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Landais M, Nay MA, Auchabie J, Hubert N, Frerou A, Yehia A, Mercat A, Jonas M, Martino F, Moriconi M, Courte A, Robert-Edan V, Conia A, Bavozet F, Egreteau PY, Bruel C, Renault A, Huet O, Feller M, Chudeau N, Ferrandiere M, Rebion A, Robert A, Giraudeau B, Reignier J, Thille AW, Tavernier E, Ehrmann S, DEMISELLE J, SASSI T, DELALE C, GROUILLE J, DE TINTENIAC A, GESLAIN M, FLOCH H, BAILLY P, BODENES L, PRAT G, KALFON P, BADRE G, JOURDAIN C, MAZZONI T, LE MEUR A, FAYOLLE PM, HERON A, MAILLET O, LEDOUX N, ROLLE A, RICHARD R, VALETTE M, AZAIS MA, POUPLET C, BACHOUMAS K, CALLAHAN JC, GUITTON C, DARREAU C, LEFEVRE M, LELOUP G, BERTEL M, DAUVERGNE J, PACAUD L, LAKHAL K, MARTIN M, GARRET C, LASCARROU JB, BOULAIN T, MATHONNET A, MULLER G, PHILIPPART F, TRAN M, FOURNIER J, FRAT JP, COUDROY R, CHATELLIER D, HALLEY G, GACOUIN A, HOFF J, VASTAL S, TELLIER AC, BARBAZ M, SALMON GANDONNIERE C, MERCIER E, DARWICHE W. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: an open-label, cluster-randomised, parallel-group, non-inferiority trial. Lancet Respir Med 2023; 11:319-328. [PMID: 36693402 DOI: 10.1016/s2213-2600(22)00413-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Fasting is frequently imposed before extubation in patients in intensive care units, with the aim to reduce risk of aspiration. This unevaluated practice might delay extubation, increase workload, and reduce caloric intake. We aimed to compare continued enteral nutrition until extubation with fasting before extubation in patients in the intensive care unit. METHODS We conducted an open-label, cluster-randomised, parallel-group, non-inferiority trial in 22 intensive care units in France. Patients aged 18 years or older were eligible for enrolment if they had received invasive mechanical ventilation for at least 48 h in the intensive care unit and received prepyloric enteral nutrition for at least 24 h at the time of extubation decision. Centres were randomly assigned (1:1) to continued enteral nutrition until extubation or 6-h fasting with concomitant gastric suctioning before extubation, to be applied for all patients within the unit. Masking was not possible because of the nature of the trial. The primary outcome was extubation failure (composite criteria of reintubation or death) within 7 days after extubation, assessed in both the intention-to-treat and per-protocol populations. The non-inferiority margin was set at 10%. Pneumonia within 14 days of extubation was a key secondary endpoint. This trial is now complete and is registered with ClinicalTrials.gov, NCT03335345. FINDINGS Between April 1, 2018, and Oct 31, 2019, 7056 patients receiving enteral nutrition and mechanical ventilation were admitted to the intensive care units and 4198 were assessed for eligibility. 1130 patients were enrolled and included in the intention-to-treat population and 1008 were included in the per-protocol population. In the intention-to-treat population, extubation failure occurred in 106 (17·2%) of 617 patients assigned to receive continued enteral nutrition until extubation versus 90 (17·5%) of 513 assigned to fasting, meeting the a priori defined non-inferiority criterion (absolute difference -0·4%, 95% CI -5·2 to 4·5). In the per-protocol population, extubation failure occurred in 101 (17·0%) of 595 patients assigned to receive continued enteral nutrition versus 74 (17·9%) of 413 assigned to fasting (absolute difference -0·9%, 95% CI -5·6 to 3·7). Pneumonia within 14 days of extubation occurred in ten (1·6%) patients assigned to receive continued enteral nutrition and 13 (2·5%) assigned to fasting (rate ratio 0·77, 95% CI 0·22 to 2·69). INTERPRETATION Continued enteral nutrition until extubation in critically ill patients in the intensive care unit was non-inferior to a 6-h fasting maximum gastric vacuity strategy comprising continuous gastric tube suctioning, in terms of extubation failure within 7 days (a patient-centred outcome), and thus represents a potential alternative in this population. FUNDING French Ministry of Health. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Mickaël Landais
- Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | - Mai-Anh Nay
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans Cedex 2, France
| | | | - Noemie Hubert
- Réanimation de Chirurgie Cardiaque, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Aurélien Frerou
- Médecine Intensive Réanimation et Maladies Infectieuses, CHU de Rennes, Rennes, France
| | - Aihem Yehia
- Médecine Intensive Réanimation, CHD Vendée, La Roche sur Yon, France
| | - Alain Mercat
- Médecine Intensive Réanimation, CHU Angers, France
| | - Maud Jonas
- Médecine Intensive Réanimation, CH de Saint-Nazaire, Saint-Nazaire, France
| | | | | | - Anne Courte
- Réanimation, CH de Saint-Brieuc, Saint-Brieuc, France
| | | | | | | | | | - Cédric Bruel
- Médecine Intensive Réanimation, Hôpital Saint Joseph, Paris, France
| | - Anne Renault
- Médecine Intensive Réanimation, CHU de Brest, Brest, France
| | - Olivier Huet
- Réanimation Chirurgicale, CHU de Brest, Brest, France
| | - Marc Feller
- Réanimation Médico-Chirurgicale, CH de Blois, Blois, France
| | - Nicolas Chudeau
- Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | | | - Anne Rebion
- Clinical Investigation Centre, INSERM 1415, CHRU Tours, Tours, France
| | - Alain Robert
- Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | - Bruno Giraudeau
- Universities of Tours and Nantes, INSERM 1246-SPHERE, Tours, France; Clinical Investigation Centre, INSERM 1415, CHRU Tours, Tours, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, INSERM CIC 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Elsa Tavernier
- Universities of Tours and Nantes, INSERM 1246-SPHERE, Tours, France; Clinical Investigation Centre, INSERM 1415, CHRU Tours, Tours, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CHRU Tours, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France; INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, Tours, France; Université de Tours, Tours, France.
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