Association between caloric adequacy and short-term clinical outcomes in critically ill patients using a weight-based equation: Secondary analysis of a cluster-randomized controlled trial

Abstract

BackgroundThere is controversy over the optimal energy delivery in intensive care units (ICUs). In this study, we aimed to evaluate the association between different caloric adequacy assessed by a weight-based equation and short-term clinical outcomes in a cohort of critically ill patients.MethodsThis is a secondary analysis of a cluster-randomized controlled trial (N = 2,772). The energy requirement was estimated as 25 kcal/kg of body weight. The study subjects were divided into three groups according to their caloric adequacy as calculated by the mean energy delivered from days 3 to 7 of enrollment divided by the estimated energy requirements: (1) received < 70% of energy requirement (hypocaloric), (2) received 70–100% of energy requirement (normocaloric), and (3) received > 100% of energy requirement (hypercaloric). Cox proportional hazards models were used to analyze the association between caloric adequacy and 28-day mortality and time to discharge alive from the ICU.ResultsA total of 1,694 patients were included. Compared with normocaloric feeding, hypocaloric feeding significantly increased the risk of 28-day mortality (hazard ratio [HR] = 1.590, 95% confidence interval [CI]: 1.162–2.176, p = 0.004), while hypercaloric feeding did not. After controlling for potential confounders, the association remained valid (adjusted HR = 1.596, 95% CI: 1.150–2.215, p = 0.005). The caloric adequacy was not associated with time to discharge alive from the ICU in the unadjusted and the adjusted models.ConclusionEnergy delivery below 70% of the estimated energy requirement during days 3–7 of critical illness is associated with 28-day mortality.Clinical trial registration[https://www.isrctn.com/ISRCTN12233792], identifier [ISRCTN12233792].

What the clinician needs to know about medical nutrition therapy in critically ill patients in 2023: A narrative review

“…20 A secondary analysis of a cluster-randomized controlled trial including 2772 critically ill patients showed that hypocaloric feeding (energy intake <70% of calculated EE) compared with energy-balanced feeding during days 3-7 after ICU admission was associated with increased 28-day mortality. 21 These results strengthen the evidence for a energy intake of 80%-100% after day 3, as suggested by the ESPEN guideline. 2 Another substudy of The Augmented Versus Routine Approach to Giving Energy Trial (TARGET) showed that augmented energy delivery (1.5 kcal/ml or 1.0 kcal/ml enteral formulas) was not associated with attenuated muscle loss or recovery of strength or function 6 months after ICU discharge.…”

“…A secondary analysis of a cluster‐randomized controlled trial including 2772 critically ill patients showed that hypocaloric feeding (energy intake <70% of calculated EE) compared with energy‐balanced feeding during days 3–7 after ICU admission was associated with increased 28‐day mortality 21 . These results strengthen the evidence for a energy intake of 80%–100% after day 3, as suggested by the ESPEN guideline 2 .…”

Nutrition in the intensive care unit: from the acute phase to beyond

“…Observational studies have associated a cumulative protein and energy deficit with impaired outcome of critical illness [2,3,11]. However, the results of these studies might also be explained by feeding intolerance as a marker of severity of illness [2,3,12]. In the last decade, several large RCTs have addressed the timing, route and dosage of medical nutrition therapy in critically ill patients.…”

Immunmodulation durch Ernährung bei kritisch kranken Patienten

“…Tatsächlich leidet ein Großteil der intensivmedizinischen Patienten unter einer Mangelernährung [113]. Diese korreliert mit einem verlängerten Aufenthalt auf der Intensivstation, protrahierter maschineller Beatmung, vermehrten Infektionen und einer erhöhten Mortalität [55, 123,159,201]. Eine adäquate Erfassung des Ernährungsstatus, die Identifikation etwaiger Risiken einer Mangelernährung, eine sinnvolle diagnostische Überwachung und kontrollierte Ernährungstherapie sind also insbesondere aufgrund des per definitionem kritischen Ernährungszustandes von intensivmedizinischen Patienten von fundamentaler Bedeutung und für das Outcome des kritisch kranken Patienten essenziell.…”