How to Feed Critically Ill Patients: A Randomized Trial

This is for our providers who practice in the critical care unit.

Authors: Harvey SE et al., N Engl J Med 2014 Oct 1;

Patients in the intensive care unit had similar outcomes, whether they were fed enterally or parenterally.

Debate is ongoing over the appropriate way to deliver early nutritional support to critically ill patients. Although U.S. guidelines recommend enteral nutrition and delayed initiation of parenteral nutrition, European guidelines advocate earlier consideration and initiation of parenteral nutrition. Many studies of nutrition in intensive care units (ICUs) are small and dated, so we can reasonably ask which is the better route. Investigators in the U.K. randomized 2400 adults (mean age, 63) with unplanned ICU admissions to receive either enteral nutrition or parenteral nutrition starting within 36 hours of admission; patients were fed exclusively via their assigned routes for 5 days or until discharge from the ICU, transition to oral feeding, or death. The daily energy target for all patients was 25 kcal per kg of actual body weight. About 14% of both groups had surgery within 24 hours of admission; almost all patients (83%) received mechanical ventilation.

Thirty-day all-cause mortality (the primary outcome) and nearly all secondary outcomes did not differ between groups. The parenteral nutrition group had lower rates of hypoglycemia and vomiting. In contrast to results from previous studies, patients who received parenteral nutrition versus enteral nutrition were not more likely to develop infectious complications. Most patients in both study arms did not achieve caloric-intake targets.

Comment
This study demonstrated neither benefit nor harm with early parenteral nutrition, compared with early enteral nutrition. Because parenteral nutrition is more costly and requires central venous catheters, enteral feeding should be the favored approach for patients without gastrointestinal contraindications.