WHAT THIS REPORT ADDS:

• Early enteral feeding appears to have both positive and negative consequences, and should probably be used with caution.

ORLANDO, FLA—Enteral nutrition has been shown to improve outcomes when given early to surgical or burn patients. However, the optimal timing of enteral feeding for critically ill patients on mechanical ventilation has not been determined. In fact, some studies have shown that early feeding can increase the risk of infections, such as aspiration pneumonia.

At the annual meeting of the American College of Chest Physicians, Bruno DiGiovine, MD, from Henry Ford Hospital in Detroit, Michigan, presented his findings from a retrospective analysis using the Project Impact database: Early enteral feeding is an important part of the management of seriously ill medical patients.[1]

The study reviewed data from 4,389 mechanically ventilated medical patients from ICUs across the nation. Of these, 2,689 had received enteral feeding within 48 hours of intubation; 1,700 were not fed within this time.

Absolute ICU mortality rate was lower in the early-feeding group than in the late-feeding group (18.6% vs 22.8%). Likewise, hospital mortality was 29.5% in the early-feeding group compared with 34.6% in the late-feeding group.

There were no between-group differences in the rates of hospital-acquired pneumonia or gastrointestinal bleeding, or in the length of ICU stay. After controlling for differences in severity of illness (the early-feeding group was less severely ill), early enteral feeding was still associated with a decreased risk of death in both the ICU and the hospital.

PNEUMONIA RISK?

Although Dr. DiGiovine’s study showed clear benefits with early feeding, it cannot yet be considered the last word on the subject. A previous study by Ibrahim et al,[2] which had also compared early and late feeding in mechanically ventilated patients, found that early feeding was detrimental. Two groups of 75 patients each were fed enterally starting on either the first or the fifth day of mechanical ventilation. Early feeding resulted in a greater incidence of ventilator-associated pneumonia (49.3%, vs 30.7% in the late-feeding group). Patients in the early-feeding group also had longer ICU and hospital stays. There was no between-group difference in mortality. Thus, more research is needed to confirm or refute Dr. DiGiovine’s study.

Nevertheless, he said, there are grounds for believing that early enteral feeding is more helpful than harmful. For example, studies have shown that injured animals who get fed early have decreased translocation of bacteria from the intestine into the bloodstream, explained Dr. DiGiovine. This prevents sepsis and multiorgan dysfunction.

“Feeding can increase the risk of pneumonia,” Dr. DiGiovine admitted, “because food can be regurgitated back up and go into the lung.” In his group’s study, he said, “The increased pneumonia risk was probably offset by the immunomodulatory effects of early feeding.”

—Gale Jurasek

References
1. DiGiovine B. The effects of early enteral feeding on the clinical outcomes of critically ill patients. Presented at: annual meeting of the American College of Chest Physicians; October 27, 2003; Orlando, Fla.
2. Ibrahim EH, Mehringer L, Prentice D, et al. Early versus late enteral feeding of mechanically ventilated patients: Results of a clinical trial. J Parenter Enteral Nutr. 2002;26:174-181.

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