Trial of the Route of Early Nutritional Support in Critically Ill Adults

To the Editor: In reporting the results of the CALORIES trial, Harvey and colleagues (Oct.30 issue) 1 indicate that the route of delivery of early nutritional support in the intensive care unit (ICU) does not alter patient outcomes.This message contradicts the widely held belief that the enteral route, which is more physiological, is to be preferred.However, we think that there is another implicit message: this study suggests that the role of nutritional support in the ICU should be reconsidered.Past evidence has led researchers to implement an overzealous approach to nutritional support in patients in the ICU.Given the results from the present study, we should probably take a step backward.There is still an unanswered question regarding which critically ill patients should receive early nutritional support.Some recent trials 1-3 suggest that such patients may be those with depleted body stores due to malnutrition rather than all those who are at nutritional risk as a consequence of critical illness.We believe that targeting early nutritional support to the right patients constitutes a key point that should be addressed.Once that question is addressed, we could focus again on timing, the route of delivery, protein and caloric targets, and nutrients that have putative pharmacologic activity.