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JOURNAL CLUB CRITIQUE
Jean C. PREISER, Fabio S. TACCONE
Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
Both the optimal caloric intake and the best route of delivery of nutrition to critically ill patients fuel an intense debate. Recently, two large pragmatic, multicenter, controlled, randomized clinical trials evaluated these issues in large cohorts of patients. In the CALORIES Study, the authors compared the parenteral with the enteral route as the most effective way to deliver early (e.g. within 36 hours from admission) nutritional support in critically ill adults in 33 English ICUs (N.=2388). The primary endpoint, 30-day mortality (33.1% in the parenteral group and 34.2% in the enteral group), as well as the infection rate, were similar in both groups, while patients of the parenteral group experienced less hypoglycemia and vomiting than the enteral group. In the PermiT Study, 894 enterally fed patients from 7 ICUs were randomized to a restrictive strategy for non-protein calories (e.g. “permissive underfeeding” — 40% to 60% of energy expenditure) or to standard feeding (70 to 100% of energy expenditure) for up to 2 weeks. The primary endpoint (90-day mortality) was similar in both groups (27.2% in the permissive-underfeeding group and 28.9% in the standard-feeding group) without significant differences in feeding intolerance, diarrhea or ICU-acquired infections. We herein discuss how these studies should be interpreted with regard to the existing evidence and propose some practical suggestions for nutrition management in the critically ill patient.