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Early parenteral nutrition doesn’t help mortality

Sunday May 26, 2013
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The early provision of intravenous nutrition among critically ill patients with contraindications to early use of enteral nutrition did not result in significant differences in 60-day mortality or shorter ICU or hospital length of stay, compared with standard care, according to a study.

The intervention did result in a significant reduction in days of invasive mechanical ventilation, researchers reported in a study published May 20 on the website of the Journal of the American Medical Association and presented at the American Thoracic Society’s international conference in Philadelphia.

"Parenteral nutrition has been in common use since the 1960s and is accepted as the standard of care for patients with chronic nonfunctioning gastrointestinal tracts," according to background information in the study. In critical illness, controversy surrounds the appropriate use of parenteral nutrition. "Systematic reviews suggest adult patients in ICUs with relative contraindications to early, enteral nutrition may benefit from PN provided within 24 hours of ICU admission."

Gordon S. Doig, PhD, of the University of Sydney, Australia, and colleagues conducted a multicenter clinical trial to assess the effects of providing parenteral nutrition within 24 hours of ICU admission to critically ill adult patients who would not otherwise receive nutrition therapy because of short-term relative contraindications to enteral nutrition.

The randomized trial was conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults who were expected to remain in the ICU longer than two days.

A total of 1,372 patients were randomized to standard care or early PN. Of 682 patients receiving standard care, 29.2% initially began enteral nutrition, 27.3% began parenteral nutrition and 40.8% remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days. Patients receiving early PN began it an average of 44 minutes after enrollment in the trial.

The researchers found that day-60 mortality did not differ significantly between groups (22.8% for standard care vs. 21.5% for early parenteral nutrition). There also were no significant differences between groups in rates of new infection. Standard care patients experienced significantly greater muscle wasting and significantly greater fat loss over the duration of their ICU stay.

Early parenteral nutrition patients rated day-60 quality of life higher statistically, but not to a degree that was clinically meaningful. Early PN patients required fewer days of invasive ventilation, but this did not result in a statistically significant reduction in ICU or hospital length of stay. No harm was associated with the use of early parenteral nutrition in this trial.

In an accompanying editorial, Juan B. Ochoa Gautier, MD, of the University of Pittsburgh, and Flavia R. Machado, MD, PhD, of the Federal University of Sao Paulo in Brazil, wrote: "A significant amount of additional work is required to determine how to best deliver nutrition interventions in the ICU. It is essential (and indeed ethically imperative) for investigators at the forefront of this debate to be circumspect in their conclusions and clinical recommendations, to avoid their findings being misinterpreted and creating more harm than good.

"For now clinicians should attempt to optimize oral/enteral nutrition, avoid forced starvation if at all possible and judiciously use supplemental parenteral nutrition."

Read the study: http://jama.jamanetwork.com/article.aspx?articleid=1689534.


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