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Abdelbaky AM, Elmasry WG, Awad AH. Bolus Versus Continuous Enteral Feeding for Critically Ill Patients: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54136. [PMID: 38487150 PMCID: PMC10939480 DOI: 10.7759/cureus.54136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/17/2024] Open
Abstract
Enteral feeding is a crucial aspect of nutritional support for critically ill patients. However, the optimal feeding approach, whether bolus or continuous, remains a subject of debate. This systematic review and meta-analysis aimed to compare the outcomes of bolus feeding and continuous enteral feeding in critically ill patients. A systemic search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Ultimate, Web of Science, Scopus, and Google Scholar to identify relevant studies. To ensure that we obtain the latest evidence on the topic, the search was limited to the last five years. Risk of bias assessments and meta-analyses were performed for relevant clinical outcomes. A total of nine randomized controlled trials (RCTs) were included, involving a total of 863 patients. All the studies were published between 2020 and 2023. High-risk performance bias was observed in seven studies, with unclear risk in two studies. In terms of clinical outcomes, no statistically significant differences were found between bolus and continuous enteral feeding in terms of diarrhea (odds ratio {OR} 0.60, 95% CI 0.27 to 1.30, p=0.20), constipation (OR 1.52, 95% CI 0.91 to 2.53, p=0.11), vomiting (OR 0.74, 95% CI 0.36 to 1.49, p=0.39), distention (OR 0.70, 95% CI 0.14 to 3.58, p=0.66), aspiration (OR 0.61, 95% CI 0.16 to 2.73, p=0.48), and gastric residual volume (GRV) (OR 0.80, 95% CI 0.30 to 2.15, p=0.66). Furthermore, no significant differences between bolus and continuous feeding were observed in terms of intensive care unit (ICU) mortality (OR 0.66, 95% CI 0.42 to 1.04, p=0.07), hospital mortality (OR 0.57, 95% CI 0.31 to 1.03, p=0.06), ICU length of stay (OR 0.70, 95% CI 0.50 to 1.90, p=0.25), and hospital length of stay (OR -0.86, 95% CI -3.04 to 1.33, p=0.44). This systematic review and meta-analysis suggest that bolus and continuous enteral feeding methods exhibit comparable outcomes in critically ill patients. However, both ICU mortality and hospital mortality outcomes were close to achieving statistical significance, which favored the continuous feeding approach.
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Affiliation(s)
| | - Wael G Elmasry
- Intensive Care Unit, Rashid Hospital - Dubai Health, Dubai, ARE
| | - Ahmed H Awad
- Intensive Care Unit, Rashid Hospital - Dubai Health, Dubai, ARE
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Qu J, Xu X, Xu C, Ding X, Zhang K, Hu L. The effect of intermittent versus continuous enteral feeding for critically ill patients: a meta-analysis of randomized controlled trials. Front Nutr 2023; 10:1214774. [PMID: 37671198 PMCID: PMC10475573 DOI: 10.3389/fnut.2023.1214774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023] Open
Abstract
Objectives The appropriate strategy for enteral feeding in critically ill patients still remains controversial. Therefore, we conducted this meta-analysis to compare the effect of intermittent versus continuous enteral feeding method for critically ill patients. Methods Electronic databases including PubMed, Embase, Scopus, and Cochrane Library were searched up to April 10th, 2023 for randomized controlled trials evaluating the effect of intermittent versus continuous enteral feeding for critically ill patients. The primary outcomes were feeding intolerances, including diarrhea, vomiting, distension, constipation, gastric retention, and aspiration pneumonia. The secondary outcomes were mortality in intensive care unit (ICU), length of stay in ICU, and achievement of nutritional goal. Results Thirteen studies with a total of 884 patients were analyzed in this meta-analysis. Overall, the use of intermittent enteral feeding was associated with higher incidence of diarrhea (OR 1.66, 95%CI 1.13 to 2.43, I2 = 16%) and distension (OR 2.29, 95%CI 1.16 to 4.51, I2 = 0%), lower incidence of constipation (OR 0.58, 95%CI 0.37 to 0.90, I2 = 0%), and longer length of ICU stay (MD 1.09, 95%CI 0.53 to 1.64, I2 = 0%). Moreover, no significant difference was identified for other outcome measures. Conclusion In critically ill patients, the implementation of intermittent enteral feeding was associated with higher incidence of diarrhea and distension, longer length of ICU stay, but lower occurrence of constipation. Nevertheless, the absence of sufficient high-quality randomized controlled clinical trials precludes any definitive conclusions regarding the optimal approach to enteral feeding in this population. There is an imperative need for more studies to further assess the efficacy of the two enteral feeding strategies.
