+ What to Do When Early Enteral Feeding is Not Possible in Critically Ill Patients? Results of a Multicenter Observational Study Naomi E Cahill RD MSc Queen’s University, Kingston ON 10 February 2010

+ Acknowledgements Co-authors Lauren Murch, Dr Khursheed Jeejeebhoy, Dr Stephen A. McClave, Andrew G. Day, Miao Wang, Dr Daren K. Heyland Participants of the International Nutrition Surveys Research Team at the Clinical Evaluation Research Unit

+ Background

+ What is the best course of action when early EN is not possible? Delay EN Start PN Early Start PN Late

+ Objective To evaluate the effect of early parenteral nutrition (PN) ( 48 hours) on nutritional and clinical outcomes in critically ill medical patients who received late EN.

+ International Nutrition Survey 2007 and 2008 Prospective observational cohort study 20 consecutive adult critically ill patients per ICU Mechanically ventilated within 48 hours Remained in ICU >72 hours Data collected Hospital and ICU characteristics Patients baseline information Age, admission diagnosis, APACHE II score Baseline nutrition assessment 12 days of daily nutrition data Type of nutrition, amount received 60 day hospital outcomes Mortality, length of stay

+ Statistical Analysis Descriptive statistics Late EN vs. Early PN vs. Late PN Time to hospital discharge alive Kaplan-Meier figures Cox-proportional hazards model Adjusting for age, admission diagnosis, time in hospital prior to ICU admission, APACHE II score, year of the study, geographic region, and presence of an ICU Medical Director

Study Population

+ Results: Patient Characteristics age sex APACHE II score presence of Acute Respiratory Distress Syndrome (ARDS) types of admission diagnosis duration of hospital stay prior to ICU admission No Significant Differences Significant Differences

+ Adequacy of Calories from Total Nutrition (EN+PN+Propofol) Late ENEarly PNLate PNP-value 42.9%±21.2%74.1%±21.2%53.2%±22.7%<0.0001

+ Results: Clinical Outcomes Late EN vs Early PN (a), Late EN vs. Late PN (b), and Early PN vs. Late PN (c)

+ Time to Hospital Discharge Alive Unadjusted HR (95% C.I.)Adjusted HR (95% C.I.) Early PN vs Late EN0.55 ( )0.79 ( ) Early PN vs Late PN0.85 ( )0.99 ( ) Proportion Dead or Remaining in Hospital

+ What is the best course of action when early EN is not possible? Early PN improves nutritional adequacy compared to delayed feeding Maximize EN delivery prior to initiating PN No clinical benefit of early PN compared to delayed EN …. But maybe harm

+ Important clinically relevant question Large dataset Sample size Generalizibility Robust statistical approach Observational design Residual confounding Factors influencing feeding decisions unknown Small numbers in some groups No data on infection rates StrengthsWeaknesses

+ Thank You Questions Efforts to improve the nutritional adequacy of critically ill medical patients via the enteral route with small bowel feeding tubes and motility agents, rather than early PN, are warranted.

+ Time to Hospital Discharge Alive BMI <25 Kg/m 2 Unadjusted HR (95% C.I.)Adjusted HR (95% C.I.) Early PN vs Late ENHR 0.45 ( )0.61 ( ) Proportion Dead or Remaining in Hospital