***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To compare the efficacy of combination therapy , with erythromycin and metoclopramide , to erythromycin alone in the treatment of feed intolerance in critically ill patients . DESIGN R and omized , controlled , double-blind trial . SETTING Mixed medical and surgical intensive care unit . PATIENTS Seventy-five mechanically ventilated , medical patients with feed intolerance ( gastric residual volume ≥250 mL ) . INTERVENTIONS Patients received either combination therapy ( n = 37 ; 200 mg of intravenous erythromycin twice daily + 10 mg of intravenous metoclopramide four times daily ) or erythromycin alone ( n = 38 ; 200 mg of intravenous erythromycin twice daily ) in a prospect i ve , r and omized fashion . Gastric feeding was re-commenced and 6-hourly gastric aspirates performed . Patients were studied for 7 days . Successful feeding was defined as a gastric residual volume < 250 mL with the feeding rate ≥40 mL/hr , over 7 days . Secondary outcomes included daily caloric intake , vomiting , postpyloric feeding , length of stay , and mortality . MEASUREMENTS AND MAIN RESULTS Demographic data ; use of inotropes , opioids , or benzodiazepines ; and pretreatment gastric residual volume were similar between the two groups . The gastric residual volume was significantly lower after 24 hrs of treatment with combination therapy , compared with erythromycin alone ( 136 ± 23 mL vs. 293 ± 45 mL , p = .04 ) . Over the 7 days , patients treated with combination therapy had greater feeding success , received more daily calories , and had a lower requirement for postpyloric feeding , compared with erythromycin alone . Tachyphylaxis occurred in both groups but was less with combination therapy . Sedation , higher pretreatment gastric residual volume , and hypoalbuminemia were significantly associated with a poor response . There was no difference in the length of hospital stay or mortality rate between the groups . Watery diarrhea was more common with combination therapy ( 20 of 37 vs. 10 of 38 , p = .01 ) but was not associated with enteric infections , including Clostridium difficile . CONCLUSIONS In critically ill patients with feed intolerance , combination therapy with erythromycin and metoclopramide is more effective than erythromycin alone in improving the delivery of nasogastric nutrition and should be considered as the first-line treatment . ( Crit Care Med . 2007;35:2561 - 2567 . ) NQ Nguyen , M Chapman , RJ Fraser , LK Bryant , C Burgstad , RH Holloway Introduction : Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients , particularly on severity of organic failure measured with the Sequential Organ Failure Assessment ( SOFA ) . Material s and Methods : In a double blind clinical trial , 80 critically ill adult patients were r and omized to hyperproteic hypocaloric or to isocaloric enteral nutrition ; all patients completed follow-up of at least 4 days . Prescribed caloric intake was : Hyperproteic hypocaloric enteral nutrition ( 15 kcal/kg with 1.7 g/kg of protein ) or isocaloric enteral nutrition ( 25 kcal/kg with 20 % of the calories as protein ) . The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit ( ICU ) length of stay , days on ventilator , hyperglycemic events , and insulin requirements . Results : There were no differences in SOFA score at baseline ( 7.5 ( st and ard deviation ( SD ) 2.9 ) vs 6.7 ( SD 2.5 ) P = 0.17 ) . The total amount of calories delivered was similarly low in both groups ( 12 kcal/kg in intervention group vs 14 kcal/kg in controls ) , but proteic delivery was significantly different ( 1.4 vs 0.76 g/kg , respectively P ≤ 0.0001 ) . The intervention group showed an improvement in SOFA score at 48 h ( delta SOFA 1.7 ( SD 1.9 ) vs 0.7 ( SD 2.8 ) P = 0.04 ) and less hyperglycemic episodes per day ( 1.0 ( SD 1.3 ) vs 1.7 ( SD 2.5 ) P = 0.017 ) . Discussion : Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score . We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay This document represents the first collaboration between 2 organizations — the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine — to describe best practice s in nutrition therapy in critically ill children . The target of these guidelines is intended to be the pediatric critically ill patient ( > 1 month and 2–3 days in a PICU admitting medical , surgical , and cardiac patients . In total , 2032 citations were scanned for relevance . The PubMed / MEDLINE search result ed in 960 citations for clinical trials and 925 citations for cohort studies . The EMBASE search for clinical trials culled 1661 citations . In total , the search for clinical trials yielded 1107 citations , whereas the cohort search yielded 925 . After careful review , 16 r and omized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline . We used the GRADE criteria ( Grading of Recommendations , Assessment , BACKGROUND Despite extensive use of enteral ( EN ) and parenteral nutrition ( PN ) in intensive care unit ( ICU ) population s for 4 decades , evidence to support their efficacy is extremely limited . METHODS A prospect i ve r and omized trial was conducted evaluate the impact on outcomes of intensive medical nutrition therapy ( IMNT ; provision of > 75 % of estimated energy and protein needs per day via EN and adequate oral diet ) from diagnosis of acute lung injury ( ALI ) to hospital discharge compared with st and ard nutrition support care ( SNSC ; st and ard EN and ad lib feeding ) . The primary outcome was infections ; secondary outcomes included number of days on mechanical ventilation , in the ICU , and in the hospital and mortality . RESULTS Overall , 78 patients ( 40 IMNT and 38 SNSC ) were recruited . No significant differences between groups for age , body mass index , disease severity , white blood cell count , glucose , C-reactive protein , energy or protein needs occurred . The IMNT group received significantly higher percentage of estimated energy ( 84.7 % vs 55.4 % , P < .0001 ) and protein needs ( 76.1 vs 54.4 % , P < .0001 ) per day compared with SNSC . No differences occurred in length of mechanical