CI: Initiation of Enteral Nutrition (2012)
Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009; 35 (12): 2, 018-2,027.PubMed ID: 19777207
The purpose was to determine if early standard EN has benefits to critically-ill adult patients.
- Methodologically-sound RCTs comparing delivery of EN provided within 24 hours of ICU admission, or injury to standard care
- Trials reporting meaningful patient-oriented outcomes conducted in critically-ill adult population.
- Not an RCT (letters, observational studies, systematic reviews, narrative reviews, previous meta-analyses)
- Presence of major methodological flaws (pseudo randomization, greater than 10% loss to follow-up)
- No provision of a primariy comparison of timing of EN
- Study on oral intake rather than EN
- Not adult critically-ill population
- Not primary nutritional support intervention
- Cross-over trials
- Pre-operative interventions
- Early EN not started within 24 hours of injury or ICU admission
- Sub-group of patients from a larger published trial.
- Search plan: Medline and EMBASE were searched using appropriately broad Medical Subject Heading and EMTREE terms for nutritional support and critical illness, crossed with phrases optimised to detect RCTs
- Design: Meta-analysis of RCT's
- Intervention: 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
- Alpha =0.05 denoted statistical significance
- Alpha =0.05 to 0.10 indicated a trend toward significance.
- Validity appraisal
- Clinically meaningful patient-oriented outcomes
- Complications and major ICU infections
- Sensitivity analysis.
- Primary Analysis
- Hospital stay mortality
- Discharge mortality
- Quality of life
- Physical function.
- Secondary Analysis
- Multiple organ dysfunction syndrome.
Standard EN initiated within 24 hours of admission to ICU or injury.
|Summary of Articles Reviewed||Number|
|Number of Articles Identified and Retrieved as Potentially Relevant||
|Number of Articles Reviewed for More Detailed Evaluation||
|Number and Type of Studies Considered for Meta-Analysis||
|Number of Articles that Met All Criteria for Inclusion||
|Outcome||Studies Included||Incidence with Early EN (<24 Hours)||Incidence with Standard Care||Odds Ratio (95% CI)|
- There were no other significant differences in secondary outcomes of vomiting or regurgitation, bacteremia or multiple organ dysfunction syndrome
- No included studies had incidence of sepsis as an outcome.
- There is a positive observation in reduction of mortality and pneumonia in critically-ill patients on early standard enteral nutrition
- Due to the low quality of the studies included, as well as the small size of these studies a large multi-center trial with a diverse critically-ill patient group, needs to be conducted to confirm these results.
|University/Hospital:||Northern Clinical School, University of Sydney|
- Doig 2009 meta-analysis papers for mortality: Chiarelli et al, 1990; Chuntrasakul et al, 1996; Kompan et al, 1999; Pupelis et al, 2001; Kompan et al, 2004; Nguyen et al, 2008.
- Doig authored a second meta-analysis in 2011 and the articles included for mortality were: Chuntrasakul, 1996; Kompan, 1999; Kompan, 2004; Moore, 1986.
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|