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

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.

Nutritional therapy in patients with acute pancreatitis requiring critical care unit management: a prospective observational study in Australia and New Zealand.

OBJECTIVE: To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition. DESIGN: Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months. SETTING: Intensive care units or high-dependency units within Australia and New Zealand. PATIENTS: Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded. MEASUREMENTS: The primary outcome was the proportion of patients who received enteral nutrition, parenteral nutrition, or concurrent enteral nutrition/parenteral nutrition. Secondary outcomes included other aspects of nutritional therapy and the severity and clinical outcomes of acute pancreatitis. MEASUREMENTS AND MAIN RESULTS: We enrolled 121 patients and 117 were analyzed. The mean age was 61 (sd 17) years and 53% were men. Enteral nutrition was delivered to 58 (50%; 95% confidence interval [CI], 41-59%) and parenteral nutrition to 49 (42%; 95% CI, 33-51%) patients. Parenteral nutrition was more frequently used as the initial therapy (58%; 95% CI, 49-67%) than enteral nutrition (42%; 95% CI, 33-51%). The most common reason for parenteral nutrition prescription was the treating doctor's preference (60%). Enteral nutrition (74%) was more often used than parenteral nutrition (40%) on any individual study day. Concurrent enteral nutrition and parenteral nutrition occurred in 28 (24%) patients on 14% of days. Complications of acute pancreatitis requiring critical care unit management were observed in 45 (39%) patients. The median (interquartile range) duration of intensive care unit and hospital stay were 5 (2-10) and 19 (9-31) days, respectively. The hospital mortality rate was 15% (95% CI, 8-21%), and there was a tendency toward higher mortality for patients who only received parenteral nutrition than for those who only received enteral nutrition (28% vs. 7%, p=.06). CONCLUSIONS: For patients with acute pancreatitis requiring critical care unit management in Australian and New Zealand intensive care units, enteral nutrition is used most commonly, but parenteral nutrition is more often used as the initial route of nutritional therapy. Given that clinical practice guidelines currently recommend enteral nutrition as the initial route of nutritional therapy in severe acute pancreatitis, improved education about and dissemination of these guidelines seems warranted.

Expensive care - a rationale for economic evaluations in intensive care.

The demand for intensive care services is growing, and the cost of these services is increasing, with newer technologies consuming larger portions of the health care budget. We contend that both the costs and benefits of interventions must be considered to truly understand their value in critical care. Economic evaluations provide an explicit framework to compare the costs and benefits of an intervention. If these factors are not considered together, decisions may be made that do not result in the most efficient use of constrained resources. Despite limitations arising from variations in economic evaluation methodology, logistical complexity and problems of generalisability, the Australian trial environment provides an ideal opportunity to obtain robust economic data to help decision-making. Here, we outline the rationale for conducting economic evaluations in the critical care setting and argue that these evaluations need to be routinely incorporated into all large-scale clinical trials.