Early parenteral nutrition in critically ill patients should be delayed

ENDO 2011

BOSTON — Researchers for a first-of-its-kind study suggest that patients in the ICU who do not tolerate adequate nutrition from tube feeding should wait 1 week before receiving IV feeding because it enhances recovery from critical illness, as compared with early IV feeding.

Greet Van den Berghe, MD, PhD, professor at Catholic University of Leuven, presented the results of a large randomized controlled trial that examined the optimal timing to initiate parenteral nutrition in critically ill patients who are not getting enough calories through the gut by enteral nutrition.

Van den Berghe said this study is important because there are two sets of guidelines on the optimal timing of parenteral nutrition initiation.

“The American and Canadian guidelines advocate waiting about 1 week before instituting parenteral nutrition. On the other hand, the European guidelines advocate early initiation of parenteral nutrition [within 2 days of admission] because there are associations indicating that for each 100-kcal deficit during [critical] illness the outcomes get worse,” she said at a press conference. “For either of the guidelines, there is no evidence because no one has studied it in a randomized controlled trial [until now].”

EPaNIC trial results

The EPaNIC trial included 4,640 adults at risk for malnutrition who were cared for at seven ICUs in Belgium. Of the 4,640 participants, 2,312 were randomly assigned to parenteral nutrition within 48 hours of admission and 2,328 to parenteral nutrition no earlier than day 8 in the ICU. Both groups received early enteral support and insulin to target normal blood glucose levels.

According to the results, late parenteral nutrition was superior to early parenteral nutrition, with time in the ICU a median of 1 day shorter.

Additionally, “Withholding IV nutrition for 1 week in the ICU, even in patients who could not be fed at all via the normal enteral route, surprisingly accelerated alive discharge from the ICU and from the hospital, without threatening their ability to function,” Van den Berghe said in a press release.

Frequency of complications was also lower with late parenteral nutrition, including severe infections compared with early nutrition (22.8% vs. 26.2%). Waiting 1 week also resulted in shortened time on mechanical ventilation and dialysis. Late nutrition slightly increased the number of patients with hypoglycemia (3.5% vs. 2%).

ICU mortality, hospital mortality and survival to 90 days were comparable between the two groups.

Changing standards of care

Van den Berghe said results of this study have “enormous impact” on improving quality and reducing the cost of medical care for critically ill patients. Late parenteral nutrition was shown to reduce health care costs by 2.3 million euros, or roughly $3.3 million.

“The standard of care in Europe should change,” she said.

For more information:

• Casaer MP. P1-778. Presented at: The Endocrine Society 93rd Annual Meeting & Expo; June 4-7, 2011; Boston.

Disclosure: Dr. Van den Berghe and colleagues report no relevant financial disclosures.

This multicenter study is important. Controversy has persisted for years regarding optimal nutrition standards in our ICUs. Somewhat counter-intuitively, prior data have suggested that overly aggressive feeding - particularly via the parenteral route - may actually worsen clinical outcomes. Whether this was due to an accompanying deterioration in glycemic control, an increase in oxidative stress or some other factor or factors was not clear. This study, which appears to have been well conducted, strongly suggests that advocates of a more conservative approach - with delayed parenteral nutrition when necessary - may have been correct all along.

– Silvio E. Iznucchi, MD
Professor of Medicine, Yale University
Director, Yale Diabetes Center
Yale-New Haven Hospital

Disclosure: Dr. Iznucchi reports no relevant financial disclosures.

Follow EndocrineToday.com on Twitter.