Respiratory Trials·org

Topic

Nutrition in critical care

Route, timing, and dose of nutritional support.

Feed less, later. Starting parenteral nutrition late rather than within 48 hours produced faster recovery and fewer infections (EPaNIC). Trophic feeding matched full feeding with less gastrointestinal intolerance (EDEN), and deliberate calorie restriction changed nothing (PermiT). Within a wide range, calorie delivery in early critical illness does not determine outcome.

Protein is not the answer either. High-dose protein did not improve time to discharge and may have harmed patients with acute kidney injury (EFFORT Protein); augmenting enteral protein in 3397 patients delivered nothing (TARGET Protein). Guideline advice to push protein hard has not survived.

The route does not matter — parenteral and enteral gave identical mortality (CALORIES) — and neither do gastric residuals, whose routine measurement can be abandoned without more pneumonia (Reignier 2013). Escalating to a post-pyloric tube for mildly raised residuals delivers no extra calories (Davies 2012).

How much protein

Trial Year Therapy Effect Finding
TARGET Protein 2025 Augmented enteral protein Augmenting enteral protein delivered no benefit
EFFORT Protein 2023 High-dose protein High-dose protein did not help and may have harmed patients with kidney injury

How much to feed

Trial Year Therapy Effect Finding
PermiT 2015 Permissive underfeeding Deliberately underfeeding calories made no difference to survival
EDEN 2012 Trophic enteral feeding Trophic feeding matched full feeding, with less gastrointestinal intolerance

Monitoring gastric residuals

Trial Year Therapy Effect Finding
Reignier 2013 2013 Not monitoring gastric residual volume Stopping routine gastric residual checks did not increase pneumonia

Route of enteral feeding

Trial Year Therapy Effect Finding
Davies 2012 2012 Nasojejunal feeding Post-pyloric feeding delivered no more calories than the nasogastric tube already in place

Route of nutrition

Trial Year Therapy Effect Finding
CALORIES 2014 Parenteral nutrition Parenteral and enteral routes gave identical mortality

When to start parenteral nutrition

Trial Year Therapy Effect Finding
EPaNIC 2011 Late initiation of parenteral nutrition Waiting a week before starting parenteral nutrition led to faster recovery and fewer infections

Key references

Guidelines, standards and reviews for this topic.