Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients?

Abstract

A multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.

Effects of Energy Delivery Guided by Indirect Calorimetry in Critically Ill Patients: A Systematic Review and Meta-Analysis

“…The actual dosages administered were the same or slightly higher in the IC group, but were slightly lower in the estimating formula group [11,32,33,35]. Berger et al reported that the risk of nutrient overdosage without IC creates a barrier to the administration of enteral nutrition [39]. The control group may have been hesitant to use aggressive nutritional therapy due to uncertainty regarding the calculated REE.…”

Nutrition support for patients on mechanical circulatory support

“…However, there are key factors and times when PN should be considered in the modern MCS era (e.g. pre-existing malnutrition, persistent hemodynamic instability, EN intolerance, failure to reach energy and nutrient targets) to improve nutrient delivery, especially in the first few ICU weeks or acute phase when historically majority of calorie/protein deficits are created [31 ▪▪ ,32 ▪ ].…”

A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life

“…EL entails vitamin deficiencies that require supplementation, and thus vitamins are administered as a commercial multivitamin supplement composed of vitamins C, A, E, K and the B complex (B 1 , B 2 , B 3 , B 6 , B 7 , B 9 , B 12 ) [ 79 ]. The literature includes a series of considerations with respect to SPN and vitamins: (a) there is no conclusive evidence of or studies on the possible benefit of vitamin D, although there are studies that associate it with a decrease in mortality and mechanical ventilation time; (b) vitamin C is unstable, susceptible to oxidation reactions and is usually associated with neuropathy, hemolysis and hyperglycemia phenomena [ 80 , 81 ]; (c) B group vitamins are involved in reducing fatigue syndrome [ 82 ]; (d) vitamin supplementation is justified in terms of nutritional requirements to improve immune function, regulate hypercatabolism and exert an antioxidant action, but if it is provided too early, it can have adverse effects such as prolonging the ICU stay and the risk of infections [ 83 ]; (e) ASPEN and ESPEN clinical practice guidelines refer to the need to supplement PN with vitamins in critical condition, but there is no consensus or evidence on timing, clinical criteria or protocols in EL [ 84 ].…”