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Nakamura K, Yamamoto R, Higashibeppu N, Yoshida M, Tatsumi H, Shimizu Y, Izumino H, Oshima T, Hatakeyama J, Ouchi A, Tsutsumi R, Tsuboi N, Yamamoto N, Nozaki A, Asami S, Takatani Y, Yamada K, Matsuishi Y, Takauji S, Tampo A, Terasaka Y, Sato T, Okamoto S, Sakuramoto H, Miyagi T, Aki K, Ota H, Watanabe T, Nakanishi N, Ohbe H, Narita C, Takeshita J, Sagawa M, Tsunemitsu T, Matsushima S, Kobashi D, Yanagita Y, Watanabe S, Murata H, Taguchi A, Hiramoto T, Ichimaru S, Takeuchi M, Kotani J. The Japanese Critical Care Nutrition Guideline 2024. J Intensive Care 2025; 13:18. [PMID: 40119480 PMCID: PMC11927338 DOI: 10.1186/s40560-025-00785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2025] [Accepted: 02/23/2025] [Indexed: 03/24/2025] Open
Abstract
Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.
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Affiliation(s)
- Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Minoru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hiroo Izumino
- Acute and Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba City, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Rie Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima, Japan
| | - Norihiko Tsuboi
- Department of Critical Care Medicine and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Natsuhiro Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Kanagawa, Japan
| | - Ayumu Nozaki
- Department of Pharmacy, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Sadaharu Asami
- Department of Cardiology, Musashino Tokushukai Hospital, Tokyo, Japan
| | - Yudai Takatani
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, Saitama, Japan
| | - Yujiro Matsuishi
- Adult and Elderly Nursing, Faculty of Nursing, Tokyo University of Information Science, Chiba, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yusuke Terasaka
- Department of Emergency Medicine, Kyoto Katsura Hospital, Kyoto, Japan
| | - Takeaki Sato
- Tohoku University Hospital Emergency Center, Miyagi, Japan
| | - Saiko Okamoto
- Department of Nursing, Hitachi General Hospital, Hitachi, Japan
| | - Hideaki Sakuramoto
- Department of Acute Care Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Japan
| | - Tomoka Miyagi
- Anesthesiology and Critical Care Medicine, Master's Degree Program, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Keisei Aki
- Department of Pharmacy, Kokura Memorial Hospital, Fukuoka, Japan
| | - Hidehito Ota
- Department of Pediatrics, School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taro Watanabe
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuto Nakanishi
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Ohbe
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masano Sagawa
- Department of Surgery, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Takefumi Tsunemitsu
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Matsushima
- Department of Physical Therapy, Faculty of Health Science, Kyorin University, Tokyo, Japan
| | - Daisuke Kobashi
- Department of Critical Care and Emergency Medicine, Japanese Red Cross Maebashi Hospital, Gunma, Japan
| | - Yorihide Yanagita
- Department of Health Sciences, Institute of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, Gifu, Japan
| | - Hiroyasu Murata
- Department of Rehabilitation Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Akihisa Taguchi
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takuya Hiramoto
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satomi Ichimaru
- Food and Nutrition Service Department, Fujita Health University Hospital, Aichi, Japan
| | - Muneyuki Takeuchi
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Wang Y, Li Y, Li H, Li Y, Li X, Zhang D. Small peptide formulas versus standard polymeric formulas in critically ill patients with acute gastrointestinal injury: a systematic review and meta-analysis. Sci Rep 2023; 13:20469. [PMID: 37993565 PMCID: PMC10665341 DOI: 10.1038/s41598-023-47422-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
Small peptide formulas versus standard polymeric formulas for enteral nutrition in critically ill patients with acute gastrointestinal injury (AGI) have been a topic of debate. A systematic review and meta-analysis were conducted to compare their clinical and nutritional outcomes. Relevant studies from January 1980 to June 2022 were searched in PubMed, Cochrane, and Embase databases. Randomized controlled trials involving AGI grade I-IV patients were included, while children, non-AGI patients, and non-critically ill patients were excluded. Results indicated no significant difference in all-cause mortality. Patients receiving small peptide formulas showed higher daily protein intake, greater albumin growth, and higher prealbumin levels. They also had shorter lengths of stay in the intensive care unit and hospital. Conversely, patients receiving standard polymeric formulas had a higher daily calorie intake. In conclusion, the choice of formula may not affect mortality in critically ill patients with AGI. Small peptide formulas were more conducive to increase daily protein intake, decrease intensive care unit and hospital length of stay. Further large-scale randomized controlled trials evaluating the effects of these two nutritional formulas on clinical and nutritional outcomes in critically ill patients with AGI are needed to confirm these results.
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Affiliation(s)
- Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China
| | - Yanhua Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China
| | - Hongxiang Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China
| | - Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China
| | - Xinyu Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Chaoyang District, Changchun City, 130021, Jilin Province, China.
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Hall JW, Canada TW, Mansfield PF. Changes in serum prealbumin as a marker for nitrogen balance in surgical oncology patients. Support Care Cancer 2023; 31:639. [PMID: 37851171 DOI: 10.1007/s00520-023-08091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/29/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Serum prealbumin has long been used as a marker of nutritional status. However, prealbumin is a negative acute phase reactant influenced by several non-nutritional-related factors including surgery, infection, and cancer. An increasing prealbumin has been correlated with a positive nitrogen balance in general surgery patients receiving parenteral nutrition (PN) with 88% specificity and 70% sensitivity. To date, no trial has evaluated the effect of concurrent cancer and surgery on the value of prealbumin in predicting nitrogen balance. METHODS This study is a concurrent retrospective design of post-operative patients (≥ 19 years of age) identified by the nutrition support service who received PN for ≥ 5 days, had a baseline and follow-up serum prealbumin and C-reactive Protein (CRP) measured, as well as a 24-h urinary urea nitrogen (UUN) performed between days 5-10 of PN. Exclusion criteria include anuric renal failure, Child-Pugh Class C liver failure, pregnancy, and corticosteroid use. Prealbumin was correlated to nitrogen balance, measuring sensitivity, specificity, and negative and positive predictive values. Information was collected regarding patient demographics and presence or absence of metastatic cancer. RESULTS Thirty patients were identified and evaluated for this study from December 1st, 2010 to July 15th, 2011. Patients included in the study had a mean age of 57 years old (range 20-82), 53% male, with a mean weight of 84 kg (range 42-140) and body mass index (BMI) of 29 kg/m2 (range 14.9-56.8). The mean daily caloric dose of PN per actual body weight was 21 kcal/kg (range 10-34) and the mean daily protein dose was 1.4 g/kg (range 1-2). Forty seven percent of patients were obese (BMI > 30 kg/m2) and were prescribed high-protein hypocaloric PN. The most common indication for PN was post-operative ileus (23/30 patients). 24-h urine collection for UUN was performed on average of day 8 after PN initiation (range 5-10 days). Nitrogen balance as calculated from 24-h UUN was positive in 17/30 patients. A positive prealbumin change of greater than 2.8 mg/dL was found to have a statistically significant association with positive nitrogen balance (p = 0.02). At the cut off level of positive 2.8 mg/dL, the likelihood of a positive nitrogen balance had a sensitivity of 82% (95% confidence interval (CI) 64-100%); specificity of 62% (95% CI 35-88%); positive predictive value of 74% (95% CI 54-93%); negative predictive value of 73% (95% CI 46-99%). No absolute value for prealbumin level (e.g., > 20 mg/dL) was found to be a significant predictor of positive nitrogen balance. CRP levels at initiation of PN were significantly elevated with a mean level of 147 mg/dL. CONCLUSION These results indicate a positive change in serum prealbumin (> 2.8 mg/dL) has sufficient sensitivity (82%) to predict positive changes in nitrogen balance in the surgical oncology population. However, the low specificity (62%) makes it less useful in predicting a negative nitrogen balance. Absolute prealbumin levels were greatly affected by inflammation, as evidenced by CRP levels, and single values were not useful in predicting positive nitrogen balance. CLINICAL RELEVANCY Positive changes in serum prealbumin levels have previously been associated with a positive nitrogen balance (NB) in surgical patients receiving parenteral nutrition (PN); however, it is unclear if this is true in oncologic surgery patients. This study highlights how changing levels of serum prealbumin and C-reactive protein correlates to NB for cancer patients in the post-operative period requiring PN. Changes in prealbumin levels from baseline showed sufficient sensitivity, but not specificity to utilize routinely for predicting NB in this population.
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Affiliation(s)
- Jacob W Hall
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 377, Houston, TX, 77030, USA.
| | - Todd W Canada
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Mostafa MS, Gamal Y, Soliman MH. Peptide-based enteral formula vs a whole protein enteral formula after major intestinal surgeries in children. ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00112-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Malnutrition is a common finding after major abdominal surgeries especially after prolonged period of fasting in children. Enteral feeding is the commonest support way postoperatively for stimulating gut hormones, modulating immunity, and maintaining the barrier function of the intestinal mucosa.
Our aim was to compare the results and outcome regarding tolerance, nutritional status, and hospital stay following a postoperative diet of peptide-based enteral formula against a whole protein enteral formula after major intestinal surgeries in pediatric patients who had resection and re-anastomosis after intussusception.
Results
This is a prospective cohort study on two groups of patients with a total of 30 patients during the period between January 2019 and June 2020.
All patients in both groups underwent major intestinal surgeries (resection and re-anastomosis after intussusception). The first group received postoperative whole protein formula exclusively on the 3rd postoperative day while the other group received peptide-based formula exclusively on the same day.
Postoperative mean serum albumin and pre-albumin levels were significantly higher in peptide-based formula group compared to those who had protein-based formula as their initial feeds (P value < 0.05). The average hospital stay was also significantly shorter in the peptide group (P value < 0.05). Peptide formula was easily tolerated than protein formula in postoperative children who had major intestinal surgeries.
Conclusion
Peptide-based enteral formulas are better tolerated and more useful as regards nutritional status than whole-protein formulas in post-operative course of pediatric patients regarding clinical outcome and better economically with shorter hospital stay.
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Gastrointestinal Tolerance and Protein Absorption Markers with a New Peptide Enteral Formula Compared to a Standard Intact Protein Enteral Formula in Critically Ill Patients. Nutrients 2021; 13:nu13072362. [PMID: 34371872 PMCID: PMC8308653 DOI: 10.3390/nu13072362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this exploratory study was to investigate gastrointestinal tolerance and protein absorption markers with a new enteral peptide formula (PF) compared to an isocaloric enteral intact protein standard formula (SF) containing the same amount of protein in ICU patients. Patients admitted to a cardio-thoracic intensive care unit expected to receive tube feeding for ≥5 days were randomized to receive either PF (1.5 kcal/mL) or SF in a double-blind manner for ≤14 days. Twenty-six patients were randomized (13 SF and 13 PF) and 23 (12 SF and 11 PF) completed at least 5 days of product administration. There were no statistically significant differences between the feeds during the first 5 days of intervention for diarrhea (SF:3 (23%); PF:5 (39%), p = 0.388), vomiting (SF:1 (8%); PF:2 (15%), p = 0.549), constipation (SF:7 (54%), PF:3 (23%), p = 0.115), and high gastric residual volume (>500 mL: SF:1 (8%); PF: 2 (15%), p = 0.535). There were no differences in plasma amino acids or urinary markers of protein absorption and metabolism. In conclusion, no major differences were found in tolerability and protein absorption markers between the standard intact protein formula and the peptide formula.
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Curry AS, Chadda S, Danel A, Nguyen DL. Early introduction of a semi-elemental formula may be cost saving compared to a polymeric formula among critically ill patients requiring enteral nutrition: a cohort cost-consequence model. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:293-300. [PMID: 29892200 PMCID: PMC5993029 DOI: 10.2147/ceor.s155312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Gastrointestinal (GI) intolerance is associated with adverse outcomes in critically ill patients receiving enteral nutrition (EN). The objective of this analysis is to quantify the cost of GI intolerance and the cost implications of starting with semi-elemental EN in intensive care units (ICUs). STUDY DESIGN A US-based cost-consequence model was developed to compare the costs for patients with and without GI intolerance and the costs with semi-elemental or standard EN while varying the proportion of GI intolerance cases avoided. MATERIALS AND METHODS ICU data on GI intolerance prevalence and outcomes in patients receiving EN were derived from an observational study. ICU stay costs were obtained from literature and the costs of EN from US customers' price lists. The model was used to conduct a threshold analysis, which calculated the minimum number of cases of GI intolerance that would have to be avoided to make the initial use of semi-elemental formula cost saving for the cohort. RESULTS Out of 100 patients receiving EN, 31 had GI intolerance requiring a median ICU stay of 14.4 days versus 11.3 days for each patient without GI intolerance. The model calculated that semi-elemental formula was cost saving versus standard formula when only three cases of GI intolerance were prevented per 100 patients (7% of GI intolerance cases avoided). CONCLUSION In the US setting, the model predicts that initial use of semi-elemental instead of standard EN can result in cost savings through the reduction in length of ICU stay if >7% of GI intolerance cases are avoided.
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Affiliation(s)
| | - Shkun Chadda
- Health Economics, SIRIUS Market Access, London UK
| | - Aurélie Danel
- Market Access, Nestlé Health Science, Vevey, Switzerland
| | - Douglas L Nguyen
- University of California-Irvine Department of Medicine, Orange, CA, USA
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Qiu C, Chen C, Zhang W, Kou Q, Wu S, Zhou L, Liu J, Ma G, Chen J, Chen M, Luo H, Zhang X, Lai J, Yu Z, Yu X, Liao W, Guan X, Ouyang B. Fat-Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter, Single-Blind, Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2017; 41:785-795. [PMID: 26350918 DOI: 10.1177/0148607115601858] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat-modified enteral formula on feeding tolerance in critically ill patients. MATERIALS AND METHODS This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat-modified enteral formula containing medium-chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator-free days of 28 days, length of ICU stay, length of hospital stay, and in-hospital mortality) were collected. RESULTS Daily calories and protein intake were increased in the interventional feed group compared with the control feed group ( P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group ( P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1-5 ( P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group ( P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group ( P = .03). No significant differences existed in outcomes between the 2 groups. CONCLUSIONS The fat-modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.
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Affiliation(s)
- Chunfang Qiu
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Chuanxi Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Weixing Zhang
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Qiuye Kou
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Shengnan Wu
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Lixin Zhou
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Jiyun Liu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Gang Ma
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Juan Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Minying Chen
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Hua Luo
- 2 Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Xiaofei Zhang
- 3 Department of Intensive Care Unit, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Jianbo Lai
- 4 Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhihui Yu
- 5 Department of Intensive Care Unit, The First People's Hospital of Foshan, Foshan, P.R. China
| | - Xiaochun Yu
- 6 Department of Intensive Care Unit, The First People's Hospital of Guangzhou, Guangzhou, P.R. China
| | - Wei Liao
- 7 Department of Intensive Care Unit, University Cancer Center, Guangzhou, P.R. China
| | - Xiangdong Guan
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
| | - Bin Ouyang
- 1 Department of Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P.R. China
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Liu MY, Tang HC, Hu SH, Chang SJ. Peptide-based enteral formula improves tolerance and clinical outcomes in abdominal surgery patients relative to a whole protein enteral formula. World J Gastrointest Surg 2016; 8:700-705. [PMID: 27830042 PMCID: PMC5081552 DOI: 10.4240/wjgs.v8.i10.700] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/19/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare a dipeptide- and tripeptide-based enteral formula with a standard enteral formula for tolerance and nutritional outcomes in abdominal surgery patients.
METHODS A retrospective study was performed to assess the differences between a whole-protein formula (WPF) and a dipeptide- and tripeptide-based formula (PEF) in clinical outcomes. Seventy-two adult intensive care unit (ICU) patients with serum albumin concentrations less than 3.0 g/dL were enrolled in this study. Patients were divided into two groups (WPF group = 40 patients, PEF group = 32 patients). The study patients were fed for at least 7 d, with ≥ 1000 mL of enteral formula infused on at least 3 of the days.
RESULTS The mean serum albumin level on postoperative day (POD) 10, prealbumin levels on POD-5 and POD-10, and total lymphocyte count on POD-5 were significantly higher in the PEF group compared to those in the WPF group (P < 0.05). The average maximum gastric residual volume of the PEF patients during their ICU stays was significantly lower than that for WPF patients.
CONCLUSION Dipeptide- and tripeptide-based enteral formulas are more efficacious and better tolerated than whole-protein formulas.
