Grade B+ Recommendation
 Use of early PN when EN cannot be initiated within 24 hours of ICU admit
This review may be edited
Author info
Posted By: Gordon S. Doig and Fiona Simpson
E-Mail: Gordon.Doig@EvidenceBased.net fsimpson@doh.health.nsw.gov.au
Posted Date: 6 Jan 2005
Title: Use of early PN when EN cannot be initiated within 24 hours of ICU admit
PubMed Resource Link: Click here to repeat the Medline search used to develop this EBR.
 
Evidence-based Recommendation
Best level of evidence
Level II+ (Meta-analysis of Level II trials, no heterogeneity)
Target Population
Patients admitted to the ICU who are expected to stay at least 2 days.
Purpose
To reduce hospital discharge mortality by 15% (absolute).
Exclusion criteria
  • Burns (thermal injury) patients.
  • Patients with an absolute contraindication to PN (known allergy etc).
    • Recommendation
    If EN cannot be initiated within 24 h of ICU admssion or initial injury, PN should be started.
  • The Harris-Benedict formula (with a stress factor of 1.5 to 2) can be used to calculate metabolic needs however any approach that results in a target of approximately 25–35 kcal/kg and 1.0–1.5 g protein/kg is acceptable.
  • This EBR supports the use of a parenteral formula with or without lipids, but not enhanced with additional arginine, glutamine or other immune enhancing ingredients.
    • Potential harm
    The early use of PN may be associated with an 11% (absolute) increase in infectious complications however due to reporting in the constituent clinical trials, the clinical importance of this increase is questionable.
    Development Information
    Date EBR last updated
    6 Jan 2005
    Literature source and search terms
    Extensive Medline, EMBASE and hand search of reference lists.
    The PubMed resourse link (see top of EBR) provides an updated search of Medline for additional meta-analyses on this topic. Search terms:
    enteral nutrition
    parenteral nutrition
    systematic[sb]
    NB -Pubmed maps these terms to their respective MeSH headings. Systematic[sb] maps to a collection of search terms optimised to detect Systematic Reviews.
    Study selection
    All available recent meta-analyses were reviewed. In addition, all individual trials contributing to the meta-analyes and a published and validated evidence-based guideline were also retrieved and appraised.
    References
  • Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. (Level II+)
  • Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). (Level II cRCT)
  • Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. (Level II-)
  • Link to notes on Levels of evidence employed in this section.

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