Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis

Abstract

Background Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU). Methods Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed. Results Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = − 1.85 days; 95% CI, [− 3.44, − 0.27]; P = 0.02; I2 = 0%). Conclusions Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023

Nutritional Prescription in ICU Patients: Does it Matter?

“…This observation is similar to the studies comparing different nutritional calorie or protein administration on the mortality. 8 , 9 …”

“… 8 Recent systematic review and meta-analysis evaluating the effect of permissive underfeeding vs standard feeding showed no difference in overall mortality. 9 Brazilian study on targets and prescription in the critically ill observed inadequacies in achieving nutrition targets, resulting in a negative nutritional balance. 10 A study done in the surgical ICU showed cumulative calorie and protein deficits were associated with prolonged ICU stay, fewer ventilator-free days, and increased complications.…”

Nutrition in the intensive care unit: from the acute phase to beyond

“…A recent meta-analysis confirmed harm by early full feeding in critically ill patients as compared with permissive underfeeding. Although this meta-analysis did not include the EPaNIC RCT, it likely does not affect the conclusion, as EPaNIC patients were equally harmed by early full feeding [25]. A recent meta-analysis as part of the updated American feeding guidelines did not show benefit by supplemental parenteral nutrition as compared with enteral nutrition alone.…”