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Cochrane Database of Systematic Reviews

Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit

Information

DOI:
https://doi.org/10.1002/14651858.CD012276.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 08 June 2018see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Emergency and Critical Care Group

Copyright:
  1. Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Sharon R Lewis

    Correspondence to: Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK

    [email protected]

    [email protected]

  • Oliver J Schofield‐Robinson

    Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK

  • Phil Alderson

    National Institute for Health and Care Excellence, Manchester, UK

  • Andrew F Smith

    Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK

Contributions of authors

Conceiving the review: ARB, SL.

Co‐ordinating the review: SL.

Undertaking manual searches: SL, OSR.

Screening search results: SL, OSR.

Organizing retrieval of papers: OSR.

Screening retrieved papers against inclusion criteria: SL, OSR.

Appraising quality of papers: SL, OSR.

Abstracting data from papers: SL, OSR.

Managing data for the review: SL.

Entering data into Review Manager 5 (Review Manager 2014): SL, OSR.

Analysing Review Manager 5 statistical data: SL, OSR.

Interpreting data: all review authors.

Writing the review: SL, OSR.

Securing funding for the review: PA, AS.

Serving as guarantor for the review (one author): AS.

Taking responsibility for reading and checking the review before submission: SL.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • NIHR Cochrane Collaboration Programme Grant, UK.

    'Back to normal': speed and quality of recovery after surgery, major injury and critical care. Project ref. 13/89/16

Declarations of interest

SL's institution receives the National Institute for Health Research (NIHR) Cochrane Collaboration Programme Grant for programme of reviews in perioperative care, which supported her work on this review (see Sources of support).

OSR's institution receives the NIHR Cochrane Collaboration Programme Grant for programme of reviews in perioperative care, which supported his work on this review (see Sources of support).

PA's institution receives the NIHR Cochrane Collaboration Programme Grant for programme of reviews in perioperative care, which supported his work on this review (see Sources of support). Dr Alderson is employed by NICE, which has published a clinical guideline relevant to this topic (NICE 2006).

AS's institution receives the NIHR Cochrane Collaboration Programme Grant for programme of reviews in perioperative care, which supported his work on this review (see Sources of support).

Acknowledgements

We would like to thank Anna Lee (Content Editor), Jing Xie (Statistical Editor), Michael Casaer, Ronald L Koretz, Paul Marik (Peer Reviewers), Brian Stafford (Consumer Referee) for their help and editorial advice during the preparation of this systematic review.

We would like to thank Anna Lee (Content Editor); Asieh Golozar (Statistical Editor); and Carol Braunschweig, Michael P Casaer, Paul Marik, and Todd Rice (Peer Reviewers) for help and editorial advice provided during preparation of the protocol (Lewis 2016), for the systematic review.

We would like to thank Andrew Butler who contributed to the protocol for this review. We would like to thank Dr Rachel Markham (Consultant Anaesthetist, Intensive Care) for advice during preparation of the 'Summary of findings' tables.

The following editors screened the protocol (Lewis 2016): Marialena Trivella, Anna Lee, Arash Afshari, Bronagh Blackwood, Asieh Golozar, Nathan Pace, Jane Cracknell, and Nuala Livingstone (CEU Editor).

Version history

Published

Title

Stage

Authors

Version

2018 Jun 08

Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit

Review

Sharon R Lewis, Oliver J Schofield‐Robinson, Phil Alderson, Andrew F Smith

https://doi.org/10.1002/14651858.CD012276.pub2

2016 Jul 06

Enteral versus parenteral nutrition for adults in the intensive care unit

Protocol

Sharon R Lewis, Andrew R Butler, Phil Alderson, Andrew F Smith

https://doi.org/10.1002/14651858.CD012276

Differences between protocol and review

We made the following changes to the published protocol (Lewis 2016).

  1. We changed the title to: Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit.

  2. We added a new author, Oliver Schofield‐Robinson, who independently carried out screening of search results and data collection. Andrew Butler did not contribute to completion of the review and was removed from the review author list.

  3. We edited the criteria for considering studies in the review: we intended to include only participants who were in the ICU. We edited the criteria to only include studies of mixed population if more than 75% of participants were in the ICU; at protocol stage we had not anticipated that studies may have a mixed participant population.

  4. Objectives: we noted a difference between the objectives and the outcomes in our published protocol. The list of review outcomes did not include a measure of length of hospital stay. We edited the objectives to state that we compared the effect of nutrition on the number of ICU‐free stays up to day 28.

