Enteral Nutrition Vs Parenteral Nutrition in the Critically Ill

Created on Sat, 02/27/2016 - 03:13
Last updated on Sat, 02/27/2016 - 05:03

The debate of which route of nutrition to use is now fairly well settled. Most people will agree that the enteral route is preferred whenever it is available. So, the question "which is better" is probably the wrong question. The correct questions would be "when is it appropriate to resort to TPN", or "When NOT to use enteral nutrition". The indications for enteral nutrition are expanding (eg. whereas previously we would have given a severe pancreatitis patient on complete bowel rest, these days they are fed early, and without any adverse consequences). And there is still controversy as to when and how to start it (eg. how long one can safely wait before resorting to parenteral nutrition - some say it is safe to wait for anywhere up to 7 days, whereas others recommend to start supplemental PN as soon as it becomes clear that the enteral route is not effective).

The theoretical advantages of enteral nutrition

Improved gut mucosal health

In summary, enteral nutrition improves GI blood flow and improves GI mucosal health. It maintains villous height by causing the release of trophic agents e.g.. cholecystokinin, bombesin, bile salts, etc – which cause the GI mucosal cells to proliferate. Conversely, the GI mucosa atrophies if it is not regularly exposed to food. This gives rise to gastric ulceration and malabsorption due to villus height loss.

Gut permeability increases in critical illness. It happens within hours of the insult. This results in bacterial translocation. The more severe the illness, the more permeable the gut, and the more bacterial translocation occurs. But, more weirdly,

Improved systemic immune function

Adequate enteral nutrition impacts positively on the systemic immune response. A well-fed immune system is a more vigorous defence force. There also seems to be a link between a healthy GALT (Gastrointestinal-Associated Lymphoid Tissue) in the GI tract and a healthy MALT (Mucosa-Associated Lymphoid Tissue) in the respiratory tract, which may explain why enteral nutrition has been shown to decrease the risk of pneumonia in critically ill patients (specifically trauma patients).

Efficient use of nutrients

The gut is an organ designed to extract useful nutrients from the diet. The efficiency of nutrient reclamation is therefore always going to be better from enteric formulae than from parenteral supplements because parenteral supplements are formulated with limited knowledge of what the patient's requirements actually are. The delivery of glucose may be all wrong, for example (the patient did not want so much glucose). The absorption of amino acids is never going to lead to an excess Thus, one can expecty

More convenient than parenteral nutrition

There are several non-clinical advantages to enteric feeding when compared to pareneteral nutrition. Specifically, it is cheap and easy to use. Enteric formulae are easier to prepare: it does not have to be super-sterile, and this is reflected in its bargain cost. The gut is an organ designed to receive dirty fungus-encrusted bacterially contaminated food from the Olduvai savannah, and to decontaminate it, making it safe for use - one may therefore tolerate a certain bug content in one's enteric feeds. Stomach acid will take care of those. Moreover, EN does not require a central line to administer, which drives down cost even more (a central line costs substantially more than a nasogastric tube, not to mention the cost of the consumables and sterile line access).

Safer than parenteral nutrition

Not only is there no need for central line access (which reduces the risk of line-related complications), but the infecton risk associated with PN is also abolished. PN causes more infections because it is a very effective culture medium. Apart from this, there are many other complications associated with PN which (though non-life-threatening) are undesirable, such as fat overload, fatty liver, immune dysfunction due to intravenous lipids, hyperglycaemia due to hyperalimentation, and the normal anion gap metabolic acidosis which occurs when you metabolise all the lysine and leave the chloride behind.

The theoretical disadvantages of enteral nutrition

It is not all roses. The complications of enteral nutrition  are discussed in greater detail elsewhere. In brief:

  • Nasogastric tube insertion is not without its own complications
  • Enteric feeding will requently be stopped and started in ICU patients, leading to sub-optimal nutrition
  • Absorption from the gut cannot be relied upon
  • Gastric content may not propagate beyond the stomach (eg. ileus) -there is an aspiration risk
  • Attempts to establish exclusively enteral nutrition in a patient with poor feed tolerance delays the initiation of PN, and therefore negatively affects their nutrition.

Or, there may be actual hard contraindications:

  • There may be contraindications to nasogastric tube placement (eg. oesophageal trauma)
  • The gut may be ischaemic or damaged
  • The gut may be obstructed (NG drainage is required) or interrupted (eg. a recent anastomosis)
  • The transit time may be too fast (eg. infectious diarrhoea)

The influence of enteral vs. parenteral nutrition on ICU outcomes

There is no evidence for any mortality difference between enteral and parenteral nutrition

In spite of the abovenoted theoretical benefits of enteral nutrition (and the much-spoke-op evils of PN), nobody has ever been able to demonstrate that enteral nutrition has any sort of mortality benefit when compared to PN. Not only the recent CALORIES trial (Harvey et al, 2014) had failed to find any mortality difference: five different meta analysis articles agree on this. Seems like nutrition in general improves mortality, rather than the route of nutrition specifically. Alternatively, there may be specific groups who benefit from a specific approach to nutrition, and this is not obvious from the undifferentiated populations of large trials.

