Use of a concentrated enteral nutrition solution to increase calorie delivery to critically ill patients: a randomized, double-blind, clinical trial

Abstract

Background: Critically ill patients typically receive w60% of estimated calorie requirements. Objectives: We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes. Design: A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for $2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent.

Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis

“…Till day 14 or discharge from the ICURice et al, 2011 [15]Acute respiratory failureRCT20053 years in the intervention group, 54 years in the control group4426.9 in both groups100 %Trophic feeding (300 ± 149 kcal; 15.8 ± 11 % of caloric requirement) Protein intake: 0.13 g/kg/dayFull feeding (1418 ± 686 kcal; 74.8 ± 38.5 % of caloric requirement) Protein intake 0.66 g/kg/day6 daysRice et al, 2012 [16] a ARDS patients (medical, surgical and trauma)RCT100052 years in the intervention and control groups51APACHE III: 92 in the intervention group, 90 in the control group100 %Trophic feeding (400 kcal; 25 % of estimated non-protein caloric requirement)Full feeding (1300 kcal; 80 % of estimated caloric requirement)6 daysHuang et al, 2012 [64]MedicalRCT10170.9 years in the intervention group, 68.3 years in the control group7121.0 in the intervention group, 19.6 in the control group100 %Nasoduodenal feeding (1575 kcal; 90.4 % of target energy intake). Protein intake 93.2 ± 26.9 % of targetNasogastric feeding (1343 kcal; 76.2 % of target energy intake) Protein intake 78.6 ± 28.5 % of target21 daysReignier et al, 2013 [65] a Medical and surgicalRCT44961 years in the intervention group, 62 years in the control group70Baseline SOFA 8 for both groups100 %Not monitoring residual gastric volume (calorie deficit 319 kcal)Monitoring residual gastric volume (calorie deficit 509 kcal)Not clear Follow up for 90 daysRugeles et al, 2013 [23]Medical and surgicalRCT8053.3 years in the intervention group, 55.7 years in the control group5813.9 in the intervention group, 15.1 in the control groupHyperproteic hypocaloric enteral nutrition as 15 kcal/kg/day (756 kcal) Protein intake 1.4 g/kg/dayStandard nutritional regimen as 25 kcal/kg/day (921 kcal) Protein intake 0.76 g/kg/day7 daysPeake et al, 2014 [66]Mechanically ventilated (medical and surgical)RCT11256.4 years in the intervention group, 56.5 years in the control group7423 in the intervention group, 22 in the control group100 %Nutritional formula 1.5 kcal/ml (1832 ± 381 kcal; 27.3 ± 7.4 kcal/kg; 96.0 % of requirement) Protein intake 75 % of targetNutritional formula 1 kcal/ml (1259 ± 428 kcal; 19.0 ± 6.0 kcal/kg; 68.4 % of requirement) Protein intake 79 % of target10 daysCharles et al,...…”

“…All except two studies [57, 66] were un-blinded. Agreement between reviewers (kappa) on the tool elements was 0.774 (95 % CI 0.651–0.892; p  < 0.001).…”

“…Similarly, the association between lower compared with higher caloric intake and hospital mortality was not different between studies in which the mean age of patients was ≥65 years [59, 64] and those in which the mean age was <65 years [14–16, 22, 54, 55, 57, 58, 60–63, 65–69] (RR 0.994; 95 % CI 0.825–1.079; interaction test p  = 0.54), between studies in which the mean APACHE II score was <20 [22, 61, 62, 69], and those in which the mean APACHE II score was ≥20 [14, 15, 54, 55, 57, 59, 60, 63, 64, 66–68] (RR 0.977; 95 % CI 0.862–1.108; interaction test p  = 0.73), between studies [14–16, 22, 54, 68, 69] where the lower calorie group received <60 % of requirement and studies where the lower calorie group received ≥60 % [55, 57–67] (RR 0.946; 95 % CI 0.832–1.075; interaction test p  = 0.20) and between the studies in which the calorie difference between the two groups ≥20 % [15, 16, 22, 55, 66–69] and those with calorie difference <20 % [14, 58, 60, 62, 64] (RR 0.977; 95 % CI 0.860–1.110; interaction test p  = 0.97).…”

“…Given that the full enteral intake was reached in a few studies only, the benefit of this strategy remains unclear. While some studies calculated the calories from sources other than EN and PN, such as intravenous dextrose (including medications) and propofol [14, 55, 63, 66–68], this was not a consistent approach among all trials. Most included studies have used predictive equations rather than indirect calorimetry to estimate caloric intake.…”

Feeding adequacy among Critically Ill Patients in the Intensive Care Unit and Its Association with Clinical Outcomes: A Narrative Review

“…In year 2014, Peake et al 36 randomized patients to receive isonitrogenous enteral formula with caloric density 1.5 kcal/ml and 1.0 kcal/ml. It was found that the 1.5 kcal/ml group who received significantly more calories had trend toward improved duration of survival (p=0.057), although there was no difference on VFD to day-28 and ICU & hospital length of stay.…”