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01-02-2013 | Viewpoint

Does artificial nutrition improve outcome of critical illness?

Authors: Miet Schetz, Michael Paul Casaer, Greet Van den Berghe

Published in: Critical Care | Issue 1/2013

Abstract

Nutritional support is generally considered an essential component in the management of critically ill patients. The existing guidelines advocate early enteral nutrition, with the optimal timing for the addition of parenteral nutrition to insufficient enteral feeding being the subject of transatlantic controversy. The unphysiologic intervention of artificial nutrition in critically ill patients, however, may evoke complications and side effects. Besides the classically described complications, suppression of autophagy, potentially important for cellular repair and organ recovery, was elucidated only recently. The question whether artificial nutrition in critical illness improves or worsens outcome as compared with starvation has so far not been adequately addressed. This paper provides a critical analysis of the existing literature on ICU nutrition, highlighting important methodological shortcomings of many trials and meta-analyses and underlining the urgent need for high-quality research in this field. Recent adequately designed randomized controlled trials suggest that trophic enteral feeding during the first week of critical illness is as good as full enteral feeding and that early addition of parenteral nutrition to insufficient enteral nutrition does not provide any benefit and worsens morbidity.

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Jensen GL, Mirtallo J, Campher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrup J, Labadarios D, Nyulasi I, Castillo Pineda JC, Waitzberg D, International Consensus Guideline Committee: Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr 2010, 34: 156-159. 10.1177/0148607110361910CrossRefPubMed

Correia MI, Waitzberg DL: The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003, 22: 235-239. 10.1016/S0261-5614(02)00215-7CrossRefPubMed

Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L: Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012, 31: 345-350. 10.1016/j.clnu.2011.11.001CrossRefPubMed

Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, Van den BG, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C: ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006, 25: 210-223. 10.1016/j.clnu.2006.01.021CrossRefPubMed

McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G, A.S.P.E.N. Board of Directors, American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009, 33: 277-316. 10.1177/0148607109335234CrossRefPubMed

Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN: ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr 2009, 28: 387-400. 10.1016/j.clnu.2009.04.024CrossRefPubMed

Manzanares W, Dhaliwal R, Jiang X, Murch L, Heyland DK: Antioxidant micronutrients in the critically ill: a systematic review and meta-analysis. Crit Care 2012, 16: R66. 10.1186/cc11316PubMedCentralCrossRefPubMed

Visser J, Labadarios D, Blaauw R: Micronutrient supplementation for critically ill adults: a systematic review and meta-analysis. Nutrition 2011, 27: 745-758. 10.1016/j.nut.2010.12.009CrossRefPubMed

Vanek VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M, Novel Nutrient Task Force, Parenteral Glutamine Workgroup, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors: A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract 2011, 26: 479-494. 10.1177/0884533611410975CrossRefPubMed

10.

Mizock BA: Immunonutrition and critical illness: an update. Nutrition 2010, 26: 701-707. 10.1016/j.nut.2009.11.010CrossRefPubMed

11.

Wischmeyer P: Nutritional pharmacology in surgery and critical care: 'you must unlearn what you have learned'. Curr Opin Anaesthesiol 2011, 24: 381-388. 10.1097/ACO.0b013e32834872b6CrossRefPubMed

12.

Sandri M: Signaling in muscle atrophy and hypertrophy. Physiology (Bethesda) 2008, 23: 160-170. 10.1152/physiol.00041.2007CrossRef

13.

Llano-Diez M, Gustafson AM, Olsson C, Goransson H, Larsson L: Muscle wasting and the temporal gene expression pattern in a novel rat intensive care unit model. BMC Genomics 2011, 12: 602. 10.1186/1471-2164-12-602PubMedCentralCrossRefPubMed

14.

Derde S, Hermans G, Derese I, Güiza F, Hedström Y, Wouters PJ, Bruyninckx F, D'Hoore A, Larsson L, Van den Berghe G, Vanhorebeek I: Muscle atrophy and preferential loss of myosin in prolonged critically ill patients. Crit Care Med 2012, 40: 79-89. 10.1097/CCM.0b013e31822d7c18CrossRefPubMed

15.

