Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials
CCCF ePoster library. Alshamsi F. 11/02/16; 151002; 120
Dr. Fayez Alshamsi
Dr. Fayez Alshamsi
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Topic: Systematic Review, Meta-analysis, or Meta-synthesis

Small Bowel Feeding in Critically Ill Patients: Updated Systematic Review and Meta-analysis of Randomized Trials

Alshamsi, Fayez1; Utgikar, Rucha2;  Mcintyre, Lauralyn3; Rhodes, Andrew4; Evans, Laura5; Almenawer, Saleh6,7Angus, Derek CAlhazzani, Waleed2,6,9

1Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 3Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Intensive Care Medicine, St George’s Hospital, United Kingdom; 5Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, USA; 6Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 7Department of Surgery, McMaster University, Hamilton, Ontario, Canada; 8Department of Critical Care Medicine, University of Pittsburgh School of Medicine, USA; 9Department of Critical Care, St Joseph’s Healthcare, Hamilton, Ontario, Canada


Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population can be associated with worse outcomes. Enteral feeding is associated with a high rate of gastrointestinal intolerance, which may increase the risk of aspiration, pneumonia, and interruption of feeding.

Objectives: We updated our systematic review and meta-analysis to compare the effects of small bowel and gastric feeding (SBF and GF) on risk of pneumonia, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS), gastrointestinal bleeding, aspiration, vomiting and mortality.

Methods: We searched MEDLINE, EMBASE, and clinical registries for data through May 2016 without language or date of publication restrictions. We included randomized clinical trials (RCTs) reporting on outcomes of interest in patients receiving enteral nutrition via post pyloric or gastric feeding in the ICU. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the GRADE method to assess the quality of the evidence.

Results: We included 21 RCTs enrolling 1570 patients in total. SBF reduced the risk of nosocomial pneumonia when compared with GF (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2= 11%; moderate quality) and ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P=0.02; I2=10%, moderate quality). SBF was associated with a shortened duration of MV (mean difference [MD] -2.10 days, 95% CI -3.93, -0.28; P=0.02; I2=67%, moderate quality). There was no difference between groups in the risk of death (RR 1.08, 95% CI 0.91, 1.28; P=0.39; I2=0%, moderate quality), ICU length of stay (MD -1.01 days, 95% -3.32, 1.3; P=0.39; I2=84%, low quality), aspiration, (RR 0.82, 95% CI 0.41, 1.65, P=0.57; I2=23%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P=0.87; I2=33%, very low quality) and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P=0.56; I2=0%, very low quality). While meta-analysis was not possible for nutritional outcomes due to variations in reporting the outcomes, mean daily caloric intake was significantly higher in the SBF group in four trials (n=307) and similar to GF in three trials (n=185). Four trials (n=385) reported time to reach target caloric intake, which was significantly longer in SBF.

Moderate quality evidence showed that SBF may reduce the risk of pneumonia and VAP compared to GF, with no significant impact on other outcomes. The use of SBF should be reserved for patients at high risk of aspiration in the ICU.


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