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April 15, 2009

Evidence-Based Nutrition Guidelines for Critically Ill Adults—Reply

JAMA. 2009;301(15):1542-1544. doi:10.1001/jama.2009.495

In Reply: The recent update of the Critical Care Nutrition Canadian Clinical Practice Guidelines aggregated the results of 14 randomized clinical trials of early enteral nutrition vs delayed nutrient intake. It observed that early enteral nutrition was associated with a statistically significant reduction in infectious complications (relative risk, 0.76; 95% confidence interval, 0.59-0.98; P = .04) and a statistically nonsignificant reduction in mortality (relative risk, 0.68; 95% confidence interval, 0.46-1.01; P = .06).1 We therefore agree with Dr Finucane that existing evidence supporting a survival advantage associated with the delivery of early, aggressive artificial nutrition in critically ill patients is weak, but we would disagree that this is because an association does not exist. The results of 11 of these 14 RCTs favored early enteral nutrition, but it is likely that statistical significance was not reached due to small sample sizes. In addition, all 14 of these RCTs had inherent design flaws (unconcealed randomization, unblinded outcome assessment, or no intention-to-treat analysis) that tend to bias the results and may hamper the ability to detect statistically significant associations.