  5. Unit of analysis: in the protocol, we stated "If multi‐arm studies compare more than one relevant intervention (e.g. EN vs PN and EN vs EN and PN), we will include both comparison groups but will split the data for the intervention group ‐ EN in this example ‐ by using a ‘halving’ method to avoid double‐counting, as recommended by Higgins 2011." In the review, we analysed outcome data as two separate comparisons (i.e. EN versus PN and EN versus EN and PN) and therefore we did not split data in multi‐arm studies.

  6. Summary of findings: we outlined in the published protocol (Lewis 2016), that we would include the following outcomes in the 'Summary of findings' table: mortality (in hospital, at 30 days, at 90 days, at 180 days); number of ICU‐free days; number of ventilator‐free days; and adverse events (as reported by study authors). We limited number the number of adverse events in the 'Summary of findings' table to four outcomes for each comparison group (aspiration, sepsis, pneumonia, and vomiting); we had not specified these in the protocol. Selection of appropriate adverse events was taken following discussion with a Consultant Anaesthetist in Intensive Care.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Flow diagram of search strategy.
Figures and Tables -
Figure 1

Flow diagram of search strategy.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Blank spaces in tables indicated that study authors did not report the review outcome.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Blank spaces in tables indicated that study authors did not report the review outcome.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Blank spaces in tables indicate that study authors did not report the review outcome.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Blank spaces in tables indicate that study authors did not report the review outcome.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 1 In‐hospital mortality.
Figures and Tables -
Analysis 1.1

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 1 In‐hospital mortality.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 2 Mortality at 30 days.
Figures and Tables -
Analysis 1.2

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 2 Mortality at 30 days.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 3 Mortality at 90 days.
Figures and Tables -
Analysis 1.3

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 3 Mortality at 90 days.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 4 Aspiration.
Figures and Tables -
Analysis 1.4

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 4 Aspiration.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 5 Pneumothorax.
Figures and Tables -
Analysis 1.5

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 5 Pneumothorax.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 6 Hyperglycaemia.
Figures and Tables -
Analysis 1.6

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 6 Hyperglycaemia.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 7 Vomiting.
Figures and Tables -
Analysis 1.7

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 7 Vomiting.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 8 Diarrhoea.
Figures and Tables -
Analysis 1.8

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 8 Diarrhoea.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 9 Abdominal distension.
Figures and Tables -
Analysis 1.9

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 9 Abdominal distension.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 10 Sepsis.
Figures and Tables -
Analysis 1.10

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 10 Sepsis.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 11 Pneumonia.
Figures and Tables -
Analysis 1.11

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 11 Pneumonia.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 12 Intra‐abdominal infection.
Figures and Tables -
Analysis 1.12

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 12 Intra‐abdominal infection.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 13 Wound infection.
Figures and Tables -
Analysis 1.13

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 13 Wound infection.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 14 Urinary tract infection.
Figures and Tables -
Analysis 1.14

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 14 Urinary tract infection.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 15 In‐hospital mortality: gastrointestinal (GI) medical/surgical vs non‐GI medical/surgical.
Figures and Tables -
Analysis 1.15

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 15 In‐hospital mortality: gastrointestinal (GI) medical/surgical vs non‐GI medical/surgical.

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 16 Mortality at 30 days: GI medical/surgical vs non‐GI medical/surgical.
Figures and Tables -
Analysis 1.16

Comparison 1 Enteral (EN) versus parenteral nutrition (PN), Outcome 16 Mortality at 30 days: GI medical/surgical vs non‐GI medical/surgical.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 1 In‐hospital mortality.
Figures and Tables -
Analysis 2.1

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 1 In‐hospital mortality.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 2 Mortality at 30 days.
Figures and Tables -
Analysis 2.2

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 2 Mortality at 30 days.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 3 Mortality at 90 days.
Figures and Tables -
Analysis 2.3

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 3 Mortality at 90 days.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 4 Feeding tube obstruction.
Figures and Tables -
Analysis 2.4

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 4 Feeding tube obstruction.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 5 Diarrhoea.
Figures and Tables -
Analysis 2.5

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 5 Diarrhoea.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 6 Pneumonia.
Figures and Tables -
Analysis 2.6

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 6 Pneumonia.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 7 Wound infection.
Figures and Tables -
Analysis 2.7

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 7 Wound infection.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 8 Bloodstream infection.
Figures and Tables -
Analysis 2.8

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 8 Bloodstream infection.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 9 Urinary tract infection.
Figures and Tables -
Analysis 2.9

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 9 Urinary tract infection.

