Nutrition in the Acute Phase of Critical Illness
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$ b5 j& m, s t# oMichael P. Casaer, M.D., Ph.D., and Greet Van den Berghe, M.D., Ph.D.
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Critically ill patients requiring vital organ support in the intensive care unit (ICU) commonly have anorexia and may be unable to feed volitionally by mouth for periods ranging from days to months. Unless such patients are provided with macronutrients in the form of enteral or parenteral nutrition, they accumulate an energy deficit that rapidly reaches proportions that contribute to lean-tissue wasting and that are associated with adverse outcomes. The catabolic response to acute critical illness is much more pronounced than that evoked by fasting in healthy persons, since the energy deficit in acutely ill patients is often superimposed on immobilization and pronounced inflammatory and endocrine stress responses. Severe skeletal-muscle wasting and weakness occurring during critical illness are associated with a prolonged need for mechanical ventilation and rehabilitation.9 Y% r0 x) K% g( x
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In many studies, the degree of energy deficit accumulating in critically ill patients is strongly associated with the duration of stay in the ICU, which, in turn, is associated with an increased incidence of infectious complications and risk of death.1 Until recently, however, the causality of these associations remained unclear, since the majority of studies that formed the basis of published recommendations for feeding ICU patients were either observational or small interventional studies. Recently, the field of critical care nutrition has been revived by the findings of several randomized, controlled trials, which have opened a new debate on nutritional practice in the ICU.
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6 \$ W! V6 }4 p2 wFor this review, we focus on evidence from randomized, controlled studies that met the following criteria: study-group assignments were made in a blinded fashion, the sample size was sufficiently large to detect a prespecified treatment effect, there was a clear delineation of the way in which patients were selected and followed, there was a statistical analysis plan with end points defined a priori, and there was an intention-to-treat analysis with adequate handling of competing risks (Table 1). In this review, we integrate this newer evidence with older high-level evidence to provide suggestions for feeding during the acute phase of critical illness. In cases in which such evidence does not exist, we identify areas of uncertainty that require further investigation.
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