Wait to start TPN in most critically ill adults

There's now stronger evidence for waiting to start parenteral nutrition in most critically ill adults. Waiting one week (7 days) to start parenteral nutrition instead of starting it right away reduces ICU stays by one day and hospital stays by two days.

Patients who start parenteral nutrition later also have a lower risk for infections, less time on a ventilator and lower health care costs. The downside of late initiation is a higher risk of hypoglycemia. Researchers think that starting parenteral nutrition earlier might reduce the body's ability to clear damaged cells and microbes.

          Recommend starting ENTERAL feeding right away in critical patients when possible, even in those without bowel sounds. Hold off on PARENTERAL nutrition for about seven days as long as patients aren't malnourished before admission to ICU. In the meantime, give IV fluids, electrolytes, trace elements, and vitamins.

Start parenteral nutrition right away if needed in malnourished patients. Remember that glycemic control during hospitalization reduces infections, length of stay and mortality in critically ill patients. Recommend keeping blood glucose around 140 mg/dL (7.8 mmol/L).

REFERENCES

• Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011 Aug 11;365(6):506-17. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1102662

  McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009 May-Jun;33(3):277-316. Available at: https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0148607109335234

  American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1(Suppl 1):S11-61. Available at: https://diabetesjournals.org/care/article/34/Supplement_1/S11/25857/Standards-of-Medical-Care-in-Diabetes-2011