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 10 Airway infection.
Figures and Tables -
Analysis 2.10

Comparison 2 Enteral (EN) versus combined EN and parenteral nutrition (PN), Outcome 10 Airway infection.

Summary of findings for the main comparison. Enteral versus parenteral nutrition for adults in the intensive care unit

Enteral versus parenteral nutrition for adults in the intensive care unit

Patient or population: critically ill adults admitted to the ICU for trauma, emergency, or surgical care; population excluded people with acute pancreatitis
Setting: intensive care units in: Brazil, China, Germany, Iran, Italy, Turkey, UK, and USA
Intervention: EN
Comparison: PN

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Certainty of the evidence
(GRADE)

Risk with EN

Risk with PN

Mortality

In‐hospital mortality

RR 1.19
(0.80 to 1.77)

361
(6 studies)

⊕⊕⊝⊝
Lowa

Study population

229 per 1000
(154 to 340)

192 per 1000

Mortality within 30 days

RR 1.02 (0.92 to 1.13)

3148
(11 studies)

⊕⊕⊝⊝
Lowb

Study population

304 per 1000
(274 to 336)

298 per 1000

Mortality within 90 days

RR 1.06
(0.95 to 1.17)

2461
(3 studies)

⊕⊝⊝⊝
Very lowc

Study population

393 per 1000
(352 to 434)

371 per 1000

Mortality within 180 days

RR 0.33 (0.04 to 2.97)

46
(1 study)

⊕⊝⊝⊝
Very lowd

Study population

130 per 1000

43 per 1000 (5 in 387)

Number of ICU‐free days up to day 28

Not measured

Number of ventilator‐free days up to day 28

Mean number of ventilator‐free days: 14.2 (SD ± 12.2)

Mean difference 0 days (0.97 fewer to 0.97 more)

N/A

2388
(1 study)

⊕⊝⊝⊝
Very lowd

Adverse events: aspiration (as reported by study authors at end of study follow‐up period)

Study population

RR 1.53
(0.46 to 5.03)

2437
(2 studies)

⊕⊝⊝⊝
Very lowe

5 per 1000
(2 to 17)

3 per 1000

Adverse events: sepsis (as reported by study authors at end of study follow‐up period)

Study population

RR 0.59 (0.37 to 0.95)

361
(7 studies)

⊕⊕⊝⊝
Lowf

123 per 1000
(77 to 199)

209 per 1000

Adverse events: pneumonia (as reported by study authors at end of study follow‐up period)

Study population

RR 1.10 (0.82 to 1.48)

415
(7 studies)

⊕⊕⊝⊝
Lowf

314 per 1000
(234 to 423)

268 per 1000

Adverse events: vomiting (as reported by study authors at end of study follow‐up period)

Study population

RR 3.42
(1.15 to 10.16)

2525
(3 studies)

⊕⊝⊝⊝
Very lowg

11 per 1000
(4 to 32)

3 per 1000

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; EN: enteral nutrition; ICU: intensive care unit; N/A: not applicable; PN: parenteral nutrition; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness.

bAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and study designs and evidence were less direct; downgraded one level for indirectness.

cAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and study designs and evidence were less direct; downgraded one level for indirectness. Few studies and one included study had a large number of participants relative to other included studies; downgraded one level for imprecision.

dData from only one study that had a high risk of performance bias; downgraded one level for study limitations and two levels for imprecision.

eAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness. Few studies and one included study had a large number of participants relative to other included studies; downgraded one level for imprecision.

fAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness.

gAll studies had a high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and study designs and evidence were less direct; downgraded one level for indirectness. Few studies, with very few events, and one included study had a large number of participants relative to other included studies; downgraded one level for imprecision.

Figures and Tables -
Summary of findings for the main comparison. Enteral versus parenteral nutrition for adults in the intensive care unit
Summary of findings 2. Enteral versus enteral and parenteral nutrition for adults in the intensive care unit

Enteral versus enteral and parenteral nutrition for adults in the intensive care unit

Patient or population: critically ill adults admitted to the ICU for trauma, emergency, or post‐surgical care; population excludes participants with acute pancreatitis
Setting: intensive care units in: France, Italy, Switzerland, Turkey, and USA
Intervention: EN
Comparison: EN + PN

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Certainty of the evidence
(GRADE)

Risk with EN

Risk with EN + PN

Mortality

In‐hospital mortality

RR 0.99 (0.84 to 1.16)

5111
(5 studies)

⊕⊕⊝⊝
Lowa

Study population

106 per 1000
(90 to 124)

107 per 1000

Mortality within 30 days

RR 1.64 (1.06 to 2.54)

