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Delaying total parenteral nutrition improved outcomes (RCT)
The best approach to nutrition during critical illness is unknown. Casaer et al randomized 4,640 critically-ill patients who could not get enough calories by enteral feeding to receive TPN either on ICU day 3, or to wait until ICU day 8. While waiting for their TPN in the late group, patients got calories in sugar water along with liquid vitamins and minerals. There were no differences in survival at 90 days between the groups. Those in the delayed-TPN group had a 3% absolute reduction in ICU infections and a median 3 fewer days on dialysis/CRRT. They had a barely-detectable (but statistically significant) shorter time to discharge from the ICU and hospital. However, because few ICUs have access to the liquid preparation they used in this European trial, it's hard to make a definite conclusion on equivalency and extrapolate the findings to clinical practice in the U.S. (n=4,640) NEJM 2011;June 29 online.