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A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness*

Davies, Andrew R. MBBS; Morrison, Siouxzy S. MPH; Bailey, Michael J. PhD; Bellomo, Rinaldo MD; Cooper, David J. MD; Doig, Gordon S. PhD; Finfer, Simon R. FCICM; Heyland, Daren K. MD; for the ENTERIC Study Investigators and the ANZICS Clinical Trials Group

doi: 10.1097/CCM.0b013e318255d87e
Clinical Investigations

Objective: Current guidelines recommend enteral nutrition in critically ill adults; however, poor gastric motility often prevents nutritional targets being met. We hypothesized that early nasojejunal nutrition would improve the delivery of enteral nutrition.

Design: Prospective, randomized, controlled trial.

Setting: Seventeen multidisciplinary, closed, medical/surgical, intensive care units in Australia.

Patients: One hundred and eighty-one mechanically ventilated adults who had elevated gastric residual volumes within 72 hrs of intensive care unit admission.

Interventions: Patients were randomly assigned to receive early nasojejunal nutrition delivered via a spontaneously migrating frictional nasojejunal tube, or to continued nasogastric nutrition.

Measurements and Main Results: The primary outcome was the proportion of the standardized estimated energy requirement that was delivered as enteral nutrition. Secondary outcomes included incidence of ventilator-associated pneumonia, gastrointestinal hemorrhage, and in-hospital mortality rate. There were 92 patients assigned to early nasojejunal nutrition and 89 to continued nasogastric nutrition. Baseline characteristics were similar. Nasojejunal tube placement into the small bowel was confirmed in 79 (87%) early nasojejunal nutrition patients after a median of 15 (interquartile range 7–32) hrs. The proportion of targeted energy delivered from enteral nutrition was 72% for the early nasojejunal nutrition and 71% for the nasogastric nutrition group (mean difference 1%, 95% confidence interval −3% to 5%, p = .66). Rates of ventilator-associated pneumonia (20% vs. 21%, p = .94), vomiting, witnessed aspiration, diarrhea, and mortality were similar. Minor, but not major, gastrointestinal hemorrhage was more common in the early nasojejunal nutrition group (12 [13%] vs. 3 [3%], p = .02).

Conclusions: In mechanically ventilated patients with mildly elevated gastric residual volumes and already receiving nasogastric nutrition, early nasojejunal nutrition did not increase energy delivery and did not appear to reduce the frequency of pneumonia. The rate of minor gastrointestinal hemorrhage was increased. Routine placement of a nasojejunal tube in such patients is not recommended.

From the Intensive Care Unit (ARD, SSM, DJC), Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine (ARD, SSM, MJB, RB, DJC), Monash University, Melbourne, Australia; Intensive Care Unit (RB), Austin Hospital, Melbourne, Australia; Intensive Care Unit (GSD, SRF), Royal North Shore Hospital, Sydney, Australia; Northern Clinical School (GSD), University of Sydney, Sydney, Australia; The George Institute for Global Health (SRF), University of Sydney, Sydney, Australia; Department of Medicine (DKH), Queens University, Kingston, Canada.

*See also p. 2508.

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Supported, in part, by the Intensive Care Foundation and the Australian and New Zealand College of Anaesthetists. Cook Critical Care provided the frictional nasojejunal tubes for the study but were not involved in study design, data acquisition, data analysis, or manuscript preparation.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, Email: a.davies@alfred.org.au

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins