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Critically ill patients: optimisation of energy provision with supplemental parenteral nutrition

Enteral nutrition is recommended for patients in the intensive-care unit ( ICU ), but it does not consistently achieve nutritional goals.
Researchers have assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with enteral nutrition plus supplemental parenteral nutrition ( SPN ) could optimise clinical outcome.

This randomised controlled trial was undertaken in two centres in Switzerland. Patients on day 3 of admission to the ICU who had received less than 60% of their energy target from enteral nutrition, were expected to stay for longer than 5 days, and to survive for longer than 7 days, were enrolled.

Researchers calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned ( 1:1 ) by a computer-generated randomisation sequence to receive enteral nutrition or supplemental parenteral nutrition.

The primary outcome was occurrence of nosocomial infection after cessation of intervention ( day 8 ), measured until end of follow-up ( day 28 ), analysed by intention to treat.

153 patients were randomly assigned to supplemental parenteral nutrition and 152 to enteral nutrition. 30 patients discontinued before the study end.

Mean energy delivery between day 4 and 8 was 28 kcal/kg per day for the supplemental parenteral nutrition group ( 103% of energy target ), compared with 20 kcal/kg per day for the enteral nutrition group ( 77% ).

Between days 9 and 28, 41 ( 27% ) of 153 patients in the supplemental parenteral nutrition group had a nosocomial infection compared with 58 ( 38% ) of 152 patients in the enteral nutrition group ( hazard ratio, HR=0.65; p=0.0338 ), and the supplemental parenteral nutrition group had a lower mean number of nosocomial infections per patient ( -0.42; p=0.0248 ).

The study has shown that individually optimised energy supplementation with supplemental parenteral nutrition starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom enteral nutrition is insufficient. ( Xagena )

Heidegger CP et al, The Lancet 2013; 381: 385-393