July 1, 2011

Early vs. Late Parenteral Nutrition

(Ivanhoe Newswire) "“ Controversy remains over the timing and initiation of parenteral nutrition in critically ill adults whose caloric targets cannot be met by enteral nutrition alone, which provides food through a tube placed in the nose, stomach, or small intestine. Parenteral nutrition is administered through a catheter and goes directly into a vein and supplies nutrients in a form that doesn't require digestion.

The study compared the European guidelines of early initiation of parenteral nutrition, and the American and Canadian guidelines of late initiation in adults in the intensive care unit (ICU) who were at risk of malnutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission to the early-initiation group. In 2328 patients, parenteral nutrition was not initiated before day eight to the late-initiation group. A protocol for the early initiation of parenteral nutrition was applied to both groups, and insulin was given to achieve a normal concentration of glucose in the blood.

The researchers found that there was no significant difference in mortality between late initiation and early initiation of parenteral nutrition among patients in ICU.

However, withholding parenteral nutrition until day eight was linked to fewer ICU infections, but a higher degree of acute inflammation. Late initiation was associated with a shorter duration of mechanical ventilation, which is used when a patient cannot naturally breathe. Late initiation also resulted in a shorter ICU stay despite a slight increase in hypoglycemic episodes, an overall shorter hospital stay, and reduced health care costs.

The researchers believe that although the patients' vital status was unaffected, all primary and secondary morbidity end points indicated that early parenteral nutrition was not beneficial. "In conclusion, the early initiation of parenteral nutrition during the first week after ICU administration in severely ill patients appears to be inferior to the strategy of withholding parenteral nutrition until day 8 while providing vitamins, trace elements, and minerals," the authors write.

"Late parenteral nutrition was associated with fewer infections, enhanced recovery, and lower health care costs," the authors write.

SOURCE: The New England Journal of Medicine, June 30, 2011