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Philpott JD, Rodriguez Hovnanian KM, Stefater-Richards M, Mehta NM, Martinez EE. The enteroendocrine axis and its effect on gastrointestinal function, nutrition, and inflammation. Curr Opin Crit Care 2024; 30:290-297. [PMID: 38872371 DOI: 10.1097/mcc.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
PURPOSE OF REVIEW Gastrointestinal (GI) dysfunction limits enteral nutrition (EN) delivery in critical illness and contributes to systemic inflammation. The enteroendocrine (EE) axis plays an integral role in this interface between nutrition, inflammation, and GI function in critical illness. In this review, we present an overview of the EE system with a focus on its role in GI inflammation and function. RECENT FINDINGS Enteroendocrine cells have been primarily described in their role in macronutrient digestion and absorption. Recent research has expanded on the diverse functions of EE cells including their ability to sense microbial peptides and metabolites and regulate immune function and inflammation. Therefore, EE cells may be both affected by and contribute to many pathophysiologic states and interventions of critical illness such as dysbiosis , inflammation, and alternative EN strategies. In this review, we present an overview of EE cells including their growing role in nonnutrient functions and integrate this understanding into relevant aspects of critical illness with a focus on EN. SUMMARY The EE system is key in maintaining GI homeostasis in critical illness, and how it is impacted and contributes to outcomes in the setting of dysbiosis , inflammation and different feeding strategies in critical illness should be considered.
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Affiliation(s)
- Jordan D Philpott
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital
- Mucosal Immunology and Biology Research Center, Mass General for Children
| | - K Marco Rodriguez Hovnanian
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital
- Mucosal Immunology and Biology Research Center, Mass General for Children
| | - Margaret Stefater-Richards
- Department of Medicine, Division of Endocrinology, Boston Children's Hospital
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital
- Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital
- Mucosal Immunology and Biology Research Center, Mass General for Children
- Harvard Medical School, Boston, Massachusetts, USA
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Yang Q, Cai HF, Zhong D. Effect of soluble dietary fiber plus synbiotics on nutrition status, tolerance of enteral nutrition, and intestinal barrier function in elderly patients with severe acute exacerbation of severe chronic obstructive pulmonary disease on enteral nutrition. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:438-446. [DOI: 10.11569/wcjd.v32.i6.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
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McClave SA, Omer E, Eisa M, Klosterbauer A, Lowen CC, Martindale RG. The importance of providing dietary fiber in medical and surgical critical care. Nutr Clin Pract 2024; 39:546-556. [PMID: 37947011 DOI: 10.1002/ncp.11092] [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: 07/19/2023] [Revised: 09/24/2023] [Accepted: 10/12/2023] [Indexed: 11/12/2023] Open
Abstract
The early provision of soluble/insoluble fiber to the patient who is critically ill has been controversial in the past. Especially in the setting of hemodynamic instability, dysmotility, or impaired gastrointestinal transit, fear of inspissation of formula with precipitation of nonocclusive mesenteric ischemia (NOMI)/nonocclusive bowel necrosis (NOBN) limited its utilization by medical and surgical intensivists. The incidence of NOMI/NOBN has been estimated at 0.2%-0.3% for all intensive care unit (ICU) patients receiving enteral nutrition (EN), and the occurrence of inspissated formula is even less. The science supporting a benefit from providing fiber has recently increased exponentially. The fermentation of soluble fibers leading to the production of short chain fatty acids supports gut barrier function, modulates immune responses, and promotes refaunation of commensal organisms. The "butyrate effect" refers to local (gastrointestinal tract) and systemic anti-inflammatory responses mediated by the M2 polarization of macrophages, inhibition of histone deacetylase, and stimulation of ubiquitous G protein receptors. Both soluble and insoluble fiber have been shown to promote intestinal motility, reduce feeding intolerance, and shorten hospital length of stay. The benefit of providing dietary fiber early upon admission to the ICU outweighs its minimal associated risk. The point at which the intensivist determines that is safe to initiate EN, both soluble and insoluble fiber should be included in the enteral formulation.
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Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Endashaw Omer
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Mohamed Eisa
- Department of Medicine, Allegheny Center for Digestive Health, Allegheny Health Network Medicine Institute, Pittsburg, Pennsylvania, USA
| | | | - Cynthia C Lowen
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
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Tay VXP, Mohamed Noor NA, Tan LB. Effects of fibre-supplemented enteral feeds on bowel function of non-critically ill tube-fed adults: a meta-analysis of randomised controlled trials. Br J Nutr 2023; 130:2076-2087. [PMID: 37272621 DOI: 10.1017/s0007114523001289] [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] [Indexed: 06/06/2023]
Abstract
Diarrhoea is common in enterally fed patients and can impact their nutritional and overall outcomes. This meta-analysis evaluates the potential benefits of fibre-supplemented (FS) feeds on incidence of diarrhoea and stool frequency in non-critically ill tube-fed adults. Databases including PubMed, Embase and CINAHL with full text were searched for randomised controlled trials (RCT) with adults on exclusive tube feeding, published until August 2022. The Cochrane Collaboration's tool was used for quality assessment. Studies with published results on incidence of diarrhoea and stool frequency were analysed using RevMan 5. Thirteen RCT with 847 non-critically ill patients between 20 and 90 years old without diarrhoea at the onset of enteral feeding were included. Study duration ranged from 3 to 35 d. Nine papers investigated the incidence of diarrhoea where intervention group was given FS and control was given non-fibre-supplemented (NFS) enteral feeds. Those receiving FS feeds were significantly less likely to experience diarrhoea as compared with those using NFS feeds (OR 0·44; 95 % CI 0·20, 0·95; P = 0·04; I2 = 71 %). Combined analysis showed no differences in stool frequency in those receiving NFS feeds (SMD 0·32; 95 % CI -0·53, 1·16; P = 0·47; I2 = 90 %). Results should be interpreted with caution due to considerable heterogeneity between study population, assessment tool for diarrhoea, potential conflict of interest and short duration of studies. This meta-analysis shows that FS feeds can reduce the incidence of diarrhoea in non-critically ill adults; however, the effects of stool frequency remain debatable.
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Affiliation(s)
- Valerie Xin Pei Tay
- Department of Dietetics, Singapore General Hospital, Outram Road Singapore 169608, Singapore
| | | | - Lee Boo Tan
- Department of Dietetics, Singapore General Hospital, Outram Road Singapore 169608, Singapore
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Aliyu AI, Nixon A, Hoad CL, Marciani L, Corsetti M, Aithal GP, Cordon SM, Macdonald IA, Alhussain MH, Inoue H, Yamada M, Taylor MA. A comparative, randomised MRI study of the physiological and appetitive responses to gelling (alginate) and non-gelling nasogastric tube feeds in healthy men. Br J Nutr 2023; 130:1316-1328. [PMID: 36746392 PMCID: PMC10511685 DOI: 10.1017/s0007114523000302] [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: 10/05/2022] [Revised: 01/13/2023] [Accepted: 01/25/2023] [Indexed: 02/08/2023]
Abstract
Inclusion in nasogastric tube feeds (NGTF) of acid-sensitive, seaweed-derived alginate, expected to form a reversible gel in the stomach, may create a more normal intragastric state and modified gastrointestinal responses. This may ameliorate NGTF-associated risk of diarrhoea, upper gastrointestinal symptoms and appetite suppression. In a randomised, crossover, comparison study, undertaken in twelve healthy males, an alginate-containing feed (F + ALG) or one that was alginate-free (F-ALG) (300 ml) was given over 1 h with a 7-14-d washout period between treatments. Baseline and for 4-h post-feed initiation, MRI measurements were made to establish small bowel water content (SBWC), gastric contents volume (GCV) and appearance, and superior mesenteric artery blood flux. Blood glucose and gut peptides were measured. Subjective appetite and upper gastrointestinal symptoms scores were obtained. Ad libitum pasta consumption 3-h post-feeding was measured. F + ALG exhibited a gastric appearance consistent with gelling surrounded by a freely mobile water halo. Significant main effects of feed were seen for SBWC (P = 0·03) and peptide YY (PYY) (P = 0·004) which were attributed to generally higher values for SBWC with F + ALG (max difference between adjusted means 72 ml at 210 min) and generally lower values for PYY with F + ALG. GCV showed a faster reduction with F + ALG, less between-participant variation and a feed-by-time interaction (P = 0·04). Feed-by-time interactions were also seen with glucagon-like-peptide 1 (GLP-1) (P = 0·02) and glucose-dependent insulinotropic polypeptide (GIP) (P = 0·002), both showing a blunted response with F + ALG. Apparent intragastric gelling with F + ALG and subsequent differences in gastrointestinal and endocrine responses have been demonstrated between an alginate-containing and alginate-free feed.
