The NUTRIREA-2 study - Authors' reply

[...]we agree that the unblinded study design could have caused detection bias. Whether the enteral feeding route and the enteral-nutrition calorie target could have beneficial or deleterious effects on the gut mucosa of critically ill patients with shock is unclear.4,5 Current guidelines recommend prokinetic drug therapy of gastroparesis before lowering the calorie target in patients intolerant to early enteral nutrition.6 Lastly, we disagree with Alessio Molfino and Alessandro Laviano's suggestion that some patients in the enteral nutrition group could have had contraindications to enteral feeding, thus explaining the higher frequency of bowel ischaemia in this group compared with the parenteral nutrition group. The European Society for Clinical Nutrition and Metabolism guidelines6 on supplemental parenteral nutrition were supported only by low-level evidence and have been contradicted by the EPaNIC trial results.7 The possibility that enteral nutrition might decrease the risk of infectious and non-infectious complications compared with parenteral nutrition is not supported by the results of the NUTRIREA-2 and CALORIES trials.