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Background: The Augmented Versus Routine Approach to Giving Energy Trial (TARGET) is the largest blinded enteral nutrition (EN) intervention trial evaluating energy delivery to be conducted in the critically ill. To determine the external validity of TARGET results, nutrition practices in intensive care units (ICUs) in Australia and New Zealand (ANZ) are described and compared with international practices., Methods: This was a retrospective analysis of prospectively collected data for the International Nutrition Surveys, 2007-2013. Data are presented as mean (SD)., Results: A total of 17,154 patients (ANZ: n = 2776 vs international n = 14,378) from 923 ICUs (146 and 777, respectively) were included. EN was the most common route of feeding (ANZ: 85%, n = 2365 patients vs international: 84%, n = 12,034; P = .258), and EN concentration was also similar (<1.25 kcal/mL ANZ: 70%, n = 12,396 vs international: 65%, n = 56,891 administrations; P < .001). Protein delivery was substantially below the estimated prescriptions but similar between the regions (0.6 [0.4] g/kg/day vs 0.6 [0.4] g/kg/day; P = .849). Patients in ANZ received slightly more energy (1133 [572] vs 948[536] kcal/day; P < .001), possibly because more energy was prescribed (1947 [348] vs 1747 [376] kcal/day; P < .001), nutrition protocols were more commonly used (98% vs 75%; P < .001) and included recommendations for therapies such as prokinetic agents (87% vs 51%, n = 399; P < .001) and small bowel feeding (62% vs 40%; P < .001) when compared with international ICUs., Conclusions: Key elements of nutrition practice are similar in ANZ and international ICUs. These data can be used to determine the external validity and relevance of TARGET results., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48-72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery., Methods: This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted., Results: There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m 2 . Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups., Conclusions: This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups., Trial Registration: Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016).

Background: Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed "supplemental parenteral nutrition"), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill., Methods/design: This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first)., Discussion: This trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial., Trial Registration: NCT01847534 (First registered 5 February 2013, last updated 14 October 2015).

Objectives: To describe current nutrition delivery practices and to identify barriers to nutrition in patients receiving venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) in multiple centres in Australia and New Zealand., Design, Setting and Participants: A prospective, multicentre, observational study, set in eight intensive care units in Australia and New Zealand, of adults treated with ECMO who were expected to receive enteral nutrition (EN) or parenteral nutrition (PN) therapy for > 72 hours. Data were collected from the start of ECMO until 7 days after ECMO cessation., Results: There were 107 patients enrolled, with a median age of 42 years (interquartile range [IQR], 31-56 years), and 54 patients (50%) were men. EN was the most commonly delivered mode of nutrition (on 84% of days) although it was interrupted on 53% of days. The median interruption duration was 8 hours (IQR, 4-5 hours] per episode. The two most common barriers to EN delivery were fasting for a therapeutic or diagnostic procedure and high gastric residual volumes. Median daily calorie and protein deliveries from EN and/or PN were 1680 kcal (IQR, 960-2100 kcal) and 72 g (IQR, 42-98 g) of protein. For patients who received EN and/or PN, median calorie and protein deficits during the study period were -7118 kcal (IQR, -11 614 to -4510 kcal) and -325 g (IQR, - 525 to -188 g) of protein., Conclusions: EN was the most commonly used nutrition-delivery mode during ECMO treatment but was frequently interrupted. Compared with estimated calorie and protein requirements, lesser but reasonably acceptable amounts were delivered, although calorie and protein deficits still existed.

Importance: Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission., Objective: To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes., Design, Setting, and Participants: Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days., Interventions: Random allocation to pragmatic standard care or early PN., Main Outcomes and Measures: Day-60 mortality; quality of life, infections, and body composition., Results: A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, -1.26%; 95% CI, -6.6 to 4.1; P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, -0.47; 95% CI, -0.82 to -0.11; P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, -0.16; 95% CI, -0.28 to -0.038; P = .01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, -0.13; 95% CI, -0.25 to -0.01; P = .04)., Conclusions and Relevance: The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays., Trial Registration: anzctr.org.au Identifier: ACTRN012605000704695.

Objective: To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition., Design: Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months., Setting: Intensive care units or high-dependency units within Australia and New Zealand., Patients: Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded., Measurements: The primary outcome was the proportion of patients who received enteral nutrition, parenteral nutrition, or concurrent enteral nutrition/parenteral nutrition. Secondary outcomes included other aspects of nutritional therapy and the severity and clinical outcomes of acute pancreatitis., Measurements and Main Results: We enrolled 121 patients and 117 were analyzed. The mean age was 61 (sd 17) years and 53% were men. Enteral nutrition was delivered to 58 (50%; 95% confidence interval [CI], 41-59%) and parenteral nutrition to 49 (42%; 95% CI, 33-51%) patients. Parenteral nutrition was more frequently used as the initial therapy (58%; 95% CI, 49-67%) than enteral nutrition (42%; 95% CI, 33-51%). The most common reason for parenteral nutrition prescription was the treating doctor's preference (60%). Enteral nutrition (74%) was more often used than parenteral nutrition (40%) on any individual study day. Concurrent enteral nutrition and parenteral nutrition occurred in 28 (24%) patients on 14% of days. Complications of acute pancreatitis requiring critical care unit management were observed in 45 (39%) patients. The median (interquartile range) duration of intensive care unit and hospital stay were 5 (2-10) and 19 (9-31) days, respectively. The hospital mortality rate was 15% (95% CI, 8-21%), and there was a tendency toward higher mortality for patients who only received parenteral nutrition than for those who only received enteral nutrition (28% vs. 7%, p=.06)., Conclusions: For patients with acute pancreatitis requiring critical care unit management in Australian and New Zealand intensive care units, enteral nutrition is used most commonly, but parenteral nutrition is more often used as the initial route of nutritional therapy. Given that clinical practice guidelines currently recommend enteral nutrition as the initial route of nutritional therapy in severe acute pancreatitis, improved education about and dissemination of these guidelines seems warranted.

