Diabetes-specific enteral nutrition formula in hyperglycemic, mechanically ventilated, critically ill patients: a prospective, open-label, blind-randomized, multicenter study

Effects of high-fat, low-carbohydrate enteral nutrition in critically ill patients: A systematic review with meta-analysis

BACKGROUND & AIMS

High-fat, low-carbohydrate enteral nutrition has gained attention, with expectations of an improved respiratory condition, fewer complications, and lower mortality. The present study performed a systematic review and meta-analysis of randomized controlled trials to examine the effects of high-fat, low-carbohydrate enteral nutrition in critically ill adult patients.

METHODS

We searched MEDLINE via Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL), and ICHUSHI for randomized controlled trials comparing high-fat, low-carbohydrate enteral nutrition to standard enteral nutrition in critically ill adult patients who received enteral nutrition. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) mortality, length of ICU stay, length of mechanical ventilation, and adverse events of diarrhea and gastric residual volume. We examined the risk of bias using the Cochrane risk-of-bias tool for randomized trials version 2. We assessed the overall certainty of evidence based on the Grading of Recommendations Assessment, Development, and Evaluation methodology. Synthesis results were calculated with risk ratios and 95% confidence intervals using a Mantel-Haenszel random-effects model.

RESULTS

Eight trials with 607 patients were included. The effects of high-fat, low-carbohydrate enteral nutrition on mortality did not significantly differ from those of standard enteral nutrition (62/280 [22.1%] vs. 39/207 [18.8%], risk ratios = 1.14, 95% confidence intervals 0.80 to 1.62, P = 0.47). No significant differences were observed in ICU mortality, ICU length of stay, diarrhea, or gastric residual volume between the two groups. However, high-fat, low-carbohydrate enteral nutrition was associated with a significantly shorter duration of mechanical ventilation (mean difference -1.72 days, 95% confidence intervals -2.93 to -0.50, P = 0.005).

CONCLUSION

High-fat, low-carbohydrate enteral nutrition may not affect mortality, but may decrease the duration of mechanical ventilation in critically ill adult patients. Limitations include the small number of studies and potential for bias. Further research is needed to confirm these results and investigate effects on other outcomes and in a subgroup of patients requiring mechanical ventilation.

Chinese Guidelines for Medical Nutrition Therapy for Patients with Diabetes (2022 Edition)

Medical nutrition therapy (MNT) is the foundation of the comprehensive treatment of patients with diabetes. In 2010, the Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association developed the first Chinese guideline on MNT for patients with diabetes, and it was updated in 2015. Since then, new evidence has emerged in the field of MNT and metabolic therapy in patients with diabetes. The Nutrition and Metabolic Management Branch of the China International Exchange and Promotive Association for Medical and Health Care organized a team of experts from related institutions, including the Clinical Nutrition Branch of the Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutri-tion, and Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association. Their task was to develop the Chinese Guidelines of Medical Nutrition Therapy in Diabetes (2022 Edition) in accordance with the requirements of the Guidelines for the Formulation/Revision of Clinical Guidelines in China (2022 Edition) by combining the questions raised and evidence gathered in clinical practices in China, to guide and standardize the clinical MNT.

Diabetes-Specific Complete Smoothie Formulas Improve Postprandial Glycemic Response in Obese Type 2 Diabetic Individuals: A Randomized Crossover Trial

This study aimed to compare newly developed diabetes-specific complete smoothie formulas with a standard diabetes-specific nutritional formula (DSNF) regarding their effects on glucose homeostasis, insulin levels, and lipid metabolism in obese type 2 diabetes (T2DM) patients. We conducted a randomized, double-blind, crossover study with 41 obese T2DM participants to compare two developed diabetes-specific complete smoothie formulas, a soy-based regular smoothie (SM) and a smoothie with modified carbohydrate content (SMMC), with the standard DSNF, Glucerna. Glycemic and insulin responses were assessed after the participants randomly consumed 300 kilocalories of each formulation on three separate days with a 7-day gap between. Postprandial effects on glycemic control, insulin levels, and lipid metabolism were measured. SMMC resulted in a significantly lower glucose area under the curve (AUC0-240) compared to Glucerna and SM (p < 0.05 for both). Insulin AUC0-240 after SMMC was significantly lower than that after SM and Glucerna (p < 0.05). During the diets, the suppression of NEFA was more augmented on SM, resulting in a less total AUC0-240 of NEFA compared to the SMMC diet (p < 0.05). C-peptide AUC0-240 after SMMC was significantly lower than that after Glucerna (p < 0.001). Conversely, glucagon AUC0-240 after SMMC was significantly higher than that after SM and Glucerna (p < 0.05). These results highlight SMMC as the better insulin-sensitive formula, potentially achieved through increased insulin secretion or a direct reduction in glucose absorption. The unique composition of carbohydrates, amino acids, and fats from natural ingredients in the smoothies may contribute to these positive effects, making them promising functional foods for managing diabetes and obesity.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Night fasting as an alternative to improve nutritional support and glycaemic control in hospitalised patients with exclusive enteral nutrition

BACKGROUND

Enteral nutrition (EN) assists in the nutritional status of hospitalised patients unable to feed orally. The aim of this study was to determine which method-continuous EN or discontinuous EN, a diet in which the infusion is discontinued for 4h during the night,-is more effective in meeting nutrient recommendations and improving glycaemic control and biochemical parameters related to protein anabolism.

METHODS

Patients were divided into two groups: discontinuous (EN administered in mL/h, 18h/day, 4-h night fasting) and continuous (EN administered in mL/h, 22h/day). All patients with EN receive the diet over a 22-h daily period, in which the diet is suspended for two hours/day for daily hospital routines such as bathing, and physiotherapy, and followed for seven days. Evaluated data: prescribed and administered volume, calories, protein, and fibre; capillary blood glucose; erythrogram; serum albumin.

RESULTS

52 patients were followed-up, with 23 (44.2%) in the discontinuous group and 29 (55.8%) in the continuous group. Compared with the continuous group, the discontinuous group received volumes closer to those prescribed, equal or higher calories, and more protein. The capillary glucose values were within the reference range in the discontinuous group, while the continuous group presented elevated values. Both groups presented hypoalbuminaemia, haemoglobin, and haematocrit below the reference values; however, in the discontinuous group, the serum albumin values improved during hospitalisation relative to the continuous.

CONCLUSIONS

The method involving discontinuation of EN for 4h was more effective in meeting nutrient recommendations compared with the continuous method. Additionally, in the discontinuous group, we observed a better control of glycaemia when compared to that of the continuous group.

Effects of a novel rice-based diabetes-specific formula on postprandial glucose and gastrointestinal hormones: a double-blinded multi-arm randomized crossover trial

Introduction

We developed a novel rice-based medical food for diabetes (MFDM) powder formula, using locally available ingredients in Thailand, which can potentially improve patient access to diabetes-specific formula (DSF) by reducing cost and improving availability.

Purpose

The goals of our studies were to 1) measure the glycemic index (GI) and glycemic load (GL) of the MFDM powder formula in healthy individuals, and 2) assess postprandial glucose, insulin, satiety, hunger, and gastrointestinal (GI) hormone responses in adults with prediabetes or early type 2 diabetes after consuming MFDM in comparison with a commercially available standard formula (SF) and a DSF.

Methods

In Study 1, glycemic responses were assessed using the area under the curve (AUC), which was used to calculate GI and GL. Study 2 was a double-blinded multi-arm randomized crossover trial enrolling participants with either prediabetes or type 2 diabetes of ≤6 years. At each study visit, participants consumed either MFDM, SF, or DSF which contained 25 g of carbohydrates. Hunger and satiety were assessed using a visual analog scale (VAS). Glucose, insulin, and GI hormones were assessed using AUC.

