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Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial

Published online by Cambridge University Press:  16 July 2020

Aileen Hill
Affiliation:
Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany 3CARE—Cardiovascular Critical Care & Anaesthesia Evaluation and Research, Medical Faculty RWTH Aachen, Aachen, Germany
Daren K. Heyland
Affiliation:
Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
Gunnar Elke
Affiliation:
Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
Stefan J. Schaller
Affiliation:
Department of Anaesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
Reto Stocker
Affiliation:
Department of Anaesthesiology and Intensive Care, Klinik Hirslanden, Zürich, Switzerland
Christoph Haberthür
Affiliation:
Department of Anaesthesiology and Intensive Care, Klinik Hirslanden, Zürich, Switzerland
Christian von Loeffelholz
Affiliation:
Department of Anaesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
Ulrich Suchner
Affiliation:
Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
Zudin A. Puthucheary
Affiliation:
William Harvey Research Institute, Queen Mary, University of London, London, UK
Danielle E. Bear
Affiliation:
Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Julia Ney
Affiliation:
Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany 3CARE—Cardiovascular Critical Care & Anaesthesia Evaluation and Research, Medical Faculty RWTH Aachen, Aachen, Germany
Kai C. Clasen
Affiliation:
Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany 3CARE—Cardiovascular Critical Care & Anaesthesia Evaluation and Research, Medical Faculty RWTH Aachen, Aachen, Germany
Patrick Meybohm
Affiliation:
Department of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
Simone Lindau
Affiliation:
Department of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
Thea Laurentius
Affiliation:
Department of Internal Medicine and Geriatrics, Franziskushospital Aachen, Aachen, Germany
Christian Stoppe
Affiliation:
Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany 3CARE—Cardiovascular Critical Care & Anaesthesia Evaluation and Research, Medical Faculty RWTH Aachen, Aachen, Germany
Corresponding

Abstract

While medical nutrition therapy is an essential part of the care for critically ill patients, uncertainty exists about the right form, dosage, timing and route in relation to the phases of critical illness. As enteral nutrition (EN) is often withheld or interrupted during the intensive care unit (ICU) stay, combined EN and parenteral nutrition (PN) may represent an effective and safe option to achieve energy and protein goals as recommended by international guidelines. We hypothesise that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the ICU. Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching energy and protein goals in patients at high nutritional risk, while avoiding overfeeding. This approach will be tested in the here-presented EFFORTcombo trial. Nutritionally high-risk ICU patients will be randomised to either high (≥2·2 g/kg per d) or low protein (≤1·2 g/kg per d). In the high protein group, the patients will receive EN+PN; in the low protein group, patients will be given EN alone. EN will be started in accordance with international guidelines in both groups. Efforts will be made to reach nutrition goals within 48–96 h. The efficacy of the proposed nutritional strategy will be tested as an innovative approach by functional outcomes at ICU and hospital discharge, as well as at a 6-month follow-up.

Type
Review Article
Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of The Nutrition Society

