Topic: Systematic Review, Meta-analysis, or Meta-synthesis
Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials
Alshamsi, Fayez1; Utgikar, Rucha2; Mcintyre, Lauralyn3; Rhodes, Andrew4; Evans, Laura5; Almenawer, Saleh6,7; Angus, Derek C; Alhazzani, Waleed2,6,9
1Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 3Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Intensive Care Medicine, St George’s Hospital, United Kingdom; 5Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, USA; 6Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 7Department of Surgery, McMaster University, Hamilton, Ontario, Canada; 8Department of Critical Care Medicine, University of Pittsburgh School of Medicine, USA; 9Department of Critical Care, St Joseph’s Healthcare, Hamilton, Ontario, Canada
Abstract:
Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population can be associated with worse outcomes. Enteral feeding is associated with a high rate of gastrointestinal intolerance, which may increase the risk of aspiration, pneumonia, and interruption of feeding.
Objectives: We updated our systematic review and meta-analysis to compare the effects of small bowel and gastric feeding (SBF and GF) on risk of pneumonia, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS), gastrointestinal bleeding, aspiration, vomiting and mortality.
Methods: We searched MEDLINE, EMBASE, and clinical registries for data through May 2016 without language or date of publication restrictions. We included randomized clinical trials (RCTs) reporting on outcomes of interest in patients receiving enteral nutrition via post pyloric or gastric feeding in the ICU. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the GRADE method to assess the quality of the evidence.
Results: We included 21 RCTs enrolling 1570 patients in total. SBF reduced the risk of nosocomial pneumonia when compared with GF (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2= 11%; moderate quality) and ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P=0.02; I2=10%, moderate quality). SBF was associated with a shortened duration of MV (mean difference [MD] -2.10 days, 95% CI -3.93, -0.28; P=0.02; I2=67%, moderate quality). There was no difference between groups in the risk of death (RR 1.08, 95% CI 0.91, 1.28; P=0.39; I2=0%, moderate quality), ICU length of stay (MD -1.01 days, 95% -3.32, 1.3; P=0.39; I2=84%, low quality), aspiration, (RR 0.82, 95% CI 0.41, 1.65, P=0.57; I2=23%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P=0.87; I2=33%, very low quality) and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P=0.56; I2=0%, very low quality). While meta-analysis was not possible for nutritional outcomes due to variations in reporting the outcomes, mean daily caloric intake was significantly higher in the SBF group in four trials (n=307) and similar to GF in three trials (n=185). Four trials (n=385) reported time to reach target caloric intake, which was significantly longer in SBF.
Conclusions:
Moderate quality evidence showed that SBF may reduce the risk of pneumonia and VAP compared to GF, with no significant impact on other outcomes. The use of SBF should be reserved for patients at high risk of aspiration in the ICU.
References:
1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
2. Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370(13):1227-1236.
3. Alhazzani W, Almasoud A, Jaeschke R, et al. Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials. Critical Care (London, England). 2013;17(4):R127.
4. Acosta-Escribano J, Fernandez-Vivas M, Grau Carmona T, et al. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Med. 2010;36(9):1532-1539.
5. Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med. 2001;29(10):1916-1919.
6. Davies AR, Froomes PR, French CJ, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med. 2002;30(3):586-590.
7. Davies AR, Morrison SS, Bailey MJ, et al. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med. 2012;40(8):2342-2348.
8. Day L, Stotts NA, Frankfurt A, et al. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. J Neurosci Nurs. 2001;33(3):148-149, 155-149.
9. Eatock FC, Chong P, Menezes N, et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100(2):432-439.
10. Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med. 2001;27(4):660-664.
11. Friedman G, Flavia Couto CL, Becker M. Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying. Indian Journal of Critical Care Medicine. 2015;19(2):71-75.
12. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29(8):1495-1501.
13. Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med. 2009;37(6):1866-1872.
14. Huang HH, Chang SJ, Hsu CW, Chang TM, Kang SP, Liu MY. Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. J Acad Nutr Diet. 2012;112(8):1138-1146.
15. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28(6):1742-1746.
16. Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma. 1999;46(6):992-996; discussion 996-998.
17. Kumar A, Singh N, Prakash S, Saraya A, Joshi YK. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol. 2006;40(5):431-434.
18. Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med. 1992;20(10):1377-1387.
19. Montejo JC, Grau T, Acosta J, et al. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med. 2002;30(4):796-800.
20. Neumann DA, DeLegge MH. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med. 2002;30(7):1436-1438.
21. Singh N, Sharma B, Sharma M, et al. Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial. Pancreas. 2012;41(1):153-159.
