Enteral versus parenteral nutrition: a pragmatic study

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route.