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References

Preiser, J-C, van Zanten, ARH, Berger, MM, et al. (2015) Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care 19, 35.CrossRefGoogle ScholarPubMed
Elke, G, van Zanten, ARH, Lemieux, M, et al. (2016) Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 20, 117.CrossRefGoogle ScholarPubMed
McClave, SA, Taylor, BE, Martindale, RG, et al. (2016) 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 40, 159211.CrossRefGoogle Scholar
Weimann, A, Braga, M, Carli, F, et al. (2017) ESPEN guideline: clinical nutrition in surgery. Clin Nutr 36, 623650.CrossRefGoogle ScholarPubMed
Singer, P, Blaser, AR, Berger, MM, et al. (2018) ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 38, 4879.CrossRefGoogle ScholarPubMed
Reintam Blaser, A, Starkopf, J, Alhazzani, W, et al. (2017) Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 43, 380398.CrossRefGoogle ScholarPubMed
Heyland, DK, Schroter-Noppe, D, Drover, JW, et al. (2003) Nutrition support in the critical care setting: current practice in canadian ICUs – opportunities for improvement? JPEN J Parenter Enteral Nutr 27, 7483.CrossRefGoogle ScholarPubMed
Bost, RB, Tjan, DH & van Zanten, AR (2014) Timing of (supplemental) parenteral nutrition in critically ill patients: a systematic review. Ann Intensive Care 4, 31.CrossRefGoogle ScholarPubMed
Rice, TW, Mogan, S, Hays, MA, et al. (2011) Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 39, 967974.CrossRefGoogle ScholarPubMed
Arabi, YM, Aldawood, AS, Al-Dorzi, HM, et al. (2017) Permissive underfeeding or standard enteral feeding in high- and low-nutritional-risk critically ill adults. Post hoc analysis of the PermiT trial. Am J Respir Crit Care Med 195, 652662.CrossRefGoogle ScholarPubMed
Allingstrup, MJ, Kondrup, J, Wiis, J, et al. (2017) Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med 43, 16371647.CrossRefGoogle ScholarPubMed
Arabi, YM, Casaer, MP, Chapman, M, et al. (2017) The intensive care medicine research agenda in nutrition and metabolism. Intensive Care Med 43, 12391256.CrossRefGoogle ScholarPubMed
Heyland, DK, Patel, J, Bear, D, et al. (2018) The effect of higher protein dosing in critically ill patients: a multicenter registry-based randomized trial: the EFFORT trial. JPEN J Parenter Enteral Nutr 43, 326334.CrossRefGoogle ScholarPubMed
Heyland, DK, Weijs, PJM, Coss-Bu, JA, et al. (2017) Protein delivery in the intensive care unit: optimal or suboptimal? Nutr Clin Pract 32, Suppl., 58S71S.CrossRefGoogle ScholarPubMed
van Zanten, ARH, Petit, L, De Waele, J, et al. (2018) Very high intact-protein formula successfully provides protein intake according to nutritional recommendations in overweight critically ill patients: a double-blind randomized trial. Crit Care 22, 156.CrossRefGoogle ScholarPubMed
Ridley, EJ, Peake, SL, Jarvis, M, et al. (2018) Nutrition therapy in Australia and New Zealand intensive care units: an international comparison study. JPEN J Parenter Enteral Nutr 42, 13491357.CrossRefGoogle ScholarPubMed
Cahill, NE, Dhaliwal, R, Day, AG, et al. (2010) Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med 38, 395401.CrossRefGoogle ScholarPubMed
Heyland, D, Cook, DJ, Winder, B, et al. (1995) Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med 23, 10551060.CrossRefGoogle ScholarPubMed
Adam, S & Batson, S (1997) A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Med 23, 261266.CrossRefGoogle ScholarPubMed
McClave, SA, Sexton, LK, Spain, DA, et al. (1999) Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med 27, 12521256.CrossRefGoogle ScholarPubMed
Berger, MM & Chiolero, RL (2009) Enteral nutrition and cardiovascular failure: from myths to clinical practice. JPEN J Parenter Enteral Nutr 33, 702709.CrossRefGoogle ScholarPubMed
Berger, MM, Revelly, J-P, Cayeux, M-C, et al. (2005) Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass. Clin Nutr 24, 124132.CrossRefGoogle ScholarPubMed
Villet, S, Chiolero, RL, Bollmann, MD, et al. (2005) Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 24, 502509.CrossRefGoogle ScholarPubMed
