CI: Initiation of Enteral Nutrition (2012)
Doig GS, Heighes PT, Simpson F, Sweetman EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomised controlled trials. Injury. 2011 Jan; 42(1): 50-56.PubMed ID: 20619408
To determine whether early EN has benefits to critically ill adult trauma patients.
- Methodologically sound RCT that compared standard EN provided within 24 hours of injury to standard care
- Subjects were critically ill adult trauma patients (eg, mechanically ventilated, multi-trauma with urgent laparotomy, appropriate illness severity score)
- ICU stay more than two days.
- Major methodological flaws
- Publication based on sub-groups of patients from larger published trials
- Observational studies
- Systematic reviews
- Narrative reviews
- Previous meta-analyses
- No provision of primary comparison of timing of EN
- Non-adult trauma population
- Crossover trials
- Pre-operative interventions
- Failure to report mortality
- Evaluation of specialty EN formula
- Early EN not commenced within 24 hours.
MEDLINE and EMBASE were searched using appropriately broad medical subject heading and EMTREE terms for nutritional support and critical illness.
Meta-analysis of RCTs.
To be included in meta-analysis, studies had to incorporate standard EN within 24 hours of ICU admission.
- Fixed effects model with OR
- Tests for heterogeneity
- α=0.05 denoted statistical significance
- α=0.05 to 0.10 indicated a trend toward significance.
- Methodological quality appraisal
- Included trial characteristics
- Patient-oriented outcomes
- Complications and major ICU infections.
- Primary outcomes:
- Hospital discharge mortality
- ICU discharge mortality
- Secondary outcomes:
- Incidence of vomiting or aspiration
- Incidence of pneumonia
- Incidence of bacteremia
- Incidence of sepsis
- Incidence and severity of multiple organ dysfunction syndrome.
Early standard EN within 24 hours of ICU admission.
|Summary of Articles Reviewed|
|Number of articles identified and retrieved as potentially relevant||701|
|Number of articles reviewed for more detailed evaluation||525|
|Number and type of studies considered for meta-analysis||33|
|Number of articles that met all criteria for inclusion||4|
|Variable||Number of Studies||Early EN (Less than 24 hours)||Standard Care||P-value|
|Mortality (deaths/total subjects)||3||1/65||6/61||0.04|
|MODS severity (organ failures)||1||2.5±0.7||3.1±0.8||0.057|
Small studies of low quality suggest that there is a positive correlation between reduction in ICU and hospital discharge mortality to the initiation of early standard enteral nutrition. A large multi-center trial should be conducted to support these findings.
|University/Hospital:||Northern Clinical School, University of Sydney|
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?||No|
|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|