Streat SJ, Beddoe AH, Hill GL: Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. J Trauma 1987, 27: 262-266. 10.1097/00005373-198703000-00006CrossRefPubMed

16.

Frankenfield DC, Smith JS, Cooney RN: Accelerated nitrogen loss after traumatic injury is not attenuated by achievement of energy balance. J Parenter Enteral Nutr 1997, 21: 324-329. 10.1177/0148607197021006324CrossRef

17.

Hart DW, Wolf SE, Herndon DN, Chinkes DL, Lal SO, Obeng MK, Beauford RB, Mlcak RT RP: Energy expenditure and caloric balance after burn: increased feeding leads to fat rather than lean mass accretion. Ann Surg 2002, 235: 152-161. 10.1097/00000658-200201000-00020PubMedCentralCrossRefPubMed

18.

Tappy L, Berger M, Schwarz JM, McCamish M, Revelly JP, Schneiter P, Jéquier E, Chioléro R: Hepatic and peripheral glucose metabolism in intensive care patients receiving continuous high- or low-carbohydrate enteral nutrition. JPEN J Parenter Enteral Nutr 1999, 23: 260-267. 10.1177/0148607199023005260CrossRefPubMed

19.

Schwarz JM, Chioléro R, Revelly JP, Cayeux C, Schneiter P, Jéquier E, Chen T, Tappy L: Effects of enteral carbohydrates on de novo lipogenesis in critically ill patients. Am J Clin Nutr 2000, 72: 940-945.PubMed

20.

Hiesmayr M: Nutrition risk assessment in the ICU. Curr Opin Clin Nutr Metab Care 2012, 15: 174-180. 10.1097/MCO.0b013e328350767eCrossRefPubMed

21.

Ziegler TR: Parenteral nutrition in the critically ill. N Engl J Med 2009, 361: 1088-1097. 10.1056/NEJMct0806956PubMedCentralCrossRefPubMed

22.

Moreau K, Luo S, Rubinsztein DC: Cytoprotective roles for autophagy. Curr Opin Cell Biol 2010, 22: 206-211. 10.1016/j.ceb.2009.12.002PubMedCentralCrossRefPubMed

23.

Mizushima N, Komatsu M: Autophagy: renovation of cells and tissues. Cell 2011, 147: 728-741. 10.1016/j.cell.2011.10.026CrossRefPubMed

24.

Cuervo AM, Macian F: Autophagy, nutrition and immunology. Mol Aspects Med 2012, 33: 2-13. 10.1016/j.mam.2011.09.001PubMedCentralCrossRefPubMed

25.

Derde S, Vanhorebeek I, Güiza F, Derese I, Gunst J, Fahrenkrog B, Martinet W, Vervenne H, Ververs EJ, Larsson L, Van den Berghe G: Early parenteral nutrition evokes a phenotype of autophagy deficiency in liver and skeletal muscle of critically ill rabbits. Endocrinology 2012, 153: 2267-2276. 10.1210/en.2011-2068CrossRefPubMed

26.

Vanhorebeek I, Gunst J, Derde S, Derese I, Boussemaere M, Güiza F, Martinet W, Timmermans JP, D'Hoore A, Wouters PJ, Van den Berghe G: Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. J Clin Endocrinol Metab 2011, 96: E633-E645. 10.1210/jc.2010-2563CrossRefPubMed

27.

Gunst J, Derese I, Aertgeerts A, Ververs EJ, Wauters A, Van den Berghe G, Vanhorebeek I: Insufficient autophagy contributes to mitochondrial dysfunction, organ failure and adverse outcome in an animal model of critical illness. Crit Care Med 2012, 41: 177-189.CrossRef

28.

Masiero E, Sandri M: Autophagy inhibition induces atrophy and myopathy in adult skeletal muscles. Autophagy 2010, 6: 307-309. 10.4161/auto.6.2.11137CrossRefPubMed

29.

Masiero E, Agatea L, Mammucari C, Blaauw B, Loro E, Komatsu M, Metzger D, Reggiani C, Schiaffino S, Sandri M: Autophagy is required to maintain muscle mass. Cell Metab 2009, 10: 507-515. 10.1016/j.cmet.2009.10.008CrossRefPubMed

30.

