[Effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis]

Association Between Energy Delivery and Outcomes in Adult Critically Ill Patients Diagnosed With or At Risk of Malnutrition: A Systematic Review and Meta-analysis With Trial Sequential Analysis

CONTEXT

There is a common belief that adult critically ill patients diagnosed with or at risk of malnutrition would benefit from higher energy delivery.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the association between energy delivery and mortality in adult critically ill patients diagnosed with or at risk of malnutrition.

DATA SOURCES

Databases including Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, and Google Scholar were searched from inception to November 20, 2023.

DATA EXTRACTION

Randomized controlled trials (RCTs) and observational studies that (1) included critically ill patients (aged ≥18 years) diagnosed with or at risk of malnutrition using validated tools following intensive care unit (ICU) admission, (2) had at least 20% energy difference between intervention and comparison groups, and (3) reported mortality outcomes were included. The random-effects model was used to pool the data.

DATA ANALYSIS

Two RCTs (4681 at-risk patients) and 5 observational studies (1587 at-risk patients [including 389 high-risk patients]) were included. The pooled mean energy delivered during the first 7-14 days of ICU admission in higher vs lower energy groups was 25.6 ± 5.9 vs 9.7 ± 5.6 kcal/kg per day (P = .004) in RCTs and 21.0 ± 5.2 vs 13.3 ± 5.3 kcal/kg per day (P < .001) in observational studies. No mortality difference was found between higher vs lower energy groups in at-risk patients (risk ratio: 0.99; 95% CI: 0.85, 1.17; P = .94) in RCTs and high-risk patients (adjusted odds ratio: 1.37; 95% CI: 0.43, 4.32; P = .59) in observational studies. Trial sequential analysis was performed and 31 232 patients were required to show a potential treatment effect.

CONCLUSION

These data do not support the prevailing belief that higher energy delivery improves survival in adult critically ill patients diagnosed with or at risk of malnutrition.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021274378.

Clinical Outcomes of Hypocaloric/Hyperproteic vs Normocaloric Enteral Feeding in the Acute Phase of Critical Illness among Patients Admitted in the Intensive Care Unit: A Systematic Review with Meta-analysis

Objectives

To examine the effect of hypocaloric/hyperproteic enteral feeding vs normocaloric feeding on the survival of critically ill patients in the acute phase in the intensive care unit (ICU).

Methodology

Randomized clinical trials utilizing hypocaloric, hyperproteic, and normocaloric enteral feeding in the ICU were searched using the following terms ((((critically ill) OR (intensive care) OR (mechanically ventilated)) AND ((low-calorie enteral feeding) OR (high-protein enteral feeding)))) in MEDLINE, PubMed, Scopus, and Google Scholar by two independent authors.

Results

There were no significant differences in hospital mortality [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.77, 1.31; p = 0.99, I 2 = 0%], days on mechanical ventilation (MD, -0.05; 95% CI, -0.37, 0.28; p = 0.78, I 2 = 0%), the odds of acquiring infectious complications (OR, 0.90; 95% CI, 0.71, 1.14; p = 0.38, I 2 = 0%), and the length of ICU stay (MD, 0.60; 95% CI, -2.39, 3.59; p = 0.69, I 2 = 96%). The length of hospital stay was significantly lower by 4.18 days in the normocaloric group (MD, 4.18; 95% CI, 2.50, 5.85; p < 0.00001, I 2 = 0%).

Conclusion

This meta-analysis showed no significant differences in mortality, infectious complications, days of mechanical ventilation, and ICU length of stay between groups. Findings on hospital length of stay were interpreted with caution due to the low quality of evidence and clinical heterogeneity.

How to cite this article

Permejo CC, Evangelista TJP. Clinical Outcomes of Hypocaloric/Hyperproteic vs Normocaloric Enteral Feeding in the Acute Phase of Critical Illness among Patients Admitted in the Intensive Care Unit: A Systematic Review with Meta-analysis. Indian J Crit Care Med 2024;28(11):1069-1083.

Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis

BACKGROUND

Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).

METHODS

Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.

RESULTS

Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%).

CONCLUSIONS

Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.

Current insights in ICU nutrition: tailored nutrition

PURPOSE OF REVIEW

To summarize recent research on critical care nutrition focusing on the optimal composition, timing, and monitoring of enteral feeding strategies for (post)-ICU patients. We provide new insights on energy and protein recommendations, feeding intolerance, and describe nutritional practices for coronavirus disease 2019 ICU patients.

RECENT FINDINGS

The use of indirect calorimetry to establish individual energy requirements for ICU patients is considered the gold standard. The limited research on optimal feeding targets in the early phase of critical illness suggests avoiding overfeeding. Protein provision based upon the absolute lean body mass is rational. Therefore, body composition measurements should be considered. Body impedance analysis and muscle ultrasound seem reliable, affordable, and accessible methods to assess body composition at the bedside. There is inadequate evidence to change our practice of continuous enteral feeding into intermittent feeding. Finally, severe acute respiratory syndrome coronavirus 2 patients are prone to underfeeding due to hypermetabolism and should be closely monitored.

SUMMARY

Nutritional therapy should be adapted to the patient's characteristics, diagnosis, and state of metabolism during ICU stay and convalescence. A personalized nutrition plan may prevent harmful over- or underfeeding and attenuate muscle loss. Despite novel insights, more research is warranted into tailored nutrition strategies during critical illness and convalescence.