Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition

Doig, Gordon S.; Simpson, F. O.; Sweetman, Elizabeth A.; Finfer, Simon; Cooper, David; Heighes, Philippa T.; Davies, Andrew R.; O’Leary, Michael J.; Solano, Thomas; Peake, Sandra

doi:10.1097/01.sa.0000441042.75441.36

Cited by 105 publications

(160 citation statements)

References 1 publication

Supporting

Mentioning

149

Contrasting

Unclassified

Order By: Relevance

“…In a trial conducted at two sites, Heidegger et al 11 found no difference in the rate of infection between day 8 and day 28 among patients who started receiving individually optimized parenteral nutrition to supplement inadequate enteral intake on day 4 and patients receiving only enteral nutrition. 11 In a trial conducted at 31 sites involving patients with relative contraindications to enteral nutrition, Doig et al 31 found no differences in 60-day mortality and the number of infectious episodes but fewer days of mechanical ventilation in patients receiving early parenteral nutrition, as compared with standard care. However, in the standard-care group, 27% of patients received early parenteral nutrition and 41% received no nutritional support.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Trial of the Route of Early Nutritional Support in Critically Ill Adults

et al. 2014

View full text Add to dashboard Cite

Section: Discussionmentioning

confidence: 99%

“…However, in the standard-care group, 27% of patients received early parenteral nutrition and 41% received no nutritional support. 31 In drawing any comparison, it must be noted that in our study, we asked a different research question in a different population of critically ill patients.…”

Section: Discussionmentioning

confidence: 99%

Trial of the Route of Early Nutritional Support in Critically Ill Adults

et al. 2014

View full text Add to dashboard Cite

“…No mortality difference between trophic versus full enteric feeding (7) or early versus late total parenteral nutrition (TPN) (8) has been observed. Even with short-term contraindication for enteric feeding, early PN did not show any mortality benefit (9). There are no previous randomized trials that directly compared EN versus PN in the initial phase of critical illness.…”

Section: Reviewed By Hammad Arshadmentioning

confidence: 84%

Comparison of Video Laryngoscopy versus Direct Laryngoscopy during Urgent Endotracheal Intubation; Trial of the Route of Early Nutritional Support in Critically Ill Adults; and Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 versus a 1:1:2 Ratio and Mortality in Patients with Severe Trauma

Rali

Arshad

Lamba

2015

Am J Respir Crit Care Med

View full text Add to dashboard Cite

Airway management is a critical skill for the intensivist to master. Training critical care fellows in intubation skills is a difficult challenge: urgent endotracheal intubations in intensive care unit (ICU) settings are associated with complications such as hypoxemia, hemodynamic collapse, and cardiac arrhythmias (2). Joffe and colleagues showed that most internal medicine-based critical care training programs include at least 1 month of airway education during their first year of training (3). Unfortunately, more than half of the programs reported that their fellows had fewer than 10 supervised uses of a video laryngoscope (VL). The first-pass success rate was improved with a VL in the emergency department setting (4). Similar results were seen in retrospective observational studies in the ICU setting when comparing VL with direct laryngoscopy (DL) (5).The study by Silverberg and colleagues (1) is the first randomized trial comparing DL versus VL for urgent intubation by physicians in training. It was a single-center trial in a tertiary care center. Eight pulmonary and critical care fellows whose training ranged from postgraduate years 4 through 8 performed intubations under direct supervision. All fellows had been trained in performing VL and DL. Intubations were performed in the medical ICU or, if needed, during a rapid response. Exclusion criteria were as follows: saturation below 92% after bag mask ventilation, recognition of difficult airway, or elective intubation. One hundred and seventeen patients were randomized to undergo intubation by either DL or VL. If the operator was unsuccessful despite two attempts, it was required that the device be switched or that another operator make the attempt. Neuromuscular (NM) blockade was not used as per hospital policy. Propofol or etomidate was used as the induction agent.The first-pass attempt was successful in 40% of the DL group versus 74% in the VL group (P , 0.01). Of the patients in the DL group, 27% needed more than two attempts compared with 9% in the VL group (P , 0.01). All failed DLs were successfully intubated by VL; of these, 82% were on the first attempt. Fellows were able to intubate all but two patients. There was no significant difference between the groups in terms of complications including esophageal intubation, aspiration events, desaturation, and hypotension.There were several limitations to the study, including failure to compare VL versus DL in difficult airways, subjective assessment of airways by trainees, and lack of power to detect complications. The 40% success rate for DL could be related to the greater reliance on video-assisted technology or to not using NM blockade. VL showed supremacy over DL in critically ill patients in terms of first-pass success rate, and as a backup tool when attempts at DL failed. However, this study did not address whether NM blockade would have made any difference on first attempt, using VL versus DL. Another highlighted feature of the study was to have a structured algorithm for airway management as a part...