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Affiliation(s)
- Abdulsalam I. Aliyu
- Department of Human Physiology, College of Medical Sciences, Gombe State University, Gombe, Nigeria
- The David Greenfield Human Physiology Unit, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Aline Nixon
- The David Greenfield Human Physiology Unit, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Caroline L. Hoad
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Luca Marciani
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Guruprasad P. Aithal
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sally M. Cordon
- The David Greenfield Human Physiology Unit, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Ian A. Macdonald
- The David Greenfield Human Physiology Unit, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A, Lausanne, Switzerland
| | - Maha H. Alhussain
- Department of Food Science and Nutrition, King Saud University, Riyadh, Saudi Arabia
| | - Hiroaki Inoue
- Global Planning Group, Medical Solutions Vehicle, KANEKA CORPORATION, Osaka, Japan
| | - Masahiko Yamada
- Regenerative Medicine and Cell Therapy Laboratories, KANEKA CORPORATION, Kobe, Japan
| | - Moira A. Taylor
- The David Greenfield Human Physiology Unit, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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Lionetti P, Wine E, Ran Ressler R, Minor GJ, Major G, Zemrani B, Gottrand F, Romano C. Use of fiber-containing enteral formula in pediatric clinical practice: an expert opinion review. Expert Rev Gastroenterol Hepatol 2023; 17:665-675. [PMID: 37278084 DOI: 10.1080/17474124.2023.2217355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/19/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Children who require enteral nutrition often report gastrointestinal symptoms. There is a growing interest in nutrition formulas that meet nutritional requirements and also maintain gut ecology and function. Fiber-containing enteral formulas can improve bowel function, promote the growth of healthy gut microbiota, and improve immune homeostasis. Nonetheless, guidance in clinical practice is lacking. AREAS COVERED This expert opinion article summarizes the available literature and collects the opinion of eight experts on the importance and use of fiber-containing enteral formulas in pediatrics. The present review was supported by a bibliographical literature search on Medline via PubMed to collect the most relevant articles. EXPERT OPINION The current evidence supports using fibers in enteral formulas as first-line nutrition therapy. Dietary fibers should be considered for all patients receiving enteral nutrition and can be slowly introduced from six months of age. Fiber properties that define the functional/physiological properties of the fiber must be considered. Clinicians should balance the dose of fiber with tolerability and feasibility. Introducing fiber-containing enteral formulas should be considered when initiating tube feeding. Dietary fiber should be introduced gradually, especially in fiber-naïve children, with an individualized symptom-based approach. Patients should continue with the fiber-containing enteral formulas they tolerate best.
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Affiliation(s)
- Paolo Lionetti
- Department Neurofarba, University of Florence - Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Firenze, Italy
| | - Eytan Wine
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Rinat Ran Ressler
- Nestle Product Technology Center, Nestlé Health Sciences, Bridgewater, NJ, US
| | - Gerard J Minor
- Pediatric Gastroenterology Hepatology and Nutrition, Kidz Medical Services, Florida, USA
| | - Giles Major
- Department Gastrointestinal Health, Nestlé Institute of Health Sciences, Lausanne, Switzerland
| | - Boutaina Zemrani
- Clinical Research and Development, Pediatric Medical Nutrition, Nestlé Health Science, Lausanne, Switzerland
| | - Frédéric Gottrand
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Institute for Translational Research in Inflammation, University Lille, Lille, France
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Italy
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Lou X, Xue J, Shao R, Mo C, Wang F, Chen G. Postbiotics as potential new therapeutic agents for sepsis. BURNS & TRAUMA 2023; 11:tkad022. [PMID: 37334140 PMCID: PMC10271603 DOI: 10.1093/burnst/tkad022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/01/2023] [Indexed: 06/20/2023]
Abstract
Sepsis is the main cause of death in critically ill patients and gut microbiota dysbiosis plays a crucial role in sepsis. On the one hand, sepsis leads to the destruction of gut microbiota and induces and aggravates terminal organ dysfunction. On the other hand, the activation of pathogenic gut flora and the reduction in beneficial microbial products increase the susceptibility of the host to sepsis. Although probiotics or fecal microbiota transplantation preserve gut barrier function on multiple levels, their efficacy in sepsis with intestinal microbiota disruptions remains uncertain. Postbiotics consist of inactivated microbial cells or cell components. They possess antimicrobial, immunomodulatory, antioxidant and antiproliferative activities. Microbiota-targeted therapy strategies, such as postbiotics, may reduce the incidence of sepsis and improve the prognosis of patients with sepsis by regulating gut microbial metabolites, improving intestinal barrier integrity and changing the composition of the gut microbiota. They offer a variety of mechanisms and might even be superior to more conventional 'biotics' such as probiotics and prebiotics. In this review, we present an overview of the concept of postbiotics and summarize what is currently known about postbiotics and their prospective utility in sepsis therapy. Overall, postbiotics show promise as a viable adjunctive therapy option for sepsis.
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Affiliation(s)
- Xiran Lou
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Jinfang Xue
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Ruifei Shao
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Chunyan Mo
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Fuping Wang
- Department of Emergency Medicine, The First People's Hospital of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming 650034, China
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Niero M, Bartoli G, De Colle P, Scarcella M, Zanetti M. Impact of Dietary Fiber on Inflammation and Insulin Resistance in Older Patients: A Narrative Review. Nutrients 2023; 15:nu15102365. [PMID: 37242248 DOI: 10.3390/nu15102365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The beneficial impact of dietary fiber on the prevention and management of several chronic conditions associated with aging, including diabetes, neurodegenerative, cardiovascular diseases, and cancer, is well-known. High fiber intake has been associated with reduced inflammatory mediators counteracting the low-grade chronic inflammation typical of older age. In addition, dietary fiber improves postprandial glucose response and insulin resistance. In contrast, during acute diseases, its effects on insulin resistance and modulation of immune response are unclear. The aim of this narrative is to summarize the evidence for the potential impact of dietary fiber on inflammation and insulin resistance in older adults, with a particular focus on those acutely ill. Available evidence suggests that dietary fiber has the potential to counteract acute inflammation and to improve metabolic health. In addition, modulation of gut microbiota composition may contribute to improved immune function, particularly in the setting of aging-associated dysbiosis. This phenomenon has relevant implications in those acutely ill, in whom dysbiosis can be exacerbated. Our review leads to the conclusion that dietary interventions based on fiber manipulation could exploit its beneficial effects on inflammation and insulin resistance, if conducted from a precision nutrition perspective. This could also be true for the acutely ill patient, even though strong evidence is lacking.
