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Parenteral nutrition in the critically ill.
Jan Gunst1, Greet Van den Berghe
1Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
Current Opinion in Critical Care
|January 13, 2017
Summary
Current evidence suggests avoiding early parenteral nutrition in critically ill patients. Low macronutrient intake during the acute phase is acceptable, but optimal timing for parenteral nutrition remains uncertain.
Area of Science:
- Critical care medicine
- Nutritional support
- Clinical nutrition
Background:
- Traditional feeding guidelines recommended early, full nutritional support for critically ill patients to prevent hypercatabolism and muscle weakness.
- Early enteral nutrition was considered superior to early parenteral nutrition, with supplemental parenteral nutrition recommended when enteral nutrition targets were not met.
- Recent large randomized controlled trials (RCTs) have provided new insights into these practices.
Purpose of the Study:
- To review recent evidence on the indications, timing, and dosing of parenteral nutrition in critically ill patients.
- To evaluate the impact of early enteral nutrition versus early parenteral nutrition.
- To assess the safety and efficacy of supplemental parenteral nutrition when enteral nutrition is insufficient.
Main Methods:
- Systematic review of recent large randomized controlled trials (RCTs).
- Analysis of evidence regarding early enteral nutrition versus early parenteral nutrition.
- Evaluation of studies on supplemental parenteral nutrition and macronutrient dosing.
Main Results:
- One large RCT found no difference between early enteral nutrition and early parenteral nutrition.
- Two multicenter RCTs indicated harm from early supplemental parenteral nutrition, potentially due to suppressed autophagy.
- Several RCTs showed no benefit or harm from higher caloric/amino acid intake and harm from glutamine administration.
Conclusions:
- Current evidence supports accepting lower macronutrient intake during the acute phase of critical illness.
- Early parenteral nutrition is not supported by current evidence.
- The optimal timing for initiating parenteral nutrition safely and effectively remains undetermined.
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