show abstract

“…We acknowledge this may not be a beneficial treatment in this small study, but large-scale trials do support the safety of early PN patients when clinicians are careful not to overfeed. 7,8 …”

Section: Letters To the Editormentioning

confidence: 99%

More Questions Than Answers

Heyland¹,

Dhaliwal²,

Lemieux³

2015

J Parenter Enteral Nutr

View full text Add to dashboard Cite

We urge caution in overinterpreting the randomized trial by Braunschweig et al 1 published in the Journal of Parenteral and Enteral Nutrition. From a single center, a total of 78 patients were randomized to an intensive medical nutrition therapy (IMNT) designed to provide patients >75% of their estimated energy and protein requirements compared with standard care. At the first interim analysis, the investigators observed a statistically significant increase in mortality in the INMT group compared with standard nutrition care (40% vs 16%, P = .02). Randomized trials that are terminated prematurely are likely to significantly overestimate the treatment effect. 2 Moreover, a small study from 1 center has limited generalizability and should not inform practice patterns worldwide. In our opinion, to draw the conclusion that "provision of IMNT to hospital discharge increases mortality" seems premature. Nevertheless, the results cannot be ignored, and further questions about this trial are warranted.We note that with very broad inclusion criteria (patients aged ≥18 years with acute lung injury), there was no intention to enroll nutritionally "at-risk" patients 3 and that most were normo-nourished, with a body mass index that is shown to be insensitive to the provision of macronutrients. 4 When trying to understand the results of this trial, we think it is important to separate the nutrition intervention into its components. Patients were moderately dosed with protein and received only approximately 82 g/d or <1 g/kg/d-it is implausible that such protein doses are associated with harm, especially given recent recommendations for doses around 2-2.5 g/kg/d. 5 Patients were targeted to receive 30 kcal/kg and received approximately 85% of their prescriptions. From examination of Figure 2, it appears that some patients received more than 100% of their prescription, which is already high since most guidelines recommend 20-25 kcal/kg/d. Moreover, we note that patients in the IMNT group received more parenteral nutrition (PN) and significantly more parenteral lipids. If these are soybean-based emulsions, this may explain the excess mortality. 6 It may be useful to report the rates of overfeeding per group and the amount of calories from parenteral and enteral sources rather than just combined. We think it is also important to separate the INMT intervention into its 2 phases: in the intensive care unit (ICU) and following extubation or post-ICU discharge. Can the investigators report the % calorie and protein received in these 2 phases separately? As the investigators note, the increased mortality was due to early deaths or an early separation in the survival curves. It is difficult to fathom how optimal nutrition intake in the post-ICU phase of this study caused an early separation of the survival curves.Our main concern is that this study may represent overfeeding with parenteral calories in a normo-nourished or low-nutrition risk patient population in the early phase of critical illness. We acknowledge this may not be a benefi...

show abstract

Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition

Cited by 105 publications

References 1 publication

Trial of the Route of Early Nutritional Support in Critically Ill Adults

Trial of the Route of Early Nutritional Support in Critically Ill Adults

More Questions Than Answers

Contact Info

Product

Resources

About