title: Comparisons between small intestinal and gastric feeding in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials.
abstract: OBJECTIVE
  Nutritional support is highly recommended for reducing the risk of nosocomial infections, such as pneumonitis, in patients with severe traumatic brain injury (TBI). Currently, there is no consensus for the preferred route of feeding. The authors compared the risks of pneumonitis and other important outcomes associated with small intestinal and gastric feeding in patients with severe TBI.
  
  
  METHODS
  This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant randomized controlled trials (up to December 16, 2013) that compared small bowel to gastric feeding in patients with severe TBI were identified from searches in the PubMed and Embase databases. The primary outcome was risk of pneumonia. Secondary outcomes included ventilator-associated pneumonia, mortality, length of intensive care unit stay, length of hospital stay, duration of mechanical ventilation, total number of complications, aspiration, diarrhea, distention, Glasgow Coma Scale score, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II score.
  
  
  RESULTS
  Five randomized controlled trials with 325 participants in total were included in the meta-analysis. Compared with gastric feeding, small bowel feeding was associated with a significant reduction in the incidence of pneumonitis (risk ratio [RR] 0.67; 95% CI 0.52-0.87; p=0.002; I2=0.0%) and ventilator-associated pneumonia (RR 0.52; 95% CI 0.34-0.81; p=0.003; I2=0.0%). Small intestinal feeding was also associated with a decrease in the total number of complications (RR 0.43; 95% CI 0.20-0.93; p=0.03; I2=68%). However, small intestinal feeding did not seem to significantly convert any of the other end points in the meta-analysis.
  
  
  CONCLUSIONS
  The limited evidence suggests that small bowel feeding in patients with severe TBI is associated with a risk of pneumonia that is lower than that with gastric feeding. From this result, the authors recommend the use of small intestinal feeding to reduce the incidence of pneumonitis in patients with severe TBI.
authors.affiliation: Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College;|Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and.
authors.forename: Dong
authors.initials: D
authors.lastname: Wang
authors.affiliation: Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College;
authors.forename: Shao-Qin
authors.initials: SQ
authors.lastname: Zheng
authors.affiliation: Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and.
authors.forename: Xian-Cai
authors.initials: XC
authors.lastname: Chen
authors.affiliation: Department of Biomedical Science, Mercer University School of Medicine, Savannah, Georgia.
authors.forename: Shi-Wen
authors.initials: SW
authors.lastname: Jiang
authors.affiliation: Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College;|Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and.
authors.forename: Hai-Bin
authors.initials: HB
authors.lastname: Chen
mesh_terms: D001930:Brain Injuries / Q000628:therapy*; D004750:Enteral Nutrition / Q000379:methods*; D006801:Humans; D007421:Intestine, Small; D007442:Intubation, Intratracheal / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D013270:Stomach; D016896:Treatment Outcome
keywords: APACHE II = Acute Physiology and Chronic Health Evaluation II; GCS = Glasgow Coma Scale; ICU = intensive care unit; ISS = Injury Severity Score; MV = mechanical ventilation; RCT = randomized controlled trial; RR = risk ratio; TBI = traumatic brain injury; VAP = ventilator-associated pneumonia; WMD = weighted mean difference; enteral nutrition; gastric feeding; meta-analysis; small bowel feeding; traumatic brain injury