Casaer, MP, Mesotten, D, Hermans, G, et al. (2011) Early versus late parenteral nutrition in critically ill adults. N Engl J Med 365, 506517.CrossRefGoogle ScholarPubMed
Kelly, DG, Tappenden, KA & Winkler, MF (2014) Short bowel syndrome: highlights of patient management, quality of life, and survival. JPEN J Parenter Enteral Nutr 38, 427437.CrossRefGoogle ScholarPubMed
Braunschweig, CL, Levy, P, Sheean, PM, et al. (2001) Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 74, 534542.CrossRefGoogle ScholarPubMed
Gramlich, L, Kichian, K, Pinilla, J, et al. (2004) Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 20, 843848.CrossRefGoogle ScholarPubMed
Heyland, DK, Montalvo, M, MacDonald, S, et al. (2001) Total parenteral nutrition in the surgical patient: a meta-analysis. Can J Surg 44, 102111.Google ScholarPubMed
Peter, JV, Moran, JL & Phillips-Hughes, J (2005) A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 33, 213220; discussion 260–261.CrossRefGoogle ScholarPubMed
De Vlieger, G, Ingels, C, Wouters, PJ, et al. (2018) Impact of supplemental parenteral nutrition early during critical illness on invasive fungal infections: a secondary analysis of the EPaNIC randomized controlled trial. Clin Microbiol Infect 25, 359364.CrossRefGoogle ScholarPubMed
Hermans, G, Casaer, MP, Clerckx, B, et al. (2013) Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: a subanalysis of the EPaNIC trial. Lancet Respir Med 1, 621629.CrossRefGoogle ScholarPubMed
Vanderheyden, S, Casaer, MP, Kesteloot, K, et al. (2012) Early versus late parenteral nutrition in ICU patients: cost analysis of the EPaNIC trial. Crit Care 16, R96.CrossRefGoogle ScholarPubMed
Casaer, MP, Langouche, L, Coudyzer, W, et al. (2013) Impact of early parenteral nutrition on muscle and adipose tissue compartments during critical illness. Crit Care Med 41, 22982309.CrossRefGoogle ScholarPubMed
Dellinger, RP, Levy, MM, Rhodes, A, et al. (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 41, 580637.CrossRefGoogle ScholarPubMed
Dhaliwal, R, Cahill, N, Lemieux, M, et al. (2014) The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. Nutr Clin Pract 29, 2943.CrossRefGoogle ScholarPubMed
Singer, P, Berger, MM, Van den Berghe, G, et al. (2009) ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 28, 387400.CrossRefGoogle ScholarPubMed
Heyland, DK, Dhaliwal, R, Drover, JW, et al. (2003) Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 27, 355373.CrossRefGoogle ScholarPubMed
Harvey, SE, Parrott, F, Harrison, DA, et al. (2014) Trial of the route of early nutritional support in critically ill adults. N Engl J Med 371, 16731684.CrossRefGoogle ScholarPubMed
Reignier, J, Boisrame-Helms, J, Brisard, L, et al. (2018) Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet 391, 133143.CrossRefGoogle Scholar
Heidegger, C-P, Romand, J-A, Treggiari, MM, et al. (2007) Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient? Intensive Care Med 33, 963969.CrossRefGoogle ScholarPubMed
Heidegger, CP, Berger, MM, Graf, S, et al. (2013) Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 381, 385393.CrossRefGoogle ScholarPubMed
Wischmeyer, PE, Hasselmann, M, Kummerlen, C, et al. (2017) A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Crit Care 21, 142.CrossRefGoogle ScholarPubMed
Chow, CK (1979) Nutritional influence on cellular antioxidant defense systems. Am J Clin Nutr 32, 10661081.CrossRefGoogle ScholarPubMed
Khare, M, Mohanty, C, Das, BK, et al. (2014) Free radicals and antioxidant status in protein energy malnutrition. Int J Pediatr 2014, 254396.CrossRefGoogle ScholarPubMed
Heyland, DK, Dhaliwal, R, Jiang, X, et al. (2011) Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 15, R268.CrossRefGoogle ScholarPubMed
Kondrup, J, Allison, SP, Elia, M, et al. (2003) ESPEN guidelines for nutrition screening 2002. Clin Nutr 22, 415421.CrossRefGoogle ScholarPubMed
Alberda, C, Gramlich, L, Jones, N, et al. (2009) The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 35, 17281737.CrossRefGoogle ScholarPubMed
Artinian, V, Krayem, H & DiGiovine, B (2006) Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 129, 960967.CrossRefGoogle ScholarPubMed
