Early or late parenteral nutrition: ASPEN vs. ESPEN

Expanded AbstractCitationCasaer MP, Mesotten D, Hermans G et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365: 506-517.BackgroundControversy exists about the timing of the initiation of parenteral nutrition (PN) in critically ill adults in whom caloric targets cannot be met by enteral nutrition (EN) alone.MethodsObjectiveTo compare early-initiation of PN (European guidelines) with late-initiation (American and Canadian guidelines) in adults who are receiving insufficient enteral nutrition in the intensive care unit (ICU).DesignProspective, randomized, controlled, parallel-group, multicenter clinical trial.SettingSeven multidisciplinary ICUs in Belgium.SubjectsAll adults admitted to participating ICUs with a nutritional risk score of 3 or more who did not meet any exclusion criteria.InterventionAfter enrollment, 2312 patients were randomized to receive PN 48 hours after ICU admission (early-initiation) and 2328 patients were randomized to receive PN on day 8 (late-initiation group). Both groups received early EN using a standardized protocol. PN was continued until EN met 80% of calorific goals, or when oral nutrition was resumed. It was restarted if enteral or oral feeding fell below 50% of calculated calorific needs.OutcomesPrimary end point was the duration of dependency on intensive care, defined as the number of intensive care days and time to discharge from the ICU.ResultsThe median stay in the ICU was one day shorter for the late-initiation group (3 v. 4; p = 0.02). The late-initiation group had a relative increase, of 6.3%, in the likelihood of being discharged earlier, and alive, from the ICU (hazard ratio 1.06; 95% confidence interval [CI] 1.00-1,13; p = 0.04). Rates of death in the ICU and survival at 90 days were similar between the two groups. The late-initiation group, as compared to the early-initiation group, had fewer ICU infections (22.8% v. 26.2%; p = 0.008), less days of renal replacement therapy (7 days (interquartile range [IQR] 3-16) v. 10 days (IQR 5-23); p = 0.008) and fewer patients requiring more than 2 days of mechanical ventilation (36.3% v. 40.2%; p = 0.006).ConclusionsLate-initiation of PN was associated with faster recovery and fewer complications, when compared with early-initiation.Trial Registration NCT00512122