Effect of Early Parenteral Nutrition on the HPA Axis and on Treatment With Corticosteroids in Intensive Care Patients.
BACKGROUND
Nutrition can affect the hypothalamus-pituitary-adrenal axis. We hypothesized that early administration of parenteral nutrition (PN) during critical illness reduces plasma ACTH and cortisol concentrations and thereby increases the use of corticosteroids.


METHODS
This is a preplanned substudy of a randomized controlled trial (EPaNIC) that compared early PN with late PN in 4640 critically ill patients. We investigated the effect of early vs late PN on any steroid treatment and on treatment for ≥ 5 days to capture patients with clinical suspicion of adrenal insufficiency, and assessed whether this was related to an effect on septic shock. Also, in a propensity score-matched subgroup (n=174) of patients not receiving steroids, plasma ACTH and (free) cortisol were quantified.


RESULTS
Compared with late PN, more patients on early PN received treatment with corticosteroids (26.2% vs 23.8%; P = .05) and with corticosteroids for ≥ 5 days (14.0% vs 11.9%; P = .03). However, plasma ACTH and (free) cortisol concentrations were unaffected and thus could not explain the higher use of corticosteroids with early PN. Instead, more patients developed new septic shock with early PN (17.0%) than with late PN (14.2%) (P = .01). In multivariate logistic regression analysis, new septic shock was an independent determinant for ≥ 5 days steroid treatment (odds ratio, 6.25; 95% confidence interval, 4.93-7.94; P < .0001), statistically explaining the effect of early PN on steroid treatment.


CONCLUSIONS
Early PN did not affect plasma concentrations of ACTH and (free) cortisol, but increased the incidence of septic shock, which statistically explained why more patients on early PN received corticosteroids.
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Philippe
P
Meersseman
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Eva
E
Boonen
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Bram
B
Peeters
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Sarah
S
Vander Perre
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Pieter J
PJ
Wouters
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Lies
L
Langouche
Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine (P.M., E.B., B.P., S.V.P., P.J.W., L.L., G.V.d.B.), KU Leuven, 3000 Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine (P.M.), University Hospital Leuven, 3000 Leuven, Belgium; and Department of Intensive Care Medicine (E.B., B.P., P.J.W., L.L., G.V.d.B.), University Hospital Leuven, 3000 Leuven, Belgium.
Greet
G
Van den Berghe
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000309:Adrenal Insufficiency / Q000453:epidemiology / Q000209:etiology; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000368:Aged; D003422:Critical Care / Q000379:methods / Q000706:statistics & numerical data; D016638:Critical Illness / Q000453:epidemiology* / Q000628:therapy*; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007030:Hypothalamo-Hypophyseal System / Q000503:physiopathology*; D008297:Male; D016555:Matched-Pair Analysis; D008875:Middle Aged; D010288:Parenteral Nutrition / Q000009:adverse effects / Q000706:statistics & numerical data*; D010913:Pituitary-Adrenal System / Q000503:physiopathology*; D012307:Risk Factors; D013997:Time Factors
D000305:Adrenal Cortex Hormones; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone