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Recommendations Summary

CI: Enteral vs. Parenteral Nutrition 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Enteral vs. Parenteral Nutrition

    If enteral nutrition (EN) is not contraindicated (e.g.,  by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus) then the Registered Dietitian (RD) should recommend EN over parenteral nutrition (PN) for the critically ill adult patient. Research shows less septic morbidity, fewer infectious complications and significant cost savings in critically ill adult patients who received EN vs. PN. There is limited evidence that EN vs. PN affects hospital length of stay (LOS),  but an impact on mortality has not been demonstrated.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      A series of case studies have indicated that jejunally fed EN administered to patients with inadequate mesenteric perfusion may be associated with hypoxia and might promote the development of small bowel hypoxia and necrosis (Rai et al, 1996; Lawlor et al, 1998; and Melis et al, 2006). Enteral nutrition should be withheld in hypotensive patients with a mean arterial pressure (MAP) of <60mmHg and/or receiving escalating doses of pharmacologic agents (e.g., epinephrine, norephinephrine, dopamine, etc.) to maintain hemodynamic stability (McClave et al, 2009).
       

    • Conditions of Application

      • Appropriate enteral access
      • Patient and/or family concurrence with EN
      • Ability to determine contraindications (e.g.,  hemodynamic instability, bowel obstruction, high output fistula, or severe ileus).

    • Potential Costs Associated with Application

      Enteral nutrition is significantly less expensive than PN.

    • Recommendation Narrative

      Studies that examined combined EN and PN interventions were not included in this phase of the evidence analysis.

      A total of 17 studies were included in the evidence analysis for this recommendation:

      • Five positive quality randomized controlled trials (RCTs) (Abou-Assi et al, 2002; Borzotta et al, 1994; Kalfarentzos et al,  1997; Kudsk et al, 1992; and Young et al, 1987)
      • Three positive quality meta-analyses (Braunschweig et al,  2001; Heyland et al, 2003; and Simpson and Doig, 2005) 
      • Six neutral quality RCTs (Adams 1986; Cerra 1988; Hadfield RJ. 1995; Hadley MN et al, 1986; Moore et al, 1989; and Woodcock et al 2001)
      • One positive quality prospective cohort study (Kutsogiannis et al, 2011)
      • Two neutral quality meta-analyses (Moore et al, 1992; and Trice et al, 1997).

      Mortality 

      • Fifteen studies provide evidence that it is unclear whether there is a difference in mortality rate when comparing EN vs. PN in critically ill adult patients
      • Evidence is based on the following studies: Abou-Assi et al, 2002; Adams 1986; Borzotta et al, 1994; Braunschweig et al,  2001; Cerra 1988; Hadfield RJ. 1995; Hadley et al, 1986; Heyland et al, 2003; Kalfarentzos et al,  1997; Kudsk et al, 1992; Kutsogiannis et al, 2011; Moore, et al, 1992; Simpson and Doig, 2005; Woodcock et al 2001; and Young et al, 1987.

      Infectious Complications

      • Fourteen studies provide evidence that when compared to PN, EN is associated with reductions in infectious complications in critically ill adult patients 
      • Evidence is based on the following studies: Abou-Assi et al, 2002; Adams, 1986; Braunschweig et al,  2001; Borzotta et al, 1994; Cerra 1988; Hadley et al, 1986; Heyland et al, 2003; Kalfarentzos et al,  1997; Kudsk et al, 1992; Moore et al, 1989; Moore, et al, 1992; Simpson and Doig, 2005; Trice et al, 1997; and Woodcock et al 2001.

      Length of Hospital Stay (LOS)

      • Six studies provide limited evidence that early EN vs. PN decreases hospital LOS in critically ill adult patients
      • Evidence is based on the following studies: Abou-Assi et al, 2002; Adams, 1986; Borzotta et al, 1994; Kudsk et al, 1992; and Kutsogiannis et al, 2011; and Moore, et al, 1992.

      Cost of Medical Care

      • Six studies provide evidence that when compared to PN, EN is associated with reduced cost of medical care in critically ill adult patients. No new studies were identified in the update. All studies supported the conclusion that EN therapy costs less than PN therapy.
      • Evidence is based on the following studies: Abou-Assi et al, 2002; Adams 1986; Borzotta et al, 1994; Kalfarentzos et al,  1997; Cerra 1988; and Trice et al, 1997.

    • Recommendation Strength Rationale

      • Two positive quality meta-analyses (Heyland et al, 2003; and Braunschweig et al, 2001) strongly recommend EN over PN in critically ill adult patients
      • Studies represented a variety of critically ill and injured patients
      • Grade I evidence is available for the conclusion statement regarding the effect of EN vs. PN on infectious complications in critically ill patients
      • Grade II evidence is available for the conclusion statements regarding the effect of EN vs. PN in critically ill patients on:
        • LOS
        • Mortality 
        • Cost of medical care.

    • Minority Opinions

      None.