Results

All participants tolerated the MFDM well with no adverse events. In Study 1, the measured GI was 39 ± 6 (low GI) and GL was 11 ± 2 (medium GL). In Study 2, glucose and insulin responses were significantly lower after MFDM compared with SF (p-value<0.01 for both), however, those responses were similar between MFDM and DSF. MFDM suppressed hunger, promoted satiety, stimulated active GLP-1, GIP, and PYY, and suppressed active ghrelin although these changes were similar to SF and DSF.

Conclusions

MFDM had a low GI and a low-to-medium GL. In people with prediabetes or early type 2 diabetes, MFDM elicited reduced glucose and insulin responses when compared with SF. Rice-based MFDM may be an option for patients who are at risk for postprandial hyperglycemia.

Clinical Trial Registration

https://www.thaiclinicaltrials.org/show/TCTR20210731001, identifier TCTR20210731001; https://www.thaiclinicaltrials.org/show/TCTR20210730007, identifier TCTR20210730007.

Designing blenderized tube feeding diets for children and investigating their physicochemical and microbial properties and Dietary Inflammatory Index

BACKGROUND

Due to the benefits of blenderized tube feeding (BTF) diets, the interest in using them is increasing. This study aimed to design BTFs for children and investigate their physicochemical and microbial properties, as well as Dietary Inflammatory Index (DII).

METHODS

Five BTF diets were formulated mainly with fresh foods; their DII, physical (viscosity), and chemical (moisture, ash, protein, fat, energy, and micronutrients) characteristics were assessed. Also, the Hazard Analysis and Critical Control Points (HACCP) system was implemented for quality assurance of preparation, storage, and delivery of BTFs to patients in hospital. The microbial contamination (total count, Salmonella, Escherichia coli, Bacillus cereus, Listeria monocytogenes, coliforms, Staphylococcus aureus coagulase positive, mold, and yeast) was analyzed.

RESULTS

Energy and percentages of protein, fat, and carbohydrate in BTFs were in the range of 103-112 kcal/100 ml, 16%-22%, 28%-34%, and 48%-52%, respectively. The viscosity of the five developed BTFs was between 29 and 64 centipoises, which allows the formulas to flow without syringe pressure. The DII of all BTFs was between -0.73 and -2.24. Due to the implementation of HACCP, monitoring the production line of BTFs, and performance of corrective measures, no microbial contamination was observed by indicator pathogenic microorganisms.

CONCLUSION

A planned BTF diet can be an excellent selection for children using enteral nutrition with tube feeding especially when they are made from fresh and anti-inflammatory foods such as recipes prepared in this study.

The syndromic triad of COVID-19, type 2 diabetes, and malnutrition

The coronavirus disease 2019 (COVID-19) pandemic challenges our collective understanding of transmission, prevention, complications, and clinical management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Risk factors for severe infection, morbidity, and mortality are associated with age, environment, socioeconomic status, comorbidities, and interventional timing. Clinical investigations report an intriguing association of COVID-19 with diabetes mellitus and malnutrition but incompletely describe the triphasic relationship, its mechanistic pathways, and potential therapeutic approaches to address each malady and their underlying metabolic disorders. This narrative review highlights common chronic disease states that interact epidemiologically and mechanistically with the COVID-19 to create a syndromic phenotype-the COVID-Related Cardiometabolic Syndrome-linking cardiometabolic-based chronic disease drivers with pre-, acute, and chronic/post-COVID-19 disease stages. Since the association of nutritional disorders with COVID-19 and cardiometabolic risk factors is well established, a syndromic triad of COVID-19, type 2 diabetes, and malnutrition is hypothesized that can direct, inform, and optimize care. In this review, each of the three edges of this network is uniquely summarized, nutritional therapies discussed, and a structure for early preventive care proposed. Concerted efforts to identify malnutrition in patients with COVID-19 and elevated metabolic risks are needed and can be followed by improved dietary management while simultaneously addressing dysglycemia-based chronic disease and malnutrition-based chronic disease.

