Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

Goixart, L. Serviá; Grau-Carmona, Teodoro; Trujillano, Javier; Mor-Marco, Esther; Portugal-Rodriguez, E.; Lorencio, C.; Vera-Artázcoz, Paula; Macaya-Redin, Laura; Iglesias-Rodriguez, R.; Monge-Donaire, D.; Llorente-Ruiz, B.; Menor-Fernández, Eva M.; Lagran, Itziar Martínez-de; Escobar-Ortiz, Joan; Montserrat-Ortiz, Neus; Zapata-Rojas, Amalia; Bautista-Redondo, Iris; Cruz-Ramos, Ana; Diaz-Castellanos, Laura; Morales-Cifuentes, Miriam; Bono, Montserrat Plaza; Montejo-González, Juan Carlos; Temprano-Vazquez, Susana; Arjona-Diaz, Veronica; García-Fuentes, C.; Mudarra-Reche, C.; Orejana-Martin, Maria; López-Delgado, Juan Carlos; Lores-Obradors, Africa; Anguela-Calvet, Laura; Rio, Gloria Muñoz-del; Revelo-Esquibel, Pamela Alejandra; Alanez-Saavedra, Henry; Serra-Paya, Pau; Luna-Solis, Stephani Maria; Salinas-Canovas, Alvaro; Frutos-Seminario, Fernando De; Rodriguez-Queralto, Oriol; Gonzalez-Iglesias, Carlos; Zamora-Elson, Monica; Fuente-O'Connor, Eugenia de la; Arbeloa, C. Serón; Bueno-Vidales, Néstor; Martin-Luengo, Ana; Sánchez-Miralles, Ángel; Marmol-Peis, Enrique; Ruiz-Miralles, M.; Gonzalez-Sanz, Maria; Server-Martinez, Arantzazu; Vila-García, Belen; Lorencio-Cardenas, Carol; Flecha-Viguera, Raquel; Aldunate-Calvo, S.; Lasierra, J.L. Flordelís; Rio, Irene Jimenez-del; Mampaso-Recio, Jose Ramon; Rodriguez-Roldan, Jose Manuel; Gastaldo-Simeon, Rosa; Gimenez-Castellanos, Josefina; Fernández-Ortega, Juan Francisco; Martinez-Carmona, Juan Francisco; Lopez-Luque, Esther; Ortega-Ordiales, Ane; Crespo-Gomez, Monica; Ramirez-Montero, Victor; López-Garcı́a, Esther; Navarro-Lacalle, Arturo; Martínez-García, Pilar; Dominguez-Fernandez, Maria Inmaculada; Izura-Gomez, Marta; Hernandez-Duran, Susana; Bordeje-Laguna, M Luisa; Rovira-Valles, Yaiza; Philibert, Viridiana; Alcazar-Espin, Maravillas de las Nieves; Higon-Cañigral, Aurea; Calvo-Herranz, Enrique; Manzano-Moratinos, Diego; Andaluz‐Ojeda, David; Parra-Morais, Laura; Citores-Gonzalez, Rafael; García‐González, M. T.; Sanchez-Giron, Gloria Renedo; Navas-Moya, Elisabeth; Ferrer-Pereto, Carles; Lluch-Candal, Cristina; Ruiz-Izquierdo, Jessica; Castor-Bekari, Silvia; Leon-Cinto, Cristina; Zurbano, Itziar Martínez de Lagrán; Yébenes-Reyes, Juan Carlos; Nieto-Martino, Beatriz; Alonso, C. Vaquerizo; Almanza-López, Susana; Perez-Quesada, Sonia; Antón-Pascual, José Luis; Marín‐Corral, Judith; Sistachs-Baquedano, Maite; Hacer-Puig, Maria; Picornell-Noguera, Marina; Mateu‐Campos, Lidón; Martinez-Valero, Clara; Ortiz-Suñer, Andrea; Martinez-Diaz, María Cristina; Peña, Maria Trascasa Muñoz De La; Rodríguez-Serrano, Diego Aníbal; Fernandez-Salvatierra, Leticia; Barcelo-Castello, Mireia; Millan-Taratiel, Paula; Tejada-Artigas, A; Martinez-Arroyo, Ines; Araujo-Aguilar, Pilar; Fuster-Cabre, Maria; Andres-Gines, Laura; Soldado-Olmo, Sonia; MaMenor-Fernandez, Eva; Lage-Cendon, Lucas; Touceda-Bravo, Alberto; Sanchez-Ales, Laura; Almorin-Gonzalvez, Laura; Gero-Escapa, María; Martinez-Barrio, Esther; Ossa-Echeverri, Sergio

doi:10.1016/j.clnesp.2021.11.018

Cited by 13 publications

(8 citation statements)

References 35 publications

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“…This finding is in line with the recent update of the ASPEN guidelines suggesting a lower energy target, between 12 and 20 kcal/kg/d, during the first week of the ICU [ 11 ]. A similar observation was made by Servia-Goixart et al in a multicentre prospective study that included 639 critically ill patients, where a multivariable analysis adjusted for patient characteristics and severity showed that a higher mean energy intake was associated with mortality [ 51 ]. However, the authors reported a protective effect associated with the mean protein intake that did not match our results.…”

Section: Discussionsupporting

confidence: 64%

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

et al. 2023

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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.