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Heyland DK, Konopad E, Alberda C, Keefe L, Cooper C, Cantwell B. How Well Do Critically Ill Patients Tolerate Early, Intragastric Enteral Feeding? Results of a Prospective, Multicenter Trial. Nutr Clin Pract 2016. [DOI: 10.1177/088453369901400105] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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de Brito-Ashurst I, Preiser JC. Diarrhea in Critically Ill Patients: The Role of Enteral Feeding. JPEN J Parenter Enteral Nutr 2016; 40:913-23. [PMID: 27271709 DOI: 10.1177/0148607116651758] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
Abstract
This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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BLASER AREINTAM, STARKOPF J, KIRSIMÄGI Ü, DEANE AM. Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol Scand 2014; 58:914-22. [PMID: 24611520 DOI: 10.1111/aas.12302] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 12/16/2022]
Abstract
Clinicians and researchers frequently use the phrase 'feeding intolerance' (FI) as a descriptive term in enterally fed critically ill patients. We aimed to: (1) determine what is the most accepted definition of FI; (2) estimate the prevalence of FI; and (3) evaluate whether FI is associated with important outcomes. Systematic searches of peer-reviewed publications using PubMed, MEDLINE, and Web of Science were performed with studies reporting FI extracted. We identified 72 studies defining FI. In 33 studies, the definition was based on large gastric residual volumes (GRVs) together with other gastrointestinal symptoms, while 30 studies relied solely on large GRVs, six studies used inadequate delivery of enteral nutrition (EN) as a threshold, and three studies gastrointestinal symptoms without reference to GRV. The median volume used to define a 'large' GRV was 250 ml (ranges from 75 to 500 ml). The pooled proportion (n = 31 studies) of FI was 38.3% (95% CI 30.7-46.2). Five studies reported outcomes, all of them observed adverse outcome in FI patients. In three studies, respectively, FI was associated with increased mortality and ICU length-of-stay. In summary, FI is inconsistently defined but appears to occur frequently. There are preliminary data indicating that FI is associated with adverse outcomes. A standard definition of FI is required to determine the accuracy of these preliminary data.
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Affiliation(s)
- A. REINTAM BLASER
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
| | - J. STARKOPF
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
- Department of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
| | - Ü. KIRSIMÄGI
- Department of Surgery; Tartu University Hospital; Tartu Estonia
| | - A. M. DEANE
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
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Mutlu GM, Mutlu EA, Factor P. Prevention and Treatment of Gastrointestinal Complications in Patients on Mechanical Ventilation. ACTA ACUST UNITED AC 2012; 2:395-411. [PMID: 14719992 DOI: 10.1007/bf03256667] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.
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Affiliation(s)
- Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Evanston Northwestern Healthcare, Evanston Illinois and Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Casaer MP, Mesotten D. Enteral nutrition: better navigation, yet unknown destination? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:1015. [PMID: 22136401 PMCID: PMC3388650 DOI: 10.1186/cc10538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The nutrition dose truly absorbed by a patient is crucial information in the management or the investigation of nutrition during critical illness. In the present issue of Critical Care, assessment of nutritional losses in stools was studied. These losses together with enteral nutrition lost in gastric fluids and enteral nutrition prescribed but never infused make up the difference between the dose supposedly given to a patient and the amount effectively taken up. Additionally, the optimal dosing and timing of nutrition during critical illness are still debated. When enteral nutrition is insufficient, the options are limited.
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Clinical review: Optimizing enteral nutrition for critically ill patients--a simple data-driven formula. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:234. [PMID: 22136305 PMCID: PMC3388694 DOI: 10.1186/cc10430] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In modern critical care, the paradigm of 'therapeutic nutrition' is replacing traditional 'supportive nutrition'. Standard enteral formulas meet basic macro- and micronutrient needs; therapeutic enteral formulas meet these basic needs and also contain specific pharmaconutrients that may attenuate hyperinflammatory responses, enhance the immune responses to infection, or improve gastrointestinal tolerance. Choosing the right enteral feeding formula may positively affect a patient's outcome; targeted use of therapeutic formulas can reduce the incidence of infectious complications, shorten lengths of stay in the ICU and in the hospital, and lower risk for mortality. In this paper, we review principles of how to feed (enteral, parenteral, or both) and when to feed (early versus delayed start) patients who are critically ill. We discuss what to feed these patients in the context of specific pharmaconutrients in specialized feeding formulations, that is, arginine, glutamine, antioxidants, certain ω-3 and ω-6 fatty acids, hydrolyzed proteins, and medium-chain triglycerides. We summarize current expert guidelines for nutrition in patients with critical illness, and we present specific clinical evidence on the use of enteral formulas supplemented with anti-inflammatory or immune-modulating nutrients, and gastrointestinal tolerance-promoting nutritional formulas. Finally, we introduce an algorithm to help bedside clinicians make data-driven feeding decisions for patients with critical illness.
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Abstract
OBJECTIVE To assess the incidence of diarrhoea in intensive care patients with a length of stay (LOS) greater than 3 days who were receiving any type of enteral tube feeding, and to measure the effect of implementing a bowel management protocol. DESIGN A 2-year prospective audit, with an intervention after 12 months. Diarrhoea was defined as bowel activity exceeding three stools of any consistency per day, or three or more unformed stools (or 300 mL) per day, for two consecutive days. SETTING A tertiary referral intensive care unit (ICU) in a large public hospital. SAMPLE Six hundred fifty-six consecutive patients admitted to ICU with a LOS >3 days. INTERVENTION A bowel management protocol was implemented to address both diarrhoea and constipation. MAIN OUTCOME MEASURES Number of patients who experienced diarrhoea during their ICU stay; number of ICU patient-days on which diarrhoea occurred. RESULTS After the protocol was implemented, diarrhoea was experienced by 13% fewer patients (p = 0.0002) and occurred on 8% fewer ICU days (p < 0.0001). CONCLUSION Use of an evidence-based protocol, and improved monitoring and reporting of bowel activity, can decrease the incidence of diarrhoea in ICU patients.
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Affiliation(s)
- Suzie Ferrie
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW 2042, Australia.
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Kreymann KG, Berger MM, Deutz NEP, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006; 25:210-23. [PMID: 16697087 DOI: 10.1016/j.clnu.2006.01.021] [Citation(s) in RCA: 816] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/07/2023]
Abstract
Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.
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Affiliation(s)
- K G Kreymann
- Department of Intensive Care Medicine, University Hospital Eppendorf, Hamburg, Germany.
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Abstract
The purpose of this article is to give an overview of the relation between feeding and gastrointestinal symptoms and complaints, and to review different motility disorders that have implications for food intake. We also report the consequences for nutrition state and the evidence-based principles of dietary modification in patients with motility disorders.
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Affiliation(s)
- G Karamanolis
- Division of Gastroenterology, Department of Internal Medicine, Center for Gastroenterological Research, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
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19
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Abstract
Surrogate nutrition markers are used to assess adequacy of nourishment and to define malnutrition despite evidence that fails to link nourishment, surrogate markers, and outcomes. Markers such as serum levels of albumin, prealbumin, transferrin, and IGF-1 and delayed hypersensitivity and total lymphocyte count may be valid to help stratify risk. However, it is not appropriate to consider these as markers of adequacy of nourishment in the sick patient.
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Affiliation(s)
- David S Seres
- Department of Medicine, Beth Israel Medical Center and Albert Einstein College of Medicine, New York, New York, USA.
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Abstract
Mechanical ventilation (MV) can be lifesaving by maintaining gas exchange until the underlying disorders are corrected, but it is associated with numerous organ-system complications, which can significantly affect the outcome of critically ill patients. Like other organ systems, GI complications may be directly attributable to MV, but most are a reflection of the severity of the underlying disease that required intensive care. The interactions of the underlying critical illness and MV with the GI tract are complex and can manifest in a variety of clinical pictures. Incorporated in this review are discussions of the most prevalent GI complications associated with MV, and current diagnosis and management of these problems.
