Early Enteral Nutrition in Trauma: Is There Still Any Doubt?

Abstract

Early enteral nutrition support has been standard in the care of the injured patient for nearly three decades. The Eastern Association for the Surgery of Trauma (EAST) provided the most recent management recommendations for nutritional support of trauma patients in 2004. Simply stated, the recommendation provided by the authors described the superiority of support via the enteral route within the first 72 h of injury when feasible. This statement implied that both the timing of initiation and route of support had potential to impact patient outcomes. The American Society of Parenteral and Enteral Nutrition (ASPEN) in conjunction with the Society of Critical Care Medicine (SCCM) published a broader set of guidelines in 2009 and 2016 that generally agreed with the EAST recommendations and were applicable to critically ill patients. The superiority of the enteral route for delivery of nutritional support has been theorized to be associated with the non-nutritional benefits of substrate provision at the level of the gastrointestinal tract within a 72-h therapeutic window. These concepts, at least in part, were the product of trials performed by surgeons in the setting of severe trauma and are now applied broadly to critically ill patients. However, as is clearly stated in the above guidelines, there are significant limitations inherent in the available literature. The breadth of literature in clinical nutrition has been plagued with issues including small trial size, the presence of multiple confounding variables, diverse control groups, and heterogeneous patient populations. Trials examining the role of early enteral nutrition support in injured patients have similar limitations. Over the last decade several significant trials have been conducted examining questions regarding nutrition support in the ICU, many of which conflict with historical findings. As a result of these trials, the practice of clinical nutrition is evolving rapidly. The objectives of this review include the following: discussion of the historical perspective on nutrition support in the setting of trauma, brief summary of existing data and more recent trials of importance, and how these trials may impact longstanding dogma.