Early vs Late TPN in ICU Patients, Dr. Mjos

Bahar Mjos, DO
PGY-4 Resident at RCRMC who will do a Critical Care Fellowship at John's Hopkins University on graduation

Early versus Late Parenteral Nutrition in Critically Ill Adults

Prior data on early vs. late feeding in critically ill patients have been difficult to interpret. *A metaanalysis of 15 studies examining early enteral nutrition (containing 753 subjects) suggested that early enteral nutrition was associated with a significantly lower incidence of infections (RR 0.45; p =.00006) and a reduced hospital stay (mean 2.2 days; p =.004), however there were no significant differences in mortality* or noninfectious complications. The results of this meta-analysis must be interpreted with some caution because of the *significant heterogeneity between studies.*

More recently, seven Belgian ICUs performed *The Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) Study *, a prospective, randomized, controlled, parallel-group, multicenter investigator-initiated trial (partially funded by Baxter) in which 4640 nutritionally at-risk patients were randomized to early (within 48 hours) vs. late (at least 8 days) initiation of parenteral nutrition (2007 to 2010). While the early nutrition group clearly received more nutrition (both in terms of total energy and percentage of target), *the late group was discharged from the ICU one day earlier (p = 0.04), had a lower

incidence of hypoglycemia (p = 0.001), fewer infections (22.8% vs. 26.2%, p = 0.008), and a reduction in total healthcare costs of ~ $1600 (€1,110)*. Mortality was the same. Importantly, mean units of insulin and average glucose in the early and late groups were 58U/107 mg/dL and 31U/102 mg/dL, respectively.