Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study

Abstract

Background Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort. Methods The ‘French-Speaking ICU Nutritional Survey’ (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses. Results During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23–2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00–1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01–1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98–1.11). Conclusions In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk. Trial registration ClinicalTrials.gov Identifier: NCT02599948. Retrospectively registered on November 5th 2015.

Highlights in the clinical nutrition literature: A critical appraisal of current research

“…Regarding the role of macronutrient intake in critically ill patients, the EFFORT 15 protein and NUTRIREA‐3 RCTs challenged current beliefs about the potential clinical relevance of high‐dose protein and energy targets. Supported by the observational findings of the FRANS and EuroPN study, 16,17 which both indicated potential harmful effects of an aggressive feeding regime in less severely ill patients and potential clinical benefits of a moderate and progressively increased nutrition strategy, both the EFFORT protein and NUTRIREA‐3 trials could not demonstrate a clinical benefit of reaching early nutrition targets. The EFFORT protein RCT did not show clinically meaningful effects of a high‐dose protein strategy while identifying potential harmful effects of high protein in patients with high degrees of organ injury, as reflected by the Sequential Organ Failure Assessment score and those with acute kidney injury.…”

Nutrition support for patients on mechanical circulatory support

“…The discussion about optimal energy intake timing and dosing has further been boosted by the results of recent studies such as EuroPN [39 ▪ ], FRANS [40 ▪ ], and NUTRIREA-3 [41 ▪ ], which predominantly focused on patients with septic shock, medical, and surgical admission type, respectively. In a nutshell, these trials emphasize that high energy supply and intense nutrition support in the very early phase of critical illness may be associated with worse outcome.…”

“…For critically ill patients in general, the optimal dosing and timing of protein supply is further discussed in the context of recently published trials such as EuroPN [39 ▪ ], FRANS [40 ▪ ], EFFORT Protein [48 ▪ ], and NUTRIREA-3 [41 ▪ ]. Again, in a nutshell, protein supply should be increased progressively throughout the ICU LOS to reach targets as recommended by current international critical care nutrition guidelines [20,21,28 ▪▪ ,29 ▪▪ ].…”

Measurement and estimation of energy in the critically ill

“…Recent clinical trials showed early aggressive NS resulted in potential harms including hyperglycemia, hepatic steatosis, and mortality [5 ▪▪ ,6,7]. On the other hand, energy deficits may result in negative nitrogen balance, increased length of hospital stay, infection, organ, failure, prolonged mechanical ventilation, and mortality [8–13].…”