Abstract
Our objective was to evaluate the impact of gastric versus post-pyloric feeding on the incidence of pneumonia, caloric intake, intensive care unit (ICU) length of stay (LOS), and mortality in critically ill and injured ICU patients. Data sources were Medline, Embase, Healthstar, citation review of relevant primary and review articles, personal files, and contact with expert informants. From 122 articles screened, nine were identified as prospective randomized controlled trials (including a total of 522 patients) that compared gastric with post-pyloric feeding, and were included for data extraction. Descriptive and outcomes data were extracted from the papers by the two reviewers independently. Main outcome measures were the incidence of nosocomial pneumonia, average caloric goal achieved, average daily caloric intake, time to the initiation of tube feeds, time to goal, ICU LOS, and mortality. The meta-analysis was performed using the random effects model. Only medical, neurosurgical and trauma patents were enrolled in the studies analyzed. There were no significant differences in the incidence of pneumonia, percentage of caloric goal achieved, mean total caloric intake, ICU LOS, or mortality between gastric and post-pyloric feeding groups. The time to initiation of enteral nutrition was significantly less in those patients randomized to gastric feeding. However, time to reach caloric goal did not differ between groups. In this meta-analysis we were unable to demonstrate a clinical benefit from post-pyloric versus gastric tube feeding in a mixed group of critically ill patients, including medical, neurosurgical, and trauma ICU patients. The incidences of pneumonia, ICU LOS, and mortality were similar between groups. Because of the delay in achieving post-pyloric intubation, gastric feeding was initiated significantly sooner than was post-pyloric feeding. The present study, while providing the best current evidence regarding routes of enteral nutrition, is limited by the small total sample size.
Highlights
Enteral nutrition is increasingly being recognized as an integral component in the management of critically ill patients, having a major effect on morbidity and outcome
Articles were excluded for the following reasons: the end-points of interest were not recorded [9,23], non-intensive care unit (ICU) patients were studied [24], and two studies compared early versus delayed enteral nutrition [25,26], Only medical, neurosurgical, and trauma patents were enrolled in the studies analyzed
There were no significant differences in the incidence of pneumonia, percentage of caloric goal achieved (–5.2%, 95% confidence intervals (CIs) –18.0% to +7.5%, P = 0.4; Fig. 2), mean total caloric intake (–169 calories, 95% CI –320 to +34 calories, P = 0.09), ICU length of stay (LOS) (–1.4 days, 95% CI –3.7 to +0.85 days, P = 0.2), or mortality between those patients fed gastrically and those who received postpyloric tube feeding
Summary
Enteral nutrition is increasingly being recognized as an integral component in the management of critically ill patients, having a major effect on morbidity and outcome. 46 CI = confidence interval; ICU = intensive care unit; LOS = length of stay; OR = odds ratio These data suggest that enteral nutrition should be initiated as soon as possible after admission to the intensive care unit (ICU). Many prefer to feed critically ill patients via the post-pyloric route, believing that it reduces the incidence of pneumonia. A number of randomized controlled trials comparing gastric with post-pyloric feeding in critically ill patients have been performed, the results of these studies have been inconclusive and/or conflicting. Our objective was to evaluate the impact of gastric versus post-pyloric feeding on the incidence of pneumonia, caloric intake, intensive care unit (ICU) length of stay (LOS), and mortality in critically ill and injured ICU patients.
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