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Affiliation(s)
- G M Mutlu
- Section of Respiratory and Critical Care Medicine, University of Illinois at Chicago, Chicago, IL, USA
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21
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MacLaren R. Intolerance to intragastric enteral nutrition in critically ill patients: complications and management. Pharmacotherapy 2000; 20:1486-98. [PMID: 11130221 DOI: 10.1592/phco.20.19.1486.34853] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Compared with parenteral nutrition, early administration of enteral nutrition (EN) to critically ill patients improves clinical outcomes and reduces infection rates. Intragastric EN often is complicated by intolerance, as indicated by elevated volumes of aspirated gastric residuals. Conflicting data are available for the volume of residual that represents intolerance, but most clinicians use 150-200 ml to signify gastrointestinal motility dysfunction. Intolerance is associated with mortality. Data support an association between intragastric EN and aspiration pneumonia, but little information is available regarding the contributory effect of intolerance. Transpyloric migration of the feeding tube may facilitate tolerance but does not reduce the likelihood of aspiration pneumonia. Prokinetic agents (cisapride, erythromycin, metoclopramide) promote gastric emptying. Results of most studies are limited because patients did not receive or tolerated intragastric EN. Metoclopramide is the agent of choice for treating intolerance. Further studies are necessary before prokinetic drugs can be recommended for preventing intragastric EN-associated aspiration pneumonia.
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Affiliation(s)
- R MacLaren
- School of Pharmacy, University of Colorado Health Sciences Center, Denver 80262, USA
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23
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Abstract
The number of enteral diets has increased from a handful in the 1970s to over 100 at present. These can be classified as polymeric, chemically defined, disease-specific, and specialized diets, as well as oral dietary supplements. The properties, indications, pros and cons for the use of these diets are outlined in an effort to assist clinicians in their selection.
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Affiliation(s)
- D B Silk
- Department of Gastroenterology and Nutrition, Central Middlesex Hospital NHS Trust, London, UK
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24
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Dietscher JE, Foulks CJ, Smith RW. Nutritional response of patients in an intensive care unit to an elemental formula vs a standard enteral formula. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 1998; 98:335-6. [PMID: 9508019 DOI: 10.1016/s0002-8223(98)00078-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J E Dietscher
- Department of Medicine, University of North Dakota, Fargo, USA
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25
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Tueux O. Techniques et modalités d'apport et de surveillance de la nutrition entérale. NUTR CLIN METAB 1998. [DOI: 10.1016/s0985-0562(98)80023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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26
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Weinstein DS, Furman J. ENTERAL FORMULAS. Nurs Clin North Am 1997. [DOI: 10.1016/s0029-6465(22)02684-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Heimburger DC, Geels VJ, Bilbrey J, Redden DT, Keeney C. Effects of small-peptide and whole-protein enteral feedings on serum proteins and diarrhea in critically ill patients: a randomized trial. JPEN J Parenter Enteral Nutr 1997; 21:162-7. [PMID: 9168369 DOI: 10.1177/0148607197021003162] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has been proposed that enteral feeding formulas containing small peptides are more efficacious and better tolerated than whole-protein formulas in critically ill patients. METHODS Intensive care unit patients were stratified with regard to treatment with antibiotics and serum albumin and randomized to treatment with a small-peptide enteral diet or an isoenergetic, isonitrogenous whole-protein diet for 10 days. To assess efficacy, we measured serum prealbumin and fibronectin, and to assess tolerance, we monitored the incidence of diarrhea. A protocol was followed to ascertain all causes of diarrhea (defined as > 200 g stool or > or = 3 liquid stools on 2 consecutive days). RESULTS Fifty subjects completed the trial. Serum prealbumin and fibronectin increased between 21% and 36% in both groups, but the increase was significant only in the small-peptide group. The change in fibronectin between days 5 and 10 was significantly greater in the small-peptide group (p = .02). Diarrhea occurred in 10 subjects (17.8% of days) receiving small-peptide feeding and 4 subjects (7.5% of days) receiving whole-protein feeding (P = .07 for incidence and 0.03 for prevalence), but the difference was explained by the coincidental use of more diarrhea-causing medications in the former. Only one case of diarrhea could be attributed to tube feeding. CONCLUSIONS During 10 days of feeding, the small-peptide diet produced slightly greater increases in serum rapid-synthesis proteins than did the whole-protein diet, especially between days 5 and 10. The clinical implications of this difference between the diets are unknown. Both small-peptide and whole-protein diets were well tolerated.
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Affiliation(s)
- D C Heimburger
- Department of Nutrition Sciences, University of Alabama at Birmingham, USA
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Abstract
Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.
