In the Journals

Early parenteral nutrition not linked to adrenal insufficiency, increases septic shock risk

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June 22, 2015

Critically ill patients in intensive care who receive early IV feeding are no more likely to experience adrenal insufficiency than patients who receive only tube feeding for the first 7 days, according to research in The Journal of Clinical Endocrinology & Metabolism.

In a preplanned subanalysis of the EPaNIC clinical trial measuring the effects of early vs. late parenteral nutrition in ICU patients, researchers also found that patients who receive early parenteral nutrition were more likely to experience septic shock, requiring more treatment with corticosteroids.

“Early or late [parenteral nutrition] did not affect the suppressed plasma concentrations of [adrenocorticotropic hormone] and the elevated plasma (free) cortisol concentration in critically ill patients,” the researchers wrote. “However, early [parenteral nutrition] increased the incidence of new septic shock, which statistically explained why more patients on early [parenteral nutrition] received corticosteroid treatment.”

Philippe Meersseman, MD, PhD, of Catholic University of Leuven, Belgium, and colleagues analyzed data from 4,640 critically ill adult patients in seven Belgian ICUs participating in the EPaNIC trial, a randomized study comparing the early initiation of parenteral nutrition to supplement insufficient enteral nutrition (early PN) with withholding parenteral nutrition for 1 week (late PN) in the ICU between 2007 and 2010. Parenteral nutrition was administered within 48 hours after ICU admission in the early PN group, which included 2,312 participants; in the late PN group of 2,328 participants, parenteral nutrition was not administered before day 8 in the ICU. Both groups received early enteral support and insulin to target normal blood glucose levels.

Greet Van den Berghe

Greet Van den Berghe

Researchers documented the impact of early vs. late PN on the use of corticosteroids and incidents of septic shock.

In a subanalysis, researchers also measured plasma adrenocorticotropic hormone (ACTH) and cortisol in a propensity score matched subgroup of 174 participants who did not receive steroids during their first 7 days in the ICU. Within the subgroup, 87 participants received early PN (66% men; mean age, 66 years) and 87 participants received late PN (66% men; mean age, 66 years).

In the early PN arm of the EPaNIC cohort, 26.2% of patients received corticosteroids after randomization vs. 23.8% in the late PN arm, and 14% of patients in the early PN arm were treated with corticosteroids for at least 5 consecutive days vs. 11.9% in the late PN arm (P = .03).

In the subgroup of patients who were not assigned corticosteroids, early PN did not affect plasma concentrations of ACTH or cortisol compared with late PN patients.

“The observation that the early nutritional management of ICU patients did not affect plasma concentrations of ACTH and (free) cortisol was unexpected, as we had hypothesized that tolerating the substantial caloric deficit in the late PN group, which is comparable to quite severe caloric restriction, would have activated the HPA axis and hence would have increased plasma control and ACTH concentration,” the researchers wrote. “We can only speculate as to why such an effect, which has been reported in healthy subjects, was absent in critical illness.”

In addition, 17% of patients receiving early PN developed new septic shock vs. 14.2% of patients receiving late PN (P = .01). This ultimately led to more patients who received early PN receiving 5 or more days of corticosteroid treatment, according to researchers.

“Parenteral nutrition should not be given to critically ill patients during the first week in ICU,” Greet Van den Berghe, MD, PhD, of the department of intensive care medicine at Catholic University Hospital in Leuven, told Endocrine Today. “Further research should focus on the underlying mechanisms both of the finding that parenteral nutrition increases septic shock and of the alterations of the hypothalamus-pituitary adrenal axis during critical illness.” by Regina Schaffer

Disclosure: The researchers report no relevant financial disclosures.

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