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CI: Gastric vs. Small Bowel Feeding (2011)

Citation:

Kortbeek JB, Haigh PI, Doig C. Duodenal vs. gastric feeding in ventilated blunt trauma patients: A randomized controlled trial. J Trauma. 1999; 46: 992-998.

PubMed ID: 10372614
 
Study Design:
Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To evaluate transpyloric feeds as they have been proposed as a means of providing enteral nutrition more rapidly and minimizing morbidity in ventilated trauma patients.

Inclusion Criteria:
  • Injury severity score higher than 16
  • Need ventilation more than 48 hours.
Exclusion Criteria:
  • Disruption of GI tract
  • Traumatic pancreatitis
  • Hemodynamic instability precluding transport to fluoroscopy for tube placement
  • Hopeless prognosis
  • Enrollment into another trial
  • Prior nutrition support
  • Failure to enroll patient within 72-hour admission to ICU.
Description of Study Protocol:

Initial N 

  • N=89
  • NG: N=43 (79% male)
  • SB: N=37 (76% male).

Age

  • NG: N=43; NS=34.7±15.7 years
  • SB: N=37; NS=33.6±17.5 years.

Other Relevant Setting Characteristics

Trauma patients. 

Anthropometrics 

  • ISS: NG=30.0±11 years vs. SB=33.0±9.7 years
  • APACHE II: NG=18±6 vs. SB=18±7.4

Location

Canada.

Data Collection Summary:

Timing and Method of Measurements

  • Baseline: Age, gender, ISS, APACHE II
  • ICU stay: Time on ventilator (days).

Dependent Variables (Outcomes)

  • Ventilator-associated pneumonia: Centers for Disease Control and Prevention criteria of new infiltrate of more than 48 hours duration confirmed by radiography plus at least two of the following:
    • Temperature more than 38.5oC
    • Leukocyte count higher than 3,000cm3
    • Purulent sputum or isolation of pathogenic bacteria from endotracheal aspirate
  • ICU LOS
  • Days on mechanical ventilation
  • Mortality
  • Time to reach nutrition goal.

Independent Variables (Intervention or Procedure)

Gastric or SB placement of feeding tube.

Description of Actual Data Sample:
  • 43 gastric (G)
  • 37 duodenal (D).
Summary of Results:

Key Findings

Transpyloric-duodenal feedings significantly reduced time to achieve nutrition goals, but did not decrease LOS or days on mechanical ventilation.

Outcomes of Gastric vs. Transpyloric Small Bowel Feeding

 
Outcome

NG

(N=43)

Post-Pyloric

(N=37)

 Statistical Significance
Time to tolerate full-strength feedings for 24 consecutive hours 43.8±22.6 hours 34±7.1 hours P=0.02
ICU LOS (mean, range) 7 (3-32) 10 (3-24) P>0.05
Days on mechanical ventilation (median, range) 25 (9-88) 30 (16-47) P>0.05
Ventilator-Associated Pneumonia 18/43 (42%) 10/37 (27%) P>0.05
Mortality 7% 10.8% P>0.05

Other Findings

Study was underpowered; 400 patients (200 per arm) would be required to demonstrate difference of pneumonia at 10% (α=0.05 at 90% power).

 

Author Conclusion:
  • Length of stay and ventilator days were not significantly different
  • A larger trial is needed to determine 20% difference in pneumonia rates
  • Transpyloric feeds significantly reduce the time to achieve targeted enteral nutrition.
Funding Source:
Government: Calgary Regional Health Authority
University/Hospital: University of Calgary (Canada)
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? Yes
  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? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
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? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  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? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  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.) Yes
  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? Yes
  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? Yes
  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? Yes
  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? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  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)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  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? Yes
  10.2. Was the study free from apparent conflict of interest? Yes