22. Wan B, Fu H, Yin J. Early jejunal feeding by bedside placement of a nasointestinal tube significantly improves nutritional status and reduces complications in critically ill patients versus enteral nutrition by a nasogastric tube. Asia Pac J Clin Nutr. 2015;24(1):51-57.
23. White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009;13(6):R187.
24. Zeng RC, Jiang FG, Xie Q. Comparison of nose jejunal tube and nasogastric tube in providing early enteral nutrition for patients with severe craniocerebral injury. [Chinese]. 2010(1674-635X)
Document: File 1 File 2 File 3
Topic: Systematic Review, Meta-analysis, or Meta-synthesis
Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials
Alshamsi, Fayez1; Utgikar, Rucha2; Mcintyre, Lauralyn3; Rhodes, Andrew4; Evans, Laura5; Almenawer, Saleh6,7; Angus, Derek C; Alhazzani, Waleed2,6,9
1Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 3Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Intensive Care Medicine, St George’s Hospital, United Kingdom; 5Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, USA; 6Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 7Department of Surgery, McMaster University, Hamilton, Ontario, Canada; 8Department of Critical Care Medicine, University of Pittsburgh School of Medicine, USA; 9Department of Critical Care, St Joseph’s Healthcare, Hamilton, Ontario, Canada
Abstract:
Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population can be associated with worse outcomes. Enteral feeding is associated with a high rate of gastrointestinal intolerance, which may increase the risk of aspiration, pneumonia, and interruption of feeding.
Objectives: We updated our systematic review and meta-analysis to compare the effects of small bowel and gastric feeding (SBF and GF) on risk of pneumonia, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS), gastrointestinal bleeding, aspiration, vomiting and mortality.
Methods: We searched MEDLINE, EMBASE, and clinical registries for data through May 2016 without language or date of publication restrictions. We included randomized clinical trials (RCTs) reporting on outcomes of interest in patients receiving enteral nutrition via post pyloric or gastric feeding in the ICU. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the GRADE method to assess the quality of the evidence.
Results: We included 21 RCTs enrolling 1570 patients in total. SBF reduced the risk of nosocomial pneumonia when compared with GF (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2= 11%; moderate quality) and ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P=0.02; I2=10%, moderate quality). SBF was associated with a shortened duration of MV (mean difference [MD] -2.10 days, 95% CI -3.93, -0.28; P=0.02; I2=67%, moderate quality). There was no difference between groups in the risk of death (RR 1.08, 95% CI 0.91, 1.28; P=0.39; I2=0%, moderate quality), ICU length of stay (MD -1.01 days, 95% -3.32, 1.3; P=0.39; I2=84%, low quality), aspiration, (RR 0.82, 95% CI 0.41, 1.65, P=0.57; I2=23%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P=0.87; I2=33%, very low quality) and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P=0.56; I2=0%, very low quality). While meta-analysis was not possible for nutritional outcomes due to variations in reporting the outcomes, mean daily caloric intake was significantly higher in the SBF group in four trials (n=307) and similar to GF in three trials (n=185). Four trials (n=385) reported time to reach target caloric intake, which was significantly longer in SBF.
Conclusions:
Moderate quality evidence showed that SBF may reduce the risk of pneumonia and VAP compared to GF, with no significant impact on other outcomes. The use of SBF should be reserved for patients at high risk of aspiration in the ICU.
References:
1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
2. Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370(13):1227-1236.
3. Alhazzani W, Almasoud A, Jaeschke R, et al. Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials. Critical Care (London, England). 2013;17(4):R127.
4. Acosta-Escribano J, Fernandez-Vivas M, Grau Carmona T, et al. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Med. 2010;36(9):1532-1539.
5. Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med. 2001;29(10):1916-1919.
6. Davies AR, Froomes PR, French CJ, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med. 2002;30(3):586-590.
7. Davies AR, Morrison SS, Bailey MJ, et al. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med. 2012;40(8):2342-2348.
8. Day L, Stotts NA, Frankfurt A, et al. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. J Neurosci Nurs. 2001;33(3):148-149, 155-149.
9. Eatock FC, Chong P, Menezes N, et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100(2):432-439.
10. Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med. 2001;27(4):660-664.
11. Friedman G, Flavia Couto CL, Becker M. Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying. Indian Journal of Critical Care Medicine. 2015;19(2):71-75.
12. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29(8):1495-1501.
13. Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med. 2009;37(6):1866-1872.
14. Huang HH, Chang SJ, Hsu CW, Chang TM, Kang SP, Liu MY. Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. J Acad Nutr Diet. 2012;112(8):1138-1146.
15. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28(6):1742-1746.
16. Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma. 1999;46(6):992-996; discussion 996-998.
17. Kumar A, Singh N, Prakash S, Saraya A, Joshi YK. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol. 2006;40(5):431-434.
18. Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med. 1992;20(10):1377-1387.
19. Montejo JC, Grau T, Acosta J, et al. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med. 2002;30(4):796-800.
20. Neumann DA, DeLegge MH. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med. 2002;30(7):1436-1438.
21. Singh N, Sharma B, Sharma M, et al. Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial. Pancreas. 2012;41(1):153-159.
22. Wan B, Fu H, Yin J. Early jejunal feeding by bedside placement of a nasointestinal tube significantly improves nutritional status and reduces complications in critically ill patients versus enteral nutrition by a nasogastric tube. Asia Pac J Clin Nutr. 2015;24(1):51-57.
23. White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009;13(6):R187.
24. Zeng RC, Jiang FG, Xie Q. Comparison of nose jejunal tube and nasogastric tube in providing early enteral nutrition for patients with severe craniocerebral injury. [Chinese]. 2010(1674-635X)
Document: File 1 File 2 File 3
Topic: Systematic Review, Meta-analysis, or Meta-synthesis
Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials
Alshamsi, Fayez1; Utgikar, Rucha2; Mcintyre, Lauralyn3; Rhodes, Andrew4; Evans, Laura5; Almenawer, Saleh6,7; Angus, Derek C; Alhazzani, Waleed2,6,9
1Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 3Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Intensive Care Medicine, St George’s Hospital, United Kingdom; 5Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, USA; 6Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 7Department of Surgery, McMaster University, Hamilton, Ontario, Canada; 8Department of Critical Care Medicine, University of Pittsburgh School of Medicine, USA; 9Department of Critical Care, St Joseph’s Healthcare, Hamilton, Ontario, Canada
Abstract:
Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population can be associated with worse outcomes. Enteral feeding is associated with a high rate of gastrointestinal intolerance, which may increase the risk of aspiration, pneumonia, and interruption of feeding.
Objectives: We updated our systematic review and meta-analysis to compare the effects of small bowel and gastric feeding (SBF and GF) on risk of pneumonia, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS), gastrointestinal bleeding, aspiration, vomiting and mortality.
Methods: We searched MEDLINE, EMBASE, and clinical registries for data through May 2016 without language or date of publication restrictions. We included randomized clinical trials (RCTs) reporting on outcomes of interest in patients receiving enteral nutrition via post pyloric or gastric feeding in the ICU. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the GRADE method to assess the quality of the evidence.
Results: We included 21 RCTs enrolling 1570 patients in total. SBF reduced the risk of nosocomial pneumonia when compared with GF (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2= 11%; moderate quality) and ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P=0.02; I2=10%, moderate quality). SBF was associated with a shortened duration of MV (mean difference [MD] -2.10 days, 95% CI -3.93, -0.28; P=0.02; I2=67%, moderate quality). There was no difference between groups in the risk of death (RR 1.08, 95% CI 0.91, 1.28; P=0.39; I2=0%, moderate quality), ICU length of stay (MD -1.01 days, 95% -3.32, 1.3; P=0.39; I2=84%, low quality), aspiration, (RR 0.82, 95% CI 0.41, 1.65, P=0.57; I2=23%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P=0.87; I2=33%, very low quality) and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P=0.56; I2=0%, very low quality). While meta-analysis was not possible for nutritional outcomes due to variations in reporting the outcomes, mean daily caloric intake was significantly higher in the SBF group in four trials (n=307) and similar to GF in three trials (n=185). Four trials (n=385) reported time to reach target caloric intake, which was significantly longer in SBF.
Conclusions:
Moderate quality evidence showed that SBF may reduce the risk of pneumonia and VAP compared to GF, with no significant impact on other outcomes. The use of SBF should be reserved for patients at high risk of aspiration in the ICU.
References:
1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
2. Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370(13):1227-1236.
3. Alhazzani W, Almasoud A, Jaeschke R, et al. Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials. Critical Care (London, England). 2013;17(4):R127.
4. Acosta-Escribano J, Fernandez-Vivas M, Grau Carmona T, et al. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Med. 2010;36(9):1532-1539.
5. Boivin MA, Levy H. Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill. Crit Care Med. 2001;29(10):1916-1919.
6. Davies AR, Froomes PR, French CJ, et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med. 2002;30(3):586-590.
7. Davies AR, Morrison SS, Bailey MJ, et al. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med. 2012;40(8):2342-2348.
8. Day L, Stotts NA, Frankfurt A, et al. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. J Neurosci Nurs. 2001;33(3):148-149, 155-149.