Khalid, I, Doshi, P & DiGiovine, B (2010) Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 19, 261268.CrossRefGoogle ScholarPubMed
Bear, DE, Wandrag, L, Merriweather, JL, et al. (2017) The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review. Crit Care 21, 226.CrossRefGoogle ScholarPubMed
Friedman, J, Lussiez, A, Sullivan, J, et al. (2015) Implications of sarcopenia in major surgery. Nutr Clin Pract 30, 175179.CrossRefGoogle ScholarPubMed
Jolley, SE, Bunnell, AE & Hough, CL (2016) ICU-acquired weakness. Chest 150, 11291140.CrossRefGoogle ScholarPubMed
Koga, Y, Fujita, M, Yagi, T, et al. (2018) Early enteral nutrition is associated with reduced in-hospital mortality from sepsis in patients with sarcopenia. J Crit Care 47, 153158.CrossRefGoogle ScholarPubMed
Heyland, DK, Stapleton, R & Compher, C (2018) Should we prescribe more protein to critically ill patients? Nutrients 10, 462.CrossRefGoogle ScholarPubMed
Heyland, DK, Stephens, KE, Day, AG, et al. (2011) The success of enteral nutrition and ICU-acquired infections: a multicenter observational study. Clin Nutr 30, 148155.CrossRefGoogle ScholarPubMed
Heyland, DK, Cahill, N & Day, AG (2011) Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med 39, 26192626.CrossRefGoogle ScholarPubMed
Ferrie, S, Allman-Farinelli, M, Daley, M, et al. (2016) Protein requirements in the critically ill: a randomized controlled trial using parenteral nutrition. JPEN J Parenter Enteral Nutr 40, 795805.CrossRefGoogle ScholarPubMed
Doig, GS, Simpson, F, Bellomo, R, et al. (2015) Intravenous amino acid therapy for kidney function in critically ill patients: a randomized controlled trial. Intensive Care Med 41, 11971208.CrossRefGoogle ScholarPubMed
Davies, ML, Chapple, L-AS, Chapman, MJ, et al. (2017) Protein delivery and clinical outcomes in the critically ill: a systematic review and meta-analysis. Crit Care Resusc 19, 117127.Google ScholarPubMed
Elke, G, Hartl, WH, Kreymann, KG, et al. (2018) DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“ (DGEM Guideline: ‘Clinical Nutrition in Intensive Care Medicine’). Aktuel Ernährungsmed 43, 341408.Google Scholar
Poolman, RW, Swiontkowski, MF, Fairbank, JCT, et al. (2009) Outcome instruments: rationale for their use. J Bone Joint Surg Am 91, Suppl. 3, 4149.CrossRefGoogle ScholarPubMed
Dowdy, DW, Eid, MP, Sedrakyan, A, et al. (2005) Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med 31, 611620.CrossRefGoogle ScholarPubMed
Needham, DM, Dowdy, DW, Mendez-Tellez, PA, et al. (2005) Studying outcomes of intensive care unit survivors: measuring exposures and outcomes. Intensive Care Med 31, 11531160.CrossRefGoogle ScholarPubMed
Hopkins, RO, Suchyta, MR, Kamdar, BB, et al. (2017) Instrumental activities of daily living after critical illness: a systematic review. Ann Am Thorac Soc 14, 13321343.CrossRefGoogle ScholarPubMed
Dinglas, VD, Faraone, LN & Needham, DM (2018) Understanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies. Curr Opin Crit Care 24, 401409.CrossRefGoogle ScholarPubMed
Parry, SM, Huang, M & Needham, DM (2017) Evaluating physical functioning in critical care: considerations for clinical practice and research. Crit Care 21, 249.CrossRefGoogle ScholarPubMed
Chen, F (2011) Influence of different routes of nutrition on the respiratory muscle strength and outcome of elderly patients in respiratory intensive care unit. Chin J Clin Nutr 19, 711.Google Scholar
Wu, W, Zhong, M, Zhu, D-M, et al. (2017) Effect of early full-calorie nutrition support following esophagectomy: a randomized controlled trial. JPEN J Parenter Enteral Nutr 41, 11461154.CrossRefGoogle ScholarPubMed
Devlin, JW, Skrobik, Y, Gélinas, C, et al. (2018) Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 46, e825e873.CrossRefGoogle ScholarPubMed
Berger, MM, Reintam-Blaser, A, Calder, PC, et al. (2019) Monitoring nutrition in the ICU. Clin Nutr 38, 584593.CrossRefGoogle ScholarPubMed

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Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial
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