Permissive Underfeeding or Standard Enteral feeding in Critically Ill

Adults

Arabi Y.M., Aldawood A.S., Haddad S.H., et al. N Eng J Med 372(25): 2398-408

Background:

Achieving caloric targets recommended on the premise that malnutrition &

protein catabolism are associated with increased morbidity & mortality
Previous studies has shown:
o Higher enteral nutritional delivery vs usual care in critically ill patients
showed no reduction in mortality
o Early parenteral nutrition has shown no change in mortality nor in
discharge time from intensive care unit (ICU).
Conversely, caloric restriction may be beneficial: critically ill patients
receiving trophic enteral feeding (with no protein supplementation) showed
outcomes similar to those with standard feeding

Question:
Whether restricting nonprotein calories (permissive underfeeding) in conjuction
with meeting full protein requirements improves outcomes?
Method:

Single centre, randomized controlled trial of permissive underfeeding (40

to 60% of caloric requirements) vs standard-feeding group (70-100%)
Protein requirements were calculated at 1.2 to 1.5 g / kg
Primary outcome: 90-day all-cause mortality

Results

Average caloric intake in permissive underfeeding group was 46% vs 71% of

daily intake in the standard-feeding group (P<0.001) with no significant
difference in protein intake
No significant difference in 90-day mortality between the permissiveunderfeeding group and the standard-feeding group (27.2% vs 28.9%, P=
0.58)
No significant difference in probability of survival between the two groups
either (P=0.43)
No significant difference in days free from mechanical ventilation not the
number of ICU-free days
No significant difference with respect to hypoglycaemia, hypokalaemia,
hypomagnesemia, hypophosphatemia, transfusion of packed red cell, ICUacquired infections, diarrhoea or feeding intolerance.

Only significant difference was that renal-replacement therapy was

required less frequently in the permissive-underfeeding group (7.1%
vs 11.4%, P=0.04)- Note post hoc analysis

Strengths

Volume delivery of feed was adjusted for with the permissive-underfeeding

group receiving additional protein and normal saline or water
Calculation of total calorie intake included propofol, IV dextrose and
parenteral nutrition

Weakness
Patients in ICU whose enteral feeding was initiated late were not included in
the trial
Conclusion
A strategy of moderate amounts of nonprotein calories, along with full
recommended amount of protein in critically ill adults had no significant effects
in mortality as compared with higher amounts of caloric feeds.
Caveats

About 97% of the patients in both groups were mechanically ventilated

Similar to 2 previous trials evaluating trophic feeds (15 to 25% of caloric
requirements) for up to 6 days in patients with acute lung injury or acute
respiratory failure.

Take Home Message

We should consider moderate caloric feeds in critically ill patients with acute lung
pathology on mechanical ventilation. Furthermore, caloric restriction may be
renoprotective, though further research is required.
This has the potential to alleviate some anxiety related to underfeeding critically
ill patients as long as adequate protein intake is ensured.