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Section: Discussionsupporting

confidence: 64%

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

et al. 2023

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“…However, the latest large-scale study on practical nutritional management for ICU patients receiving artificial nutrition [ 20 ] reports that PN was initiated on the second to third day (38 h) of ICU admission, which was close to our study results of the third day of ICU admission. In addition, a multicenter observational study conducted recently [ 21 ] demonstrated the association between an increase in the amino acid dose and a decrease in mortality, although the relationship between the energy dose and mortality was small, which supports our study results.…”

Section: Discussionsupporting

confidence: 91%

Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database

Yasuda,

Horikoshi,

Kamoshita

et al. 2023

Nutrients

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Some critically ill patients completely rely on parenteral nutrition (PN), which often cannot provide sufficient energy/amino acids. We investigated the relationship between PN doses of energy/amino acids and clinical outcomes in a retrospective cohort study using a medical claims database (≥10.5 years, from Japan, and involving 20,773 adult intensive care unit (ICU) patients on mechanical ventilation and exclusively receiving PN). Study patients: >70 years old, 63.0%; male, 63.3%; and BMI < 22.5, 56.3%. Initiation of PN: third day of ICU admission. PN duration: 12 days. In-hospital mortality: 42.5%. Patients were divided into nine subgroups based on combinations of the mean daily doses received during ICU days 4–7: (1) energy (very low <10 kcal/kg/day; low ≥10, <20; and moderate ≥20); (2) amino acids (very low <0.3 g/kg/day; low ≥0.3, <0.6; and moderate ≥0.6). For each subgroup, adjusted odds ratios (AORs) of in-hospital mortality with 95% confidence intervals (CIs) were calculated by regression analysis. The highest odds of mortality among the nine subgroups was in the moderate calorie/very low amino acid (AOR = 2.25, 95% CI 1.76–2.87) and moderate calorie/low amino acid (AOR = 1.68, 95% CI 1.36–2.08) subgroups, meaning a significant increase in the odds of mortality by between 68% and 125% when an amino acid dose of <0.6 g/kg/day was prescribed during ICU days 4–7, even when ≥20 kcal/kg/day of calories was prescribed. In conclusion, PN-dependent critically ill patients may have better outcomes including in-hospital mortality when ≥0.6 g/kg/day of amino acids is prescribed.

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“…Moreover, barrier factors influencing enteral feeding include delay in the start of EN, low infusion rate, lack of standardized and failure to follow EN protocols, disruptions to EN (e.g., diagnostic testing, accidental pull-out of nasogastric tubing, gastrointestinal intolerance), insufficient dietitian coverage, and prioritize other aspects of patient care over nutrition ( 19–22 ). Despite these factors can be overcome by improving adherence to guidelines, there are some ICU patients not able to tolerate prescribed EN due to the occurrence of gastrointestinal (GI) complications (e.g., high gastric residual volumes, diarrhea, vomiting), leading to the lack of optimal nutrient provision ( 23 , 24 ). In consequence, this suboptimal EN intake may worsen nutritional status, which is associated with higher complications (e.g., infections) and higher mortality ( 25 ).…”

Section: Introductionmentioning

confidence: 99%

Factors associated with the need of parenteral nutrition in critically ill patients after the initiation of enteral nutrition therapy

Lopez-Delgado,

Servia-Goixart,

Grau-Carmona

et al. 2023

Front. Nutr.

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Background and aimsDespite enteral nutrition (EN) is the preferred route of nutrition in patients with critical illness, EN is not always able to provide optimal nutrient provision and parenteral nutrition (PN) is needed. This is strongly associated with gastrointestinal (GI) complications, a feature of gastrointestinal dysfunction and disease severity. The aim of the present study was to investigate factors associated with the need of PN after start of EN, together with the use and complications associated with EN.MethodsAdult patients admitted to 38 Spanish intensive care units (ICUs) between April and July 2018, who needed EN therapy were included in a prospective observational study. The characteristics of EN-treated patients and those who required PN after start EN were analyzed (i.e., clinical, laboratory and scores).ResultsOf a total of 443 patients, 43 (9.7%) received PN. One-third (29.3%) of patients presented GI complications, which were more frequent among those needing PN (26% vs. 60%, p = 0.001). No differences regarding mean energy and protein delivery were found between patients treated only with EN (n = 400) and those needing supplementary or total PN (n = 43). Abnormalities in lipid profile, blood proteins, and inflammatory markers, such as C-Reactive Protein, were shown in those patients needing PN. Sequential Organ Failure Assessment (SOFA) on ICU admission (Hazard ratio [HR]:1.161, 95% confidence interval [CI]:1.053–1.281, p = 0.003) and modified Nutrition Risk in Critically Ill (mNUTRIC) score (HR:1.311, 95% CI:1.098–1.565, p = 0.003) were higher among those who needed PN. In the multivariate analysis, higher SOFA score (HR:1.221, 95% CI:1.057–1.410, p = 0.007) and higher triglyceride levels on ICU admission (HR:1.004, 95% CI:1.001–1.007, p = 0.003) were associated with an increased risk for the need of PN, whereas higher albumin levels on ICU admission (HR:0.424, 95% CI:0.210–0.687, p = 0.016) was associated with lower need of PN.ConclusionA higher SOFA and nutrition-related laboratory parameters on ICU admission may be associated with the need of PN after starting EN therapy. This may be related with a higher occurrence of GI complications, a feature of GI dysfunction.Clinical trial registrationClinicalTrials.gov: NCT03634943.

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Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

Cited by 13 publications

References 35 publications

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

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

Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database

Factors associated with the need of parenteral nutrition in critically ill patients after the initiation of enteral nutrition therapy

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