title: Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study.
abstract: OBJECTIVE
  Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.
  
  
  METHODS
  In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.
  
  
  RESULTS
  We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.
  
  
  CONCLUSIONS
  In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.
authors: Medical-Surgical Intensive Care Unit, CHD de la Vendée, La Roche-sur-Yon, France, jean.reignier@chd-vendee.fr.
authors: Jean
authors: J
authors: Reignier
authors: Michael
authors: M
authors: Darmon
authors: Romain
authors: R
authors: Sonneville
authors: Anne-Laure
authors: AL
authors: Borel
authors: Maité
authors: M
authors: Garrouste-Orgeas
authors: Stéphane
authors: S
authors: Ruckly
authors: Bertrand
authors: B
authors: Souweine
authors: Anne-Sylvie
authors: AS
authors: Dumenil
authors: Hakim
authors: H
authors: Haouache
authors: Christophe
authors: C
authors: Adrie
authors: Laurent
authors: L
authors: Argaud
authors: Lilia
authors: L
authors: Soufir
authors: Guillaume
authors: G
authors: Marcotte
authors: Virginie
authors: V
authors: Laurent
authors: Dany
authors: D
authors: Goldgran-Toledano
authors: Christophe
authors: C
authors: Clec'h
authors: Carole
authors: C
authors: Schwebel
authors: Elie
authors: E
authors: Azoulay
authors: Jean-François
authors: JF
authors: Timsit
mesh_terms: D000328:Adult; D000368:Aged; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009752:Nutritional Status; D010288:Parenteral Nutrition / Q000379:methods*; D053717:Pneumonia, Ventilator-Associated / Q000401:mortality*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000401:mortality*; D012769:Shock / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome