The Effectiveness and Safety of Perioperative Enteral Feeding in Patients with Burn Injuries: a Systematic Review

Abstract

This systematic review was undertaken as a result of a clinical question. The question being, “what is the optimum perioperative fasting/feeding regime for patients with burn injuries?” Fasting for theatre has been identified in research to have deleterious effects on surgical patients’ nutrient intake, wellbeing and insulin resistance. Perioperative fasting is however intended to protect patients from regurgitation and pulmonary aspiration during surgery and immediately thereafter. Within the burns specialty, it was noted that some published research existed which investigated either short fasting or intraoperative feeding on clinical outcomes in patients with burn injuries. This systematic review aimed to synthesise all of the available research evidence and provide evidenced-based recommendations as to whether perioperative nutrition was safe for patients with burn injuries and whether it influenced patient outcomes. A quantitative review of effectiveness, in keeping with JBI methodology, was identified as the most appropriate approach to address the aims and objectives of this research. The population of interest in this systematic review was people admitted for primary management of an acute burn injury which required surgical management. The intervention of either intraoperative enteral feeding or short fasting (less than 2 hours before surgery) was compared to perioperative fasting. Outcome measures were mortality, wound infection, length of stay, pulmonary aspiration events, pneumonia, Calorie delivery, ventilator days, wellbeing as well as any other relevant outcomes (e.g. bacteremia, clinical sepsis, antibiotic days, intensive care length of stay, supplemental albumin and length of stay per percentage of full-thickness burn). Key databases searched were PubMed, CINAHL, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Only studies published in English were considered. There were no date limits. Full texts of selected studies were retrieved and assessed against inclusion criteria. Studies that did not meet the inclusion criteria were excluded and reasons provided. Where possible, data synthesis was pooled in a statistical meta-analysis. When statistical pooling was not possible, the findings are presented in narrative form. The systematic search identified 327 studies for potential inclusion (after duplicates were removed) however 320 studies were excluded. Seven studies were identified to have met the inclusion criteria. Two of the included studies were randomised controlled trials, three were retrospective cohort studies, one was a case series and one was a case report. The results of the systematic review indicate intraoperative post pyloric feeding was safe in the patient groups investigated, since there were nil aspiration events in a combined intervention population of 509 patients. The safety of short fasting (feeds up to 1 hour before surgery) on aspiration events in non-ventilated patients with nasogastric enteral nutrition was less clear. There were nil aspiration events recorded but there was only one included study with 7 patients who received short fasting for nasogastric nutrition. The effectiveness of perioperative nutrition was demonstrated by the consistent result of increased Caloric provision in patients who received intraoperative post pyloric feeding. Other outcome measures relating to the effectiveness of perioperative nutrition had varied results. Patient wellbeing was improved with shorter perioperative fasting in the singular case report and this result is consistent with literature for other surgical patients, but the certainty of the results from the included case report was very low. The outcomes of mortality, wound infection, length of stay, and ventilator days were inconsistent, with some studies showing improvements with perioperative feeding and others indicating worsening of these outcome measures. Two studies reported on pneumonia and both reported a slightly higher occurrence of pneumonia in the patient groups who received intraoperative post pyloric enteral feeding. Small sample sizes, high heterogeneity and major confounding factors between control and intervention groups contributed to very low certainty of findings. Although this systematic review indicated perioperative enteral nutrition is safe and improves Caloric intake in patients with burn injuries, further research is needed to determine whether perioperative feeding has an impact on other patient outcomes. A recommendation for future research could be a large-scale multi-centre research project where patients are randomly allocated to receive either standard treatment or post pyloric perioperative feeding. Outcome measures could include patient wellbeing, insulin resistance, as well as wound infection, length of stay, mortality, pneumonia, ventilator days and Caloric intake.