3. RATIONALE FOREN…….
• FAVOURS INTESTINAL VILLOUS
TROPHICITY
• PROMOTES GUT MOTILITY
• REDUCES TRANSLOCATION OF
BACTERIA FROM GUT
• LESS COSTLY THAN PN
20. GUIDELINE DEVELOPMENT
Effect size
Confidence Intervals
Validity
Homogeneity
Adequacy of control group
Biological plausibility
Generalizability
Safety
Feasibility
Cost
evidence integration of values+
practice
guidelines
2009 2013
21. LANGUAGE OF RECOMMENDATIONS
CONDITIONS LANGUAGE OF
RECOMENDATION
No reservations about endorsing
intervention.
“ strongly
recommend”
Evidence supportive but minor
uncertainties about safety, feasibility, or
costs of intervention.
“recommend”
Supportive evidence weak and/or major
uncertainties about safety, feasibility, or
costs of intervention.
“ should be
considered”
Inadequate or conflicting evidence. “ insufficient data”
23. Topic 2009 2013 Total
Enteral vs Parenteral 12 2 14
Early vs. delayed 14 2 16
Indirect Calorimetry 1 1 2
Arginine containing 24 2 26
Fish Oils/Borage Oils 4 4 8
Protein/peptides 4 1 5
Fibre 6 2 8
Small Bowel vs. Feeding 11 4 15
Probiotics 11 12 23
NEWRCTS PERTOPIC
24. Topic 2009 2013 Total
Combination EN + PN 5 3 8
PN Branched Chain A Acids 5 1 6
Intensive insulin 22 3 25
PN Type of lipids 5 4 9
PN Glutamine 17 11 28
Antioxidants 16 8 24
PN Selenium 11 7 18
NEWRCTS PERTOPIC
25. New Topic # RCTs
Intentional Underfeeding: Trophic vs Full Feeds 2
Intentional Underfeeding: Hypocaloric EN 1
Fish Oils only 1
Threshold of GRVs 2
Discarding GRVs 1
EN: ß Hydroxyl Methyl Butyrate (HMB) 1
Early Supplemental PN vs Late 1
PN + EN Glutamine 1
Optimal glucose control: CHO Restricted Formula +
Insulin Therapy
1
Vitamin D 1
NEWTOPICS (N=10)
The concept that enteral feeding should be preferred whenever possible is gaining acceptance [2], for the reasons outlined in Table 1. Indeed, complete bypass of the gut leads to adverse structural and functional modifications of the mucosal barrier, which can be reversed by enteral feeding [3]. This favorable effect stems from factors such as the stimulation of epithelial cell metabolism by direct contact with nutrients, increase in mucosal blood flow, and secretion of class A immunoglobulin, as well as enterotrophic gastrointestinal hormones such as gastrin and enteroglucagon [4]. Preventing mucosal atrophy is certainly an important goal, as animal studies indicate that the associated increase in gut permeability can induce translocation of bacteria and toxins from the gut lumen to the circulation [5], although there is no proof of such an occurrence in critically ill patients
Cyclic feeding Administration of enteral formula via continuous drip over a defined period of 8 to 12 hours, usually nocturnally
Need to check these numbers again MV: Updated on June 28 th 2013: - changed date to 2013 (from 2012) - included articles changed from ~305 to 275 (309 is the amount of RCTS NOT accounting for duplicates) - changed to 45 topics (was 44) - Updated: 67 new RCTs across 27 topics Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
Total n = 58 of all RCTs MV: Updated on June 28 th 2013 – changed date to 2013 (from 2012) , updated fish oils (from 3 to 4), Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
Total n = 58 of all RCTs MV: Updated on June 28 th 2013 – changed date to 2013 (from 2012), updated intensive insulin (changed 4 to 3), lipid type (3 to 4), Aox (7 to 8), Selenium (6 to 7). Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
Total n = 66 MV: Updated on June 28 th 2013 – threshold GRVs (changed from 1 to 2 new RCTs) Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
