Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle

Simpson, F. O.; Doig, Gordon S.

doi:10.1007/s00134-004-2511-2

Cited by 389 publications

(231 citation statements)

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“…Specifically, we observed neither the trend towards decreased mortality nor the increase in infectious complications previously reported for patients fed via the parenteral route. [2][3][4] It is possible that the lack of an infectious burden from feeding via the parenteral route is because of improvements in central venous catheter management (CALORIES data indicate a low incidence of catheter-related and bloodstream infections); 60 delivery and composition of feed; and avoidance of overfeeding and hyperglycaemia.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4] Meta-analyses of the trials comparing nutritional support via the enteral and parenteral route in critically ill patients have been published, but interpretation of their results is complicated by small sample size, poor methodological quality, select groups of critically ill patients studied, lack of standardised definitions for outcome measures and interventions combining more than one element of nutritional support, for example timing and route.…”

Section: Background and Rationalementioning

confidence: 99%

“…3 In addition, they reported no difference in length of unit stay or days on ventilation, but indicated that there were insufficient data to analyse these statistically. Using a different methodological approach to assessing quality of included studies (one less biased towards including the poorer-quality studies), Simpson and Doig,4 in 2005, found a significant reduction in mortality but a significant increase in infections with parenteral nutritional support compared with the enteral nutritional support. However, the significant mortality benefit with parenteral nutrition (PN) appeared to exist when compared with the provision of delayed, rather than early enteral nutritional support and thus this was not a like-for-like comparison.…”

Section: Background and Rationalementioning

confidence: 99%

“…[2][3][4] Interpretation of the existing, published meta-analyses of trials comparing nutritional support via the enteral and parenteral routes in critically ill patients was complicated by small sample sizes; poor methodological quality; selected groups of critically ill patients studied; lack of standardised definitions for outcome measures; and interventions combining more than one element of nutritional support, for example timing and route. CALORIES, as the largest trial addressing the question of optimal route for early nutritional support in critical care, has substantially added to, and improved, the evidence base.…”

Section: Guidelinesmentioning

confidence: 99%

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A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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BackgroundMalnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.ObjectivesTo estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.DesignA pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.SettingAdult general critical care units in 33 NHS hospitals in England.Participants2400 eligible patients.InterventionsFive days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.Main outcome measuresAll-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.ResultsBy 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) −2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at −£1320 (95% CI −£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective – given the data – is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.LimitationsBlinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.ConclusionsThere was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.Future workNutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.Trial registrationCurrent Controlled Trials ISRCTN17386141.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.

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Section: Discussionmentioning

confidence: 99%

Section: Background and Rationalementioning

confidence: 99%

Section: Background and Rationalementioning

confidence: 99%

Section: Guidelinesmentioning

confidence: 99%

See 2 more Smart Citations

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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“…However, the ENT started later may have deleterious results 8 . In a meta-analysis 12 , Simpson and Doig (2005) demonstrated that the survival of critically ill patients (including trauma victims) was higher in patients undergoing early PNT versus late ENT (OR 0.29, 95% CI 0.12-0.70).…”

Section: Introduction Introduction Introduction Introduction Introducmentioning

confidence: 99%

Terapia nutricional precoce no trauma: após o A, B, C, D, E, a importância do F (FEED)

Bicudo-Salomão

Moura

Aguilar-Nascimento

2013

Rev. Col. Bras. Cir.

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Um número significativo de mortes no trauma ocorre dias a semanas após a injúria inicial, sendo causado por infecções e insuficiência orgânica, relacionadas a hipercatabolismo e consequente desnutrição proteica aguda. A terapia nutricional deve ser planejada e incluída com as demais condutas de reanimação para pacientes politraumatizados e grandes queimados. A rápida aquisição de uma via para suporte nutricional é importante para inicio da terapia nutricional precoce em até 48 horas do atendimento. A via enteral é a opção preferencial no pós-operatório de pacientes traumatizado mas a via parenteral deve ser prescrita quando a enteral está contraindicada ou insuficiente. Após as medidas iniciais ditadas pelo ATLS, sintetizadas em A (air), B (breath), C (circulation), D (disability) e E (exposure), nós incluímos a letra F (feed) para enfatizar a importância do atendimento nutricional precoce no trauma.

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Nutrition Support in the Intensive Care Unit

Blackburn

Wollner²,

Bistrian³

2010

Arch Surg

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Recent investigations of nutrition support in the intensive care unit (ICU) have revived discussion of optimal strategies for tight glucose control and the administration of total parenteral nutrition. Mode, timing, and adequacy of nutritional support affect glycemic control and outcomes in critically ill patients. The delivery of correctly formulated and safely administered nutritional and metabolic support is a matter of life or death in surgical and critical care units. High-quality research, adequately powered to detect differences in clinically meaningful outcomes, is needed to inform the delivery of nutrition support and serve as the foundation for future clinical trials. These are issues that will need to be addressed in the months and years ahead. Today, the field is in the midst of challenges and change, and though much has been accomplished, much remains to be done. The last 30 years have seen radical changes in the rates of severe obesity, metabolic syndrome, and weight loss surgery. Obese patients heighten surgical risk and require extra caution by ICU nutrition support specialists. This commentary will address the direction of nutrition support services by covering the history, progress, and potential of the field. It will review parenteral nutrition from its inception to its current standing in ICU patient care and discuss the future role of parenteral nutrition in a rapidly changing and increasingly diverse population.

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Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle

Cited by 389 publications

References 64 publications

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Terapia nutricional precoce no trauma: após o A, B, C, D, E, a importância do F (FEED)

Nutrition Support in the Intensive Care Unit

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