The safety of enteral and parenteral nutrition in ICU patients receiving vasopressors

Patel JJ, et al. Phase 3 Pilot Randomized Controlled Trial Comparing Early Trophic Enteral Nutrition With “No Enteral Nutrition” in Mechanically Ventilated Patients With Septic Shock. JPEN J Parenter Enteral Nutr. 2020 Jul;44(5):866-873.

Full-text for Emory users.

Results: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the “no EN” arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the “no EN” group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the “no EN” arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the “no EN” arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in “no EN” arm (P = .009).

Conclusion: Our protocol comparing early trophic EN with “no EN” in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.

Reignier J, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018 Jan 13;391(10116):133-143.

Full-text for Emory users.

Added Value of this Study: “The NUTRIREA-2 study is the second, large, RCT assessing the effect of the route of nutritional support in critically ill adults without contraindications to enteral or parenteral nutrition. By contrast with the CALORIES trial, NUTRIREA-2 focused on patients treated with invasive mechanical ventilation and vasopressor support for shock, because previous studies suggested that mechanically ventilated patients in ICU with haemodynamic instability might have better survival when early nutrition is given enterally rather than parenterally.

In the NUTRIREA-2 trial, nutrition delivery was adapted according to a predetermined definition of the acute phase of critical illness. Furthermore, nutritional intakes were far closer to targets than in the CALORIES trial. The groups given early normocaloric enteral versus parenteral nutrition showed no significant differences in day 28 mortality; frequency of infectious complications; organ failure severity or duration; life support duration; ICU and hospital stay lengths; and ICU, hospital, or day 90 mortality.

Compared with the parenteral route, the enteral route was associated with slightly lower calorie and protein intakes and with higher frequencies of hypoglycaemia. Proportions of patients with bowel ischaemia and colonic pseudo-obstruction were higher in the enteral group than in the parenteral group.

See also:

Taylor BE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438. Full-text for Emory users.

More PubMed results on enteral nutrition and vasopressors.

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