Glycemic Management of Hospitalized Patients Receiving Nutrition Support

Enteral nutrition (EN) and parenteral nutrition (PN) increase the risk of hyperglycemia and adverse outcomes, including mortality, in patients with and without diabetes. A blood glucose target range of 140-180 mg/dL is recommended for hospitalized patients receiving artificial nutrition. Using a diabetes-specific EN formula, lowering the dextrose content, and using a hypocaloric PN formula have all been shown to prevent hyperglycemia and associated adverse outcomes. Insulin, given either subcutaneously or as a continuous infusion, is the mainstay of treatment for hyperglycemia. However, no subcutaneous insulin regimen has been shown to be superior to others. This review summarizes the evidence on and provides recommendations for the treatment of EN- and PN-associated hyperglycemia and offers strategies for hypoglycemia prevention. The authors also highlight their institution's protocol for the safe use of insulin in the PN bag. Randomized controlled trials evaluating safety and efficacy of targeted insulin therapy synchronized with different types of EN or PN delivery are needed.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Practice of hyperglycaemia control in intensive care units of the Military Hospital, Sudan—Needs of a protocol

Hyperglycaemia is a major risk factor in critically ill patients leading to adverse outcomes and mortality in diabetic and non-diabetic patients. The target blood glucose remained controversial; this study aimed to contribute in assessing the practice of hyperglycaemia control in intensive care units of the Military Hospital. Furthermore, the study proposed a protocol for hyperglycaemia control based on findings. A hospital-based cross-sectional study assessed the awareness and practice towards hyperglycaemia management in a sample 83 healthcare staff selected through stratified random sampling technique. In addition, 55 patients were enrolled, through quota sampling, after excluding those with diabetic ketoacidosis, hyperosmolar-hyperglycaemic state and patients < 18 years. A self-administrated questionnaire enabled to collect data from health staff and patient data were extracted from the medical records. SPSS-23 was used to analyze the collected data. Chi-square and ANOVA tests assessed the association among variables, these tests were considered statistically significant when p ≤ 0.05. The training on hyperglycaemia control differed (p = 0.017) between doctors and nurses. The target glycaemic level (140–180 mg/dl) was known by 11.1% of the study participants. Neither the knowledge nor the practice of hyperglycaemia control methods differed among staff (p> 0.05). The use of sliding scale was prevalent (79.3%) across the ICUs (p = 0.002). 31.5% of the patients had received different glycaemic control methods, 11.8% were in the targeted blood glucose level. Sliding scale was the method used by doctors and nurses (71.4% and 81.6% respectively). Lack of awareness about hyperglycaemia management methods was prevalent among ICU healthcare staff. Use of obsolete methods was the common practice in the ICUS of the Military Hospital. Target blood glucose for patients were unmet. Development of a local protocol for glycaemic control in all ICUs is needed along with sustained training programs on hyperglycaemia control for ICU healthcare staff.

Therapeutic Properties and Use of Extra Virgin Olive Oil in Clinical Nutrition: A Narrative Review and Literature Update

Extra virgin olive oil (EVOO) is a cornerstone of the Mediterranean diet (MedD). In this narrative review, we synthesize and illustrate the various characteristics and clinical applications of EVOO and its components—such as oleic acid, hydroxytyrosol, and oleuropein—in the field of clinical nutrition and dietetics. The evidence is split into diet therapy, oleic acid-based enteral nutrition formulations and oral supplementation formulations, oleic acid-based parenteral nutrition, and nutraceutical supplementation of minor components of EVOO. EVOO has diverse beneficial health properties, and current evidence supports the use of whole EVOO in diet therapy and the supplementation of its minor components to improve cardiovascular health, lipoprotein metabolism, and diabetes mellitus in clinical nutrition. Nevertheless, more intervention studies in humans are needed to chisel specific recommendations for its therapeutic use through different formulations in other specific diseases and clinical populations.

Nutritional therapy in critically ill patients with diabetes

PURPOSE OF REVIEW

There has been a significant increase in nutrition therapy related studies within the critical care cohort in recent years. Management of patients with both diabetes and stress hyperglycaemia through targeted nutrition interventions is no exception. The aim of this review is to outline current available diabetes specific nutrition formula, its impact on gastric emptying and subsequently glycaemic control as well as explore recent literature on the efficacy of utilizing nutrition support to optimize glycaemic control in critically ill patients.

