Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial.The data supporting U.S. and European guideline recommendations for early enteral feeding are limited, particularly with respect to the sickest population of intensive care unit (ICU) patients.
Prof Reignier J et al.hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition and conducted a randomised, controlled, multicentre, open-label, parallel-group study at 44 French intensive-care units (ICUs).The researchers found that similar mortality was encountered in early enteral vs. parenteral nutrition in critically ill patients.
In the study adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20–25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by center using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lac
After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI −1·9 to 5·8]; p=0·33).Mortality (28-day, 90-day, in-ICU, and in-hospital) was similar between groups. It was found that both groups had similar lengths of stay and rates of liberation from life support. Infections were not different between groups, in contrast to other studies in which parenteral nutrition was associated with greater risk. Gastrointestinal complications were more common in patients who received enteral feeding, including a statistically significant difference in the numbers of patients who developed bowel ischemia (19 enteral vs. 5 parenteral)
The researchers concluded that in critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition.
For more details click on the link: DOI: http://dx.doi.org/10.1016/S0140-6736(17)32146-3
Dr. Kamal Kant Kohli
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