Some secondary outcomes are improved enteral nutrition

If not mortality, then length of stay, severity of SIRS, or perhaps risk of infection are affected. Evidence in support of this exists in specific patient groups.  Enteral nutrition is demonstrably better than TPN in the following ways and in the following settings:

  • In severe acute pancreatitis, where it appears to decrease the SIRS severity (apparently because of decreased bacterial translocation)
  • In abdominal trauma,where it seems to decrease the risk of infectious complications (probably also because of improved mucosal health)
  • In mechanically ventilated head injury, where it seems to improve return of cognitive function (throretically, because less gatsrointestinal bacterial translocation occurs, and therefore less encephalopathy is produced. Also, TPN tends to resul;t in hyperglycaemia, and we know this is bad for the head patients)



Rice, Todd W., et al. "A randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure." Critical care medicine 39.5 (2011): 967.

Heighes, Philippa T., Gordon S. Doig, and Fiona Simpson. "Timing and Indications for Enteral Nutrition in the Critically Ill." Nutrition Support for the Critically Ill. Springer International Publishing, 2016. 55-62.

McClave, Stephen A., et al. "Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)." Journal of Parenteral and Enteral Nutrition 40.2 (2016): 159-211.

Mentec, Hervé, et al. "Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications." Critical care medicine 29.10 (2001): 1955-1961.

Heyland, Daren K., et al. "Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients." Journal of Parenteral and Enteral nutrition 27.5 (2003): 355-373.

Montejo, J. C., et al. "Gastric residual volume during enteral nutrition in ICU patients: the REGANE study." Intensive care medicine 36.8 (2010): 1386-1393.

Poulard, Fanny, et al. "Impact of Not Measuring Residual Gastric Volume in Mechanically Ventilated Patients Receiving Early Enteral Feeding A Prospective Before–After Study." Journal of Parenteral and Enteral Nutrition 34.2 (2010): 125-130.

Desachy, Arnaud, et al. "Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients." Intensive care medicine 34.6 (2008): 1054-1059.

Juvé-Udina, Maria-Eulàlia, et al. "To return or to discard? Randomised trial on gastric residual volume management." Intensive and Critical Care Nursing 25.5 (2009): 258-267.

Bing, Guo. "Gastric residual volume management in critically ill mechanically ventilated patients: A literature review." Proceedings of Singapore Healthcare (2015): 2010105815598451.

Nguyen, Nam Q. "Pharmacological therapy of feed intolerance in the critically ills." World journal of gastrointestinal pharmacology and therapeutics 5.3 (2014): 148.

Marino, L. V., et al. "To determine the effect of metoclopramide on gastric emptying in severe head injuries: a prospective, randomized, controlled clinical trial." British journal of neurosurgery 17.1 (2003): 24-28.

Nguyen, Nam Q., et al. "Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness*." Critical care medicine 35.2 (2007): 483-489.

Fraser, R. J., A. M. Deane, and Marianne J. Chapman. "Prokinetic drugs for feed intolerance in critical illness: current and potential therapies." Critical Care and Resuscitation 11.2 (2009): 132.

Singer, Pierre, et al. "ESPEN guidelines on parenteral nutrition: intensive care." Clinical nutrition 28.4 (2009): 387-400.

van Zanten, Arthur RH, et al. "Enteral glutamine supplementation in critically ill patients: a systematic review and meta-analysis." Critical Care 19.1 (2015): 1-16.

Oldani, Massimo, et al. "Glutamine Supplementation in Intensive Care Patients: A Meta-Analysis of Randomized Clinical Trials." Medicine 94.31 (2015).

Wernerman, Jan. "How to understand the results of studies of glutamine supplementation." Critical Care 19.1 (2015): 1-3.

van Zanten, Arthur RH, Zandrie Hofman, and Daren K. Heyland. "Consequences of the REDOXS and METAPLUS Trials The End of an Era of Glutamine and Antioxidant Supplementation for Critically Ill Patients?." Journal of Parenteral and Enteral Nutrition (2015): 0148607114567201.

Heyland, Daren, et al. "A randomized trial of glutamine and antioxidants in critically ill patients." New England Journal of Medicine 368.16 (2013): 1489-1497.

Van Zanten, Arthur RH, et al. "High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial." Jama 312.5 (2014): 514-524.

Ridley, Emma, Dashiell Gantner, and Vincent Pellegrino. "Nutrition therapy in critically ill patients-a review of current evidence for clinicians." Clinical Nutrition 34.4 (2015): 565-571.

Singer, Pierre, et al. "The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients." Intensive care medicine 37.4 (2011): 601-609.

Casaer, Michael P., et al. "Early versus late parenteral nutrition in critically ill adults." N Engl J Med 365.6 (2011): 506-517.

Heidegger, Claudia Paula, et al. "Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial." The Lancet 381.9864 (2013): 385-393.

Doig, Gordon S., et al. "Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial." Jama 309.20 (2013): 2130-2138.

Davies, Andrew R., et al. "A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness*." Critical care medicine 40.8 (2012): 2342-2348.

Harvey, Sheila E., et al. "Trial of the route of early nutritional support in critically ill adults." New England Journal of Medicine 371.18 (2014): 1673-1684.

Andrews, Peter JD, et al. "Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients." Bmj 342 (2011): d1542.

Vassilyadi, Frank, Alkistis-Kira Panteliadou, and Christos Panteliadis. "Hallmarks in the History of Enteral and Parenteral Nutrition From Antiquity to the 20th Century." Nutrition in Clinical Practice 28.2 (2013): 209-217.