RECENT FINDINGS

Studies explored within this review were similar in terms of outcomes measures, focusing primarily on insulin use and glycaemic control. Although there were promising results in terms of the impact of diabetes-specific nutrition formula on these outcome measures, there were no significant associations with clinical outcomes.

SUMMARY

The use of diabetes-specific formulae in critically ill patients with pre-existing diabetes and stress hyperglycaemia can be considered a logical approach to minimize the risks associated with high doses of insulin. Additional research is required to address the effects of these formulae on the dysglycaemia, nursing workload, safety of glycaemic control and cost-effectiveness.

Nutrition priorities in obese critically ill patients

PURPOSE OF REVIEW

During critical illness, several neuroendocrine, inflammatory, immune, adipokine, and gastrointestinal tract hormone pathways are activated; some of which are more intensified among obese compared with nonobese patients. Nutrition support may mitigate some of these effects. Nutrition priorities in obese critically ill patients include screening for nutritional risk, estimation of energy and protein requirement, and provision of macronutrients and micronutrients.

RECENT FINDINGS

Estimation of energy requirement in obese critically ill patients is challenging because of variations in body composition among obese patients and absence of reliable predictive equations for energy expenditure. Whereas hypocaloric nutrition with high protein has been advocated in obese critically ill patients, supporting data are scarce. Recent studies did not show differences in outcomes between hypocaloric and eucaloric nutrition, except for better glycemic control. Sarcopenia is common among obese patients, and the provision of increased protein intake has been suggested to mitigate catabolic changes especially after the acute phase of critical illness. However, high-quality data on high protein intake in these patients are lacking. Micronutrient deficiencies among obese critically ill patients are common but the role of their routine supplementation requires further study.

SUMMARY

An individualized approach for nutritional support may be needed for obese critically ill patients but high-quality evidence is lacking. Future studies should focus on nutrition priorities in this population, with efficient and adequately powered studies.

Nutrition support for critically ill patients

Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.

Diabetes in COVID-19 patients: challenges and possible management strategies

Background

The recent pandemic of coronavirus disease 19 (COVID-19) has been causing intense stress among the global population. In the case of hospitalized and ICU-admitted COVID-19 patients with comorbidities, it has been observed that a major portion of them are diabetic. Therefore, researchers had indicated a link between diabetes mellitus (DM) and COVID-19. Furthermore, DM is a potential risk factor for the severity of COVID-19 cases. Thus, in this study, the correlation existing between diabetic patients and COVID-19 was summarized.

Main body of the abstract

Diabetic patients have a weaker immune system, less viral clearance rate, malfunctions of metabolic activity due to their high blood glucose level, and other associated problems. This does not increase the susceptibility for the patients to be infected with COVID-19. However, the severity of COVID-19 can worsen due to the comorbidity of DM.

Short conclusion

Proper management, appropriate use of drugs that do not increase the ACE2 expression, lowering blood glucose level, decreasing the susceptibility of SARS-CoV-2, and maintaining a healthy lifestyle could be effective.

Relationship between blood glucose variability and muscle composition in ICU patients receiving nutrition support: A pilot study

BACKGROUND AND AIMS

Many critically ill patients experience increased blood glucose variability (BGV). The objective of the current pilot study was to assess the relationship between muscle composition (defined as average Hounsfield units (HU)) among ICU patients with an abdominal CT scan within seven days of intubation, and BGV (defined as coefficient of variation (CV)) calculated from blood glucose levels measured each morning while intubated.

METHODS

The first serum blood glucose measurement obtained each day during intubation was recorded, blood glucose CV ((mean/SD)∗100) was calculated. Cross-sectional muscle area (CSA; cm²) at the third lumbar region was identified using the -29 to +150 HU range; muscle composition was calculated as the average HU. BGV predictors were determined using linear regression.

