Supplemental parenteral nutrition versus usual care in critically ill adults: a pilot randomized controlled study

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Abstract

Background

In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48–72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery.

Methods

This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted.

Results

There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m ². Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups.

Conclusions

This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups.

Trial registration

Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016)

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1939-7) contains supplementary material, which is available to authorized users.

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Most cited references 23

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ESPEN Guidelines on Enteral Nutrition: Intensive care.

K. G. Kreymann, M Berger, N Deutz … (2006)

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

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The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study.

Cathy Alberda, Leah Gramlich, Naomi Jones … (2009)

The objective of this study was to examine the relationship between the amount of energy and protein administered and clinical outcomes, and the extent to which pre-morbid nutritional status influenced this relationship. We conducted an observational cohort study of nutrition practices in 167 intensive care units (ICUs) across 21 [corrected] countries. Patient demographics were collected, and the type and amount of nutrition received were recorded daily for a maximum of 12 days. Patients were followed prospectively to determine 60-day mortality and ventilator-free days (VFDs). We used body mass index (BMI, kg/m2) as a marker of nutritional status prior to ICU admission. Regression models were developed to evaluate the relationship between nutrition received and 60-day mortality and VFDs, and to examine how BMI modifies this relationship. Data were collected on 2,772 mechanically ventilated patients who received an average of 1,034 kcal/day and 47 g protein/day. An increase of 1,000 cal per day was associated with reduced mortality [odds ratio for 60-day mortality 0.76; 95% confidence intervals (CI) 0.61-0.95, p = 0.014] and an increased number of VFDs (3.5 VFD, 95% CI 1.2-5.9, p = 0.003). The effect of increased calories associated with lower mortality was observed in patients with a BMI or =35 with no benefit for patients with a BMI 25 to or =35.

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Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

Claudia Paula Heidegger, Mette Berger, Séverine Graf … (2013)

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. 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. 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). 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. Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Emma J. Ridley: emma.ridley@monash.edu

Andrew R. Davies: andrew.davies@monash.edu

Rachael Parke: RParke@adhb.govt.nz

Michael Bailey: michael.bailey@monash.edu

Colin McArthur: ColinM@adhb.govt.nz

Lyn Gillanders: gillanders@xtra.co.nz

D. James Cooper: jamie.cooper@monash.edu

Shay McGuinness: ShayMc@adhb.govt.nz

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 23 January 2018

Publication date PMC-release: 23 January 2018

Publication date Collection: 2018

Volume: 22

Electronic Location Identifier: 12

Affiliations

[1 ]ISNI 0000 0004 1936 7857, GRID grid.1002.3, Australian and New Zealand Intensive Care Research Centre, , School of Public Health and Preventative Medicine, Monash University, ; Level 3, 553 St Kilda Road, Melbourne, 3004 Australia

[2 ]ISNI 0000 0004 0432 5259, GRID grid.267362.4, Nutrition Department, Alfred Health, ; Commercial Road, Melbourne, VIC 3004 Australia

[3 ]ISNI 0000 0000 9027 2851, GRID grid.414055.1, Cardiothoracic and Vascular Intensive Care Unit, , Auckland City Hospital, ; Park Road, Grafton, Auckland, New Zealand

[4 ]ISNI 0000 0004 0432 511X, GRID grid.1623.6, Intensive Care Unit, , The Alfred Hospital, ; Commercial Road, Melbourne, VIC 3004 Australia

[5 ]ISNI 0000 0004 0445 6830, GRID grid.415117.7, Medical Research Institute of New Zealand, ; Wellington, New Zealand

[6 ]ISNI 0000 0000 9027 2851, GRID grid.414055.1, The Department of Critical Care Medicine, , Auckland City Hospital, ; Park Road, Grafton, Auckland, New Zealand

[7 ]ISNI 0000 0000 9027 2851, GRID grid.414055.1, Nutrition and Dietetics, , Auckland City Hospital, ; Park Road, Grafton, Auckland, New Zealand

[8 ]ISNI 0000 0004 0372 3343, GRID grid.9654.e, Faculty of Medical and Health Sciences, , University of Auckland, ; Park Road, Grafton, Auckland, New Zealand

Article

Publisher ID: 1939

DOI: 10.1186/s13054-018-1939-7

PMC ID: 5781264

PubMed ID: 29361959

SO-VID: 6d86f6cd-c0a4-4eef-a18b-9db6eec75a3d

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 21 September 2017

Date accepted : 2 January 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100007658, Baxter Healthcare Corporation;

Award ID: n/a

Award Recipient : D. James Cooper

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: enteral nutrition,parenteral nutrition,randomized controlled trial,nutrition therapy,clinical nutrition,critical care,intensive care

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: enteral nutrition, parenteral nutrition, randomized controlled trial, nutrition therapy, clinical nutrition, critical care, intensive care

Supplemental parenteral nutrition versus usual care in critically ill adults: a pilot randomized controlled study

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Abstract

Background

Methods

Results

Conclusions

Trial registration

Electronic supplementary material

Related collections

Preventive and Emergency Medicine Insights

Most cited references 23

ESPEN Guidelines on Enteral Nutrition: Intensive care.

The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study.

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

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