Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study

Abstract

Background: Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort.

Methods: The 'French-Speaking ICU Nutritional Survey' (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses.

Results: During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23-2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00-1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01-1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98-1.11).

Conclusions: In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk. Trial registration ClinicalTrials.gov Identifier: NCT02599948. Retrospectively registered on November 5th 2015.

Keywords: Clinical nutrition; Clinical nutrition guidelines; Critical illness; Early nutrition support; Enteral nutrition; Intensive care unit; Mortality; Parenteral nutrition.

Fig. 1

Flowchart of inclusion and early-nutrition-type distribution

Fig. 2

Ten-day evolution of early nutrition type and caloric intake. Alluvial plot showing the trend for the distribution of the different nutrition types per day for the 10-day follow-up period (left y-axis represents the number of patients). Introduction of nutrition support increased gradually from day 1 to day 10; enteral nutrition was the predominant route. Almost half of the patients received no nutrition support during the first two days. The peak number of patients receiving parenteral nutrition was observed on D4. Mixed nutrition (EN + PN) remained in the minority during the 10-day follow-up. The blue and red curves represent the energy intake trends for patients who received early nutrition support and those who did not, respectively (right y-axis expresses the amount of energy in calories per kilo per day). When early nutrition was administered, an energy intake plateau was reached on day 3 and remained stable thereafter. In the absence of early nutrition, intakes increased linearly and progressively over the 10 days. EN enteral nutrition, EN + PN simultaneous enteral and parenteral nutrition, PN parenteral nutrition, ICU intensive care unit

Fig. 3

Early nutrition effects in different subgroups. Forest plot depicting the adjusted odds ratios (ORs) from a multilevel, multivariable analysis with a random effect on the centre of inclusion and adjustment of age, sex, admission diagnosis type, body mass index (BMI) range and admission Sequential Organ Failure Assessment (SOFA) score. The association between early nutrition and mortality at day 28 is assessed in subgroups according to sex, age, type of admission, BMI and SOFA score