Give enteral nutrition a chance in critically ill adultsBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8387 (Published 12 December 2012) Cite this as: BMJ 2012;345:e8387
Intensive care specialists are still debating the best way to meet the complex nutritional needs of critically ill adults. International guidelines recommend enteral nutrition first but diverge on what to do when this is not enough. The latest trial tested top-up parenteral (intravenous) nutrition, starting on day 4 for five days. Adults given the top-up had fewer nosocomial infections than controls managed with enteral nutrition throughout (27% (41/153) v 38% (58/152); hazard ratio 0.65, 95% CI 0.43 to 0.97). They spent less time on antibiotics, but no less time in intensive care. Staff followed carefully crafted protocols for both types of feeding, including close metabolic monitoring. They used calorimetry to set targets for energy intake and avoid overfeeding. Adults given the extra parenteral nutrition received 103% of their target intake, compared with 77% for controls⇑.
Although trials in this area don’t always agree on the precise timing of parenteral nutrition, the evidence so far indicates that there is no particular hurry, says a linked comment (doi:10.1016/S0140-6736(12)61893-5). Day 4 is plenty soon enough, and most patients will come to little harm if they wait a few days longer. Parenteral nutrition should be considered only for patients who can’t get what they need from the enteral route. All participants in the latest trial had energy deficits of 40% or more. They were expected to need intensive care for at least five days and to survive for at least a week. All had a functioning gastrointestinal tract. Thirteen per cent of adults given parenteral nutrition and 18% of controls died within 28 days, a non-significant difference.
Cite this as: BMJ 2012;345:e8387