measuring energy and protein targets should confirm this hypothesis and therefore establish energy and protein as a power couple.
    Full-text · Article · Nov 2015 · Clinical nutrition (Edinburgh, Scotland)
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