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Affiliation(s)
- Jing Qu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Chaobo Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Xuzhong Ding
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Leshuang Hu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
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Kouw IW, Heilbronn LK, van Zanten AR. Intermittent feeding and circadian rhythm in critical illness. Curr Opin Crit Care 2022; 28:381-388. [PMID: 35797531 PMCID: PMC9594144 DOI: 10.1097/mcc.0000000000000960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Circadian rhythms, i.e., periodic oscillations in internal biological processes, modulate metabolic processes such as hormonal signalling, nutrient absorption, and xenobiotic detoxification. Meal timing is a strong entraining cue for peripheral clocks in various organs, and eating out of circadian phases can impair glucose, gastrointestinal, and muscle metabolism. Sleep/wake cycles and circadian rhythms are extremely disrupted during critical illness. Timing of nutritional support may help preserve circadian rhythms and improve post-Intensive Care Unit (ICU) recovery. This review summarises circadian disruptors during ICU admission and evaluates the potential benefits of intermittent feeding on metabolism and circadian rhythms. RECENT FINDINGS Rhythmic expression of core clock genes becomes rapidly disturbed during critical illness and remains disturbed for weeks. Intermittent, bolus, and cyclic enteral feeding have been directly compared to routine continuous feeding, yet no benefits on glycaemic control, gastrointestinal tolerance, and muscle mass have been observed and impacts of circadian clocks remain untested. SUMMARY Aligning timing of nutritional intake, physical activity, and/or medication with circadian rhythms are potential strategies to reset peripheral circadian rhythms and may enhance ICU recovery but is not proven beneficial yet. Therefore, selecting intermittent feeding over continuous feeding must be balanced against the pros and cons of clinical practice.
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Affiliation(s)
- Imre W.K. Kouw
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Leonie K. Heilbronn
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
- Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Arthur R.H. van Zanten
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
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Suzuki K, Sugiyama R, Katano T, Shigehara H, Takagiwa T, Katafuchi I, Tanabe M, Ozaki H, Numao S, Aoki J, Nishiyama Y, Kimura K. The safety of rapid administration of enteral nutrition in acute stroke patients. J Neurol Sci 2022; 437:120270. [DOI: 10.1016/j.jns.2022.120270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW To review the mechanisms how intermittent feeding regimens could be beneficial in critically ill patients. RECENT FINDINGS Large randomized controlled trials (RCTs) have failed to demonstrate consistent benefit of early, enhanced nutritional support to critically ill patients, and some trials even found potential harm. Although speculative, the absence of a clear benefit could be explained by the continuous mode of feeding in these trials, since intermittent feeding regimens had health-promoting effects in healthy animals and humans through mechanisms that also appear relevant in critical illness. Potential protective mechanisms include avoidance of the muscle-full effect and improved protein synthesis, improved insulin sensitivity, better preservation of circadian rhythm, and fasting-induced stimulation of autophagy and ketogenesis. RCTs comparing continuous versus intermittent feeding regimens in critically ill patients have shown mixed results, albeit with different design and inclusion of relatively few patients. In all studies, the fasting interval was relatively short (4-6 h maximum), which may be insufficient to develop a full fasting response and associated benefits. SUMMARY These findings open perspectives for the design and clinical validation of intermittent feeding regimens for critically ill patients. The optimal mode and duration of the fasting interval, if any, remain unclear.
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Affiliation(s)
- Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Ma Y, Cheng J, Liu L, Chen K, Fang Y, Wang G, Zhu J, Chen L. Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials. Int J Nurs Stud 2020; 113:103783. [PMID: 33161333 DOI: 10.1016/j.ijnurstu.2020.103783] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/12/2020] [Accepted: 09/27/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Enteral formula delivery strategy is an important part of enteral nutrition. We aimed to synthesize up-to-date studies to clarify the effects of intermittent versus continuous feeding on feeding intolerance during enteral nutrition in critically ill adults. DESIGN A meta-analysis of randomized controlled trials. DATA SOURCES Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases were searched from inception to 17th of June 2020. REVIEW METHODS The Cochrane "risk of bias" tool was used to assess the quality of individual studies, and the quality of each outcome was assessed by GRADE approach. Fixed or random effect meta-analysis was used pending the presence of heterogeneity. Dichotomous data synthesis was presented as risk ratio and 95% confidence interval, and quantitative data synthesis was shown as mean difference and 95% confidence interval. RESULTS Fourteen trials with 1025 critically ill adults were included in the meta-analysis. We found that intermittent feeding could significantly increase the occurrence of feeding intolerance (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001) compared with continuous feeding, as well as the incidence of high gastric volume (risk ratio = 3.62, 95% confidence interval = 1.43-9.12, P = 0.006) and aspiration (risk ratio = 3.29, 95% confidence interval = 1.18-9.16, P = 0.02) in > 1-week trial duration, while constipation rate was reduced in intermittent feeding group (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = 0.04). Patients in intermittent feeding group received more calories compared with continuous feeding group (mean difference = 184.81, 95% confidence interval = 56.61-313.01, P = 0.005). The quality of all evidence synthesis was "low" or "very low". CONCLUSIONS In critically ill adults, continuous feeding was associated with lower overall incidence of feeding intolerance, especially in high gastric volume and aspiration. However, decreased constipation incidence and more calorie intake were observed in intermittent feeding group. Because quality of the synthesized evidence was "low" or "very low", there is considerable uncertainty about this estimate.
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Affiliation(s)
- Yuanyuan Ma
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Jun Cheng
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Liang Liu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Kexi Chen
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Yuli Fang
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, Liaoning, China; Department of Basic Nursing, School of Nursing, Army Medical University, Chongqing, China
| | | | - Jingci Zhu
- Department of Basic Nursing, School of Nursing, Army Medical University, Chongqing, China
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