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Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential
Han-Yang Yue1, Wei Peng1, Jun Zeng1,2
1Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
Insights
Permissive underfeeding in intensive care units (ICUs) may reduce ICU mortality and mechanical ventilation duration. However, this nutritional strategy did not improve overall mortality in critically ill patients.
Area of Science:
- Critical Care Medicine
- Nutritional Support
- Evidence-Based Medicine
Background:
- Previous research suggested permissive underfeeding might improve outcomes in patients receiving parenteral nutrition.
- The tentative conclusion from a small 2011 study necessitated further investigation.
- This study updates the evidence on permissive underfeeding in intensive care unit (ICU) patients.
Purpose of the Study:
- To systematically review and meta-analyze randomized controlled trials (RCTs) on permissive underfeeding in ICU patients.
- To assess the impact of permissive underfeeding on mortality, length of stay, and adverse events.
- To perform trial sequential analyses (TSA) for robust mortality outcome evaluation.
Main Methods:
- A systematic search of seven major databases was conducted.
- Twenty-three RCTs involving 11,444 critically ill patients were included.
- Risk of bias was assessed using ROB 2, and data were synthesized using RevMan software with TSA.
Main Results:
- Permissive underfeeding significantly reduced ICU mortality (RR 0.90; 95% CI [0.81, 0.99]) and gastrointestinal adverse events (RR 0.79; 95% CI [0.69, 0.90]).
- Mechanical ventilation duration was shortened by an average of 1.85 days (MD -1.85 days; 95% CI [-3.44, -0.27]).
- No significant differences were observed in overall mortality, hospital mortality, length of hospital stays, or overall infection incidence.
Conclusions:
- Permissive underfeeding appears to lower ICU mortality and reduce mechanical ventilation duration in critically ill patients.
- Overall mortality was not significantly improved by this nutritional approach.
- Further large-scale, well-designed RCTs are needed to confirm these findings due to sample size and patient heterogeneity.
Background:
Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).
Methods:
Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.
Results:
Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%).
Conclusions:
Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.
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