Impact of SPN on Infection Rate, Duration of Mechanical Ventilation & Rehabilitation in ICU Patients
Impact of Supplemental Parenteral Nutrition (SPN) on Infection Rate, Duration of Mechanical Ventilation and Rehabilitation in Intensive Care Unit Patients: A Quality Control Program for the Implementing of New Nutrition Guidelines
Rationale: Enteral nutrition (EN) in the intensive care (ICU) patients is recommended as a
standard of care. However, EN alone is often associated with insufficient energy intakes and
increased complication rates. Recently the investigators proposed to decrease this deficit
by combining EN and supplemental parenteral nutrition (SPN) whenever EN is insufficient (<
60% of their predicted energy needs) at day 3 after admission in the ICU.
Objective: This study aims at: a/ investigating if the delivery of optimal nutrition support
(100 % of predicted energy targets) in ICU patients by the combined administration of SPN
and EN optimizes their clinical outcome; b/ implementing the new ICU nutrition guidelines.
Study design: Prospective, controlled, randomized clinical study.
Study site: Service of Intensive Care, Geneva University Hospital.
Patient population: 220 ICU patients to be included: expected length of stay > 5 days,
expected survival > 7 days, no contraindication to EN, obtained informed consent from
themselves or their next of keen.
Exclusion criteria: refusal of consent, age < 18 years, short bowel syndrome, significant
persistent gastrointestinal dysfunction with ileus, high output proximal fistula (> 1,5
liter/d), patients receiving PN.
Nutrition: At day 3 after admission, if energy input is < 60%; patients are randomized into
either the "Control group" (EN alone) or the "SPN group" (EN + PN) to reach 100% of their
predicted energy needs. Tight glycaemic control (target 6.0 to 8.3 mmol/l) to be achieved
according to our local practice by insulin administration.
- Primary: nosocomial infections (CDC criteria)
- Secondary: Mechanical ventilation duration, ICU and hospital length of stay, antibiotic
free days, ICU complications (extra-renal epuration, neurological, cardiac and
respiratory complications), energy and protein balance, 28 days clinical outcome.
Nutritional support of the intensive care (ICU) patients is recommended as a standard of
care. It is also strongly recommended to start enteral feeding as soon as possible whenever
the gastrointestinal tract is functioning (1). However, studies have repeatedly shown that
with enteral support alone, insufficient energy and protein intakes often occur (2). The
resulting energy and protein deficit is associated with an increased complication rate in
ICU patients (3-5). Recently we proposed to decrease this deficit by promoting a combined
nutrition support by enteral nutrition (EN) and supplemental parenteral nutrition (SPN)
whenever EN is insufficient (6).
Contrary to former beliefs, recent meta-analyses show that parenteral nutrition (PN) does
not carry excess mortality (7, 8). These reports convey a concept that is a major
break-through in current routine of nutritional support in ICU patients by promoting a much
wider use of PN. SPN could be the optimal modality to provide the calculated energy targets
if this cannot be reached by EN alone. To improve ICU patient's outcome and minimise
complications, we propose to implement feeding protocols which combine both EN and PN, when
EN is insufficient to cover more than 60% of caloric needs at day 4 to reach 100% of the
energy targets by adding PN from day 4 (6).
The administration of SPN, in ICU patients receiving < 60% of targeted energy needs by EN
alone, has a positive impact on their clinical outcome by optimising their nutritional
support (reduced infectious complications rate, mechanical ventilation days, duration of ICU
and hospital length of stay and rehabilitation).
The aim of the present study is to investigate if the delivery of optimal nutrition support
(100 % of predicted energy targets) in ICU patients achieved with the combined
administration of SPN and EN optimizes their clinical outcome.
Critically ill, nutrition, randomised controlled clinical trial, human, adult, Supplemental parenteral nutrition
University Hospital, Geneva
University Hospital, Geneva, University of Lausanne Hospitals
Heidegger CP, Romand JA, Treggiari MM, Pichard C. Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient? Intensive Care Med. 2007 Jun;33(6):963-9.