Fasting may not be necessary for ICU patients ahead of extubation

Continuing enteral nutrition until extubation may be a safe and better option than fasting, according to study results presented at Society of Critical Care Medicine’s Critical Care Congress and published in The Lancet Respiratory Medicine.

Stephan Ehrmann

“The impact of these findings is major for daily clinical practice,” Stephan Ehrmann, MD, PhD, professor at Centre Hospitalier Régional et Universitaire de Tours, told Healio. “Most ICU practitioners impose a fasting period to patients prior to extubation; however, the study results show that this practice is not useful and only cumbersome. Continuing enteral nutrition until extubation enables faster extubation and discharge from the ICU, thus the study results call for change in practice in most ICUs worldwide.”

In an open-label, cluster-randomized, parallel-group, noninferiority trial, Ehrmann and colleagues screened 4,198 adults who underwent invasive mechanical ventilation for no less than 48 hours in the ICU and prepyloric enteral nutrition for no less than 24 hours at the time of extubation decision from 22 ICUs in France between April 1, 2018, and Oct. 31, 2019. Researchers randomly assigned each ICU to provide continued enteral nutrition before extubation or fasting for 6 hours with simultaneous gastric suctioning prior to extubation.

Researchers assessed the primary endpoint of extubation failure (reintubation or death) within 7 days following extubation and the secondary endpoint of pneumonia within 14 days of extubation in both the intention-to-treat group (n = 1,130) and the per-protocol group (n = 1,008) with a noninferiority margin of 10%.

Results

Within the intention-to-treat group, 617 patients received continued enteral nutrition whereas 513 patients fasted. Researchers observed noninferiority for extubation failure with continued extubation vs. fasting (17.2% vs. 17.5%; absolute difference = –0.4%; 95% CI, –5.2 to 4.5).

In the per-protocol group, 595 patients received continued enteral nutrition whereas 413 fasted. Similar to the intention-to-treat population, researchers observed extubation failure among 17% of those receiving continued enteral nutrition and 17.9% of those fasting, which met the criteria for noninferiority (absolute difference = –0.9%, 95% CI, –5.6 to 3.7).

Incidence of pneumonia at 14 days also did not differ between the groups (continued enteral, 1.6% vs. fasting, 2.5%; RR = 0.77; 95% CI, 0.22-2.69), according to researchers.

Compared with those fasting, researchers found that those who received continued enteral nutrition had a quicker extubation (median, 2 hours vs. 17.6 hours), shorter ICU stays (4 days vs. 6.6 days; HR = 1.45, 95% CI, 1.19-1.77), less frequent occurrences of hypoglycemia and hyperglycemia at certain timepoints around extubation and fewer ICU deaths (3.9% vs. 6.8%; RR = 0.56, 95% CI, 0.32-0.99).

“The fact that continued enteral nutrition was associated with faster discharge from the ICU is a patient-centered benefit which was not anticipated,” Ehrmann told Healio. “Additionally, the fact that mortality was lower in the continued enteral nutrition group was unexpected and deserves further evaluation to understand potential mechanisms.”

Future studies

Additional studies are necessary to further understanding of these results, according to Ehrmann.

“The study results call for other studies on extubation in the ICU, such as evaluating optimal time of the day, which would be interesting to evaluate now that the fasting is shown to be useless,” he told Healio. “Furthermore, the study results will impact the design of studies evaluating nutrition in the second phase of ICU care and post-intensive care syndrome evaluation.”

This study by Ehrmann and colleagues demonstrates a new option for patients in the ICU undergoing extubation, but collecting real-world evidence may be necessary before the practice is widely implemented, according to an accompanying editorial by Elisabeth Lobmeyr, MD, study fellow in the department of medicine I at Medical University of Vienna, and Karin Amrein, MD, MSc, associate professor in the division for endocrinology and diabetology at Medical University of Graz.

“The study by Landais and colleagues should prompt an immediate radical change in clinical practice,” Lobmeyr and Amrein wrote. “However, as is usually the case with emerging data that should inform an important clinical routine change, this might be too fast for some ICUs, and it will take a while until confirmatory data will convince all clinicians working in this field. Therefore, we believe it will be important to collect more comprehensive data on real-life implementation of continued enteral nutrition until extubation on the basis of the results of this study.”

For more information:

Stephan Ehrmann, MD, PhD, can be reached at stephanehrmann@gmail.com.

References:

• Ehrmann S, et al. Continued enteral nutrition until extubation compared to fasting prior to extubation in the intensive care unit: A cluster randomised trial. Presented at: Society of Critical Care Medicine’s Critical Care Congress; Jan. 21-24, 2023; San Francisco.
• Lobmeyr E, et al. Lancet Respir Med. 2023;doi:10.1016/S2213-2600(22)00481-7.