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Enteral Versus Parenteral Early Nutrition in Ventilated Adults with Shock: A Randomised, Controlled, Multicentre, Open-Label, Parallel-Group Study (Nutrirea-2)
Reignier J, Boisramé-Helms J, Brisard L, et al. Lancet. 2018; 391: 133-43.
Study Question: Does early first-line enteral nutrition have benefits over early first-line parenteral nutrition in patients requiring mechanical ventilation and vasopressor support for shock?
Study Description: This randomized, controlled trial was completed across 44 ICUs in France and evaluated critically ill adult patients requiring mechanical ventilation and vasopressor support for shock. Patients were treated with either early enteral nutrition or early parenteral nutrition at a caloric goal of 20-25 kcal/kg/day. Patients received a minimum of 72 hours of the assigned therapy, after which patients could be switched from parenteral nutrition to enteral nutrition if shock had resolved. The primary outcome was 28-day all-cause mortality.
Results: A total of 2410 patients were enrolled (1202 in enteral group and 1208 in parenteral group). Respiratory failure (50%) was the most common reason for ICU admission and sepsis (62.4%) was the most common cause of shock. Most patients were admitted with a medical diagnosis (92.5%) and were at significant risk for mortality, with an overall mean SAPS II of 60. Baseline demographics were well-balanced. At day 28, mortality was similar between the enteral and parenteral cohorts (37% vs. 35%, p = 0.33). Patients in the enteral nutrition group experienced more vomiting (34% vs. 24%, p < 0.0001), diarrhea (36% vs. 33%, p = 0.009), and bowel ischemia (2% vs. <1%, p = 0.007). There were no differences in other outcomes, including infection rates.
Conclusion(s): In critically ill adults with shock, early enteral nutrition did not reduce mortality or the risk of secondary infections, but was associated with a greater risk of digestive complications compared with early parenteral nutrition.
Perspective: Route of early feeding in this large analysis did not impact overall outcome in this severely-ill patient population. While gastrointestinal complications were higher in the enteral feeding group, most notably bowel ischemia, the incidence is likely too low to merit first-line parenteral nutrition.