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their active involvement in the field as supported by their
educational, research, or professional committee involvement in pharmacy nutrition support, particularly in the
American Society for Parenteral and Enteral Nutrition. Six
author participants are board certified in pharmacy nutrition
support, whereas 2 are not certified in pharmacy nutrition
support but are certified in areas (e.g., critical care and pediatrics) whereby nutrition support is part of their practice. The
duration of individual practice experience of the authors
ranges from 4 years to more than 30 years post-training.
Members of this authorship group have advanced practice
roles with direct patient care responsibilities for prescribing
parenteral nutrition (PN) and/or enteral nutrition (EN), laboratory analysis, and pharmacotherapy integrated with nutrition therapy (e.g., fluid and electrolytes, vitamins, trace
elements, prokinetic drugs, insulin, antidiarrheal and laxative therapy), and some have administrative or supervisory
roles with respect to nutrition support therapy. This authorship group has a broad range of practice experiences. Most
authors are acute care based, but some have long-term care
(home PN and EN) responsibilities. Current practices of the
group range from pediatrics to geriatrics. Some members
have a diverse patient population, whereas others practice
within a focused patient population (e.g., pediatrics, oncology, and trauma/thermal injury).
The author participants were asked by the corresponding author to identify articles published from January
2018 to December 2018 that resulted in a change or affirmation of their current clinical practice or that they considered to be important for future clinical practice. Some
authors collated papers read from their personal journal
subscriptions, organizational membership newsletters, or
institutional-based journal clubs. Others included those
articles retrieved from an online search strategy. The article was considered important if at least 5 of 8 participants
voted for a paper to be of high priority in its relevance to
pharmacy nutrition support practice. From this scoring
system, a culled list of the most important articles was
created. The sorting and ranking process for the articles is
depicted by Figure 1.

Results
A total of 117 articles were collectively collated for initial
evaluation by the authorship group. An average of 25 papers
(range: 17-39) were denoted as significant by individual
members of the author group. According to a majority consensus vote, 8 papers from the primary literature collective
were identified as the most important for pharmacy nutrition
support practice.6-13 An additional 13 articles comprising
organizational guidelines, consensus, recommendation, and
position papers included separately as important papers to
our practice.14-26 Of these 21 finalist publications, 5 were
published in Journal of Parenteral and Enteral Nutrition, 4

Hospital Pharmacy 54(5)
in Clinical Nutrition, 3 in Anesthesia & Analgesia, 2 in
Nutrition in Clinical Practice, and 2 in New England Journal
of Medicine. The remaining 5 papers were from 5 different
journals. Individual rankings, based on relevancy to pharmacy nutrition support clinical practice according to the
author participant group, are given in Table 1. The finalist
articles from the primary literature are summarized in the
discussion along with a narrative regarding their implications for pharmacy nutrition support practice. A list of guidelines, position, recommendation, and consensus papers from
organizational societies is provided in Table 2. A total of 96
citations from the primary literature that received a cumulative of 4 votes or fewer as significant by the group are provided in an online supplement.

Discussion
1.

Reignier et al6: Enteral versus parenteral early nutrition in ventilated adults with shock: a randomized,
controlled, multicentre, open-label, parallel-group
study (NUTRIREA-2).

NUTRIREA-2 is the first study to evaluate outcomes
associated with early enteral nutrition (EEN) versus PN in
severe critical illness. In this randomized, controlled,
multicenter, open-label, parallel-group study, 2 410
patients met inclusion criteria (≥18 years of age, admitted
to the intensive care unit [ICU], expected to require ≥48
hours of mechanical ventilation concomitantly with vasoactive therapy for shock, initiated on nutrition support
within 24 hours after endotracheal intubation or within 24
hours after ICU admission if intubation occurred before
ICU admission). Patients were randomized to receive normocaloric goals (20-25 kcal/kg/day) via EN (n = 1 202)
or PN (n = 1 208). Greater than 90% of the population had
a medical diagnosis at admission. EEN compared with PN
did not reduce day 28 mortality (37% vs 35%, p = 0.33)
or ICU-acquired infections (14% vs 16%, p = 0.25) but
was associated with a greater risk for gastrointestinal
complications, including bowel ischemia (19 [2%] vs 5
[<1%], p = 0.007).
In contrast to current guidelines, this study did not show
a benefit for early feeding with EN over PN in severe critical illness.27 The lack of difference in mortality and secondary infections between EN and PN in this study likely
reflects improvements in PN management and infection prevention. Historically, PN administration may have resulted
in unfavorable outcomes because of clinical practices that
are now known to be suboptimal.28 However, given the similar outcomes and economic considerations, early EN should
continue to be used when feasible. With the alarming finding that concomitant EN and vasopressors resulted in 19
cases of bowel ischemia, close monitoring of tolerance is
warranted. This prevalence of bowel ischemia may have

Hospital Pharmacy - October 2019

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