A multicenter randomized controlled trial comparing three-times-a-day intermittent enteral postural feeding to continuous enteral feeding among mechanically ventilated patients in intensive care.

BACKGROUND AND AIMS: Previous randomized controlled trials (RCTs) comparing intermittent feeding versus continuous feeding used different methods, employed shorter fasting intervals, ignored patients' posture in bed during feeds, and showed mixed results. Prolonged fasting intervals are hypothesized to have several benefits. Additionally, there is evidence for more efficient gastric emptying in the right lateral position. In this multicenter RCT, we aimed to compare the effects of three-times-a-day gastric feeding while in the right lateral tilt position (intermittent postural feeding) versus standard continuous gastric feeding (standard feeding) on gastrointestinal intolerance and mortality among mechanically ventilated patients in ICU. METHODS: Adult ICU patients with gastric feeding tube in-situ and requiring invasive mechanical ventilation were randomized to either intermittent postural feeding group or to the standard feeding group. The feeding formula, target daily feed volume and posture turns were determined as per standard practice for all patients. Primary outcome was an incidence rate per 100 patient-days of gastrointestinal intolerance, a composite outcome of vomiting, diarrhea or constipation. Secondary outcomes were all-cause hospital mortality, gastrointestinal intolerance-free days, ventilator-free days, episodes of vomiting or diarrhea per patient, and mean diet volume ratio (diet received/diet prescribed). RESULTS: At five multidisciplinary ICUs, 120 mechanically ventilated, adult ICU patients (median age 65 years, 60% males) were randomly allocated to intermittent postural feeding (n = 61) and standard feeding (n = 59). The primary outcome did not differ between intermittent feeding arm versus standard arm (8.5, 95% confidence interval (CI): 5.9-11.8, versus 6.2, 95% CI: 4.1-9.1 per 100 patient-days; p = 0.23). Gastrointestinal intolerance-free days until day 14 were similar (6 [2-8] versus 5 [2-10]; p = 0.68) in both groups. Number of episodes per patient of vomiting, diarrhea, or constipation also did not differ in between groups. All-cause hospital mortality between intermittent feeding arm versus standard arm was 20% versus 31% (p = 0.17). There were no significant between-group differences in any of the other secondary outcomes. CONCLUSIONS: Intermittent gastric feeds delivered three-times-a-day while in the right lateral tilt position among mechanically ventilated patients was as well tolerated as the continuous enteral feeding. A definitive RCT to assess other clinically important outcomes is justified. TRIAL REGISTRATION: ACTRN12616000212459 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365526&isReview=true.

A comparison of survival following out-of-hospital cardiac arrest in Sydney, Australia, between 2004-2005 and 2009-2010.

OBJECTIVE: To determine whether survival following out-of- hospital cardiac arrest (OHCA) in Sydney, Australia, improved between 2004-2005 and 2009-2010, and whether there was a change in incidence of OHCA. DESIGN: Retrospective study using the Ambulance Service of New South Wales and NSW Registry of Births, Deaths and Marriages databases. PARTICIPANTS AND SETTING: All patients who had an OHCA in the Sydney metropolitan area and who used the Ambulance Service of NSW between June 2009 and May 2010 (2009-2010), and between June 2004 and May 2005 (2004-2005). MAIN OUTCOME MEASURES: Survival to 90 days. Other outcome measures included the incidence of OHCA and survival to the day following OHCA, 28 days and 1 year following OHCA. Survival and incidence were also calculated according to initial electrocardiograph rhythm. RESULTS: Survival to 90 days was 12.3% in 2004-2005 and 10.2% in 2009-2010 (P = 0.015). In 2004-2005, the age standardised incidence of OHCA was 52.6 events per 100 000 person-years (95% CI, 51.6-53.6 events per 100 000 person-years), and in 2009-2010 it was 48.4 events per 100 000 person-years (95% CI, 46.3-50.4 events per 100 000 person-years). In 2004-2005, the incidence of ventricular fibrillation (VF) was 31.3% (95% CI, 28.4%- 33.9%) and in 2009-2010 it was 22.1% (95% CI, 20.0%- 24.3%). CONCLUSION: There was no improvement in survival following OHCA in Sydney between 2004-2005 and 2009- 2010. There has been a decrease in overall survival from OHCA and a decrease in the overall age-standardised incidence of OHCA. The decrease in overall survival may be due to a decline in the incidence of VF.