Meta Analysis Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomised controlled trials.
This review may be edited
Summary
Posted By:	Pip Heighes
E-Mail:	pheighes@med.usyd.edu.au
Posted Date:	7/6/11
Title:	Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomised controlled trials.
Authors:	Doig GS, Heighes PT, Simpson F, Sweetman EA.
Reference:	Injury. 2011 Jan;42(1):50-6.
Link:	Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract:	INTRODUCTION: To determine whether the provision of early standard enteral nutrition (EN) confers treatment benefits to adult trauma patients who require intensive care. MATERIALS AND METHODS: MEDLINE and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted. Methodologically sound randomised controlled trials (RCTs) conducted in adult trauma patients requiring intensive care that compared the delivery of standard EN, provided within 24 h of injury, to standard care were included.The primary analysis was conducted on clinically meaningful patient-oriented outcomes, which included mortality, functional status and quality of life. Secondary analyses considered vomiting/regurgitation, pneumonia, bacteraemia, sepsis and multiple organ dysfunction syndrome. Meta-analysis was conducted using an analytical method known to minimise bias in the presence of sparse events. The impact of heterogeneity was assessed using the I2 metric. RESULTS: Three RCTs with 126 participants were found to be free from major flaws and were included in the primary analysis. The provision of early EN was associated with a significant reduction in mortality(OR = 0.20, 95% confidence interval 0.04–0.91, I2 = 0). No other outcomes could be pooled. A sensitivity analysis and a confirmatory analysis conducted using a different analytical method confirmed the presence of a mortality reduction. CONCLUSION: Although the detection of a statistically significant reduction in mortality is promising,overall trial quality was low and trial size was small. The results of this meta-analysis should be confirmed by the conduct of a large multi-center trial.
Are the Results Valid?
1. Did the overview address a focused clinical question?
	Yes. The title of the article clearly identifies the clinical question is as follows: patient group (trauma patients requiring Intensive Care), exposure to a specific treatment (early standard enteral nutrition), and one or more specific outcomes of interest (mortality).
2. Were the criteria used to select articles for inclusion appropriate?
	The authors report their selection criteria in enough detail to determine that the criteria appear appropriate. Only RCT's were eligible for inclusion in this meta-analysis which seems relevant to removing the bias that may be introduced with inclusion of non-randomised studies. The authors also chose to only include methodologically sound (ie no major flaws) RCT's and state that major flaws were defined as pseudo-randomisation and excessive (>10%) loss to follow up.
3. Is it unlikely that important, relevant studies were missed?
	Unlikely. The authors searched Medline and EMBASE using a broad range of nutrition terms that should have detected relevant studies. the authors also contacted academic and industry experts and hand searched others systematic reviews and guidelines. The search was not restricted by language which can be an important factor in not missing studies published abroad.
4. Was the validity of the included studies appraised?
	As mentioned above, only RCT's were eligible for inclusion in the MA. All trials deemed eligbile were appraised on reporting of 3 key methodological criteria that are known to increase bias in a trial (maintenance of allcoation concealment; use of any form of blinding; completeness of patient follow-up). It should be noted that 3 of 4 included trials did not have any MAJOR flaws, however 1 did have a major flaw (excessive loss to follow-up) and was therefore not inculded in the priamry analysis. It should also be noted that they were all fairly small trials and of poor quality.
5. Were assessments of studies reproducible?
	The authors show their assessment of studies clearly in a QUOROM flow diagram. Sufficient detail is reported on the assessment of stuides such that it can be presumed the assessment could be reproduced. 3 or 4 of the authors always participated in the selection and assessment of studies which can give us more confidence in their results.
6. Were the results similar from study to study?
	The results from each study appear similar. The authors performed an I2 measure test for heterogeneity which is reported as 0%. This indicates that there are no major differences between each of the trials that would lead to concern over pooling the results.
What are the Results?
1. What are the overall results of the overview?
	The primary analysis showed that there was a statistically significant reduction in mortality in favour of early standard EN provided within 24 hours of injury: OR = 0.20, 95% CI 0.04 - 0.91, p=0.04, I2=0.
2. How precise were the results?
	See above for 95% CI.
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
	The patients in the trials included in the MA were all patients suffering severe/ multiple/ abdominal trauma with Injury Severity Scores (ISS) greater than 15, which according to the New South Wales Institute of Trauma and Injury Management (ITIM) is indicative of serious injury. In Australia approximately half of patients with an ISS>15 will require care in Intensive Care.
2. Were all clinically important outcomes considered?
	In addition to mortality, the authors considered rates of pneumonia and MODS. They also attempted to investigate outcomes such as vomiting/ aspiration, bacteremia and sepsis but were unable to perform analysis as none of the included trials reported the incidence of these outcomes.
3. Are the benefits worth the harms and costs?
	No patient harms were documented. As EN is a relatively cheap intervention, it is worth consideration in this patient population due to mortality benefit demonstrated.
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