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Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study

Jean Reignier| Michael Darmon| Romain Sonneville| Anne-Laure Borel| Maité Garrouste-Orgeas| Stéphane Ruckly| Bertrand Souweine| Anne-Sylvie Dumenil| Hakim Haouache| Christophe Adrie| Laurent Argaud| Lilia Soufir| Guillaume Marcotte| Virginie Laurent| Dany Goldgran-Toledano| Christophe Clec’h| Carole Schwebel| Elie Azoulay| Jean-François Timsit
Original
Volume 41, Issue 5 / May , 2015

Pages 875 - 886

Abstract

Purpose

Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.

Methods

In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.

Results

We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81–0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66–0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89–1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00–1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27–8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78–0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00–1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.

Conclusion

In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.

Keywords

References

  1. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P (2003) Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 27:355–373
    • View reference on publisher's website
    • View reference on PubMed
  2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C (2006) ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 25:210–223
    • View reference on publisher's website
    • View reference on PubMed
  3. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G (2009) Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN J Parenter Enteral Nutr 33:277–316
    • View reference on publisher's website
    • View reference on PubMed
  4. Hurel D, Lefrant JY, Cano NJ, Ichai C, Preiser JC, Tamion F (2014) Nutrition artificielle en réanimation. Guidelines for nutrition support in critically ill patient. Réanimation 23:332–350
    • View reference on publisher's website
  5. Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK (2010) Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med 38:395–401
    • View reference on publisher's website
    • View reference on PubMed
  6. Elke G, Schadler D, Engel C, Bogatsch H, Frerichs I, Ragaller M, Scholz J, Brunkhorst FM, Loffler M, Reinhart K, Weiler N (2008) Current practice in nutritional support and its association with mortality in septic patients—results from a national, prospective, multicenter study. Crit Care Med 36:1762–1767
    • View reference on publisher's website
    • View reference on PubMed
  7. Blaser AR, Starkopf J, Kirsimagi U, Deane AM (2014) Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol Scand 58:914–922
    • View reference on publisher's website
    • View reference on PubMed
  8. Passier RH, Davies AR, Ridley E, McClure J, Murphy D, Scheinkestel CD (2013) Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Med 39:1221–1226
  9. Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G (2001) Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 29:1955–1961
    • View reference on publisher's website
    • View reference on PubMed
  10. Berger MM, Revelly JP, Cayeux MC, Chiolero RL (2005) Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass. Clin Nutr 24:124–132
    • View reference on publisher's website
    • View reference on PubMed
  11. 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
  12. Khalid I, Doshi P, DiGiovine B (2010) Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 19:261–268
    • View reference on publisher's website
    • View reference on PubMed
  13. Mutlu GM, Mutlu EA, Factor P (2001) GI complications in patients receiving mechanical ventilation. Chest 119:1222–1241
    • View reference on publisher's website
    • View reference on PubMed
  14. 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
  15. Ekpe K, Novara A, Mainardi JL, Fagon JY, Faisy C (2014) Methicillin-resistant Staphylococcus aureus bloodstream infections are associated with a higher energy deficit than other ICU-acquired bacteremia. Intensive Care Med 40:1878–1887
  16. Deane AM, Rayner CK, Keeshan A, Cvijanovic N, Marino Z, Nguyen NQ, Chia B, Summers MJ, Sim JA, van Beek T, Chapman MJ, Horowitz M, Young RL (2014) The effects of critical illness on intestinal glucose sensing, transporters, and absorption. Crit Care Med 42:57–65
    • View reference on publisher's website
    • View reference on PubMed
  17. Mancl EE, Muzevich KM (2013) Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr 37:641–651
    • View reference on publisher's website
    • View reference on PubMed
  18. Thibault R, Pichard C, Wernerman J, Bendjelid K (2011) Cardiogenic shock and nutrition: safe? Intensive Care Med 37:35–45
  19. Gatt M, MacFie J, Anderson AD, Howell G, Reddy BS, Suppiah A, Renwick I, Mitchell CJ (2009) Changes in superior mesenteric artery blood flow after oral, enteral, and parenteral feeding in humans. Crit Care Med 37:171–176
