Early enteral nutrition for cardiogenic or obstructive shock requiring venoarterial extracorporeal membrane oxygenation: a nationwide inpatient database study
Despite extensive research on enteral nutrition (EN) for patients in shock, it remains unclear whether this should be postponed in patients with cardiogenic or obstructive shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). In this study, we aimed to compare outcomes of early and delayed EN for patients with cardiogenic or obstructive shock requiring VA-ECMO.
In this retrospective database study drawing on the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2016, we identified patients with cardiogenic or obstructive shock who had received VA-ECMO for more than 2 days. We allocated the patients to two groups: those who received EN within 2 days (early) or 3 days or more (delayed) after starting VA-ECMO. We then used a marginal structural model to analyze associations between early EN and various outcomes, including in-hospital mortality and 28-day mortality.
We identified 1769 eligible patients during the 69-month study period, 220 of whom (12%) received early EN. After using a marginal structural model to adjust for baseline and time-dependent confounders, we found that the early EN group showed significantly lower in-hospital mortality [hazard ratio 0.78, 95% confidence interval (95% CI) 0.62–0.98, P = 0.032] and lower 28-day mortality (hazard ratio 0.74, 95% CI 0.56–0.97, P = 0.031) than the delayed EN group.
According to this retrospective database study, early EN is not associated with harm but rather with lower mortality in patients with cardiogenic or obstructive shock requiring at least 2 days of VA-ECMO.
KeywordsEnteral nutrition Extracorporeal membrane oxygenation Venoarterial Bowel ischemia Marginal structural model
This work was supported by grants from the Ministry of Health, Labour and Welfare of Japan (H29-Policy-Designated-009 and H29-ICT-General-004); Ministry of Education, Culture, Sports, Science and Technology of Japan (17H04141); and Japan Agency for Medical Research and Development.
Compliance with ethical standards
Conflicts of interest
All authors declare that they do not have any conflicts of interest.
- 2.Aso S, Matsui H, Fushimi K, Yasunaga H (2016) In-hospital mortality and successful weaning from venoarterial extracorporeal membrane oxygenation: analysis of 5263 patients using a national inpatient database in Japan. Crit Care 20:80. https://doi.org/10.1186/s13054-016-1261-1 CrossRefPubMedPubMedCentralGoogle Scholar
- 4.Reignier J, Boisrame-Helms J, Brisard L et al (2018) Enteral versus parenteral early nutrition in ventilated adults with shock: randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet 13(391):133–143. https://doi.org/10.1016/s0140-6736(17)32146-3 CrossRefGoogle Scholar
- 8.Umezawa Makikado LD, Flordelis Lasierra JL, Perez-Vela JL, Colino Gómez L, Torres Sánchez E, Maroto Rodríguez B, Arribas López P, Montejo González JC (2013) Early enteral nutrition in adults receiving venoarterial extracorporeal membrane oxygenation: an observational case series. JPEN J Parenter Enter Nutr 37:281–284. https://doi.org/10.1177/0148607112451464 CrossRefGoogle Scholar
- 15.Doig G, Heighes P, Simpson F, Sweetman E, Davies A (2015) Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med 35:2018–2027CrossRefGoogle Scholar
- 18.Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V (2011) Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 173:676–682. https://doi.org/10.1093/aje/kwq433 CrossRefPubMedGoogle Scholar
- 29.Zhao L, Luo L, Chen J, Xiao J, Jia W, Xiao Y (2014) Utilization of extracorporeal membrane oxygenation alleviates intestinal ischemia-reperfusion injury in prolonged hemorrhagic shock animal model. Cell Biochem Biophys 70:1733–1740. https://doi.org/10.1007/s12013-014-0121-3 CrossRefPubMedGoogle Scholar