Commencing early enteral nutrition (i.e. within the first 24-48 hours after intensive care unit [ICU] admission) and reaching nutritional targets through a nasogartric tube is recommended by current practice guidelines.1-4 However, gastric intolerance or poor gastric motility prevents nutritional targets from being achieved and is known to be an important risk factor for reduced energy delivery and hospital-acquired pneumonia.5 The nasojejunal route is thought to be preferable to nasogastric delivery due to the fact that the small bowel has greater absorptive capacity and is less subject to impaired motility.6-7 Multiple studies have compared nasojejunal and nasogastric nutrition in adult ICU patients but with inconsistent results. In addition, compared with previous trials that mostly included low-risk patients, this study by Davis and colleagues looked at early nasojejunal nutrition in patients experiencing poor gastric motility (as manifest by elevated gastric residual volumes) such as those requiring narcotic infusions and mechanical ventilation. The authors in this recent study sought to determine whether early nasojejunal nutrition, when compared to nasogastric nutrition, would increase energy delivery. They also sought to compare the effects on the occurrence rate of ventilator-associated pneumonia (VAP) and other clinical outcomes.8
This was a prospective, randomized, controlled trial that included 181 mechanically ventilated patients, who had elevated gastric residual volumes within 72 hours of ICU admission, from 17 medical/surgical intensive care units in Australia. A total of 92 patients were assigned to early nasojejunal nutrition and 89 patients to nasogastric nutrition. The authors found that the proportion of targeted energy delivered from enteral nutrition was 72% for the early nasojejunal nutrition and 71% for the nasogastric nutrition group (95% CI −3% to 5%, p = .66) and the rates of ventilator-associated pneumonia (20% vs. 21%, p = .94). Despite the fact that gastrointestinal hemorrhage (minor) was more common in the early nasojejunal nutrition group (12 (13%) vs. 3 (3%), p = .02), vomiting, witnessed aspiration, diarrhea, and mortality were similar. The authors concluded that in mechanically ventilated patients with elevated gastric residual volumes and receiving nasogastric nutrition, early nasojejunal nutrition did not increase energy delivery and did not appear to reduce the frequency of pneumonia. More minor gastrointestinal hemorrhage occurred in the group receiving nasojejunal nutrition.
1. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian Critical Care Clinical Practice Guidelines Committee: Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003;27:355–373.
2. Kreymann KG, Berger MM, Deutz NE, et al. DGEM (German Society for Nutritional Medicine); ESPEN (European Society for Parenteral and Enteral Nutrition): ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr
3. Doig GS, Simpson F, Finfer S, et al. Nutrition Guidelines Investigators of the ANZICS Clinical Trials Group: Effect of evidence-based feeding guidelines on mortality of critically ill adults: A cluster randomized controlled trial. JAMA