Mitchell JR, Verweij M, Brand K, van de Ven M, Goemaere N, van den Engel S, Chu T, Forrer F, Müller C, de Jong M, van IJcken W, IJzermans JN, Hoeijmakers JH, de Bruin RW: Short-term dietary restriction and fasting precondition against ischemia reperfusion injury in mice. Aging Cell 2010, 9: 40-53. 10.1111/j.1474-9726.2009.00532.xPubMedCentralCrossRefPubMed

31.

Verweij M, van de Ven M, Mitchell JR, van den Engel S, Hoeijmakers JH, Ijzermans JN, de Bruin RW: Glucose supplementation does not interfere with fasting-induced protection against renal ischemia/reperfusion injury in mice. Transplantation 2011, 92: 752-758. 10.1097/TP.0b013e31822c6ed7CrossRefPubMed

32.

Peng W, Robertson L, Gallinetti J, Mejia P, Vose S, Charlip A, Chu T, Mitchell JR: Surgical stress resistance induced by single amino acid deprivation requires Gcn2 in mice. Sci Transl Med 2012, 4: 118ra11. 10.1126/scitranslmed.3002629PubMedCentralCrossRefPubMed

33.

Dvir D, Cohen J, Singer P: Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr 2006, 25: 37-44. 10.1016/j.clnu.2005.10.010CrossRefPubMed

34.

Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNMC, Delarue J, Berger MM: Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005, 24: 502-509. 10.1016/j.clnu.2005.03.006CrossRefPubMed

35.

Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, Heyland DK: The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009, 35: 1728-1737. 10.1007/s00134-009-1567-4CrossRefPubMed

36.

Weijs PJ, Stapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, Strack van Schijndel RJ, Beishuizen A: Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012, 36: 60-68. 10.1177/0148607111415109CrossRefPubMed

37.

Krishnan JA, Parce PB, Martinez A, Diette GB, Brower RG: Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest 2003, 124: 297-305. 10.1378/chest.124.1.297CrossRefPubMed

38.

Arabi YM, Haddad SH, Tamim HM, Rishu AH, Sakkijha MH, Kahoul SH, Britts RJ: Near-target caloric intake in critically ill medical-surgical patients is associated with adverse outcomes. JPEN J Parenter Enteral Nutr 2010, 34: 280-288. 10.1177/0148607109353439CrossRefPubMed

39.

Artinian V, Krayem H, DiGiovine B: Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 2006, 129: 960-967. 10.1378/chest.129.4.960CrossRefPubMed

40.

Khalid I, Doshi P, DiGiovine B: Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 2010, 19: 261-268. 10.4037/ajcc2010197CrossRefPubMed

41.

Huang HH, Hsu CW, Kang SP, Liu MY, Chang SJ: Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study. Nutr J 2012, 11: 30. 10.1186/1475-2891-11-30PubMedCentralCrossRefPubMed

42.

Kutsogiannis J, Alberda C, Gramlich L, Cahill NE, Wang M, Day AG, Dhaliwal R, Heyland DK: Early use of supplemental parenteral nutrition in critically ill patients: results of an international multicenter observational study. Crit Care Med 2011, 39: 2691-2699.PubMed

43.

Cahill NE, Murch L, Jeejeebhoy K, McClave SA, Day AG, Wang M, Heyland DK: When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study. JPEN J Parenter Enteral Nutr 2011, 35: 160-168. 10.1177/0148607110381405CrossRefPubMed

44.

Wolfe RR, Goodenough RD, Burke JF, Wolfe MH: Response of protein and urea kinetics in burn patients to different levels of protein intake. Ann Surg 1983, 197: 163-171. 10.1097/00000658-198302000-00007PubMedCentralCrossRefPubMed

45.

Shaw JH, Wildbore M, Wolfe RR: Whole body protein kinetics in severely septic patients. The response to glucose infusion and total parenteral nutrition. Ann Surg 1987, 205: 288-294. 10.1097/00000658-198703000-00012PubMedCentralCrossRefPubMed

46.

