CI: Enteral Nutrition vs. Parenteral Nutrition (2012)

Citation:
Adams S, Dellinger EP, Wertz MJ, Oreskovich MR, Simonowitz D, Johansen K. J of Trauma; 1986;26(10);882-891 PubMed ID: 3095558
 
Study Design:
Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
To compare the efficacy of enteral versus parenteral nutrition in patients that had received a laparotomy for trauma.
Inclusion Criteria:
  • 18-60 years of age
  • Without history of hepatitis, or reanl failure
  • Significant injuries to two or more body systems
Exclusion Criteria:
Patients who were treated elsewhere for more than 2 days before admission to the hospital was not included.
Description of Study Protocol:

Patients were randomized by surgical team in the OR to receive either parenteral or enteral nutrition (jejunostomy tube).

Basal Energy Expenditure determined by Harris Benedict equation.

Nutritional prescription was BEE x 1.68. Due to intermediate data analysis indicating the both groups were in negative nitrogen balance and that enteral feeding patients were receiving less nutrition due frequent interruption, the total number of calories was increased to BEE x 2.0 and as additional 20% calories added to enteral feeding patients.

Data Collection Summary:
  • Nutritional supported initiated post op day 1 in both groups.
  • Monitored for 14 days or until patient consumed 70% of diet orally, or if the attending MD felt the patient’s recovery would be impaired if study continues.
  • Nutritional prescriptions were adjusted to biweekly nitrogen balance studies.
  • Laboratory values were obtained at baseline for all patients.
  • Tricep skin folds and mid upper arm circumferences were obtained.
  • Injury Severity Score and Prognostic Nutritional Index determined.
  • Daily monitoring included: Calorie and Nitrogen intake, Body weight, stool output,
  • Gastrointestinal distress assessed by patient or medical staff
  • At the time of discharge patients were elevated for:  LOS, intensive care unit stay, length of time on surgical service, number of days on mechanical ventilation, type of operations, and number of days receiving enteral or parenteral nutition, weight, mortality and cost of nutrition support.
Description of Actual Data Sample:
Summary of Results:
N=46, randomized (23 in each group)  
  • No differences in ICU days
  • Mortality: 3 TPN patients, 1 EN patient
  • Feeding interruptions were significantly more in EN group than in TPN group (p< 0.001)
  • Time to achieve desired nutrition prescriptions was similar for both groups.
  • Lab values and medical complications were similar between groups.
  • Complications related to nutritional support were similar in frequency but differed in type. TPN patients had significantly more hyperglycemica patients’ days than EN group.
  • No significant difference in diarrhea (18 times in EN vs 10 times in TPN group)
  • Cost of TPN was $3,729 versus 1, 346.00 in enteral group.
Author Conclusion:
Success of enteral feeding (nutritional prescription) was equivalent to that of the parenteral route.
Traumatized patients can be supported enterally with equal efficacy and no more complications and less expense.
 
Patients undergoing laparotomy and who most likely will need nutrition may benefit from a feeding jejunostomy to maximize enteral nutrition administration.
Funding Source:
Government: NIH, NIDDK, NCRR
Reviewer Comments:
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? N/A
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? N/A
  2.4. Were the subjects/patients a representative sample of the relevant population? N/A
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? No
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? N/A
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? No
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? No
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes