CI: Initiation of Enteral Nutrition (2012)
Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN. 2003; 27: 355-373.PubMed ID: 12971736
Meta-analysis or Systematic Review
M - Click here for explanation of classification scheme.
To develop evidence-based clinical practice guidelines for nutrition support in mechanically-ventilated critically-ill patients.
PRCT or evidence analysis reports concerning any of the following topics:
- Enteral vs. parenteral
- Early vs. late enteral
- Composition of enteral formula
- Strategies to optimize enteral delivery and minimize risks
- Rate of advancement
- Checking residuals
- Bedside algorithms
- Motility agents
- Small bowel vs. gastric feedings
- Semi-recumbent positioning
- Closed delivery systems
- Bolus administration
- Enteral plus supplemental parenteral nutrition
- Composition of parenteral nutrition
- Intensive insulin therapy.
Description of Study Protocol:
- Search Medline, CINAHL, EMBASE and Cochrane Library for RCT and meta-analyses of RCT of nutrition support in critically-ill adults
- Search reference lists and personal files
- Systematically appraise each study in duplicate using standard scoring system
- Clinical trials score level-one if randomization concealed, outcome adjudication blinded and intent-to-treat analysis performed
- Trials assigned level-two if any one of the above characteristics unfulfilled
- For reports from similar studies, we combined data to estimate the common risk ratio and associated 95% CI for death and infectious complications
- Panel discussion of findings
- External review of clinical practice guidelines developed.
Data Collection Summary:
- ICU and hospital LOS
- Quality of life
- Specific complications.
Description of Actual Data Sample:
Summary of Results:
- Enteral vs. parenteral: Compared 12 level-two and one level-one PRCT with
- No difference in mortality (RR=1.08; 0.7 to 1.65)
- Decrease in infectious complications (RR=0.61; 0.44 to 0.84).
- Early vs. late enteral nutrition: Compared eight level-two PRCT
- Trend towards reduced mortality with early (RR=0.52; 0.25 to 1.08)
- Trend towards reduced infectious complications (RR=0.66; 0.36 to 1.22; P=0.19)
- No difference in LOS
- Improved caloric, protein, percentage.
- Gastric vs. SB feeding: Reviewed 11 PRCT studies
- Mortality: NS difference between groups (RR=0.98; 95% CI, 0.72 to 1.20; P=0.6)
- Significant reduction in infections with SB vs. gastric feedings (RR=0.77; 95% CI, 0.60 to 1.00; P=0.05)
- Pneumonia: In nine studies, incidence of VAP was 83/288 for gastric vs. 6/255 for SB feedings (OR=0.77; 95% CI, 0.6 to 1.00; P=0.05). There was a modest effect size with wide CIs among heterogenous studies and investigators discussed concerns about implementation of SB feeding and associated costs.
- Achieving target dose of enteral formula: Evaluated one level-two study of patients with severe head injury and recommended optimized delivery strategies (start at goal, tolerate 250ml GRV, small bowel feedings)
- Arginine-based diets
- Evaluated two level-one and 12 level-two studies and found no difference in mortality, even when the sub-group was analyzed for high- vs. lower-quality studies and trauma vs. non-trauma patients
- No difference in infectious complications
- Associated with a reduction in hospital LOS (-0.45 days; 95% CI, -0.9 to 0.00; P=0.05), trend toward a reduction of ICU LOS and vent days. Latter findings with statistical heterogeneity.
- Fish oils, borage oils, antioxidants in ARDS
- One level-one study had fewer ICU LOS (11 vs. 14.8; P=-0.016)
- Decrease in new organ failures (10% vs. 25%; P=0.018).
- Glutamine-supplemented enteral nutrition
- Four level-two and one level-one study showed a modest treatment effect with wide Cis and heterogeneity across trials
- Largest effect in one unpublished trial.
- Peptide-based product vs. whole protein: Four level-two studies compared peptide-based to intact protein with no difference in mortality or infectious complications
- Enteral feeding protocol use
- Insufficient data from randomized trials to make recommendation
- If protocol is used, 250ml GRV and prokinetics should be considered.
- Routine use of motility agents: Given low probability of harm, favorable feasibility and cost, motility agents may be considered as strategy to optimize nutrient intake
- Small bowel vs. gastric feeding: According to 11 level-two studies, small bowel feeding may be associated with reduction in pneumonia
- Semi-recumbent positioning: According to one level-two study, head of the bed elevation to 45 degrees is recommended where possible
- Parenteral nutrition vs. standard care: Parenteral nutrition may be associated with increase in complications and LOS
- Glutamine-based parenteral nutrition: According to two level-one and three level-two studies, when parenteral nutrition is prescribed, supplementation with glutamine (where available) is recommended
- Hypocaloric PN: Two small level-two trials of patients not malnourished and tolerating some enteral nutrition determined hypocaloric parenteral nutrition should be considered
- Use of lipids
- Decrease in infectious complications in patients with no lipids (RR=0.64, 0.42-0.93)
- According to two level-two studies, in not malnourhsed patients tolerating some enteral nutrition or parenteral nutrition for less than 10 days, withholding lipid should be considered.
- Tight glucose control: According to one level-two study, in surgical critically-ill patients, intensive insulin therapy to keep glucose between 4.4mmol and 6.1mmol per L should be considered due to reduced sepsis (P=0.003), reduced ICU and hospital mortality (P=0.01).
- Strongly recommend enteral over parenteral nutrition
- Recommend use of a standard polymeric enteral formula
- Initiate formula within 24 to 48 hours after ICU admission
- Care for patients in a semi-recumbent position
- Do not use arginine-containing enteral products
- Consider strategies to optimize enteral delivery
- Start at target rate
- Use feeding protocol with a higher threshold of gastric residual volume
- Use motility agents
- Use small bowel feeding.
- Consider use of products with fish oil, borage oil and antioxidants for patients with ARDS
- Consider a glutamine-enriched formula for patients with severe burns and trauma
- Minimize parenteral nutrition risk by considering
- Hypocaloric dose
- Withhold lipids
- Intensive insulin therapy.
- Insufficient data to generate recommendations regarding:
- Use of indirect calorimetry
- Optimal pH of enteral formula
- Supplementation with trace elements, antioxidants or fiber
- Optimal mix of fats and carbohydrates
- Use of closed feeding system
- Continuous vs. bolus feedings
- Use of probiotics
- Type of lipids
|University/Hospital:||Queens University, University of Alberta, St. Paul's Hospital|
- There is a concern that aggregated results from small trials may not be adequately powered to answer mortality outcome questions
- Consideration of feasibility and cost were also included in development of these practice guidelines
- Multi-disciplinary committee members.
Quality Criteria Checklist: Review Articles
|1.||Will the answer if true, have a direct bearing on the health of patients?||Yes|
|2.||Is the outcome or topic something that patients/clients/population groups would care about?||Yes|
|3.||Is the problem addressed in the review one that is relevant to dietetics practice?||Yes|
|4.||Will the information, if true, require a change in practice?||Yes|
|1.||Was the question for the review clearly focused and appropriate?||Yes|
|2.||Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described?||Yes|
|3.||Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased?||Yes|
|4.||Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible?||Yes|
|5.||Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined?||Yes|
|6.||Was the outcome of interest clearly indicated? Were other potential harms and benefits considered?||Yes|
|7.||Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described?||Yes|
|8.||Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included?||Yes|
|9.||Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed?||Yes|
|10.||Was bias due to the review's funding or sponsorship unlikely?||Yes|