9. Eatock FC, Chong P, Menezes N, et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100(2):432-439.
10. Esparza J, Boivin MA, Hartshorne MF, Levy H. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med. 2001;27(4):660-664.
11. Friedman G, Flavia Couto CL, Becker M. Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying. Indian Journal of Critical Care Medicine. 2015;19(2):71-75.
12. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29(8):1495-1501.
13. Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med. 2009;37(6):1866-1872.
14. Huang HH, Chang SJ, Hsu CW, Chang TM, Kang SP, Liu MY. Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. J Acad Nutr Diet. 2012;112(8):1138-1146.
15. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28(6):1742-1746.
16. Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma. 1999;46(6):992-996; discussion 996-998.
17. Kumar A, Singh N, Prakash S, Saraya A, Joshi YK. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol. 2006;40(5):431-434.
18. Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team. Crit Care Med. 1992;20(10):1377-1387.
19. Montejo JC, Grau T, Acosta J, et al. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med. 2002;30(4):796-800.
20. Neumann DA, DeLegge MH. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med. 2002;30(7):1436-1438.
21. Singh N, Sharma B, Sharma M, et al. Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial. Pancreas. 2012;41(1):153-159.
22. Wan B, Fu H, Yin J. Early jejunal feeding by bedside placement of a nasointestinal tube significantly improves nutritional status and reduces complications in critically ill patients versus enteral nutrition by a nasogastric tube. Asia Pac J Clin Nutr. 2015;24(1):51-57.
23. White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009;13(6):R187.
24. Zeng RC, Jiang FG, Xie Q. Comparison of nose jejunal tube and nasogastric tube in providing early enteral nutrition for patients with severe craniocerebral injury. [Chinese]. 2010(1674-635X)
Document: File 1 File 2 File 3
Topic: Systematic Review, Meta-analysis, or Meta-synthesis
Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials
Alshamsi, Fayez1; Utgikar, Rucha2; Mcintyre, Lauralyn3; Rhodes, Andrew4; Evans, Laura5; Almenawer, Saleh6,7; Angus, Derek C; Alhazzani, Waleed2,6,9
1Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 3Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Intensive Care Medicine, St George’s Hospital, United Kingdom; 5Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, USA; 6Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 7Department of Surgery, McMaster University, Hamilton, Ontario, Canada; 8Department of Critical Care Medicine, University of Pittsburgh School of Medicine, USA; 9Department of Critical Care, St Joseph’s Healthcare, Hamilton, Ontario, Canada
Abstract:
Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population can be associated with worse outcomes. Enteral feeding is associated with a high rate of gastrointestinal intolerance, which may increase the risk of aspiration, pneumonia, and interruption of feeding.
Objectives: We updated our systematic review and meta-analysis to compare the effects of small bowel and gastric feeding (SBF and GF) on risk of pneumonia, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS), gastrointestinal bleeding, aspiration, vomiting and mortality.
Methods: We searched MEDLINE, EMBASE, and clinical registries for data through May 2016 without language or date of publication restrictions. We included randomized clinical trials (RCTs) reporting on outcomes of interest in patients receiving enteral nutrition via post pyloric or gastric feeding in the ICU. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the GRADE method to assess the quality of the evidence.
Results: We included 21 RCTs enrolling 1570 patients in total. SBF reduced the risk of nosocomial pneumonia when compared with GF (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2= 11%; moderate quality) and ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P=0.02; I2=10%, moderate quality). SBF was associated with a shortened duration of MV (mean difference [MD] -2.10 days, 95% CI -3.93, -0.28; P=0.02; I2=67%, moderate quality). There was no difference between groups in the risk of death (RR 1.08, 95% CI 0.91, 1.28; P=0.39; I2=0%, moderate quality), ICU length of stay (MD -1.01 days, 95% -3.32, 1.3; P=0.39; I2=84%, low quality), aspiration, (RR 0.82, 95% CI 0.41, 1.65, P=0.57; I2=23%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P=0.87; I2=33%, very low quality) and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P=0.56; I2=0%, very low quality). While meta-analysis was not possible for nutritional outcomes due to variations in reporting the outcomes, mean daily caloric intake was significantly higher in the SBF group in four trials (n=307) and similar to GF in three trials (n=185). Four trials (n=385) reported time to reach target caloric intake, which was significantly longer in SBF.
Conclusions:
Moderate quality evidence showed that SBF may reduce the risk of pneumonia and VAP compared to GF, with no significant impact on other outcomes. The use of SBF should be reserved for patients at high risk of aspiration in the ICU.
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