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

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 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 hypothesize that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the intensive care unit (ICU). Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching calorie 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 randomized to either high (≥2.2 mg/kg/d) or low protein (≤1.2 mg/kg/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 to international guidelines in both groups. Efforts will be made to reach nutrition goals within 48–96 hours. 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.

Nutrition in the Intensive Care Unit—A Narrative Review

“…For a long time, the issue of “enteral or parenteral” has been controversially and quite emotionally discussed [ 19 , 20 ]. Two large multicenter randomized controlled trials (RCTs) did not show any significant difference in mortality, while EN was associated with a higher risk for gastrointestinal (GI) complications [ 21 , 22 ].…”

“…Thus, particularly in the patient’s first ICU week, EN alone may lead to macronutrient deficiency [ 29 , 30 , 31 ]. To avoid large cumulative energy and protein deficits, EN and PN may be combined, either early during the patient’s ICU course (combined EN+PN), or after several days once EN is proven to be insufficient or unfeasible (supplementary PN [SPN]) [ 19 ].…”

“…The optimal amount of energy is not yet agreed upon, as the evidence remains conflicting. What the targets should be and when they should be reached is still unclear, especially in the acute phase of critical illness, as targeting only caloric adequacy did not show statistically significant improvements in many studies [ 19 ].…”

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta‐analysis

“…Critically ill patients in the intensive care unit (ICU) are at significant risk of underfeeding, which is associated with poor clinical outcomes and increased risk of mortality. 1 In addition, critically ill patients have a high prevalence of risk factors for malnutrition, including age, weight loss, inflammation, severity of disease, and history of reduced food intake. 2 During the past decades until today, the optimal feeding route in critically ill patients has remained controversial.…”

Retrospective observational study evaluating zinc plasma level in patients undergoing thoracoabdominal aortic aneurysm repair and its correlation with outcome

“…Careful planning of the surgical approach is of utmost importance, and it requires diligent assessment of the clinical condition of the patient and the comorbidities. A reliable prognostic biomarker could be of high value in this context leading to improved preoperative care 2 . Next to familiar predisposition, age, gender and genetic factors, atherosclerosis is the most common causality for the pathogenesis of TAAA 3 .…”