Intensive Care Medicine

, Volume 41, Issue 5, pp 875–886 | Cite as

Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study

  • Jean Reignier
  • Michael Darmon
  • Romain Sonneville
  • Anne-Laure Borel
  • Maité Garrouste-Orgeas
  • Stéphane Ruckly
  • Bertrand Souweine
  • Anne-Sylvie Dumenil
  • Hakim Haouache
  • Christophe Adrie
  • Laurent Argaud
  • Lilia Soufir
  • Guillaume Marcotte
  • Virginie Laurent
  • Dany Goldgran-Toledano
  • Christophe Clec’h
  • Carole Schwebel
  • Elie Azoulay
  • Jean-François Timsit



Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.


In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.


We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81–0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66–0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89–1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00–1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27–8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78–0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00–1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.


In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.


Critical illness Mechanical ventilation Parenteral Enteral Early nutrition 



We are indebted to A. Wolfe, MD, for assistance in preparing and reviewing the manuscript. We are grateful to all staff physicians, staff nurses and research nurses at the study sites for their crucial contribution to the successful conduct of the study.

Conflicts of interest

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflict of Interest and none reported any such conflict.


The study was funded by the non-profit OutcomeRea network. The OutcomeRea network took full administrative responsibility for data management, analysis and interpretation; and for manuscript preparation, review and approval.

Supplementary material

134_2015_3730_MOESM1_ESM.doc (294 kb)
Supplementary material 1 (DOC 294 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Jean Reignier
    • 1
    • 2
    • 20
  • Michael Darmon
    • 3
  • Romain Sonneville
    • 4
  • Anne-Laure Borel
    • 5
  • Maité Garrouste-Orgeas
    • 6
    • 7
  • Stéphane Ruckly
    • 7
  • Bertrand Souweine
    • 8
  • Anne-Sylvie Dumenil
    • 9
  • Hakim Haouache
    • 10
  • Christophe Adrie
    • 11
  • Laurent Argaud
    • 12
  • Lilia Soufir
    • 6
  • Guillaume Marcotte
    • 13
  • Virginie Laurent
    • 14
  • Dany Goldgran-Toledano
    • 15
  • Christophe Clec’h
    • 14
  • Carole Schwebel
    • 16
  • Elie Azoulay
    • 17
  • Jean-François Timsit
    • 7
    • 18
    • 19
  1. 1.Medical-Surgical Intensive Care UnitCHD de la VendéeLa Roche-sur-YonFrance
  2. 2.EA 3826 “Clinical and Experimental Treatments for Infections”University of MedicineNantesFrance
  3. 3.Medical Intensive Care UnitSaint Etienne University HospitalSt EtienneFrance
  4. 4.Medical Intensive Care UnitBichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP)ParisFrance
  5. 5.Endocrinology DepartmentGrenoble University HospitalGrenobleFrance
  6. 6.Medical-Surgical Intensive Care UnitSaint Joseph HospitalParisFrance
  7. 7.INSERM, IAME, UMR 1137,Team DesCIDParisFrance
  8. 8.Medical Intensive Care UnitGabriel Montpied University HospitalClermont-FerrandFrance
  9. 9.Medical-Surgical Intensive Care UnitAntoine Béclère University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP)ClamartFrance
  10. 10.Surgical Intensive Care UnitHenri Mondor University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP)CréteilFrance
  11. 11.Physiology DepartmentCochin University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne CiteParisFrance
  12. 12.Medical Intensive Care UnitLyon University HospitalLyonFrance
  13. 13.Surgical Intensive Care UnitEdouard Herriot University HospitalLyonFrance
  14. 14.Medical-Surgical Intensive Care UnitAndré Mignot HospitalVersailles-Le ChesnayFrance
  15. 15.Medical-Surgical Intensive Care UnitGonesse HospitalGonesseFrance
  16. 16.Medical Intensive Care UnitMichalon University HospitalGrenobleFrance
  17. 17.Medical Intensive Care Unit, AP-HPSaint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP)ParisFrance
  18. 18.Medical Intensive Care Unit, AP-HPBichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP)ParisFrance
  19. 19.Paris Diderot University, IAME, UMR 1137, Sorbonne Paris CitéParisFrance
  20. 20.Service de ReanimationCentre Hospitalier Départemental de la VendéeLa Roche-sur-YonFrance

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