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Affiliation(s)
- Michele Niero
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
- Department of Medical Sciences, University of Trieste, 34127 Trieste, Italy
| | - Giulio Bartoli
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
| | - Paolo De Colle
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
| | - Marialaura Scarcella
- Anesthesia, Intensive Care and Nutritional Science, Azienda Ospedaliera "Santa Maria", Via Tristano di Joannuccio, 05100 Terni, Italy
| | - Michela Zanetti
- Geriatric Clinic, Maggiore Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy
- Department of Medical Sciences, University of Trieste, 34127 Trieste, Italy
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Hirschberger S, Schmid A, Kreth S. [Immunomodulation by nutritional intervention in critically ill patients]. DIE ANAESTHESIOLOGIE 2023; 72:229-244. [PMID: 36797533 PMCID: PMC9934515 DOI: 10.1007/s00101-023-01258-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 04/12/2023]
Abstract
Critically ill patients often suffer from a complex and severe immunological dysfunction. The differentiation and function of human immune cells are fundamentally controlled through metabolic processes. New concepts of immunonutrition therefore try to use enteral and parenteral nutrition to positively impact on the immune function of intensive care unit patients. This review article concisely presents the currently available evidence on the commonly used isolated supplements (anti-oxidative substances, amino acids, essential fatty acids) and difficulties related to their clinical use. The second part presents new and more comprehensive concepts of immunonutrition to influence the intestinal microbiome and to modulate the macronutrient composition. Immunonutrition of critically ill patients bears enormous potential and could become a valuable clinical tool for modulation of the immunometabolism of intensive care unit patients.
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Affiliation(s)
- Simon Hirschberger
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Annika Schmid
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Simone Kreth
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland.
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland.
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Klingensmith NJ, Coopersmith CM. Gut Microbiome in Sepsis. Surg Infect (Larchmt) 2023; 24:250-257. [PMID: 37010964 PMCID: PMC10061326 DOI: 10.1089/sur.2022.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
Abstract The gut has been hypothesized to be the "motor" of multiple organ dysfunction in sepsis. Although there are multiple ways in which the gut can drive systemic inflammation, increasing evidence suggests that the intestinal microbiome plays a more substantial role than previously appreciated. An English language literature review was performed to summarize the current knowledge of sepsis-induced gut microbiome dysbiosis. Conversion of a normal microbiome to a pathobiome in the setting of sepsis is associated with worsened mortality. Changes in microbiome composition and diversity signal the intestinal epithelium and immune system resulting in increased intestinal permeability and a dysregulated immune response to sepsis. Clinical approaches to return to microbiome homeostasis may be theoretically possible through a variety of methods including probiotics, prebiotics, fecal microbial transplant, and selective decontamination of the digestive tract. However, more research is required to determine the efficacy (if any) of targeting the microbiome for therapeutic gain. The gut microbiome rapidly loses diversity with emergence of virulent bacteria in sepsis. Restoring normal commensal bacterial diversity through various therapies may be an avenue to improve sepsis mortality.
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Affiliation(s)
- Nathan J. Klingensmith
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig M. Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Church A, Zoeller S. Enteral nutrition product formulations: A review of available products and indications for use. Nutr Clin Pract 2023; 38:277-300. [PMID: 36787985 DOI: 10.1002/ncp.10960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/16/2023] Open
Abstract
When oral nutrition is not feasible, enteral nutrition (EN) therapy is often considered the preferred route of nutrition support to meet the nutrient needs of individuals with a functional gastrointestinal tract across multiple levels of care (critical care, acute care, and home care). Enteral formulations have progressively evolved over the last 50 years from the simple blending of hospital food thin enough to run through a feeding tube, to the development of commercial standard formulas, followed by specialized formulas with immune-modulating and disease-specific qualities, to the most recent shift to food-based or blenderized EN composed of natural, whole foods with perceived health benefits. With the vast number of enteral formulations on the market, clinicians may be overwhelmed trying to determine proven vs theoretical benefits. This review is intended to explore differences in enteral formulations, identify implications for clinical practice, and review evidenced-based clinical guidelines to assist clinicians in enteral formula selection.
