-
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 -
Clinical Infectious Diseases : An... May 2023Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions.
METHODS
A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610).
RESULTS
A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively.
CONCLUSIONS
Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.
Topics: Humans; Candidemia; Prevalence; Candidiasis; Candida albicans; Eye Infections, Fungal; Endophthalmitis
PubMed: 36750934
DOI: 10.1093/cid/ciad064 -
JPEN. Journal of Parenteral and Enteral... Nov 2020Inappropriate parenteral nutrition (PN) administration often occurs in hospitalized patients, increasing the risk of complications. Nutrition support teams (NSTs)...
Inappropriate parenteral nutrition (PN) administration often occurs in hospitalized patients, increasing the risk of complications. Nutrition support teams (NSTs) regulate and approve PN use in some hospitals. This systematic review examined whether appropriateness of PN use in hospitalized adult patients increased under NST oversight. Ten databases were searched systematically to select studies from 2004 to 2020 that analyzed appropriateness of PN use in adult hospitalized patients under NST oversight. Studies were included if appropriateness of PN was examined and NSTs were involved in PN orders or recommendations. Studies were evaluated using the Quality Criteria Checklist from the Academy of Nutrition and Dietetics Evidence Analysis Library. Nine studies were included in the final analysis. One received a positive rating on the quality checklist, whereas 8 received a neutral rating. Inappropriate PN use varied from 4.3% to 18%. Two studies compared PN use between multiple hospitals, both with and without NSTs. Two compared appropriateness before and after NST implementation, whereas another 2 studies compared it before and after NST restructuring. Three studies examined appropriateness of PN with NST oversight at a single facility with no control group. Overall, NSTs were associated with decreased incidence of inappropriate PN use. No studies were randomized, and several did not describe demographics between groups. Although NSTs appear to decrease inappropriate PN use, the results are limited because of study design or reporting. Future studies should monitor and evaluate clinical outcomes, such as mortality, and utilize more rigorous methodologies.
Topics: Adult; Hospitals; Humans; Nutritional Support; Parenteral Nutrition; Parenteral Nutrition, Total; Patient Care Team
PubMed: 32378732
DOI: 10.1002/jpen.1864 -
The American Journal of Clinical... Apr 2013The achievement of adequate nutritional intakes in preterm infants is challenging and may explain the poor growth often seen in this group. The use of early parenteral... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The achievement of adequate nutritional intakes in preterm infants is challenging and may explain the poor growth often seen in this group. The use of early parenteral nutrition (PN) is one potential strategy to address this problem, although the benefits and harms are unknown.
OBJECTIVE
We determined whether earlier administration of PN benefits growth outcomes in preterm infants.
DESIGN
We conducted a systematic review of randomized controlled trials (RCTs) and observational studies.
RESULTS
Eight RCTs and 13 observational studies met the inclusion criteria (n = 553 and 1796 infants). The meta-analysis was limited by disparate growth-outcome measures. An assessment of bias was difficult because of inadequate reporting. Results are given as mean differences (95% CIs). Early PN reduced the time to regain birth weight by 2.2 d (1.1, 3.2 d) for RCTs and 3.2 d (2.0, 4.4 d) in observational studies. The maximum percentage weight loss with early PN was lower by 3.1 percentage points (1.7, 4.5 percentage points) for RCTs and by 3.5 percentage points (2.6, 4.3 percentage points) for observational studies. Early PN improved weight at discharge or 36 wk postmenstrual age by 14.9 g (5.3, 24.5 g) (observational studies only), but no benefit was shown for length or head circumference. There was no evidence that early PN significantly affects risk of mortality, necrotizing enterocolitis, sepsis, chronic lung disease, intraventricular hemorrhage, or cholestasis.
CONCLUSIONS
The results of this review, although subject to some limitations, show that early PN provides a benefit for some short-term growth outcomes. No evidence that early PN increases morbidity or mortality was found. Neonatal research would benefit from the development of a set of core growth outcome measures.
Topics: Birth Weight; Growth; Humans; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Parenteral Nutrition; Patient Discharge; Premature Birth; Weight Loss
PubMed: 23446896
DOI: 10.3945/ajcn.112.042028 -
The Cochrane Database of Systematic... Mar 2020Nutrition is an important aspect of management in severe acute pancreatitis. Enteral nutrition has advantages over parenteral nutrition and is the preferred method of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Nutrition is an important aspect of management in severe acute pancreatitis. Enteral nutrition has advantages over parenteral nutrition and is the preferred method of feeding. Enteral feeding via nasojejunal tube is often recommended, but its benefits over nasogastric feeding are unclear. The placement of a nasogastric tube is technically simpler than the placement of a nasojejunal tube.