409
(3 studies)

⊕⊝⊝⊝
Very lowb

Study population

216 per 1000
(140 to 335)

132 per 1000

Mortality within 90 days

RR 1.00 (0.86 to 1.18)

4760

(2 studies)

⊕⊕⊝⊝
Lowc

Study population

115 per 1000

(99 to 135)

115 per 1000

Mortality within 180 days

RR 1.00
(0.65 to 1.55)

120

(1 RCT)

⊕⊝⊝⊝
Very lowd

Study population

400 per 1000

(260 to 620)

400 per 1000

Number of ICU‐free days up to day 28

Not measured

Number of ventilator‐free days up to day 28

Not measured

Adverse events: aspiration (as reported by study authors at end of study follow‐up period)

Not measured

Adverse events: sepsis (as reported by study authors at end of study follow‐up period)

Not measured

Adverse events: pneumonia (as reported by study authors at end of study follow‐up period)

350 per 1000

(228 to 538)

250 per 1000

RR 1.40 (0.91 to 2.15)

205

(2 studies)

⊕⊝⊝⊝

Very lowd

Adverse events: vomiting (as reported by study authors at end of study follow‐up period)

Not measured

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; EN: enteral nutrition; ICU: intensive care unit; PN: parenteral nutrition; RCT: randomized controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aAll studies had high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness.

bAll studies had high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness. Few studies with increased risk of imprecision; downgraded one level.

cBoth studies had high risk of performance bias; downgraded one level for study limitations. Studies included a variety of primary diagnoses and evidence was less direct; downgraded one level for indirectness.

dData from only one study that had a high risk of performance bias; downgraded one level for study limitations and two levels for imprecision.

Figures and Tables -
Summary of findings 2. Enteral versus enteral and parenteral nutrition for adults in the intensive care unit
Table 1. Adverse events for single studies: enteral nutrition versus parenteral nutrition

Study ID

Description of event

EN group (n/N)

PN group (n/N)

Mechanical events

Adams 1986

Clogged jejunostomy tube

9/23

N/A

Disconnected line

N/A

1/23

Line eroded into right upper lobe bronchus

N/A

1/23

Malfunctioned line

N/A

7/23

Dunham 1994

Transpyloric tube occlusion

2/12

0/15

Failure to intubate

0/12

0/15

Withdrawal of tube by participant

1/12

N/A

Metabolic events

Adams 1986

Hepatic failure

1/23

1/23

Acute renal failure

1/23

1/23

Pancreatitis

2/23

1/23

Fan 2016

Hypoproteinaemia

22/40

32/40

Harvey 2014

Electrolyte disturbance

5/1197

8/1191

Gastrointestinal events

Adams 1986

Nausea, cramps, bloating

19/23

16/23

Gastrointestinal bleeding

0/23

0/23

Dunham 1994

Gastric reflux

0/12

0/15

Ileus

1/12

0/15

Small bowel ileus

0/12

1/15

Fan 2016

Stress ulcer

7/40

19/40

Harvey 2014

Elevated liver enzymes

7/1197

3/1191

Jaundice

1/1197

1/1191

Ischaemic bowel

0/1197

1/1191

Xi 2014

Anastomotic leak

2/22

6/23

Infective events

Adams 1986

Persistent fever without obvious cause

1/23

5/23

Altintas 2011

Catheter infection

2/30

4/41

Borzotta 1994

Meningitis

2/28

0/21

Sinusitis

3/28

6/21

Bronchitis

6/28

6/28

Clostridium difficile

2/28

4/21

Peritonitis

0/28

1/21

Fan 2016

Intracranial infection

7/40

13/40

Pyaemia

3/40

19/40

Gencer 2010

Pulmonary infection

2/30

2/30

Kudsk 1992

Empyema

1/51

4/45

Young 1987

Aspiration pneumonia

9/28

3/23

Infection (type of infection not described)

5/28

4/23

EN: enteral nutrition; n: number of participants with an event; N: total number randomized to group; N/A: not applicable; PN: parenteral nutrition.

