Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults

Arabi, Yaseen M.; Al‐Dawood, Abdulaziz; Haddad, Samir H.; Al‐Dorzi, Hasan M.; Tamim, Hani; Jones, Gwynne; Mehta, Sangeeta; McIntyre, Lauralyn; Solaiman, Othman; Sakkijha, Maram; Sadat, Musharaf; Afesh, Lara

doi:10.1056/nejmoa1502826

Cited by 473 publications

(497 citation statements)

References 37 publications

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“…The incidence of renal replacement therapy of the latter group was significantly lower. 74 These findings suggested that maintaining a moderate starvation state to sustain autophagy activity might reduce sepsis morbidity.…”

Section: Microbe-host Interactions and Autophagymentioning

confidence: 98%

Autophagy in sepsis: Degradation into exhaustion?

Wong

et al. 2016

Autophagy

118

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Autophagy is one of the innate immune defense mechanisms against microbial challenges. Previous in vitro and in vivo models of sepsis demonstrated that autophagy was activated initially in sepsis, followed by a subsequent phase of impairment. Autophagy modulation appears to be protective against multiple organ injuries in these murine sepsis models. This is achieved in part by preventing apoptosis, maintaining a balance between the productions of pro-and anti-inflammatory cytokines, and preserving mitochondrial functions. This article aims to discuss the role of autophagy in sepsis and the therapeutic potential of autophagy enhancers.

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Section: Microbe-host Interactions and Autophagymentioning

confidence: 98%

Autophagy in sepsis: Degradation into exhaustion?

Wong

et al. 2016

Autophagy

118

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“…Six RCTs317, 318, 319, 320, 321, 322 included in the systematic review of the JSICM guidelines were extracted. All six RCTs reported on mortality rate, three reported on infection frequency, two RCTs reported on the duration of ventilation, the length of ICU stay, and length of hospital stay; four RCTs reported on ventilator‐associated pneumonia (VAP), and two RCTs reported on the frequency of continuous renal replacement therapy (CRRT) use.…”

Section: Cq13: Nutritionmentioning

confidence: 99%

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

Nishida

Ogura

Egi

et al. 2018

Acute Medicine & Surgery

157

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Background and PurposeThe Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016), a Japanese‐specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English‐language version of these guidelines was created based on the contents of the original Japanese‐language version.MethodsMembers of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two‐thirds (>66.6%) majority vote of each of the 19 committee members.ResultsA total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J‐SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta‐analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.ConclusionsBased on the evidence gathered, we were able to formulate Japanese‐specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non‐specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

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“…One perspective maintains that overfeeding is potentially harmful, 61,66 a second that underfeeding is potentially harmful [67][68][69] and a third that there is no difference between underfeeding and standard feeding. [70][71][72] Still others argue that any effect of nutritional support is likely to be seen only in selected patients who are at greater nutritional risk as a result either of pre-existing malnutrition, obesity or of the nature of their presenting illness. In the CALORIES trial, in both groups, the amount of nutrition delivered was below target but similar to that seen in previous studies in which nutritional targets were also commonly not met.…”

Section: Results In Contextmentioning

confidence: 99%

“…Other research, more recently, has suggested that it is adequacy of protein intake, rather than simply energy intake, which requires to be supported in critical illness. 70 Previous economic analyses report cost savings with the use of the enteral route, rather than the parenteral route, in critically ill patients. 3,75,76 However, these results need to be interpreted with caution, as no incremental cost-effectiveness results were provided.…”

Section: Results In Contextmentioning

confidence: 99%

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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Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults

Cited by 473 publications

References 37 publications

Autophagy in sepsis: Degradation into exhaustion?

Autophagy in sepsis: Degradation into exhaustion?

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

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)

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