Purpose of Review: Nutrition support improves clinical outcomes in the critically ill and our understanding of its effects has advanced significantly over the last few years. Three recently published evidence-based guidelines have made generally consistent and thorough recommendations to assist clinicians in providing nutrition support. This review will focus on various aspects of these recommendations, concentrating on the practicalities of nutrition support in the intensive care unit, such as its optimal mode and composition., Recent Findings: Enteral nutrition is preferred to parenteral nutrition unless there is a major gut condition which will delay commencement of enteral nutrition. Nasogastric feeding should begin within 24 h, but if intolerance develops, small bowel feeding or pro-motility drugs (erythromycin or metoclopramide) should be attempted before resorting to supplementary parenteral nutrition. Enteral nutrition should not routinely be supplemented with arginine or glutamine, but it should contain a package of eicosapentaenoic acid, gamma-linolenic acid and antioxidants if the patient has acute lung injury or sepsis. Parenteral nutrition should be glutamine supplemented and the prescription should be limited in energy to avoid hyperglycemia. Whether using enteral nutrition or parenteral nutrition, most patients should receive intravenous selenium, and may also need zinc and copper supplementation., Summary: Intensive care unit patients should have nutrition support based on recent evidence-based guidelines with a preference for nasogastric feeding. If intolerance occurs, pro-motility drugs and small bowel feeding should be attempted. Clinicians should also consider carefully the composition of the nutrition support regimen with regard to lipid content (especially eicosapentaenoic acid and gamma-linolenic acid), antioxidants, glutamine and other micronutrients.

Summary Background The amount of energy required to improve clinical outcomes in critically ill adults is unknown. Objective The aim of this systematic review and meta-analysis was to evaluate the impact of near target energy delivery to critically ill adults on mortality and other clinically relevant outcomes. Design Following PRISMA guidelines, MEDLINE, EMBASE, CINHAL and the Cochrane Library were searched for randomised controlled trials evaluating nutrition interventions in adult critical care populations. Included studies compared delivery of ≥80% of predicted energy requirements (near target) from enteral and/or parenteral nutrition to <80% (standard care) and reported mortality. The quality of individual studies was assessed using the Cochrane 'Risk of Bias' tool, and the overall body of evidence using the GRADE approach. Fixed or random effect meta-analyses were used pending the presence of heterogeneity (I2 > 50%) when 3 or more studies reported the same outcome. Outcomes are presented as risk ratio (RR), 95% confidence interval (CI). Results Ten trials with 3155 participants were included. Mortality was unaffected by the intervention (RR 1.02, 95% CI 0.81, 1.27, p = 0.89, I2 = 25%). Evaluation of studies of higher quality and low risk of bias did not alter the mortality inference (3 trials, 352 participants, RR 0.83, 95% CI 0.49, 1.40, p = 0.19, I2 = 39%). The quality of evidence across outcomes was very low. Conclusions The delivery of near target energy when compared to standard care in adult critically ill patients was not associated with an effect on mortality. Because the quality of the evidence across outcomes was very low there is considerable uncertainty surrounding this estimate. This has implications for clinical utility of the evidence within the included reviews. [ABSTRACT FROM AUTHOR]

Background: Whilst nutrition is vital to survival in health, the precise role of nutrition during critical illness is controversial. More specifically, the exact amount of energy that is required during critical illness to optimally influence clinical outcomes remains unknown. The aim of this systematic literature review and meta-analysis is to evaluate the clinical effects of optimising nutrition to critically ill adult patients, such that the entire predicted amount of energy that the patient requires is delivered, on mortality and other important outcomes. Methods: A systematic literature review and meta-analysis will be conducted by searching for studies indexed in Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Library. Searches will be restricted to English. Studies will be considered for inclusion if they are a parallel randomised controlled trial investigating a nutrition intervention in an adult critical care population, where one arm delivers 'full predicted energy from nutrition' (defined as provision of ≥80 % of the predicted energy required) and the other arm delivers energy less than 80 % of the predicted requirement. Two authors will independently perform title screening, full-text screening, data extraction and quality assessment for this review. The quality of individual studies will be assessed using the 'Risk of Bias' tool, and to assess the overall body of evidence, a 'Summary of Findings' table and the Grades of Recommendation, Assessment, Development and Evaluation system will be used, all recommended by the Cochrane Library. Pending the study heterogeneity that is determined, a fixed-effect meta-analysis with pre-defined subgroup analyses will be performed. Discussion: Currently, it is controversial whether optimal energy delivery is beneficial for outcomes in critically ill patients. This systematic review and meta-analysis will evaluate whether delivering optimal energy to critically ill adult patients improves outcomes when compared to delivery of lesser amounts. Systematic review registration: PROSPERO CRD42015027512 [ABSTRACT FROM AUTHOR]