ventilation , hospital or ICU stay , or infections . The trial was stopped early because of significantly greater hospital mortality in IMNT vs SNSC ( 40 % vs 16 % , P = .02 ) . Cox proportional hazards models indicated the hazard of death in the IMNT group was 5.67 times higher ( P = .001 ) than in the SNSC group . CONCLUSIONS Provision of IMNT from ALI diagnosis to hospital discharge increases mortality BACKGROUND Nutritional support has been recognized as an essential part of intensive care unit management . However , the appropriate caloric intake for critically ill patients remains ill defined . OBJECTIVE We examined the effect of permissive underfeeding compared with that of target feeding and of intensive insulin therapy ( IIT ) compared with that of conventional insulin therapy ( CIT ) on the outcomes of critically ill patients . DESIGN This study had a 2 × 2 factorial , r and omized , controlled design . Eligible patients were r and omly assigned to permissive underfeeding or target feeding groups ( caloric goal : 60 - 70 % compared with 90 - 100 % of calculated requirement , respectively ) with either IIT or CIT ( target blood glucose : 4.4 - 6.1 compared with 10 - 11.1 mmol/L , respectively ) . RESULTS Twenty-eight-day all-cause mortality was 18.3 % in the permissive underfeeding group compared with 23.3 % in the target feeding group ( relative risk : 0.79 ; 95 % CI : 0.48 , 1.29 ; P = 0.34 ) . Hospital mortality was lower in the permissive underfeeding group than in the target group ( 30.0 % compared with 42.5 % ; relative risk : 0.71 ; 95 % CI : 0.50 , 0.99 ; P = 0.04 ) . No significant differences in outcomes were observed between the IIT and CIT groups . CONCLUSION In critically ill patients , permissive underfeeding may be associated with lower mortality rates than target feeding . This trial was registered at controlled-trials.com as IS RCT N96294863 IMPORTANCE Monitoring of residual gastric volume is recommended to prevent ventilator-associated pneumonia ( VAP ) in patients receiving early enteral nutrition . However , studies have challenged the reliability and effectiveness of this measure . OBJECTIVE To test the hypothesis that the risk of VAP is not increased when residual gastric volume is not monitored compared with routine residual gastric volume monitoring in patients receiving invasive mechanical ventilation and early enteral nutrition . DESIGN , SETTING , AND PATIENTS R and omized , noninferiority , open-label , multicenter trial conducted from May 2010 through March 2011 in adults requiring invasive mechanical ventilation for more than 2 days and given enteral nutrition within 36 hours after intubation at 9 French intensive care units ( ICUs ) ; 452 patients were r and omized and 449 included in the intention-to-treat analysis ( 3 withdrew initial consent ) . INTERVENTION Absence of residual gastric volume monitoring . Intolerance to enteral nutrition was based only on regurgitation and vomiting in the intervention group and based on residual gastric volume greater than 250 mL at any of the 6 hourly measurements and regurgitation or vomiting in the control group . MAIN OUTCOME MEASURES Proportion of patients with at least 1 VAP episode within 90 days after r and omization , as assessed by an adjudication committee blinded to patient group . The prestated noninferiority margin was 10 % . RESULTS In the intention-to-treat population , VAP occurred in 38 of 227 patients ( 16.7 % ) in the intervention group and in 35 of 222 patients ( 15.8 % ) in the control group ( difference , 0.9 % ; 90 % CI , -4.8 % to 6.7 % ) . There were no significant between-group differences in other ICU-acquired infections , mechanical ventilation duration , ICU stay length , or mortality rates . The proportion of patients receiving 100 % of their calorie goal was higher in the intervention group ( odds ratio , 1.77 ; 90 % CI , 1.25 - 2.51 ; P = .008 ) . Similar results were obtained in the per- protocol population . CONCLUSION AND RELEVANCE Among adults requiring mechanical ventilation and receiving early enteral nutrition , the absence of gastric volume monitoring was not inferior to routine residual gastric volume monitoring in terms of development of VAP . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01137487 Introduction To compare outcomes from early post-pyloric to gastric feeding in ventilated , critically ill patients in a medical intensive care unit ( ICU ) . Methods Prospect i ve r and omized study . Ventilated patients were r and omly assigned to receive enteral feed via a nasogastric or a post-pyloric tube . Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically . Results A total of 104 patients were enrolled , 54 in the gastric group and 50 in the post-pyloric group . Bedside post-pyloric tube insertion was successful in 80 % of patients . Patients who failed post-pyloric insertion were fed via the nasogastric route , but were analysed on an intent-to treat basis . A per protocol analysis was also performed . Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II ( APACHE II ) score , which was higher in the post-pyloric group . There was no difference in length of stay or ventilator days . The gastric group was quicker to initiate feed 4.3 hours ( 2.9 - 6.5 hours ) as compared to post-pyloric group 6.6 hours ( 4.5 - 13.0 hours ) ( P = 0.0002 ) . The time to reach target feeds from admission was also faster in gastric group : 8.7 hours ( 7.6 - 13.0 hours ) compared to 12.3 hours ( 8.9 - 17.5 hours ) . The average daily energy and protein deficit were lower in gastric group 73 Kcal ( 2 - 288 Kcal ) and 3.5 g ( 0 - 15 g ) compared to 167 Kcal ( 70 - 41 
    Output:
    
The associations between lower compared with higher caloric intake and primary and secondary outcomes , including pneumonia , were not different between caloric restriction and non-caloric restriction trials , except for the hospital﻿ stay which was lo﻿nger with lower caloric intake in the c﻿aloric restriction trials .
Conclusions We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality .
Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy ( five trials only ) .