OBJECTIVES
To compare the mortality, morbidity, and nutritional status outcomes of people with severe acute pancreatitis fed via nasogastric tube versus nasojejunal tube.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS on 17 October 2019 without using any language restrictions. We also searched reference lists and conference proceedings for relevant studies and clinical trial registries for ongoing trials. We contacted authors for additional information.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs comparing enteral feeding by nasogastric and nasojejunal tubes in participants with severe acute pancreatitis.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened studies for inclusion, assessed risk of bias of the included studies, and extracted data. This information was independently verified by the other review authors. We used standard methods expected by Cochrane to assess the risk of bias and perform data synthesis. We rated the certainty of evidence according to GRADE.
MAIN RESULTS
We included five RCTs that randomised a total of 220 adult participants from India, Scotland, and the USA. Two of the trial reports were available only as abstracts. The trials differed in the criteria used to rate the severity of acute pancreatitis, and three trials excluded those who presented in severe shock. The duration of onset of symptoms before presentation in the trials ranged from within one week to four weeks. The trials also differed in the methods used to confirm the placement of the tubes and in what was considered to be nasojejunal placement. We assessed none of the trials as at high risk of bias, though reporting of methods in four trials was insufficient to judge the risk of bias for one or more of the domains assessed. There was no evdence of effect with nasogastric or nasojejunal placement on the primary outcome of mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.36 to 1.17; I = 0%; 5 trials, 220 participants; very low-certainty evidence due to indirectness and imprecision). Similarly, there was no evidence of effect on the secondary outcomes for which data were available. These included organ failure (3 trials, 145 participants), rate of infection (2 trials, 108 participants), success rate (3 trials, 159 participants), complications associated with the procedure (2 trials, 80 participants), need for surgical intervention (3 trials, 145 participants), requirement of parenteral nutrition (2 trials, 80 participants), complications associated with feeds (4 trials, 195 participants), and exacerbation of pain (4 trials, 195 participants). However, the certainty of the evidence for these secondary outcomes was also very low due to indirectness and imprecision. Three trials (117 participants) reported on length of hospital stay, but the data were not suitable for meta-analysis. None of the trials reported data suitable for meta-analysis for the other secondary outcomes of this review, which included days taken to achieve full nutrition requirement, duration of tube feeding, and duration of analgesic requirement after feeding tube placement.
AUTHORS' CONCLUSIONS
There is insufficient evidence to conclude that there is superiority, inferiority, or equivalence between the nasogastric and nasojejunal mode of enteral tube feeding in people with severe acute pancreatitis.
Topics: Enteral Nutrition; Humans; Intubation, Gastrointestinal; Length of Stay; Nutritional Status; Pancreatitis; Parenteral Nutrition; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 32216139
DOI: 10.1002/14651858.CD010582.pub2 -
Nutrition (Burbank, Los Angeles County,... May 2022We performed a systematic review to study the effect of enteral and parenteral energy intakes on neurodevelopment (NDV) and cerebral growth in preterm infants, evaluated... (Review)
Review
OBJECTIVES
We performed a systematic review to study the effect of enteral and parenteral energy intakes on neurodevelopment (NDV) and cerebral growth in preterm infants, evaluated by NDV scales, magnetic resonance imaging, and head circumference (HC).
METHODS
The MEDLINE, Scopus, and ISI Web of Knowledge databases were searched, using the following medical subject headings and terms: "Premature infants," "nutrition," "brain," "nervous system/growth," and "development." A manual search of the reference lists of all eligible articles was conducted. Studies in which the intervention applied was different energy intakes in parenteral nutrition and/or enteral nutrition (EN) during the first weeks of life and NDV was investigated were included. Data regarding nutrition and NDV were collected and analyzed.
RESULTS
Thirty-five studies were included, of which 12 were randomized controlled trials (RCTs) and 23 were cohort studies. Eight RCTs and 15 cohort studies investigated NDV using NDV scales. Of these studies, two RTCs and five cohort studies found no significant difference in NDV evaluated with the Bayley scale between neonates fed high-caloric nutrition and those who received lower energy intakes during early life. In one RCT and two cohort studies was observed a positive effect of EN on NDV. Conversely, in one cohort study, a negative correlation between parenteral energy intake and NDV was described. The analysis of the data from RCTs and cohort studies showed greater HC in the groups receiving aggressive parenteral and total enhanced nutrition, respectively. However, two RCTs and one cohort study did not report any differences in terms of HC. Inconclusive results were reported by studies that investigated cerebral growth by magnetic resonance imaging. The studies observing a positive effect of enhanced nutrition on cerebral and basal ganglia growth, caudate nucleus, cerebellum, and thalami volume investigated only the influence of EN.
CONCLUSIONS
The impact of energy intake during early life on NDV remains undefined. A positive impact on brain development encourages the administration of recommended energy intake, mainly by EN, and suggests a more cautious approach to enhanced nutritional strategies by the parenteral route. Further studies are advocated to elucidate the optimal nutritional intervention for preterm infants to improve NDV.
Topics: Energy Intake; Enteral Nutrition; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Parenteral Nutrition
PubMed: 35306422
DOI: 10.1016/j.nut.2021.111572 -
Journal of Pediatric Surgery Jan 2012The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral... (Review)
Review
OBJECTIVE
The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children.
DATA SOURCE
Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews.
STUDY SELECTION
The review of PNAC/PNALD has been divided into 4 areas to simplify one's understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC.
RESULTS
The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized.
CONCLUSIONS
Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.
Topics: Child; Child Nutritional Physiological Phenomena; Cholestasis; Evidence-Based Medicine; Fat Emulsions, Intravenous; Humans; Incidence; Parenteral Nutrition; Risk Factors; Severity of Illness Index
PubMed: 22244423
DOI: 10.1016/j.jpedsurg.2011.10.007 -
Clinical Nutrition (Edinburgh, Scotland) Feb 2021Home parenteral nutrition (HPN) is indicated in patients with chronic intestinal failure. The aim of the current study was to review existing scientific literature of...
BACKGROUND & AIMS
Home parenteral nutrition (HPN) is indicated in patients with chronic intestinal failure. The aim of the current study was to review existing scientific literature of full or partial economic evaluations associated to HPN.
METHODS
A bibliographic database search was undertaken in PubMed (MEDLINE), Embase and Scopus, complemented by a reference list search. We combined search terms regarding HPN and costs/health economics. The inclusion criteria included: a) population: all population and age groups; b) intervention: partial or full HPN; c) comparator: no parenteral nutrition, continued or intermittent hospital based PN, other nutritional interventions or no comparator; d) outcomes: cost outcomes and economic evaluations associated to HPN. A different quality assessment tool was used for each of the different type of economic approach.
RESULTS
Twenty-three papers were included in the final review. 21 were partial economic evaluations (16 cost-of-illness studies and 5 cost analyses), and 2 were full economic evaluations, both cost-utility analysis. Most studies investigated costs from a healthcare perspective (n = 18), therefore they included only direct costs. Three studies included personal costs for HPN patient. None of the studies included productivity costs.
CONCLUSIONS
Most scientific literature regarding the economic costs of HPN comes from partial economic evaluations, such as cost-of-illness studies and cost analysis. According to them, HPN is an expensive treatment, although cost saving when compared to hospital based parenteral nutrition (PN). Full economic evaluations proved HPN as being cost-effective than hospital based PN, however more research is needed to confirm this in all settings.
Topics: Chronic Disease; Cost of Illness; Cost-Benefit Analysis; Humans; Intestinal Diseases; Parenteral Nutrition, Home
PubMed: 32631611
DOI: 10.1016/j.clnu.2020.06.010 -
JPEN. Journal of Parenteral and Enteral... Feb 2022Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence.
METHODS
This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes.
RESULTS
Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P = .99), hospital LOS (mean difference, -1.44; CI, -5.59 to 2.71; P = .50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials.
CONCLUSION
A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.
Topics: Adult; Critical Illness; Enteral Nutrition; Humans; Intensive Care Units; Length of Stay; Parenteral Nutrition
PubMed: 33899951
DOI: 10.1002/jpen.2125 -
The Journal of Hospital Infection May 2022The incidence of central venous catheter (CVC)-related bloodstream infections is high in patients requiring a long-term CVC. Therefore, infection prevention is of the... (Meta-Analysis)
Meta-Analysis Review
The incidence of central venous catheter (CVC)-related bloodstream infections is high in patients requiring a long-term CVC. Therefore, infection prevention is of the utmost importance. The aim of this study was to provide an updated overview of randomized controlled trials (RCTs) comparing the efficacy of taurolidine containing lock solutions (TL) to other lock solutions for the prevention of CVC-related bloodstream infections in all patient populations. On 15 February 2021, PubMed, Embase and The Cochrane Library were searched for RCTs comparing the efficacy of TLs for the prevention of CVC-related bloodstream infections with other lock solutions. Exclusion criteria were non-RCTs, studies describing <10 patients and studies using TLs as treatment. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool. A random effects model was used to pool individual study incidence rate ratios (IRRs). Subgroup analyses were performed based on the following factors: CVC indication, comparator lock and bacterial isolates cultured. A total of 14 articles were included in the qualitative synthesis describing 1219 haemodialysis, total parenteral nutrition and oncology patients. The pooled IRR estimated for all patient groups together (nine studies; 918 patients) was 0.30 (95% confidence interval 0.19-0.46), favouring the TLs. Adverse events (10 studies; 867 patients) were mild and scarce. The quality of the evidence was limited due to a high risk of bias and indirectness of evidence. The use of TLs might be promising for the prevention of CVC-related bloodstream infections. Large-scale RCTs are needed to draw firm conclusions on the efficacy of TLs.
Topics: Catheter-Related Infections; Catheterization, Central Venous; Central Venous Catheters; Humans; Randomized Controlled Trials as Topic; Sepsis; Taurine; Thiadiazines
PubMed: 34767871
DOI: 10.1016/j.jhin.2021.10.022