Should We Aim for Full Enteral Feeding in the First Week of Critical Illness?

McClave, Stephen A.; Codner, Panna A.; Patel, Jayshil J.; Hurt, Ryan T.; Allen, Karen; Martindale, Robert G.

doi:10.1177/0884533616653809

Cited by 23 publications

(18 citation statements)

References 35 publications

(97 reference statements)

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“… There is a lack of randomized controlled trials (RCTs) that evaluate critically ill patients randomized to different doses of protein provision, adjusted for ideal energy intake, and then followed for long‐term clinical outcomes 35 , 36 Protein and calorie doses are typically recommended based on actual body weight 24 , 37 . These recommendations may be problematic in critically ill patients in the ICU who undergo large‐volume resuscitation causing fluid shifts into the extracellular space. A number of physiologic studies and observational trials suggest that providing protein doses >1.2 g/kg/d may improve mortality in critical illness 38 – 40 .…”

Section: Protein Requirements In the Icumentioning

confidence: 99%

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Summary Points and Consensus Recommendations From the International Protein Summit

et al. 2017

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The International Protein Summit in 2016 brought experts in clinical nutrition and protein metabolism together from around the globe to determine the impact of high-dose protein administration on clinical outcomes and address barriers to its delivery in the critically ill patient. It has been suggested that high doses of protein in the range of 1.2-2.5 g/kg/d may be required in the setting of the intensive care unit (ICU) to optimize nutrition therapy and reduce mortality. While incapable of blunting the catabolic response, protein doses in this range may be needed to best stimulate new protein synthesis and preserve muscle mass. Quality of protein (determined by source, content and ratio of amino acids, and digestibility) affects nutrient sensing pathways such as the mammalian target of rapamycin. Achieving protein goals the first week following admission to the ICU should take precedence over meeting energy goals. High-protein hypocaloric (providing 80%-90% of caloric requirements) feeding may evolve as the best strategy during the initial phase of critical illness to avoid overfeeding, improve insulin sensitivity, and maintain body protein homeostasis, especially in the patient at high nutrition risk. This article provides a set of recommendations based on assessment of the current literature to guide healthcare professionals in clinical practice at this time, as well as a list of potential topics to guide investigators for purposes of research in the future.

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Section: Protein Requirements In the Icumentioning

confidence: 99%

“…Protein and calorie doses are typically recommended based on actual body weight 24 , 37 . These recommendations may be problematic in critically ill patients in the ICU who undergo large‐volume resuscitation causing fluid shifts into the extracellular space.…”

Section: Protein Requirements In the Icumentioning

confidence: 99%

Summary Points and Consensus Recommendations From the International Protein Summit

et al. 2017

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“…Nine published clinical studies have shown clinical outcomes are different when underfeeding is compared with full feeding . Many of these studies were critically appraised in an earlier publication, but a brief summary is included here . Unfortunately, these studies were methodologically limited and their results must be interpreted with caution.…”

Section: Are Clinical Outcomes Different For Underfeeding Compared Wimentioning

confidence: 99%

Controversies Surrounding Critical Care Nutrition: An Appraisal of Permissive Underfeeding, Protein, and Outcomes

Patel

Martindale

McClave

2017

J Parenter Enteral Nutr

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Over the past few years, numerous studies have called into question the optimal dose, timing, composition, and advancement rate of nutrition during the early acute phase of critical illness. These studies suggest permissive underfeeding with slow advancement may be more beneficial than aggressive full feeding. These counterintuitive results were possibly explained by enhanced autophagy, less hyperglycemia, or prevention of refeeding syndrome. This review underscores the controversies surrounding permissive underfeeding, aims to answer whether permissive underfeeding is appropriate for all critically ill patients, describes the impact of optimal protein delivery on critical care outcomes, discusses nutrition risk, and cogitates on the impact of nutrition on critical care outcomes.

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“…[474849] McClave et al . 2014[48] explained that early enteral nutrients stimulate the gastrointestinal response (maintaining blood flow and gut integrity, reducing gut-lung axis of inflammation, maintaining gut associated lymphoid tissue [GALT]), the endocrine response (improves insulin sensitivity, enhance fuel utilization) and the immune response (maintain GALT, decrease bacterial translocation, maintaining bacterial commensal).…”

Section: Discussionmentioning

confidence: 99%

Effect of calories delivered on clinical outcomes in critically ill patients: Systemic review and meta-analysis

Chelkeba

Mojtahedzadeh

Mekonnen

2017

Indian Journal of Critical Care Medicine

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Introduction:International guidelines are promoting early enteral nutrition (EN) as a means of feeding critically ill adult patients to improve clinical outcomes. The question of how much calorie intake is enough to improve the outcomes still remained inconclusive. Therefore, we carried out a meta-analysis to evaluate the effect of low calorie (LC) versus high calorie (HC) delivery on critically ill patients' outcomes.Methods:We included randomized clinical trials (RCTs) that compared LC EN with or without supplemental parenteral nutrition with HC delivery in this meta-analysis irrespective of the site of nutritional delivery in the gastrointestinal tract. We searched PubMed, EMBASE, and Cochrane central register of controlled trials electronic databases to identify RCTs that compared the effects of initially different calorie intake in critical illness. The primary outcome was overall mortality.Results:This meta-analysis included 17 RCTs with a total of 3,593 participants. The result of analysis showed that there was no significant difference between the LC group and HC group in overall mortality (risk ratio [RR], 0.98; 95% confidence interval [CI], 0.87–1.10; P = 0.74; I2 = 6%; P = 0.38), or new-onset pneumonia (RR, 0.92; 95% CI, 0.73–1.16, P = 0.46; I2 = 38%, P = 0. 11).Conclusion:The current meta-analysis showed that there was no significant difference in mortality of critically ill patients initially between the two groups.

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Should We Aim for Full Enteral Feeding in the First Week of Critical Illness?

Cited by 23 publications

References 35 publications

Summary Points and Consensus Recommendations From the International Protein Summit

Summary Points and Consensus Recommendations From the International Protein Summit

Controversies Surrounding Critical Care Nutrition: An Appraisal of Permissive Underfeeding, Protein, and Outcomes

Effect of calories delivered on clinical outcomes in critically ill patients: Systemic review and meta-analysis

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