A critically ill mechanically ventilated patient in the surgical ICU cannot tolerate enteral nutrition due to high gastric residual volumes. On day 4, a decision about parenteral nutrition (PN) is being made. According to the EPANIC (Early Parenteral Nutrition) trial findings, what is the most evidence-based approach?

• A Early PN on day 1 is mandatory to prevent protein-energy deficit and muscle wasting
• B Late initiation of PN (day 8) is associated with fewer ICU-acquired infections, faster weaning, and lower mortality compared to early PN ✓
• C Supplemental PN should commence on day 4 to supplement inadequate enteral intake
• D Immediate PN is preferred for surgical patients with pre-existing malnutrition

Explanation

The EPANIC trial (Casaer et al., NEJM 2011) randomised >4,600 ICU patients to early PN (started day 2 if EN insufficient) versus late PN (withholding PN until day 8, with glucose infusion only). Late PN was associated with significantly fewer ICU infections, faster rehabilitation and weaning from mechanical ventilation, lower rates of cholestasis, and a 1.9-day reduction in ICU stay. The trial demonstrated that the autophagic response (cellular self-cleaning) during the first week is protective and should not be suppressed by early PN. Late PN is now endorsed by ESPEN guidelines for ICU patients who are not severely malnourished on admission.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.