Does this make sense? Does gastric stasis stop people weaning? What about diarrhoea/constipation? Vomiting/regurgitation? For this trial to make sense, the authors must believe at least one of these is true and also that trophic feeding reduces GI intolerance. If not, there can be no causal difference in ventilator free days.
Is your bias that 6 days of a different feeding regimen would result in extubation more than 2 days sooner?
The results showed that the number of ventilator free days was the same in both groups, as was 60 day mortality. There were small but statistically significant differences in gastrointestinal complications favoring trophic feeding. Whether these are clinically significant is a matter of judgement.
My take therefore (and yours may be different) is that this was a negative trial either because of the low rate and severity of gastrointestinal intolerance, or because intolerance does not lead to prolonged ventilation. The difference in fluid balance is also interesting, and the conclusion is worth a good read as the authors pretty comprehensively appraise their results.
Perhaps unsurprisingly, this 1 year follow up of patients in the EDEN trial with respect to their physical function (measured by SF-36 scores) showed no difference either.
It’s also probably worth highlighting that at the same time this study was being conducted, this trial was also running – it is a smaller RCT and is single centre yet shares many similarities. 200 patients were recruited, again to trophic vs full feed (the groups received 15% vs 75% of daily requirements). Again the primary outcome was ventilator free days to day 28, again there was no difference. Neither was there a difference in mortality to hospital discharge but the improved tolerance of trophic feeding was again shown.
The whole issue of feeding the critically ill is complex, and I must admit I’ve never really got my head around the conflicting results available, in part I think because of the number of variables. If you’re as confused as I am, this review might help (if only to highlight the complexity of the problem).
Based on these papers, do you think we should continue our usual practice of initiating full feed from day 1 (which we do very well at achieving), or should we change to trophic feeding – if so in which patients and for how long?
*The difference in calories between the groups was 900 kCal/day, which is roughly the same as a Big Mac and medium fries.