Which Critically Ill Patients Are More Susceptible to the Adverse Effects Associated with Feeding Intolerance? A Secondary Analysis of a Cluster-Randomized Controlled Trial

Why It Matters

Identifying patients at heightened risk of FI can guide more aggressive nutrition monitoring and protocol adjustments, potentially improving survival and resource utilization in intensive care units.

Key Takeaways

• FI increased 28‑day mortality after adjustment.
• Elderly, normal BMI, respiratory diagnosis, low SOFA showed higher risk.
• FI patients received significantly less calories and protein.
• Longer ICU stay and fewer ventilator‑free days linked to FI.
• Findings require caution due to multiple‑testing adjustments.

Pulse Analysis

Feeding intolerance remains a common obstacle in delivering early enteral nutrition to critically ill patients, with roughly half experiencing gastrointestinal symptoms or inadequate caloric intake within the first three days. International guidelines advocate prompt enteral feeding, yet the delicate balance between achieving nutritional goals and avoiding intolerance‑related complications continues to challenge intensivists. Understanding the epidemiology of FI and its downstream effects is essential for optimizing ICU nutrition strategies and reducing preventable morbidity.

The post‑hoc evaluation of the NEED cluster‑randomized trial, encompassing 1,545 patients, revealed that FI was independently associated with a 37% increase in 28‑day mortality after adjusting for age, BMI, SOFA score, and other confounders. Patients with FI also received markedly fewer calories (≈ 785 kcal vs 1,232 kcal) and protein, translating into longer ICU stays and fewer ventilator‑free days. Subgroup signals indicated that older adults, individuals with a normal body mass index, those admitted for respiratory illnesses, and patients with relatively low organ‑failure scores were disproportionately affected, suggesting that physiological reserve and disease‑specific pathways may modulate FI’s impact.

Clinicians should therefore prioritize early identification of FI, especially in the highlighted high‑risk cohorts, by employing systematic GI monitoring and adaptive feeding protocols. Tailoring nutrient delivery—such as using prokinetic agents, adjusting infusion rates, or considering post‑pyloric placement—could mitigate the caloric deficits observed. Future research must validate predictive models for FI and test targeted interventions in randomized settings to confirm whether mitigating intolerance can translate into measurable survival benefits and more efficient ICU resource use.