Reduction of Mortality in Patients After Abdominal Surgery in Critical Condition Thanks to Early Supplemental Parenteral Nutrition
Ensuring adequate nutrition is an important part of therapy for critically ill patients to achieve better clinical outcomes in terms of both survival and recovery speed. The preferred option is enteral nutrition (EN), which, however, cannot be provided for many reasons to patients after acute abdominal surgery. The results of studies assessing the efficacy of parenteral nutrition (PN) in this specific group of patients are inconsistent. The purpose of the study recently published in Clinical Nutrition was therefore to evaluate the effect of early supplementary parenteral nutrition in critically ill patients after acute abdominal surgery.
Nutrition in Patients After Surgery
According to current recommendations, enteral nutrition is preferred over parenteral, with its initiation recommended as soon as possible. In patients after acute surgery in the abdominal region, however, EN often cannot be provided due to disruption of the anatomy and function of the gastrointestinal tract. According to guidelines for the care of critically ill patients, early PN is recommended in these cases.
The results of available studies regarding the benefit of early PN are inconsistent. One reason may be the fact that the clinical state of critically ill patients is highly heterogeneous and their nutritional needs vary individually. The recently published work focused on a group of critically ill patients after acute abdominal surgery with a high nutritional risk, for whom early EN was not suitable.
Assessed Patient Population in a Retrospective Analysis
The retrospective analysis included critically ill patients who underwent acute abdominal surgery for complicated intra-abdominal infection between January 2013 and December 2018 and required postoperative intensive care. They were divided according to the modified Nutrition Risk in Critically ill (mNUTRIC) score and BMI value into a group with low and high risk of malnutrition. The high-risk malnutrition group was characterized by an mNUTRIC score ≥ 5 and BMI < 18.5 kg/m2. Each group was further divided into a subgroup that received early PN (within 48 hours of surgery) and a subgroup without this nutrition.
A total of 317 patients met the study inclusion criteria, of whom 111 were in the high-risk malnutrition group (35%) and 66 of them (59%) received early PN. In the high-risk malnutrition group, there were no differences in baseline characteristics, while in the low-risk group, those who received early PN were observed to be older and have a higher comorbidity index compared to those who did not receive the nutrition (n = 96).
Findings
The proportion of patients on EN increased over time, and by the 7th day after surgery, this form of nutrition was already administered to 42.7% of high-risk malnutrition patients and 58.4% of low-risk malnutrition patients. In the high-risk malnutrition group, no significant difference was observed between the subgroups in daily calorie and protein needs; however, in the group receiving early PN, an adequate intake of calories and a higher amount of delivered proteins were noted compared to the group without early nutrition (it was the same for patients in the low-risk malnutrition).
In the high-risk malnutrition group, early PN compared to the non-nutrition group was associated with lower 30-day mortality (7.6 vs. 26.7%; p = 0.006) and in-hospital mortality (13.6 vs. 28.9%; p = 0.048). No significant differences in infectious complications were observed between the subgroups.
In the low-risk malnutrition group, there was no significant difference in mortality between the subgroups; however, a higher incidence of pneumonia was observed in the early PN group, which, according to the authors, could be due to the higher age and initial risk in the early nutrition group.
Based on the Kaplan-Meier curve for 30-day mortality, a statistically significant difference in lower mortality was observed in the early nutrition group among patients with high nutritional risk (p = 0.001). In the low-risk malnutrition group, the difference was not statistically significant.
Conclusion
The results of this analysis indicated that the initiation of early parenteral nutrition (within 48 hours) after acute abdominal surgery in critically ill patients with complicated intra-abdominal infection and high malnutrition risk is associated with reduced mortality compared to patients who did not initiate early PN. Additionally, patients on early PN achieved better fulfillment of daily calorie and protein needs.
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Source: Sim J., Hong J., Na E. M. et al. Early supplemental parenteral nutrition is associated with reduced mortality in critically ill surgical patients with high nutritional risk. Clin Nutr 2021; 40 (12): 5678–5683, doi: 10.1016/j.clnu.2021.10.008.
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