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Affiliation(s)
- April Church
- Nutrition Services, Asante Rogue Regional Medical Center, Medford, Oregon, USA
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Kaewdech A, Sripongpun P, Wetwittayakhlang P, Churuangsuk C. The effect of fiber supplementation on the prevention of diarrhea in hospitalized patients receiving enteral nutrition: A meta-analysis of randomized controlled trials with the GRADE assessment. Front Nutr 2022; 9:1008464. [PMID: 36505240 PMCID: PMC9733536 DOI: 10.3389/fnut.2022.1008464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Enteral nutrition (EN) in hospitalized patients has several advantages. However, post-feeding diarrhea occurs frequently and has been linked to negative outcomes. The EN formula itself may have an impact on how diarrhea develops, and fiber supplements may theoretically help patients experience less diarrhea. This study aimed to thoroughly evaluate whether adding fiber to EN decreases the likelihood of developing diarrhea and whether different types of fibers pose different effects on diarrhea (PROSPERO CRD 42021279971). Methods We conducted a meta-analysis on fiber supplementation in hospitalized adult patients receiving EN. We thoroughly searched PubMed, Medline, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov databases from inception to 1 September 2022. Only randomized controlled trials (RCTs) were included. Pooled results on the incidence of diarrhea were calculated using a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was applied. Only fiber types from soy polysaccharides (n = 4), psyllium (n = 3), mixed soluble/insoluble fiber (mixed fiber, n = 3), pectin (n = 2), and partially hydrolyzed guar gum (PHGG, n = 2) were examined in the sensitivity analysis. Results Among the 4,469 titles found, a total of 16 RCTs were included. Overall, compared to fiber-free formulas, fiber supplementation reduced the occurrence of diarrhea in patients receiving EN by 36% (pooled risk ratio [RR] of 0.64 [95% confidence interval (CI): 0.49-0.82, p = 0.005; I 2 = 45%]), with GRADE showing the evidence of moderate certainty. Only mixed fiber and PHGG significantly decreased the incidence of diarrhea according to the sensitivity analyses for fiber types (RR 0.54, 95%CI: 0.39-0.75, I 2 = 0% and RR 0.47, 95%CI: 0.27-0.83, I 2 = 0%, respectively). The results for the remaining fiber types were unclear. Conclusion According to a meta-analysis, fiber supplements help lessen post-feeding diarrhea in hospitalized patients receiving EN. However, not all fiber types produced successful outcomes. Diarrhea was significantly reduced by PHGG and mixed soluble/insoluble fiber. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=279971, identifier: PROSPERO CRD 42021279971.
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Affiliation(s)
- Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Chaitong Churuangsuk
- Clinical Nutrition and Obesity Medicine Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand,*Correspondence: Chaitong Churuangsuk
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Dickerson RN, Andromalos L, Brown JC, Correia MITD, Pritts W, Ridley EJ, Robinson KN, Rosenthal MD, van Zanten ARH. Obesity and critical care nutrition: current practice gaps and directions for future research. Crit Care 2022; 26:283. [PMID: 36127715 PMCID: PMC9486775 DOI: 10.1186/s13054-022-04148-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background This review has been developed following a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting and focuses on current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition. Patients admitted to the intensive care unit (ICU) increasingly present with overweight and obesity that require individualized nutrition considerations due to underlying comorbidities, immunological factors such as inflammation, and changes in energy expenditure and other aspects of metabolism. While research continues to accumulate, important knowledge gaps persist in recognizing and managing the complex nutritional needs in ICU patients with obesity. Available malnutrition screening and assessment tools are limited in patients with obesity due to a lack of validation and heterogeneous factors impacting nutrition status in this population. Estimations of energy and protein demands are also complex in patients with obesity and may include estimations based upon ideal, actual, or adjusted body weight. Evidence is still sparse on the role of immunonutrition in patients with obesity, but the presence of inflammation that impacts immune function may suggest a role for these nutrients in hemodynamically stable ICU patients. Educational efforts are needed for all clinicians who care for complex cases of critically ill patients with obesity, with a focus on strategies for optimal nutrition and the consideration of issues such as weight stigma and bias impacting the delivery of care. Conclusions Current nutritional strategies for these patients should be undertaken with a focus on individualized care that considers the whole person, including the possibility of preexisting comorbidities, altered metabolism, and chronic stigma, which may impact the provision of nutritional care. Additional research should focus on the applicability of current guidelines and evidence for nutrition therapy in populations with obesity, especially in the setting of critical illness.
