Support therapy in the adult critically ill patient: Updated guideline by ASPEN
USA: The American Society for Parenteral and Enteral Nutrition (ASPEN) has released an updated guideline on the provision of nutrition support therapy in the adult critically ill patient. The guideline, published in the Journal of Parenteral and Enteral Nutrition, addresses five foundational questions central to critical care nutrition support.
Most critically ill patients are not able to support their own nutrition so a artificial nutrition is often provided. The purpose of the guideline is to summarize the evidence within nutrition support to guide practitioners in their provision of artificial nutrition to critically ill patients and provide/update recommendations for several foundational questions that are central to the provision of nutrition support for most critically ill adult patients.
Question 1. In adult critically ill patients, does provision of higher vs lower energy intake impact clinical outcomes?
Recommendation: No significant difference in clinical outcomes was found between patients with higher vs lower levels of energy intake. We suggest feeding between 12 and 25 kcal/kg (ie, the range of mean energy intakes examined) in the first 7–10 days of ICU stay.
Question 2. In adult critically ill patients, does provision of higher as compared with lower protein intake impact clinical outcomes?
Recommendation: There was no difference in clinical outcomes in the relatively limited data. Because of a paucity of trials with high-quality evidence, we cannot make a new recommendation at this time beyond the 2016 guideline suggestion for 1.2–2.0 g/kg/day.
Question 3: In adult critically ill patients who are candidates for EN, does similar energy intake by PN vs EN as the primary feeding modality in the first week of critical illness impact clinical outcomes?
Recommendation: There was no significant difference in clinical outcomes between early exclusive PN and EN during the first week of critical illness. As PN was not found to be superior to EN and no differences in harm were identified, we recommend that either PN or EN is acceptable.
Question 4. In adult critically ill patients receiving early EN, does provision of SPN to meet energy targets vs no SPN during the first week of critical illness impact clinical outcomes?
Recommendation: There was no significant difference in clinical outcomes. Based on findings of no clinically important benefit in providing SPN early in the ICU admission, we recommend not initiating SPN prior to day 7 of ICU admission.
Question 5A. In adult critically ill patients receiving PN, does provision of mixed-oil ILEs (ie, medium-chain triglycerides, olive oil, FO, mixtures of oils), as compared with 100% SO ILE, impact clinical outcomes?
Recommendation: Owing to limited statistically or clinically significant differences in key outcomes, we suggest that either mixed-oil ILE or 100% SO ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission.
Question 5B. In adult critically ill patients receiving PN, does provision of FO-containing ILE, as compared with non–FO-containing ILE, impact clinical outcomes?
Recommendation: Because there was only one outcome with a significant difference that was not supported by data covering the other key downstream outcomes, we suggest that either FO- or non–FO-containing ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission.
Other questions
Though we initially searched for trials related to eight questions, RCTs meeting inclusion and exclusion criteria were only found to answer the five above questions developed by the authors. Adequate data were not found to address three important critical care nutrition questions identified at the outset by the author team:
1. In adult critically ill patients, do higher nutrition risk scores predict worse outcomes than BMI alone as the indicator of nutrition risk? Our searches yielded no RCTs comparing clinical outcomes based on groups of patients randomized according to either the Nutrition Risk in the Critically Ill (NUTRIC) score or the Nutrition Risk Screening 2002 (NRS2002) tool relative to BMI. The evidence supporting each of these approaches to nutrition assessment to date has been based largely on retrospective observational studies, a level of evidence excluded in this current guideline.
2. In adult critically ill patients, do immune-enhancing nutrients provide better outcomes than standard care? This broad question encompasses differing numbers of nutrients (glutamine; ω-3 fatty acids; individual vitamins, minerals, and trace elements) that are compared at widely variable doses. Because this current guideline was focused on providing answers to foundational practice questions in the general critically ill population, the decision was made to construct a future author panel to deal with this question as its own guideline.
3. In adult critically ill patients, do probiotics provide better outcomes than standard care? The RCTs that were identified by our search strategy reported on a variety of probiotic preparations and doses and did not report consistently on the outcomes included in this guideline.
To conclude, no differences in clinical outcomes were identified among numerous nutrition interventions, including higher energy or protein intake, isocaloric PN or EN, SPN, or different ILEs.
"As more consistent critical care nutrition support data become available, more precise recommendations will be possible," the authors wrote. "In the meantime, clinical judgment and close monitoring are needed."
Reference:
Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition," was published in the Journal of Parenteral and Enteral Nutrition.
