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Effectiveness of continuous enteral nutrition versus intermittent enteral nutrition in intensive care patients: a systematic review

Aguilera‐Martinez, Rosa RN, Msc; Ramis‐Ortega, Emilia RN, Msc; Carratalá‐Munuera., Concha RN, MSc, PhD.; Fernández‐Medina, José Manuel RN.; Saiz‐Vinuesa, M Dolores RN.; Barrado‐Narvión, M Jesús RN, M Sc.

JBI Database of Systematic Reviews and Implementation Reports: January 2014 - Volume 12 - Issue 1 - p 281–317
doi: 10.11124/jbisrir-2014-1129
Systematic Reviews

Background: Feeding by nasogastric tube in critically ill adults is a controversial form of nursing care due to its great clinical variability. Research does not indicate which is the best form of administering enteral nutrition.

Objectives: To determine the existing evidence regarding the effectiveness of continuous enteral nutrition versus intermittent enteral nutrition by measuring the nutritional status, digestive intolerance and complications in adult patients with a nasogastric tube in an intensive care unit.

Inclusion criteria: Types of participants

Patients over the age of 18, with nasogastric tube and enteral nutrition, in an intensive care unit.

Types of intervention(s)

Continuous enteral nutrition: gravity administered or by feeding pump continuously for 12 hours/day or more.

Intermittent enteral nutrition: administered by bolus, gravity or feeding pump several times a day with a rest between feeds.

Types of studies

Randomized clinical trials, clinical trials without randomization, and before and after studies.

Types of outcomes

The selected studies included at least one of the following outcome measures:

Nutritional status

Digestive intolerance

Bronchoaspiration

Search strategy: The search was conducted in Cochrane Library, MEDLINE, EMBASE, AMED, CINAHL, DARE, National Research Register, Cuiden, Lilacs, IME, and Web of Science. Grey literature sources were also searched and hand‐searching was performed to locate additional studies.

Methodological quality: The studies were assessed by two independent reviewers. The methodological quality of those which fulfilled the inclusion criteria was assessed with the Joanna Briggs Institute critical appraisal form for effectiveness studies.

Data collection: Data was collected with an ad‐hoc form by two independent reviewers.

Data synthesis: The studies presented lacked homogeneity both in the way of defining intermittent enteral nutrition and in the measurement of the result variables, and so a meta‐analysis was rejected. Statistical pooling was not possible therefore the findings are presented in a narrative form.

Results: Following the search, 2853 studies were retrieved of which six articles that fulfilled the inclusion criteria were finally included.

Nutritional results: On the seventh day after commencing enteral nutrition, one included study concluded that patients with intermittent nutrition were more likely to meet the caloric objective than those with continuous nutrition (chi2 = 6.01, p = 0.01) and another included study concluded the caloric objective was achieved in 30 out of 51 patients in continuous nutrition and 52 out of 56 in intermittent nutrition (p = .000).

Digestive intolerance: There were no significant differences between groups in any of the studies.

Bronchoaspiration: One included study showed that intermittent nutrition offered a lower risk of aspiration pneumonia (8 out of 56, p = 0.00) than continuous (26 out of 51, p = 0.049). OR = 0.146, (95% CI = 0.062‐0.413; p = .000).

Conclusions: There is not sufficient evidence to support a continuous or intermittent enteral nutrition method, although the two highest quality included studies established that the intermittent form obtained better nutritional results in less time and with a reduced risk of aspiration pneumonia.

Implications for practice

The protocols of the studies reviewed reflect the variability of clinical practice regarding the administration method, the way of interpreting digestive intolerance and the taking of decisions concerning the continuity of enteral nutrition.

Implications for research: It would be relevant to continue RCTs which compare both methods of administration, taking into account the variables studied in this review, and also all the factors that affect these patients such as their pathology, severity, medication, use of ventilator and the position of the patient when feeding.

1. Spanish Collaborating Center for Evidence Based Healthcare: a Collaborating Center of the Joanna Briggs Institute

2. Intensive Care Unit, Hospital Universitario de Sant Joan d'Alacant.

3. Endocrinology and Nutrition, Hospital Universitario de Sant Joan d'Alacant

4. Universidad Miguel Hernández, Campus de San Juan.

5. Emergency Unit, Hospital de Manacor

6. Intensive Care Unit, Hospital Universitario de Albacete

7. Intensive Care Unit, Hospital Royo Villanova de Zaragoza

Corresponding author:

Rosa Aguilera‐Martinez

rosa_aguileram@hotmail.com

© 2014 by Lippincott williams & Wilkins, Inc.
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