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Affiliation(s)
- S A Shikora
- Nutrition Support Services, USAF Medical Center, Lackland AFB, Texas, USA
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Farrugia G, Camilleri M, Whitehead WE. Therapeutic strategies for motility disorders. Medications, nutrition, biofeedback, and hypnotherapy. Gastroenterol Clin North Am 1996; 25:225-46. [PMID: 8682575 DOI: 10.1016/s0889-8553(05)70373-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Gastrointestinal motility is regulated by a complex balance of inhibitory and excitatory neuronal, humoral, and mechanical factors. The goal in the management of motility disorders is to maintain adequate nutrition while decreasing symptoms. This can be accomplished by medications and support of nutrition and biofeedback; the application of these therapeutic strategies to patients with gut motility disorders is reviewed.
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Affiliation(s)
- G Farrugia
- Mayo Medical School, Rochester, Minnesota, USA
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30
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Abstract
Medical foods are enterally administered formulas used as complete or supplemental nutrition support in the treatment of diseases and clinical disorders of hospitalized or incapacitated adult patients. Because clinical trials have failed to demonstrate a consistent benefit of these products on morbidity and mortality rates, it has been difficult to reach consensus on their primary role. Are medical foods components of supportive care or should they be considered pharmacologic treatment? To date, the US Congress has defined medical foods, but the Food and Drug Administration has not developed regulatory statutes for them beyond those designed to ensure the sanitary manufacture of all processed foods. Before effective regulations can be developed, medical foods need to be defined further in order to distinguish them from each other and from other classes of nutritional products such as parenteral nutrients or infant formulas. Because we believe that the role of medical foods is in supportive care rather than pharmacologic therapy, we argue that these products should be subject to regulations similar to those that apply to conventional foods.
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Heyland DK, Cook DJ, Guyatt GH. Enteral nutrition in the critically ill patient: a critical review of the evidence. Intensive Care Med 1993; 19:435-42. [PMID: 8294625 DOI: 10.1007/bf01711083] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the relationship between enteral nutrition (EN) and infection in the critically ill. SETTING Computerized search of published research and review of relevant reference lists. STUDY SELECTION 151 citations were reviewed and 39 articles met selection criteria. Primary studies were included if they evaluated EN in critically ill humans and its effect on infectious morbidity and mortality. MEASUREMENTS AND RESULTS Relevant data were abstracted on the timing and impact of EN on morbidity, the optimal route of administration, composition and pH of EN, and bacterial contamination of EN. The evidence from human studies that EN, particularly early EN, results in reduced septic morbidity as compared to parenteral nutrition is limited to small, unblinded studies with non-rigorous definitions of pneumonia. There is no evidence to support a preference of feeding into the stomach versus the small bowel. The addition of fish oil, arginine, glutamine and fiber to enteral feeds has a variable impact on survival in animal models; there are no trials in critically ill patients that demonstrate a reduction in infectious morbidity and mortality. Acidification of enteral nutrition results in decreased bacterial colonization of the stomach in critically ill patients. Bacterial contamination of enteral nutrition is an important source of infection. CONCLUSIONS Evidence from experimental data in critically ill patients suggests that enteral nutrition may have a favourable impact on gastrointestinal immunological function and infectious morbidity.
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Affiliation(s)
- D K Heyland
- Department of Medicine, Division of Critical Care, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
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Eisenberg PG. Causes of diarrhea in tube-fed patients: a comprehensive approach to diagnosis and management. Nutr Clin Pract 1993; 8:119-23. [PMID: 8289759 DOI: 10.1177/0115426593008003119] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
In the absence of a standard definition for diarrhea, clinicians have developed their own descriptions, such as an increased frequency of stools, an increased quantity of water in the stool, an increased weight of the stool, or a change in the consistency of the stool. The clinician should first determine whether the diarrhea is osmotic or secretory. Diarrhea in patients who receive enteral nutrition is often caused by such conditions as diabetes, malabsorption syndromes, infection, gastrointestinal complications, or concomitant drug therapy instead of the enteral formula. Factors related to the enteral nutrition that may contribute to diarrhea include the composition of the formula, the manner of administration, or bacterial contamination. To ensure that the nutritional requirements of patients are met and the appropriate treatment is administered, all of the possible causes of diarrhea should be considered before discontinuing or reducing the amount of formula delivered.
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