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The Cochrane Database of Systematic... Oct 2019Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit.
OBJECTIVES
To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults.
SEARCH METHODS
We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status.
SELECTION CRITERIA
We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This included individuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition.
DATA COLLECTION AND ANALYSIS
Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia.
AUTHORS' CONCLUSIONS
Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.
Topics: Combined Modality Therapy; Critical Illness; Enteral Nutrition; Humans; Intensive Care Units; Malnutrition; Parenteral Nutrition; Randomized Controlled Trials as Topic; Time Factors
PubMed: 31684690
DOI: 10.1002/14651858.CD012340.pub2 -
American Family Physician Dec 2021Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support...
Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve quality of life. The evidence for when to use nutrition support therapy is inconsistent and based mostly on low-quality studies. Family physicians should work with registered dietitian nutritionists to complete a comprehensive nutritional assessment for patients with acute or chronic conditions that put them at risk of malnutrition. When nutrition support therapy is required, enteral nutrition is preferred for a patient with a functioning gastrointestinal tract, even in patients who are critically ill. Parenteral nutrition has an increased risk of complications and should be administered only when enteral nutrition is contraindicated. Family physicians can use the Mifflin-St Jeor equation to calculate the resting metabolic rate, and they should consult with a registered dietitian nutritionist to determine total energy needs and select a nutritional formula. Patients receiving nutrition support therapy should be monitored for complications, including refeeding syndrome. Nutrition support therapy does not improve quality of life in patients with dementia. Clinicians should engage in shared decision-making with patients and caregivers about nutrition support in palliative and end-of-life care.
Topics: Enteral Nutrition; Humans; Malnutrition; Mass Screening; Nutritional Support; Parenteral Nutrition; Referral and Consultation
PubMed: 34913658
DOI: No ID Found -
Journal of Pediatric Gastroenterology... Sep 2023Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF).
METHODS
Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment).
RESULTS
Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide.
CONCLUSIONS
Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
Topics: Humans; Infant; Child; Short Bowel Syndrome; Parenteral Nutrition; Intestine, Small; Peptides; Gastrointestinal Agents
PubMed: 37364133
DOI: 10.1097/MPG.0000000000003867 -
Nutrients Dec 2020Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical... (Review)
Review
Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.
Topics: Critical Illness; Databases, Factual; Enteral Nutrition; Humans; Intensive Care Units; Malnutrition; Nutritional Status; Parenteral Nutrition; Patient Safety; Risk Management
PubMed: 33383941
DOI: 10.3390/nu13010082 -
The Journal of Pediatrics Apr 2019
Topics: Cholestasis; Humans; Infant, Extremely Low Birth Weight; Infant, Newborn; Lipids; Parenteral Nutrition; Parenteral Nutrition, Total
PubMed: 30679054
DOI: 10.1016/j.jpeds.2018.12.044 -
World Journal of Gastroenterology Jan 2016Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract.... (Review)
Review
Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract. Currently, there are no complete cure possibilities, but combined pharmacological and nutritional therapy may induce remission of the disease. Malnutrition and specific nutritional deficiencies are frequent among IBD patients, so the majority of them need nutritional treatment, which not only improves the state of nutrition of the patients but has strong anti-inflammatory activity as well. Moreover, some nutrients, from early stages of life are suspected as triggering factors in the etiopathogenesis of IBD. Both parenteral and enteral nutrition is used in IBD therapy, but their practical utility in different populations and in different countries is not clearly established, and there are sometimes conflicting theories concerning the role of nutrition in IBD. This review presents the actual data from research studies on the influence of nutrition on the etiopathogenesis of IBD and the latest findings regarding its mechanisms of action. The use of both parenteral and enteral nutrition as therapeutic methods in induction and maintenance therapy in IBD treatment is also extensively discussed. Comparison of the latest research data, scientific theories concerning the role of nutrition in IBD, and different opinions about them are also presented and discussed. Additionally, some potential future perspectives for nutritional therapy are highlighted.
Topics: Body Composition; Colitis, Ulcerative; Crohn Disease; Diet; Diffusion of Innovation; Enteral Nutrition; Humans; Nutritional Status; Parenteral Nutrition; Risk Factors; Treatment Outcome
PubMed: 26811646
DOI: 10.3748/wjg.v22.i3.1045 -
Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients.Nutrients Nov 2023Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use,... (Observational Study)
Observational Study
BACKGROUND
Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN).
METHODS
A multicenter ( = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly.
RESULTS
From the entire population ( = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; = 0.001) compared with the PN-EN subgroup.
CONCLUSION
The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.
Topics: Adult; Humans; Critical Illness; Intensive Care Units; Parenteral Nutrition; Nutritional Status; Nutritional Support
PubMed: 37960318
DOI: 10.3390/nu15214665 -
Nutrients Jul 2021Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via... (Review)
Review
Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via parenteral nutrition (PN) becomes necessary for short-term survival, as well as long-term health. However, the elemental nutrients in PN can be a major source of oxidants due to interactions between nutrients, imbalances of anti- and pro-oxidants, and environmental conditions. Moreover, neonates fed PN are at greater risk of oxidative stress, not only from dietary sources, but also because of immature antioxidant defences. Various interventions can lower the oxidant load in PN, including the supplementation of PN with antioxidant vitamins, glutathione, additional arginine and additional cysteine; reduced levels of pro-oxidant nutrients such as iron; protection from light and oxygen; and proper storage temperature. This narrative review of published data provides insight to oxidant molecules generated in PN, nutrient sources of oxidants, and measures to minimize oxidant levels.
Topics: Antioxidants; Atrophy; Cysteine; Enteral Nutrition; Glutathione; Humans; Infant, Newborn; Infant, Very Low Birth Weight; Lipid Peroxidation; Liver Diseases; Oxidants; Oxidative Stress; Parenteral Nutrition; Parenteral Nutrition, Total; Premature Birth; Reactive Oxygen Species; Vitamins
PubMed: 34444799
DOI: 10.3390/nu13082631 -
Cellular and Molecular Gastroenterology... 2022
Topics: AMP-Activated Protein Kinases; Humans; Non-alcoholic Fatty Liver Disease; Parenteral Nutrition; Parenteral Nutrition, Total
PubMed: 35810785
DOI: 10.1016/j.jcmgh.2022.06.005 -
Archives of Disease in Childhood. Fetal... May 2019
Topics: Enteral Nutrition; Humans; Hypothermia, Induced; Hypoxia-Ischemia, Brain; Infant; Infant Care; Infant Nutritional Physiological Phenomena; Infant, Newborn; Parenteral Nutrition
PubMed: 30322974
DOI: 10.1136/archdischild-2018-315393