Underfeeding versus full enteral feeding in critically ill patients with acute respiratory failure: a systematic review with meta-analysis of randomized controlled trials

Abstract

Franzosi OS, Von Frankenberg AD, Loss SH, Nunes DSL, Vieira SR. Underfeeding versus full enteral feeding in critically ill patients with acute respiratory failure: a systematic review with meta-analysis of randomized controlled trials. Resumen Introducción: a pesar de las directrices que hacen hincapié en que la cantidad de la Nutrición Enteral (NE) administrada debe estar próxima a las necesidades del paciente, los estudios prospectivos cuestionan esta estrategia.Objetivo: comparar el efecto de dos estrategias de NE (subalimentación vs. alimentación completa) sobre la mortalidad en la UCI y general (mortalidad hospitalaria o la mortalidad en 60 días), el tiempo de internación en la UCI y en el hospital, duración de la ventilación mecánica (VM), complicaciones infecciosas y la tolerancia gastrointestinal en pacientes críticos.Métodos: metaanálisis de efectos aleatorios de ensayos clínicos aleatorizados (ECA). Nuestra búsqueda se basa en MEDLINE, EMBASE, SCOPUS y CENTRAL hasta mayo de 2015. La subalimentación fue asignada a dos grupos diferentes de acuerdo con el nivel de consumo de energía (alimentación moderada 46-72% y la alimentación trófi ca 16-25%) para el análisis de subgrupos.Resultados: se incluyeron cinco ECA entre los 904 estudios que se encontraron en la búsqueda (n = 2.432 pacientes). No se encontraron diferencias en la mortalidad general cuando se combinaron los cinco estudios. En el análisis de subgrupos, la alimentación moderada (tres estudios) mostró una mortalidad más baja en comparación con la alimentación completa (RR 0,82; IC 95% 0,68-0,98; I 2 0% p = 0,59 para la heterogeneidad). No se encontraron diferencias de mortalidad en la UCI ni en el tiempo de internación hospitalaria, la duración de la VM y las complicaciones infecciosas. La subalimentación mostró menor aparición de signos y síntomas gastrointestinales, excepto para aspiración y distensión abdominal (no se encontró ninguna diferencia).Conclusiones: este metaanálisis no encontró diferencias signifi cativas de mortalidad, duración de la estancia, duración de VM ni complicaciones infecciosas en la UCI o hospitalización total entre los grupos de subalimentación y alimentación completa. El análisis de subgrupos mostró menor mortalidad global entre los pacientes que recibieron la subalimentación moderada. Este resultado debe interpretarse con cautela debido a las limitaciones del pequeño número de estudios analizados y su metodología. Key words:Enteral nutrition. Critical care. Mortality. Artifi cial respiration. Digestive signs and symptoms. AbstractIntroduction: Although guidelines emphasize that the provision of enteral nutrition (EN) should be as close as the patient's needs, prospective studies question this strategy.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

“…The literature is replete with associations between negative protein balance and worse outcomes, including mortality . A meta‐analysis suggested that trophic feeding strategy is associated with increased mortality in critically ill patients with acute ventilatory failure . It is a pertinent recommendation that the more severe the patient, the more important it is to meet the planned nutrition goals over the subsequent 1 to 2 weeks of treatment .…”

“…34 A meta-analysis suggested that trophic feeding strategy is associated with increased mortality in critically ill patients with acute ventilatory failure. 35 It is a pertinent recommendation that the more severe the patient, the more important it is to meet the planned nutrition goals over the subsequent 1 to 2 weeks of treatment. 36 US guidelines for nutrition support therapy in critically ill adult patients do not recommend trophic feeding for previously undernourished patients or those with high nutrition risk.…”

Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: A before and after study

“…The result is not surprising because several randomized controlled trials have confirmed that full enteral feeding as compared with underfeeding was not beneficial with respect to the mortality outcome [ 35 – 37 ]. In a systematic review and meta-analysis involving 2432 patients, Stuani Franzosi O and colleagues found that the mortality rate was comparable between underfeeding and full feeding groups (RR: 0.91, 95% 0.78–1.06) [ 38 ]. An interesting finding in the subgroup analysis was that moderate feeding, which was defined as 46–72% of the total target, was associated with lower risk of death (RR: 0.82; 95% CI, 0.68–0.98) [ 2 ].…”

“…In a systematic review and meta-analysis involving 2432 patients, Stuani Franzosi O and colleagues found that the mortality rate was comparable between underfeeding and full feeding groups (RR: 0.91, 95% 0.78–1.06) [ 38 ]. An interesting finding in the subgroup analysis was that moderate feeding, which was defined as 46–72% of the total target, was associated with lower risk of death (RR: 0.82; 95% CI, 0.68–0.98) [ 2 ]. In our study, the EN feeding proportion was moderate from day 2 to 7 ( Table 5 ).…”

“…Because critical illness typically involves multiple organs, multidisciplinary approaches are required for the management of them. Among all interventions, nutrition therapy is one of the most important interventions that may significantly influence the clinical outcomes [ 2 , 3 ]. There is a large body of evidence showing that malnutrition is associated with significantly increased risk of death [ 4 , 5 ].…”