    • View reference on publisher's website
    • View reference on PubMed
  20. Rokyta R Jr, Matejovic M, Krouzecky A, Novak I (2003) Enteral nutrition and hepatosplanchnic region in critically ill patients—friends or foes? Physiol Res 52:31–37
    • View reference on PubMed
  21. Harvey SE, Parrott F, Harrison DA, Bear DE, Segaran E, Beale R, Bellingan G, Leonard R, Mythen MG, Rowan KM (2014) Trial of the route of early nutritional support in critically ill adults. N Engl J Med 371:1673–1684
    • View reference on publisher's website
    • View reference on PubMed
  22. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G (2011) Early versus late parenteral nutrition in critically ill adults. New Engl J Med 365:506–517
    • View reference on publisher's website
    • View reference on PubMed
  23. Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P (2012) Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 307:795–803
    • View reference on publisher's website
    • View reference on PubMed
  24. OUTCOMEREA Promotion et Developpement de la Recherche et de l’Enseignement en Reanimation (2014) http://www.outcomerea.org. Accessed 21 Feb 2014
  25. Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903
    • View reference on publisher's website
    • View reference on PubMed
  26. Cole SR, Hernan MA (2008) Constructing inverse probability weights for marginal structural models. Am J Epidemiol 168:656–664
    • View reference on publisher's website
    • View reference on PubMed
  27. Lin DY, Wei LJ, Ying Z (1993) Checking the Cox model with cumulative sums of martingale-based residuals. Biometrika 80:557–572
    • View reference on publisher's website
  28. Marik PE, Zaloga GP (2001) Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 29:2264–2270
    • View reference on publisher's website
    • View reference on PubMed
  29. Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR (2009) Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med 35:2018–2027
  30. Reignier J, Dimet J, Martin-Lefevre L, Bontemps F, Fiancette M, Clementi E, Lebert C, Renard B (2009) Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position. Clin Nutr 29(2):210–216
    • View reference on publisher's website
    • View reference on PubMed
  31. Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, Clavel M, Frat JP, Plantefeve G, Quenot JP, Lascarrou JB (2013) Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 309:249–256
    • View reference on publisher's website
    • View reference on PubMed
  32. Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, Thibault R, Pichard C (2013) Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 381:385–393
    • View reference on publisher's website
    • View reference on PubMed
  33. Doig GS, Simpson F (2013) Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a full economic analysis of a multicenter randomized controlled trial based on US costs. Clin Econ Outcomes Res 5:369–379
    • View reference on publisher's website
  34. Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O’Leary M, Solano T, Peake S (2013) Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 309:2130–2138
    • View reference on publisher's website
    • View reference on PubMed
  35. Ziegler TR (2011) Nutrition support in critical illness–bridging the evidence gap. New Eng J Med 365:562–564
    • View reference on publisher's website
    • View reference on PubMed
  36. Desai SV, McClave SA, Rice TW (2014) Nutrition in the ICU: an evidence-based approach. Chest 145:1148–1157
    • View reference on publisher's website
    • View reference on PubMed
  37. Peter JV, Moran JL, Phillips-Hughes J (2005) A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 33:213–220 (Discussion 260–211)
    • View reference on publisher's website
    • View reference on PubMed
  38. Simpson F, Doig GS (2005) Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 31:12–23
  39. Doig GS (2013) Parenteral versus enteral nutrition in the critically ill patient: additional sensitivity analysis supports benefit of early parenteral compared to delayed enteral nutrition. Intensive Care Med 39:981–982
  40. Singer P, Anbar R, Cohen J, Shapiro H, Shalita-Chesner M, Lev S, Grozovski E, Theilla M, Frishman S, Madar Z (2011) The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med 37:601–609
  41. Tsai JR, Chang WT, Sheu CC, Wu YJ, Sheu YH, Liu PL, Ker CG, Huang MC (2011) Inadequate energy delivery during early critical illness correlates with increased risk of mortality in patients who survive at least seven days: a retrospective study. Clin Nutr 30:209–214
    • View reference on publisher's website
    • View reference on PubMed
  42. Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNM, 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
  43. Casaer MP, Wilmer A, Hermans G, Wouters PJ, Mesotten D, Van den Berghe G (2013) Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med 187:247–255
    • View reference on publisher's website
    • View reference on PubMed

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