Thursday, June 30, 2011

Less is more. Conventional wisdom challenged in two NEJM articles


Classical views on fluid resuscitation and nutrition in critically ill patients were questioned in two papers published today in the New England Journal of Medicine.

A large study involving febrile, under-perfused children in Africa reveals that those aggressively resuscitated with fluid boluses of either saline or albumin had higher mortality rates than a control group who were not given boluses of fluid. The study was stopped earlier than planned when the research group’s data and safety monitoring committee performed an interim analysis. This paper adds to a growing body of research that shows that large-volume fluid resuscitation may be harmful in many situations.

A second article demonstrated that in some 4600 critically ill patients given enteral nutrition, late (day 8 of ICU admission) initiation of parenteral nutrition to supplement the enteral nutrition and achieve caloric goals leads to fewer complications and faster discharge from the ICU than patients whose parenteral nutrition was started within 48 hours of their ICU stay.

The papers are accompanied by editorials (here and here) that provide perspective and as usual caution against overly interpreting the results.

Although the messages seem quite clear (especially regarding large-volume fluid resuscitation), clinicians should read both papers and decide for themselves.

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