Elsevier

Critical Care Clinics

Volume 14, Issue 3, 1 July 1998, Pages 423-440
Critical Care Clinics

NUTRITIONAL SUPPORT IN THE CRITICALLY ILL PATIENT: A Critical Review of the Evidence

https://doi.org/10.1016/S0749-0704(05)70009-9Get rights and content

Among hospitalized patients, malnutrition has been associated with increased infectious morbidity, prolonged hospital stay, and increased mortality.23, 47, 79, 99 In critically ill patients, malnutrition may result in impaired immunological function, impaired ventilatory drive, and weakened respiratory muscles, leading to prolonged ventilatory dependence and increased infectious morbidity and mortality.29 The metabolic response to critical illness (or hypercatabolism) can lead to severe wasting of the lean body mass, impairment of visceral organ function, and decrease in repair and immune functions.8 Finally, beyond its digestive and absorptive capacities, the gastrointestinal tract is recognized for its immunological role and barrier function. Several studies have documented that “bowel rest” is associated with a disruption of the mucosal barrier structure and function, augmenting the inflammatory response to illness and resulting in greater infectious morbidity.13, 30 Awareness of these associations and observations has led to the practice of providing nutritional support to critically ill patients.

Although many studies have documented that providing nutritional support can change nutritional outcomes (amino acid profile, weight gain, nitrogen balance, etc.), data are lacking that demonstrate that nutrition actually influences clinically important endpoints. The purpose of this article is to systematically review and critically appraise the literature to examine the relationship between nutritional support and infectious morbidity and mortality in the critically ill patient.

Critical appraisal of the evidence allows us to put forward clinical recommendations based on rules of evidence.80 Strong clinical recommendations can be made (i.e., Grade A recommendations) when supported by rigorous randomized trials, in a critically ill patient population, with a low chance of error (level I evidence). Moderately strong recommendations (Grade B) can be made from randomized trials, in a critically ill patient population, with a high risk of error (level II evidence). Weaker recommendations (Grade C) are based on less rigorous studies or randomized trials in different patient populations or randomized trials focusing on surrogate outcomes. Finally, no recommendations are made in this article from evidence that comes from nonrandomized studies in noncritically ill patients, animal studies, or studies based on biologic rationale. A version of the relationship between levels of evidence and grades of recommendations is outlined in

Section snippets

Search Strategy

Table 1A computerized bibliographic search of MEDLINE (including pre-MEDLINE) from 1980 to December, 1996, to locate all relevant articles was conducted. The terms randomized controlled trial, double blind method, clinical trial, placebo, and comparative study were combined with explode parenteral nutrition, total, enteral nutrition, intensive care units, and critical care. Citations were limited to English-language studies on adult patients. Reference lists of relevant review articles and

Study Identification and Selection

A total of 475 citations were identified through searching the computerized bibliographic databases. Of these potentially eligible papers, 58 met the inclusion criteria (see below). Included articles were grouped into categories addressing the following questions:

  • 1

    Does providing nutritional support, compared to no nutritional support, make a difference in patient outcomes?

  • 2

    What is the effect of EN compared to TPN with respect to infectious outcomes?

  • 3

    How does timing of administration of EN

CONCLUSION

The pioneering work of many investigators has led us to understand the important role that nutrition plays in critical illness. Although providing nutritional support to critically ill patients can alter nutritional outcomes, there are few randomized controlled trials conclusively demonstrating that any form of nutritional support improves the morbidity and mortality of critically ill patients. The absence of data does not mean that nutritional support is ineffective. In many cases, it means

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    Address reprint requests to D.K. Heyland, MD, Angada 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, Canada K7L 2V7

    *

    Department of Medicine, and the Department of Community Health and Epidemiology, Queen's University Faculty of Health Sciences, Kingston, Ontario, Canada

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