Larsson J, Lennmarken C, Mårtensson J, Sandstedt S, Vinnars E: Nitrogen requirements in severely injured patients. Br J Surg 1990, 77: 413-416. 10.1002/bjs.1800770418CrossRefPubMed

47.

Ishibashi N, Plank LD, Sando K, Hill GL: Optimal protein requirements during the first 2 weeks after the onset of critical illness. Crit Care Med 1998, 26: 1529-1535. 10.1097/00003246-199809000-00020CrossRefPubMed

48.

Leung KM, Elashoff RM, Afifi AA: Censoring issues in survival analysis. Annu Rev Public Health 1997, 18: 83-104. 10.1146/annurev.publhealth.18.1.83CrossRefPubMed

49.

Peduzzi P, Henderson W, Hartigan P, Lavori P: Analysis of randomized trials. Epidemiol Rev 2002, 24: 26-38. 10.1093/epirev/24.1.26CrossRefPubMed

50.

Casaer MP, Hermans G, Wilmer A, Van den Berghe G: Impact of early parenteral nutrition completing enteral nutrition in adult critically ill patients (EPaNIC trial): a study protocol and statistical analysis plan for a randomized controlled trial. Trials 2011, 12: 21. 10.1186/1745-6215-12-21PubMedCentralCrossRefPubMed

51.

Ziegler TR: Nutrition support in critical illness - bridging the evidence gap. N Engl J Med 2011, 365: 562-564. 10.1056/NEJMe1106612CrossRefPubMed

52.

Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR: Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med 2009, 35: 2018-2027. 10.1007/s00134-009-1664-4CrossRefPubMed

53.

McClave SA, Heyland DK: The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract 2009, 24: 305-315. 10.1177/0884533609335176CrossRefPubMed

54.

Koretz RL, Avenell A, Lipman TO, Braunschweig CL, Milne AC: Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol 2007, 102: 412-429. 10.1111/j.1572-0241.2006.01024.xCrossRefPubMed

55.

Koretz RL: Enteral nutrition: a hard look at some soft evidence. Nutr Clin Pract 2009, 24: 316-324. 10.1177/0884533609335378CrossRefPubMed

56.

Doig GS, Simpson F, Sweetman EA: Evidence-based nutrition support in the intensive care unit: an update on reported trial quality. Curr Opin Clin Nutr Metab Care 2009, 12: 201-206. 10.1097/MCO.0b013e32832182b0CrossRefPubMed

57.

Simpson F, Doig GS: Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005, 31: 12-23. 10.1007/s00134-004-2511-2CrossRefPubMed

58.

Critical Care Nutrition[http://www.criticalcarenutrition.com]

59.

Dhaliwal R, Jurewitsch B, Harrietha D, Heyland DK: Combination enteral and parenteral nutrition in critically ill patients: harmful or beneficial? A systematic review of the evidence. Intensive Care Med 2004, 30: 1666-1671.CrossRefPubMed

60.

Arabi YM, Tamim HM, Dhar GS, Al-Dawood A, Al-Sultan M, Sakkijha MH, Kahoul SH, Brits R: Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr 2011, 93: 569-577. 10.3945/ajcn.110.005074CrossRefPubMed

61.

National Heart, Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P: Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012, 307: 795-803.CrossRef

62.

Griffiths RD: Nutrition for critically ill patients: how much is enough? JAMA 2012, 307: 845-846. 10.1001/jama.2012.168CrossRefPubMed

63.

Singer P, Anbar R, Cohen J, Shapiro H, Shalita-Chesner M, Lev S, Grozovski E, Theilla M, Frishman S, Madar Z: The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med 2011, 37: 601-609. 10.1007/s00134-011-2146-zCrossRefPubMed

64.

Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G: Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011, 365: 506-517. 10.1056/NEJMoa1102662CrossRefPubMed

Title: Does artificial nutrition improve outcome of critical illness?
Authors: Miet Schetz
Michael Paul Casaer
Greet Van den Berghe
Publication date: 01-02-2013
Publisher: BioMed Central
Published in: Critical Care / Issue 1/2013
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc11828

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Does artificial nutrition improve outcome of critical illness?

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Abstract

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