Role of a short parenteral nutrition coupled with early enteral nutrition in the critically ill: a double-blind randomized study versus placebo

The critically ill, stressed, sometimes undernourished may develop an intestinal dysfunction which leads to multiple organ failure. Early enteral nutrition (EN) is usually recommended but may fail to provide an adequate amount of substrate. Parenteral nutrition (PN) is used in case of failure or contraindications of EN. However, the role of early EN coupled with PN has not been evaluated. We conducted a double-blind, randomized, placebo-controlled study to assess the influence of adjuvant PN (Vitrimix KV, Pharmacia Upjohn) and early EN on the improvement of nutritional parameters, morbidity and mortality in the critically ill, excepted after elective surgery. Statistical analysis, in intention to treat, used parametric tests (chi-2, ANOVA). Two groups of 60 patients (EN + placebo versus EN + PN) have been enrolled: 82 males, 38 females, admitted for medical (51%) or 33 non elective surgical emergencies (49%), SAPS2 (42 ± 14), who were either normonourished (59%), moderate (32%) or severe undernourished (9%). On follow-up from D0 to D4, we observed a significant improvement in nutritional proteins (transthyretine, RBP, transferrine) in the treated group, but not from D0 to D7. Mortality on D90 was identical in both groups (17 vs 18) as were the number of days of ventilatory support (11 vs 10), the cumulative number of nosocomial infections (29 vs 30), the length of stay in intensive care (16.9 vs 17.3), the OSF score measured on D0, D4, D7, D14 and D21 and the OMEGA score (263 vs 244). In contrast, we observed a significant reduction in the number of days of inotropic support (3.8 vs 4.4, P = 0.0001) and the length of hospital stay (31.2 vs 33.7, P = 0.0022). These results suggest that a short PN coupled with early EN is safe, synergistic and cost-effective. By immediately achieving a minimum energetic uptake, it may provide the time necessary for EN to restore intestinal function.