title: Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial.
abstract: OBJECTIVE
  Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission.
  
  
  OBJECTIVE
  To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes.
  
  
  METHODS
  Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days.
  
  
  METHODS
  Random allocation to pragmatic standard care or early PN.
  
  
  METHODS
  Day-60 mortality; quality of life, infections, and body composition.
  
  
  RESULTS
  A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, -1.26%; 95% CI, -6.6 to 4.1; P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, -0.47; 95% CI, -0.82 to -0.11; P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, -0.16; 95% CI, -0.28 to -0.038; P = .01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, -0.13; 95% CI, -0.25 to -0.01; P = .04).
  
  
  CONCLUSIONS
  The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays.
  
  
  BACKGROUND
  anzctr.org.au Identifier: ACTRN012605000704695.
authors.affiliation: Northern Clinical School Intensive Care Research Unit, University of Sydney, Sydney, Australia. gdoig@med.usyd.edu.au
authors.forename: Gordon S
authors.initials: GS
authors.lastname: Doig
authors.forename: Fiona
authors.initials: F
authors.lastname: Simpson
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Sweetman
authors.forename: Simon R
authors.initials: SR
authors.lastname: Finfer
authors.forename: D Jamie
authors.initials: DJ
authors.lastname: Cooper
authors.forename: Philippa T
authors.initials: PT
authors.lastname: Heighes
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Davies
authors.forename: Michael
authors.initials: M
authors.lastname: O'Leary
authors.forename: Tom
authors.initials: T
authors.lastname: Solano
authors.forename: Sandra
authors.initials: S
authors.lastname: Peake
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000075202:Contraindications; D016638:Critical Illness / Q000401:mortality*; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010288:Parenteral Nutrition / Q000379:methods*; D010343:Patient Admission; D012121:Respiration, Artificial; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome