Heidegger, C.-P

Pichard, C.

Romand, J.-A

Treggiari, M.

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Intensive Care Med (2007) 33:1857DOI 10.1007/s00134-007-0807-8 C O R R E S P O N D E N C EC.-P. HeideggerJ.-A. RomandM. M. TreggiariC. PichardReply to the commentsby Drs. Marik and Emeryand Dr. SingerAccepted: 4 July 2007Published online: 1 August 2007© Springer-Verlag 2007This reply refers to the commentsavailable at: http://dx.doi.org/10.1007/s00134-007-0805-x and http://dx.doi.org/10.1007/s00134-007-0806-9.Sir: We would to like to thank Dr.Singer for his correspondence. Thepoint is extremely well taken, andwe share the view that accuratelymeasuring metabolic expendituresis an important goal. We want toemphasize the lack of randomizedcontrolled trials demonstrating theeffectiveness of this approach in thecritical care setting. Although it istrue that the caloric targets may beinaccurate based on prediction for-mulas instead of measurement withcalorimetry, it is very common incritically ill patients to lag behindfor several days before achievingan adequate caloric intake, and inmost cases a caloric deficit develops.Therefore even if the caloric goalis not established precisely, the riskof underfeeding is particularly highat least in the first few days afteradmission to the ICU. With the useof supplemental nutrition particularattention should be paid to preventexcessive caloric intake.We also thank Drs. Marik andEmery for their commentary. It seemsthat in fact their views and ours arevery close. As the authors mention,the Canadian guidelines recommendto maximize the EN before adminis-trating PN, and this is exactly what wepropose in our clinical commentary(see Fig. 1). Indeed, we recommendthat supplemental PN be consideredonly if protein and calorie targets arenot reached by the enteral route atday 4. This proposal is also in linewith the recently published ESPENguidelines (Clinical Nutrition, 2006).The various studies cited in favorof “permissive underfeeding” aredefinitively not in line with the rec-ommendations mentioned above.Many studies have demonstratedthat the ICU patient population isat greater risk of underfeeding than“eufeeding”, and in our opiniontargeting prolonged underfeedingmust not be a recommendation inthis population. Finally, and this isprobably the most important point,we have also mentioned that a wellconducted prospective clinical trial isneeded to confirm this approach ofcombined nutrition.C.-P. Heidegger () · J.-A. Romand ·M. M. TreggiariGeneva University Hospital, Service ofIntensive Care,Rue Micheli-du-Crest 24, 1211 Geneva 14,Switzerlande-mail: claudia-paula.heidegger@hcuge.chTel.: +41-22-3827460Fax: +41-22-3827470C. PichardGeneva University Hospital, ClinicalNutrition,1211 Geneva 14, Switzerland

Reply to the comments by Drs. Marik and Emery and Dr. Singer

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Reply to the comments by Drs. Marik and Emery and Dr. Singer

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