Effect of Early Nutritional Support on Clinical Outcomes of Critically Ill Patients with Sepsis and Septic Shock: A Single-Center Retrospective Study

Abstract

The initial nutritional delivery policy for patients with sepsis admitted to the intensive care unit (ICU) has not been fully elucidated. We aimed to determine whether an initial adequate nutrition supply and route of nutrition delivery during the first week of sepsis onset improve clinical outcomes of critically ill patients with sepsis. We reviewed adult patients with sepsis and septic shock in the ICU in a single tertiary teaching hospital between 31 November 2013 and 20 May 2017. Poisson log-linear and Cox regressions were performed to assess the relationships between clinical outcomes and sex, modified nutrition risk in the critically ill score, sequential organ failure assessment score, route of nutrition delivery, acute physiology and chronic health evaluation score, and daily energy and protein delivery during the first week of sepsis onset. In total, 834 patients were included. Patients who had a higher protein intake during the first week of sepsis onset had a lower in-hospital mortality (adjusted hazard ratio (HR), 0.55; 95% confidence interval (CI), 0.39−0.78; p = 0.001). A higher energy intake was associated with a lower 30-day mortality (adjusted HR, 0.94; 95% CI, 0.90−0.98; p = 0.003). The route of nutrition delivery was not associated with 1-year mortality in the group which was underfed; however, in patients who met > 70% of their nutritional requirement, enteral feeding (EN) with supplemental parenteral nutrition (PN) was superior to only EN (p = 0.016) or PN (p = 0.042). In patients with sepsis and septic shock, a high daily average protein intake may lower in-hospital mortality, and a high energy intake may lower the 30-day mortality, especially in those with a high modified nutrition risk in the critically ill scores. In patients who receive adequate energy, EN with supplemental PN may be better than only EN or PN, but not in underfed patients.

Keywords: enteral nutrition; parenteral nutrition; sepsis; septic shock.

Figure 1

Patient selection flow chart.

Figure 2

Daily energy (kcal) and protein (g/kg) received by patients following sepsis and septic shock onset. Column height represents the mean daily energy received (kcal). PN is the light grey and EN is the dark grey parts of the columns. Gray dots and lines represent protein intake (g/kg). EN, enteral nutrition; PN, parenteral nutrition.

Figure 3

Kaplan–Meier curves for 1-year mortality according to the route of nutrition delivery in critically ill patients with sepsis in the low- and high-energy intake groups. * High-energy group, EN with supplemental PN was superior to only EN (p = 0.016) or PN (p = 0.042) in patients who met >70% of their nutrition requirement; low-energy group, route of nutrition supply was not associated with 1-year mortality in the group who met < 70% of their nutrition requirement. EN is the blue line, PN is the green line, and EN with supplemental PN is the purple line. EN, enteral nutrition; PN, parenteral nutrition.