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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews.

Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle

Review published: 2005.

Bibliographic details: Simpson F, Doig G S.  Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Medicine 2005; 31(1): 12-23. [PubMed: 15592814]

Quality assessment

This review compared standard parenteral nutrition (PN) with standard enteral nutrition (EN) in critically ill patients. Reduced mortality was associated with PN but only in comparison with delayed EN. More infectious complications were noted with PN, although their clinical importance was unclear. The conclusions appear reliable, but the authors highlighted the need for higher quality studies to confirm their findings. Full critical summary


OBJECTIVE: Controversy surrounds the use of parenteral nutrition in critical illness. Previous overviews used composite scales to identify high-quality trials, which may mask important differences in true methodological quality. Using a component-based approach this meta-analysis investigated the effect of trial quality on overall conclusions reached when standard enteral nutrition is compared to standard parenteral nutrition in critically ill patients.

METHODS: An extensive literature search was undertaken to identify all eligible trials. We retrieved 465 publications, and 11 qualified for inclusion. Nine trials presented complete follow-up, allowing the conduct of an intention to treat analysis.

RESULTS: Aggregation revealed a mortality benefit in favour of parenteral nutrition, with no heterogeneity. A priori specified subgroup analysis demonstrated the presence of a potentially important treatment-subgroup interaction between studies of parenteral vs. early enteral nutrition compared to parenteral vs. late enteral. Six trials with complete follow-up reported infectious complications. Infectious complications were increased with parenteral use. The I(2) measure of heterogeneity was 37.7%.

CONCLUSIONS: Intention to treat trials demonstrated reduced mortality associated with parenteral nutrition use. A priori subgroup analysis attributed this reduction to trials comparing parenteral to delayed enteral nutrition. Despite an association with increased infectious complications, a grade B+ evidence-based recommendation (level II trials, no heterogeneity) can be generated for parenteral nutrition use in patients in whom enteral nutrition cannot be initiated within 24 h of ICU admission or injury.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2012 University of York.

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