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The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients

Pierre Singer| Ronit Anbar| Jonathan Cohen| Haim Shapiro| Michal Shalita-Chesner| Shaul Lev| Elad Grozovski| Miryam Theilla| Sigal Frishman| Zecharia Madar
Original
Volume 37, Issue 4 / April , 2011

Pages 601 - 609

Abstract

Purpose

To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients.

Methods

This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients (n = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n = 56), or (2) according to 25 kcal/kg/day (control group, n = 56). EN was supplemented with parenteral nutrition when required.

Results

The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p = 0.04) were increased.

Conclusions

In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.

Keywords

References

  1. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van Den Berghe G, Wernerman J, DGEM (German Society for Nutritional Medicine), Ebner C, Hartl W, Heymann C, Spies C, ESPEN (European Society for Parenteral and Enteral Nutrition) (2006) ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 25:210–223
    • View reference on publisher's website
    • View reference on PubMed
  2. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P, Canadian critical care clinical practice guidelines committee (2003) Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN 27:355–373
  3. Doig GS (2005) Evidence-based guidelines for nutritional support of the critically ill: results of a bi-national guideline development conference. Carlton (Australia): Australian and New Zealand Intensive Care Society (ANZICS). Available online at: http://www.guidelines.gov. Accessed 4 Aug 2009
  4. Kreymann KG (2008) Early nutrition support in critical care: a European perspective. Curr Opin Clin Nutr Met Care 11:156–159
    • View reference on publisher's website
  5. Berger MM, Chioléro RL (2007) Hypocaloric feeding: pros and cons. Curr Opin Crit Care 13:180–186
    • View reference on publisher's website
    • View reference on PubMed
  6. Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNMC, Delarue J, Berger MM (2005) Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 24:502–509
    • View reference on publisher's website
    • View reference on PubMed
  7. Rubinson L, Diette GB, Song X, Brower RG, Krishnan JA (2004) Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit. Crit Care Med 32:350–357
    • View reference on publisher's website
    • View reference on PubMed
  8. Dvir D, Cohen J, Singer P (2005) Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr 25:37–44
    • View reference on publisher's website
  9. Engel JM, Muhling J, Junger A, Engel JM, Muhling J, Junger A (2003) Enteral nutrition practice in a surgical intensive care unit: what proportion of energy expenditure is delivered enterally? Clin Nutr 22:187–192
    • View reference on publisher's website
    • View reference on PubMed
  10. Marshall AP, West SH (2006) Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding? Int Crit Care Nurs 22:95–105
    • View reference on publisher's website
  11. McClave SA, Sexton LK, Spain DA, Adams JL, Owens NA, Sullins MB, Blandford BS, Snider HL (1999) Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med 27:1252–1256
    • View reference on publisher's website
    • View reference on PubMed
  12. Singer P, Cohen J (2003) Clinical applications of indirect calorimetry in the intensive care setting. In: Yearbook of Intensive Care and Emergency Medicine. Springer, USA, 912–919
  13. Hunter DC, Jaksic T, Lewis D, Benotti PN, Blackburn GL, Bistrian BR (1988) Resting energy expenditure in the critically ill: estimations versus measurement. Br J Surg 75:875–878
    • View reference on publisher's website
    • View reference on PubMed
  14. Cerra FB, Benitez MR, Blackburn GL, Irwin RS, Jeejeebhoy K, Katz DP, Pingleton SK, Pomposelli J, Rombeau JL, Shronts E, Wolfe RR, Zaloga GP (1997) Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. Chest 111:769–778
    • View reference on publisher's website
    • View reference on PubMed
  15. Frankenfield DC, Rowe WA, Smith JS, Cooney RN (2003) Validation of several established equations for resting metabolic rate in obese and nonobese people. J Am Diet Assoc 103:1152–1159
    • View reference on publisher's website
    • View reference on PubMed
  16. Calandra T, Cohen J, International Sepsis Forum definition of infection in the ICU consensus conference (2005) The International Sepsis Forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med 33:1538–1548
    • View reference on publisher's website
    • View reference on PubMed
  17. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on publisher's website
    • View reference on PubMed
  18. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710
  19. Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ, Southwestern Ontario Critical Care Research Network (2004) Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 170:197–204
    • View reference on PubMed
  20. Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, Dobb G, Nutrition Guidelines Investigators of the ANZICS Clinical Trials Group (2008) Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA 300:2731–2741
    • View reference on publisher's website
    • View reference on PubMed
  21. Pichard C, Kreymann GK, Weimann A, Herrmann HJ, Schneider H (2008) Early energy supply decreases ICU and hospital mortality: a multicenter study in a cohort of 1,209 patients. Clin Nut Supp 3:0015
  22. Strack van Schijndel RJM, Weijs PJM, Koopmans RH, Sauerwein HP, Beishuizen A, Girbes ARJ (2009) Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care 13:R132
    • View reference on publisher's website
    • View reference on PubMed
  23. Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, Heyland DK (2009) The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 35:1728–1737
  24. Wernerman J (2008) Paradigm of early parenteral nutrition support in combination with insufficient enteral nutrition. Curr Opin Clin Nutr Metab Care 11:160–163
    • View reference on publisher's website
    • View reference on PubMed
  25. Heidegger CP, Darmon P, Pichard C (2008) Enteral vs parenteral nutrition for the critically ill patient: a combined support should be preferred. Curr Opin Crit Care 14:408–414
    • View reference on publisher's website
    • View reference on PubMed
  26. Simpson F, Doig GS (2005) Parenteral vs enteral nutrition in the critically ill patients: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 31:12–23
  27. Dissanaike S, Shelton M, Warner K, O’Keefe GE (2007) The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition. Crit Care 11:R114
    • View reference on publisher's website
    • View reference on PubMed
  28. Grau T, Bonet A (2009) Caloric intake and liver dysfunction in critically ill patients. Curr Opin Clin Nutr Metab Care 12:175–179
    • View reference on publisher's website
    • View reference on PubMed
  29. McClave SA (1997) The consequences of overfeeding and underfeeding. J Resp Care Pract 6:57–64
  30. Ward NS, Snyder JE, Ross S, Haze D, Levy MM (2004) Comparison of a commercially available clinical information system with other methods of measuring critical care outcomes data. J Crit Care 19:10–15
    • View reference on publisher's website
    • View reference on PubMed
  31. Holcomb BW, Wheeler AL, Ely EW (2001) New ways to reduce unnecessary variations and improve outcome in the intensive care unit. Curr Opin Crit Care 7:304–311
    • View reference on publisher's website
    • View reference on PubMed
  32. Berger MM, Revelly JP, Wasserfallen JB, Schmid A, Bouvry S, Cayeux MC, Musset M, Maravic P, Chiolero RL (2006) Impact of a computerized information system on quality of nutritional support in the ICU. Nutrition 22:221–229
    • View reference on publisher's website
    • View reference on PubMed
  33. Artinian V, Krayem H, DiGiovine B (2006) Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 129:960–967
    • View reference on publisher's website
    • View reference on PubMed

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