Faster Recovery Linked to Delay in IV Nutrition

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In critically ill adults, delaying parenteral nutrition leads to faster

recovery and fewer complications, researchers reported.

A later start to parenteral nutrition -- as recommended in the U.S. and

Canada -- also reduced healthcare costs by a mean of about $1,600, according

to Greet Van den Berghe, MD, PhD, of the University Hospital Leuven in

Leuven, Belgium, and colleagues.

But, in a randomized trial, there was no difference in mortality rates in

the intensive care unit, during overall inpatient care, or at 90 days, they

reported online in the *New England Journal of Medicine*.

For critically ill patients who aren't getting adequate nutrition by the

enteral route, parenteral supplementation is needed, the researchers noted.

But the timing of parenteral nutrition remains controversial: European

guidelines favor starting within two days of admission to the intensive care

unit, while U.S. and Canadian recommendations suggest waiting, as long as

patients are not malnourished at the outset.

In either case, the guidelines are " largely based on expert opinion, " the

researchers said.

To help clarify the issue, they conducted a multicenter trial in which

patients were randomly assigned to parenteral nutrition within two days of

admission to the ICU or had the IV feeding delayed until day eight.

Both groups had the same protocol for early initiation of enteral nutrition

and insulin was infused to achieve normoglycemia.

The primary efficacy endpoint of the study was duration of dependence on

intensive care, defined as the number of days in the unit and the time to

discharge.

Safety endpoints included vital status and rates of complications and

hypoglycemia. The researchers also measured several secondary endpoints,

including such things as the number of new infections, days on mechanical

ventilation, and the need for renal-replacement therapy.

All told, 4,640 patients – treated in seven Belgian intensive care units

from Aug. 1, 2007 through Nov. 8, 2010 were included in the analysis, Van

den Berghe and colleagues reported.

Rates of death in intensive care and in the hospital were similar in the two

groups, as were rates of survival at 90 days.

But 75.2% of late-start patients were discharged live from the ICU within

eight days, compared with 71.7% of early-start patients (*P*=0.007).

Late-start patients spent a median of three days in intensive care and 14

days in the hospital in total. That compared with a median of four days in

the ICU for early-start patients (*P*=0.02) and 16 days in the hospital (*P*

=0.004).

Patients in the late-start group also had fewer infections -- 22.8% versus

26.2% -- a difference that was significant at *P*=0.008.

They also had a relative reduction of 9.7% in the proportion of patients

requiring more than two days of mechanical ventilation (*P*=0.006), a median

reduction of three days in the duration of renal replacement therapy

(*P*=0.008),

and an average reduction in healthcare costs of 1,110 Euros or about $1,600

(*P*=0.04).

Taken together, the researchers argued, the findings show that late

initiation of parenteral nutrition " is associated with fewer infections,

enhanced recovery, and lower healthcare costs. "

They cautioned that – because of the study design – their study was not

blinded. As well, they noted, the parenteral nutrition used was a standard,

pre-mixed formulation and was not enhanced with substances such as glutamine

or immune-modulating compounds.

Van den Berghe and colleagues also noted that they calculated the amount of

nutrition without measuring energy expenditure by indirect calorimetry.

*Primary source: *New England Journal of Medicine

Source reference:

Casaer MP, et al " Early versus late parenteral nutrition in critically ill

adults " *N Engl J Med* 2011; DOI:

10.1056/NEJMoa1102662.<http://www.nejm.org/doi/full/10.1056/NEJMoa1102662>

--

Ortiz, MS, RD

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