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Lew CCH, Ng PS, Wong KW, Puah SH, Lim CDQ, Kayambu G, Li AY, Toh CH, Venkatachalam J, Mukhopadhyay A. Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:329-340. [PMID: 35786753 DOI: 10.47102/annals-acadmedsg.202231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. METHODS This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. RESULTS Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. CONCLUSION The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.
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Bowel Dysfunction and Enteral Nutrition in Critically Ill Adult Patients. TOP CLIN NUTR 2022. [DOI: 10.1097/tin.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu T, Wang C, Wang YY, Wang LL, Ojo O, Feng QQ, Jiang XS, Wang XH. The effect of dietary fiber on gut barrier function, gut microbiota, short-chain fatty acids, inflammation and clinical outcomes in critically ill patients: A systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2021; 46:997-1010. [PMID: 34951702 DOI: 10.1002/jpen.2319] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Although some studies have explored the relationships between dietary fiber (DF) supplement and gut barrier function, changes of gut microbiota and other clinical outcomes in critically ill patients, the results from different studies were not consistent. OBJECTIVE The purpose of this study was to explore the effect of dietary fiber on gut barrier function, gut microbiota, short-chain fatty acids (SCFAs), inflammation and clinical outcomes in critically ill patients. METHODS A search was performed through PubMed, Embase, the Cochrane Central Register of Clinical Trials, Web of Science and EBSCO-host that includes Health Sciences Research from inception to July 12, 2021. Data were pooled using fixed effects model for low heterogeneity and random effects model for high heterogeneity. Data were expressed as mean difference (MD) or odds ratio (OR) with confidence interval. RESULTS A total of 21 studies involving 2084 critically ill patients were included. The results showed that there was a significant reduction in intestinal permeability demonstrated by lactulose/rhamnose ratio (MD:-0.04; 95%CI:-0.08, -0.00; P = 0.03) on day 8 in DF supplement group. Three studies reported the relative abundance (RA) of gut microbiota and the results showed the RA of some SCFAs producers increased higher in DF supplement group. There was a significant decrease in C-reactive protein on day 14 (MD:-36.66; 95%CI:-44.40, -28.93; P<0.001) and the duration of hospital stay (MD:-3.16; 95%CI:-5.82, -0.49; P<0.05) after DF supplement. There were no significant differences on SCFAs levels, the duration of mechanical ventilation and mortality between the two groups. However, in subgroup analysis, the results indicated there was a significant reduction on the duration of mechanical ventilation in fiber combined probiotic group (MD:-13; 95%CI:-19.69, -6.31; P<0.001). Besides, significant decreases in the duration of hospital stay and risk of mortality were seen in the subgroups with fiber supplementary dose ≥20 g/d (MD:-5.62; 95%CI: -8.04, -3.21; P<0.0001; OR: 0.18, 95%CI: 0.06, 0.57, P = 0.004), as well as in medical ICU (MD:-4.77; 95%CI: -7.48, -2.07; P<0.01; OR: 0.13; 95%CI: 0.03, 0.65; P<0.05). CONCLUSIONS Dietary fiber may improve the gut barrier function, modulate the intestinal microbiota, decrease systemic inflammatory response and may advance the clinical outcomes in critically ill patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ting Liu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Can Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yu-Yu Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Li-Li Wang
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Omorogieva Ojo
- Department of Adult Nursing and Paramedic Science, University of Greenwich, London, United Kingdom
| | - Qian-Qian Feng
- School of Nursing, Medical College of Soochow University, Suzhou, 215006, China
| | - Xiao-Song Jiang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Xiao-Hua Wang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
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