Figures and Tables -
Table 1. Adverse events for single studies: enteral nutrition versus parenteral nutrition
Table 2. Adverse events for single studies: enteral nutrition versus enteral nutrition and parenteral nutrition

Study ID

Description of event

EN group (n/N)

EN + PN group (n/N)

Mechanical events

Casaer 2011

CVC obstruction

9/2328

15/2312

Nasal bleeding

18/2328

14/2312

Pneumohaemothorax after CVC placement

0/2328

2/2312

Subclavian artery puncture

0/2328

2/2312

Dunham 1994

Withdrawal of tube

1/12

0/10

Failure to intubate

0/12

2/10

Metabolic events

Fan 2016

Hypoproteinaemia

22/40

7/40

Gastrointestinal events

Casaer 2011

Vomiting or aspiration

284/2328

295/2312

Dunham 1994

Gastric reflux

0/12

2/10

Fan 2016

Stress ulcer

7/40

9/40

infective events

Fan 2016

Pyemia

3/40

10/40

Intracranial infection

7/40

5/40

Wischmeyer 2017

Catheter bloodstream infection

0/73

7/52

Intra‐abdominal infection

0/73

4/52

Upper urinary tract infection

0/73

1/52

Surgical deep infection

0/73

1/52

CVC: central venous catheter; EN: enteral nutrition; EN + PN: combined enteral and parenteral nutrition; n: number of participants with an event; N: total number randomized to group.

Figures and Tables -
Table 2. Adverse events for single studies: enteral nutrition versus enteral nutrition and parenteral nutrition
Comparison 1. Enteral (EN) versus parenteral nutrition (PN)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 In‐hospital mortality Show forest plot

6

361

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.80, 1.77]

2 Mortality at 30 days Show forest plot

11

3148

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.92, 1.13]

3 Mortality at 90 days Show forest plot

3

2461

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.95, 1.17]

4 Aspiration Show forest plot

2

2437

Risk Ratio (M‐H, Fixed, 95% CI)

1.53 [0.46, 5.03]

5 Pneumothorax Show forest plot

2

2437

Risk Ratio (M‐H, Fixed, 95% CI)

1.46 [0.19, 11.22]

6 Hyperglycaemia Show forest plot

2

2437

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.35, 0.93]

7 Vomiting Show forest plot

3

2525

Risk Ratio (M‐H, Fixed, 95% CI)

3.42 [1.15, 10.16]

8 Diarrhoea Show forest plot

6

363

Risk Ratio (M‐H, Fixed, 95% CI)

2.17 [1.72, 2.75]

9 Abdominal distension Show forest plot

3

2505

Risk Ratio (M‐H, Fixed, 95% CI)

1.53 [0.34, 6.96]

10 Sepsis Show forest plot

7

361

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.37, 0.95]

11 Pneumonia Show forest plot

7

415

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.82, 1.48]

12 Intra‐abdominal infection Show forest plot

3

202

Risk Ratio (M‐H, Fixed, 95% CI)

0.26 [0.07, 0.89]

13 Wound infection Show forest plot

3

155

Risk Ratio (M‐H, Fixed, 95% CI)

1.45 [0.55, 3.82]

14 Urinary tract infection Show forest plot

3

160

Risk Ratio (M‐H, Fixed, 95% CI)

1.48 [0.65, 3.40]

15 In‐hospital mortality: gastrointestinal (GI) medical/surgical vs non‐GI medical/surgical Show forest plot

6

361

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.80, 1.77]

15.1 GI medical/surgical

1

98

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.06, 13.74]

15.2 Non‐GI medical/surgical

5

263

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.80, 1.79]

16 Mortality at 30 days: GI medical/surgical vs non‐GI medical/surgical Show forest plot

10

3068

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.93, 1.14]

16.1 GI medical/surgical

1

60

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.12, 3.71]

16.2 Non‐GI medical/surgical

9

3008

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.93, 1.15]

Figures and Tables -
Comparison 1. Enteral (EN) versus parenteral nutrition (PN)
Comparison 2. Enteral (EN) versus combined EN and parenteral nutrition (PN)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 In‐hospital mortality Show forest plot

5

5111

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.84, 1.16]

2 Mortality at 30 days Show forest plot

3

409

Risk Ratio (M‐H, Fixed, 95% CI)

1.64 [1.06, 2.54]

3 Mortality at 90 days Show forest plot

2

4760

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.86, 1.18]

4 Feeding tube obstruction Show forest plot

2

4662

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.70, 1.32]

5 Diarrhoea Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6 Pneumonia Show forest plot

2

205

Risk Ratio (M‐H, Fixed, 95% CI)

1.40 [0.91, 2.15]

7 Wound infection Show forest plot

2

4765

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.50, 0.92]

8 Bloodstream infection Show forest plot

2

4765

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.66, 1.01]

9 Urinary tract infection Show forest plot

3

4885

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.65, 1.17]

10 Airway infection Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 2. Enteral (EN) versus combined EN and parenteral nutrition (PN)