3.3.4.2 OTHER CLINICAL OUTCOMES
CRITICAL ILLNESS AND SURGERY
Timely adminstration of PN in ICU patients with contraindications to early ETF reduced the requirement for mechanical ventilation and number of days with clinically significant coagulation failure compared with standard care
- In a large multicentre single-blind RCT evaluating the nutritional and clinical benefits of early PN (within 24 hours of admission) in critically ill adults with a short-term relative contradiction to early ETF, patients randomised to early PN required fewer days of mechanical ventilation than those receiving standard care (usual clinical practice in individual ICUs) (7.73 vs 7.26 days per 10 patient–ICU days; risk difference 0.47; 95% CI −0.82 to −0.11; p = 0.01) and had fewer days with clinically significant coagulation failure (−0.34 days per 10 patient–ICU days; 95% CI −0.57 to −0.08; p = 0.01).142
Timely initiation of SPN (ETF + PN) may optimize clinical outcomes in critically ill patients
- Heidegger and colleagues (2013) conducted an RCT (the ‘Swiss SPN study’) to determine whether delivering 100% of energy targets with SPN (ETF + PN) on days 4–8 of ICU stay would optimise clinical outcomes.140 The study involved 305 medical and surgical ICU patients who received <60% of their energy target on ETF alone on day 3 of ICU admission; patients were randomised to ETF alone or SPN. Initiation of SPN resulted in a reduced risk for hospital-acquired infection (HR 0.65; 95% CI 0.43–0.97; p = 0.0338), fewer days of antibiotics (p = 0.001), and earlier weaning from mechanical ventilation for patients without hospital-acquired infection (p = 0.0028).
- In the prospective RCT carried out by Fan and colleagues comparing the effects of timely SPN (ETF + PN), ETF alone, and PN alone on immune function, nutritional status, complications, and clinical outcomes in patients undergoing surgery for severe traumatic brain injury, SPN was associated with significantly shorter stay in the ICU (p < 0.05 and p < 0.01), number of patients receiving assisted mechanical ventilation (p < 0.05 and P < 0.01) and its duration (p < 0.05 and p < 0.01) than those receiving ETF or PN alone.
Patients receiving TPN after liver transplantation had improved respiratory muscle function, reducing the need for ventilatory support
- Reilly and colleagues (1990) conducted an RCT to evaluate the impact of perioperative TPN versus no nutritional support on ICU outcomes in malnourished (hypoalbuminemic) patients undergoing liver transplantation. Twenty-eight patients were randomised to no nutrition support (n = 10), TPN with standard amino acids (n = 8), or TPN with added branched-chain amino acids (n = 10) for 7 days post-transplant. Patients who did not receive TPN had significantly longer ICU stay (p < 0.05). Furthermore, both TPN groups achieved respiratory independence earlier than the group receiving no nutrition support, although the difference was not statistically significant. Hospital costs were also lower for patients who received TPN.223 Although conducted some years ago, this study is included in current ASPEN and ESPEN guidelines.8, 158