Starting Early Parenteral Nutrition Weakens the Critically Ill

Back in 2011 a primary analysis of the EPaNIC trial was published in the New Engalnd Journal of Medicine and showed that delaying total parenteral nutrition (TPN) for one week in critically ill patients resulted in better outcomes from a range of measures includung risk of infection and earlier release. The role of weakness remained unclear.

This time Hermans et al. published a prospectively planned subanalysis of this trial, where weakness was assessed in 600 ICU patients out of which 122 patients had muscle biopsies performed to study for autophagy and atrophy. They were able to show that early TPN resulted in a significant greater number of patients with weakness compared to late TPN (not before day eight after admission to ICU). Weakness also recovered faster with late TPN.

Interestingly autophagy marker were higher in patients given late TPN and this was independently associated with less weakness.

Dr. Van den Bergen says: “The late PN strategy, that is, not using artificial (parenteral but maybe also forcing enteral) feeding during the acute phase of critical illness, should be standard of care, as there is absolutely no good data to support benefit from such forceful feeding and there is, as we have shown, risk for harm.”… and I get the feeling he might be right.

Hermanns G. et al. The Lancet Respiratory Medicine, 10 September 2013; volume 1, issue 8

Casaer MP et al. N Engl J Med. 2011 Aug 11;365(6):506-17

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