***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: To investigate the importance of route of nutrient administration on  septic complications after blunt and penetrating trauma , 98 patients with an abdominal trauma index of at least 15 were r and omized to either enteral or parenteral feeding within 24 hours of injury .  Septic morbidity was defined as pneumonia , intra-abdominal abscess , empyema , line sepsis , or fasciitis with wound dehiscence . Patients were fed formulas with almost identical amounts of fat , carbohydrate , and protein .  Two patients died  early in the study . The enteral group sustained significantly fewer pneumonias ( 11.8 % versus total parenteral nutrition 31.% , p less than 0.02 ) , intra-abdominal abscess ( 1.9 % versus total parenteral nutrition 13.3 % , p less than 0.04 ) , and line sepsis ( 1.9 % versus total parenteral nutrition 13.3 % , p less than 0.04 ) , and sustained significantly fewer infections per patient ( p less than 0.03 ) , as well as significantly fewer infections per infected patient ( p less than 0.05 ) . Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24 , there were significantly fewer infections in patients with an injury severity score greater than 20 ( p less than 0.002 ) and abdominal trauma index greater than 24 ( p less than 0.005 ) . Enteral feeding produced significantly fewer infections in the penetrating group ( p less than 0.05 ) and barely missed the statistical significance in the blunt-injured patients ( p = 0.08 ) . In the sub population of patients requiring more than 20 units of blood , sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours , there were significantly fewer infections per patient ( p = 0.03 ) and significantly fewer infections per infected patient ( p less than 0.01 ) . There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma , with most of the significant changes occurring in the more severely injured patients . The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients , particularly in the most severely injured patients A system has been constructed to evaluate the design , implementation , and analysis of  r and omized control trials ( RCT ) . The degree of quadruple blinding ( the r and omization process , the physicians and patients as to therapy , and the physicians as to ongoing results ) is considered to be the most important aspect of any trial . The analytic techniques are scored with the same emphasis as is placed on the control of bias in the planning and implementation of the studies . Description of the patient and treatment material s and the measurement of various controls of quality have less weight . An index of quality of a RCT is proposed with its pros and cons . If published papers were to approximate these principles , there would be a marked improvement in the quality of r and omized control trials . Finally , a reasonable st and ard design and conduct of trials will facilitate the interpretation of those with conflicting results and help in making valid combinations of undersized trials Objective : To describe current nutrition practice s in intensive care units and determine “ best achievable ” practice relative to evidence -based Critical Care Nutrition Clinical Practice Guidelines . Design : An international , prospect i ve , observational , cohort study conducted January to June 2007 . Setting : One hundred fifty-eight adult intensive care units from 20 countries . Patients : Two-thous and nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients ( mean , 18.6 per site ) who stayed in the intensive care unit for at least 72 hrs . Interventions : Data on nutrition practice s were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days . Measurements and Main Results : Relative to recommendations of the Clinical Practice Guidelines , we report average , best , and worst site performance on key nutrition practice s. Adherence to Clinical Practice Guideline recommendations was high for some recommendations : use of enteral nutrition in preference to parenteral nutrition , glycemic control , lack of utilization of arginine-enriched enteral formulas , delivery of hypocaloric parenteral nutrition , and the presence of a feeding protocol . However , significant practice gaps were identified for other recommendations . Average time to start of enteral nutrition was 46.5 hrs ( site average range , 8.2–149.1 hrs ) . The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7 % ( site average range , 0%–100 % ) and 14.7 % ( site average range , 0%–100 % ) , respectively . There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils , glutamine supplementation , timing of supplemental parenteral nutrition , and avoidance of soybean oil-based parenteral lipids .  Average nutritional adequacy was 59 % ( site average range , 20.5%–94.4 % ) for energy and 60.3 % ( site average range , 18.6%–152.5 % ) for protein . Conclusions : Despite high adherence to some recommendations , large gaps exist between many recommendations and actual practice in intensive care units , and consequently nutrition therapy is suboptimal . We have identified “ best achievable ” practice that can serve as targets for future quality improvement initiatives Objective R and omized trials show that the semirecumbent position compared with the supine position is associated with less gastroesophageal aspiration and pneumonia in patients receiving mechanical ventilation . However , semirecumbency is inconsistently used in practice . The objective of this study was to underst and the perspectives of intensive care unit clinicians regarding the determinants and consequences of semirecumbency . Design Qualitative study using semistructured interviews and focus groups . Setting Three university-affiliated intensive care units . Participants A total of 93 intensive care unit clinicians , including bedside nurses , respiratory therapists , physiotherapists , nutritionists , residents , fellows , and intensivists . Methods We elicited perceptions about benefits and harms of  semirecumbency  , factors promoting and deterring use , and health systems changes to encourage semirecumbency . Interview and focus group notes were analyzed inductively to identify emerging themes . Validation methods involved triangulation by multidisciplinary analysis of several data sources collected through multiple methods and member checking . Measurements and Main Results Intensivists and nutritionists were familiar with semirecumbency as a potential pneumonia prevention strategy , whereas other clinicians were not . When made aware of the evidence , all participants endorsed semirecumbency . Nurses perceived that the main determinant of semirecumbency was physicians ’ orders , whereas intensivists perceived that the main determinant was nursing preference . Participants identified barriers to semirecumbency related to useful alternative positions ( e.g. , lateral position ) , contraindications ( e.g. , hemodynamic instability ) , risk of harm ( e.g. , decubitus ulcers ) , safety ( e.g. , sliding out of the bed ) , and re sources ( e.g. , insufficient beds facilitating semirecumbency ) . Education , guidelines , reminders , audit and feedback , charting , and quality improvement initiatives were advocated to promote semirecumbency . Conclusions Under-utilization of semirecumbency for pneumonia prevention is influenced by insufficient awareness of its benefit , real and perceived deterrents , poor agreement about implementation responsibility , and lack of enabling and reinforcing strategies . Cognitive , behavioral , and administrative approaches to enhancing evidence uptake may be needed in the complex , dynamic intensive care unit setting 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 - 411 Kcal ) and 6.5 g ( 2.8 - 17.3 g ) respectively but was only statistically significant for the average energy deficit ( P = 0.035 ) . This difference disappeared in the per protocol analysis . Complication rates were similar . Conclusions Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complicationsTrial Registration Clinical Trial : anzctr.org.au : A prospect i ve study was carried out over a 10-month period to compare nutritional status , gastric colonization , and rates of nosocomial pneumonia in intensive care unit ( ICU ) patients r and omized to either gastric tube feeding or feeding by an endoscopically placed jejunal tube . Sixty-nine patients were considered eligible for the study . Thirty-eight patients were enrolled from medical and surgical ICUs at two hospitals and were equally divided into two groups . The groups were similar in age , sex , race , underlying disease , type of surgical procedure , number of days fed , duration of ICU stay , duration of mechanical ventilation , days with fever , and days of antibiotic therapy . The jejunal tube ( JT ) group had more patients who were in circulatory shock on admission ( 79 % ) than the gastric feeding ( GT ) group ( 68.4 % ) . Additionally , the JT group had higher Acute Physiology Scores ( 24.0 vs 21.7 ) and fewer  patients with pneumonia  at the time of entry into the study ( 26.3 % us 31.6 % ) . The JT patients received a signi Objective : To determine whether medical intensive care unit ( ICU ) patients receiving nasoduodenal ( ND ) feedings  achieve optimal nutritional support and better clinical outcomes compared with patients receiving nasogastric ( NG ) feedings .  Design : A prospect i ve , r and omized , clinical study . Setting : Medical ICU of a university-affiliated tertiary medical center . Patients : One hundred twenty-one medical ICU patients required enteral feeding . Interventions : Patients were r and omized to receive enteral feeding .  One group received ND feedings and the other group received NG feedings . All patients followed the same protocol . Measurements and Main Results : The primary outcome of optimal nutritional support was assessed by measurement of time to goal tube feed rate and daily calorie and protein intake . Secondary clinical outcomes included number of ICU , hospital and ventilator days , number of the days in the study , blood – glucose levels , incidence of vomiting , diarrhea , gastrointestinal bleeding , tube replaced , tube clogged , fever , bacteremia , and ventilator-associated pneumonia ( VAP ) , and mortality rate . Results showed that the ND group had a higher average daily calorie and protein intake compared with NG group and achieved nutritional goals earlier . In terms of clinical outcomes , patients in the ND group had a lower rate of vomiting and VAP . The other clinical outcomes such as number of ICU days , hospital days , ventilator days , blood – glucose level , tube replaced or clogged , diarrhea , gastrointestinal bleeding , fever , bacteremia , and mortality rate were not significantly different between two groups . Conclusions : Patients who received ND feedings achieved nutritional goals earlier than those who received NG feeding . ND feeding group also has a lower rate of vomiting and VAP in the medical ICU setting Objective To compare the incidence of enteral nutrition-related gastrointestinal complications , the efficacy of diet administration  , and the incidence of nosocomial pneumonia in patients fed in the stomach or in the jejunum . Design Prospect i ve , r and omized multicenter study . Setting Intensive care units ( ICUs ) in 11 teaching hospitals . Patients Critically ill patients who could receive early enteral nutrition more than 5 days . Interventions Enteral nutrition was started in the first 36 hrs after admission . One group was fed with a nasogastric tube ( GEN group ) and the other in the jejunum through a dual-lumen nasogastrojejunal tube ( JEN group ) . 
    Output:
    
Risk of gastrointestinal complications , overall mortality and length of ITU stay were similar between the two techniques of enteral feeding .
In summary , PP feeding in ITU patients  reduces the gastric residual volume and risk of aspiration pneumonia .
PP feeding is also superior to NG feeding in terms of delivering higher proportion of daily caloric requirements .