Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
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Those who read the medical literature should understand the principles of evidence-based medicine. Even randomized trials can contain design or interpretative flaws that allow bias to produce, or exaggerate the size of, beneficial effects. Such problems beset the literature of enteral nutrition (EN). ⋯ Thus, although systematic reviews have alleged that EN benefits patients undergoing surgery, patients in the critical care unit, patients with liver disease, and patients with pancreatitis, the presence of bias limits any positive conclusions. As a manifestation of this issue, when the various trials are separated into studies with high and low risks of bias, those with low risks have not shown any benefit. EN has been accepted and implemented despite the lack of convincing scientific support of efficacy.
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In developing the evidence-based Enteral Nutrition Practice Recommendations, the American Society for Parenteral and Enteral Nutrition (A. S. P. ⋯ Both general and specific strategies have been devised with the expansion of the new discipline of implementation science. The high degree of evidence now available in medicine gives clinicians more opportunity to improve patient outcomes and quality of care. It remains for clinicians to evaluate their institutional mission and goals, and to investigate those CPGs appropriate to improve patient care in that setting.
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The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. ⋯ A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.