In the News
NOVEMBER 13, 2019
‘If the Gut Works, Use
It’
Experts urge early enteral nutrition when feasible
To maximize the bene ts and minimize
costs of nutrition therapy in the hospital
setting, physicians should evaluate
nutrition risk early and use enteral
administration whenever feasible.
That advice comes from John K. DiBaise,
MD, a professor of medicine in the Division
of Gastroenterology and Hepatology at
Mayo Clinic Arizona, in Scottsdale, who
said because enteral nutrition (EN) is
associated with lower risks and costs, as
well as increasingly comparable outcomes,
parenteral nutrition (PN) should be used
only in hospitalized patients at high
nutritional risk when enteral alternatives
are not possible or su cient.
“Recent trials suggest that the differences
in outcome between EN and PN are
diminishing, at least in the ICU setting,” Dr.
DiBaise told Gastroenterology &
Endoscopy News. “However, PN carries a
narrower risk–bene t ratio and is more
costly. The potential clinical bene ts of EN
include reduced risk of infection,
decreased total complications, shorter
length of hospital stay and lower cost.” Dr.
DiBaise discussed the bene ts of early EN
at the American Gastroenterological
Association’s 2019 James W. Freston
Conference.
However, EN is not associated with lower
mortality than PN. A 2016 meta-analysis
(Crit Care 2016;20[1]:117) found that the
use of EN versus PN in critically ill patients
showed no differences in overall mortality,
but EN was associated with a reduction in
infectious complications (relative risk [RR],
0.64; P=0.004) and length of stay in the ICU
(weighted mean difference, –0.8;
P=0.0003). A more recent Cochrane review
(Cochrane Database Syst Rev
2018;6:CD012276) reported little or no
difference between EN and PN in terms of
adverse events and mortality, although EN
may reduce the risk for sepsis (RR, 0.59).
While EN carries some disadvantages, Dr.
DiBaise urged physicians to weigh the risks
and bene ts carefully when choosing a
delivery method for clinical nutrition.
“Potential drawbacks of EN include less
reliable delivery of nutrients, perceived
discomfort associated with nasoenteral
tubes, and the presence of GI
dysfunction/intolerance, but clinicians
should be wary of the latter two drawbacks
in determining EN versus PN,” Dr. DiBaise
said. “Importantly, the mere presence of a
PICC [peripherally inserted central
catheter] in a hospitalized patient—a
ubiquitous occurrence—requiring nutrition
support should not automatically lead to
use of PN. If the gut works, use it, even if a
PICC is already in place.”
Given that EN is preferred for the majority
of patients, clinicians still need to be
knowledgeable about patient selection and
administration of PN so it can be used
readily in the patient populations for whom
this delivery method is appropriate,
according to Carolyn A. Newberry, MD, of
the Division of Gastroenterology and
Hepatology at Weill Cornell Medicine, in
New York City.
“There’s been a lot of discussion about the
optimal way to feed over the last decade or
so, and paradigms have changed a bit,” Dr.
Newberry told Gastroenterology &
Endoscopy News. “There’s been a fear of
using parenteral IV nutrition because of the
risks associated with it, and while we know
that EN is going to be the best method for
a patient if they can tolerate it, you
shouldn’t be scared to use PN as long as
you understand its limitations and how to
care for the lines.”
Citing the CALORIES trial and the more
recent NUTRIREA-2 trial showing no
signi cant difference in outcomes between
early EN and PN in ICU patients, Dr. DiBaise
stressed that PN can be equivalent to EN
for high-risk patients under controlled
conditions.
So, knowing “where” to deliver nutrition
therapy is important—but what about
“when”? Experts agree that early
intervention is crucial for improving
outcomes. Guidelines from the Society of
Critical Care Medicine and the American
Society for Parenteral and Enteral Nutrition
(ASPEN) report that EN initiated within 24
to 48 hours is associated with signi cant
reductions in mortality (RR, 0.7; P=0.05)
and infectious morbidity (RR, 0.74; P=0.01)
(JPEN J Parenter Enteral Nutr
2016;40[2]:159-211).
“All patients with GI disease should be
screened for malnutrition, and those who
meet speci c criteria should be considered
for nutrition support,” Dr. Newberry said.
“Recognizing when patients need medical
nutrition therapy and when to pull the
trigger on starting nutrition therapy is key.”
Unfortunately, recognition of malnutrition
is poor, according to Dr. DiBaise (box).
While malnutrition is prevalent in U.S.
hospitals, affecting between 15% and 60%
of hospitalized patients, only 3.2% of
hospital discharges in 2010 had a
diagnostic code for the condition (JPEN J
Parenter Enteral Nutr 2014;38[2]:186-195).
Clinicians should always assess the
following criteria to determine
whether, when and how nutrition
therapy should be used in
hospitalized patients:
evidence of malnutrition/nutrition risk
using standardized assessment tools like
the Academy of Nutrition &
Dietetics/ASPEN Malnutrition Consensus
Criteria;
albumin, prealbumin and transferrin should
not be considered markers of nutrition;
comorbidities and illness-related bodily
stress;
function of GI tract; and
risk for aspiration.
—Adam Leitenberger
Dr. DiBaise was a co-author of the
American College of Gastroenterology’s
clinical guideline on nutrition therapy in
adults. Dr. Newberry reported no relevant
nancial con icts of interest.