RESULTS

Eighty-two patients were included (53% female), with a median age of 64 (25th, 75 percentile (IQR): 51, 70) years. The median CV was 29% (IQR: 20, 37); 40% of subjects required insulin. The median CSA was 100.4 cm² (IQR: 84.0, 120.8) and muscle composition was 20.4 HU (IQR: 12.2, 29.4). Patients received only 36% of estimated calorie requirements. Insulin administration, history of diabetes, and muscle composition were significant BGV predictors.

CONCLUSION

Among these adult intubated ICU patients, higher muscle composition was associated with lower BGV. Future research is needed to corroborate these findings, determine other factors associated with poor muscle quality, and identify methods to describe muscle composition for all ICU patients.

Glycemic targets in critically ill adults: A mini-review

Illness-induced hyperglycemia impairs neutrophil function, increases pro-inflammatory cytokines, inhibits fibrinolysis, and promotes cellular damage. In turn, these mechanisms lead to pneumonia and surgical site infections, prolonged mechanical ventilation, prolonged hospitalization, and increased mortality. For optimal glucose control, blood glucose measurements need to be done accurately, frequently, and promptly. When choosing glycemic targets, one should keep the glycemic variability < 4 mmol/L and avoid targeting a lower limit of blood glucose < 4.4 mmol/L. The upper limit of blood glucose should be set according to casemix and the quality of glucose control. A lower glycemic target range (i.e., blood glucose 4.5-7.8 mmol/L) would be favored for patients without diabetes mellitus, with traumatic brain injury, or who are at risk of surgical site infection. To avoid harm from hypoglycemia, strict adherence to glycemic control protocols and timely glucose measurements are required. In contrast, a higher glycemic target range (i.e., blood glucose 7.8-10 mmol/L) would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus. These targets may be modified if technical advances for blood glucose measurement and control can be achieved.

A clinical appraisal of the different types of enteral nutrition support and humanized nursing among cerebral apoplexy ICU patients on mechanical ventilation

OBJECTIVE

To study the clinical effectiveness of different types of enteral nutrition support combined with humanized nursing in intensive care unit (ICU) stroke patients on mechanical ventilation.

METHODS

One hundred patients with stroke admitted to our hospital's ICU from April 2019 to July 2020 were established as the study cohort and divided into a control group and an experimental group, with 50 cases in each group. The control group was administered one-time injections of enteral nutrition combined with general nursing, and the experimental group was administered enteral nutrition pump infusions combined with humanized nursing. The nursing efficiency, the nursing satisfaction, the Barthel index (BI) scores, the National Institutes of Health Stroke Scale (NIHSS) scores, the adverse reactions, the serum albumin, serum total protein, and serum prealbumin levels, the ICU stay durations, the hospital stay durations, and the mini-nutritional assessment (MNA) scores at 1, 2, and 3 weeks were compared between the two groups.

RESULTS

Compared with the control group, the nursing efficiency and satisfaction levels, the BI index scores, the serum albumin, serum total protein, serum pre-albumin levels and the MNA nutritional evaluation scores at weeks 1, 2, and 3 in the experimental group were significantly higher (P < 0.05), while the NIHSS scores, the adverse reactions, the time costs in the ICU and the hospital stay durations were significantly lower, with statistical significance (P < 0.05).

CONCLUSION

Humanized nursing combined with enteral nutrition pumping can remarkably improve the quality of life and the malnutrition in ICU stroke patients on mechanical ventilation.

Blood glucose-related indicators are associated with in-hospital mortality in critically ill patients with acute pancreatitis

Acute pancreatitis (AP) results in potentially harmful blood glucose fluctuations, affecting patient prognosis. This study aimed to explore the relationship between blood glucose-related indicators and in-hospital mortality in critically ill patients with AP. We extracted data on AP patients from the Multiparameter Intelligent Monitoring in Intensive Care III database. Initial glucose (Glucose_initial), maximum glucose (Glucose_max), minimum glucose (Glucose_min), mean glucose (Glucose_mean), and glucose variability (glucose standard deviation [Glucose_SD] and glucose coefficient of variation [Glucose_CV]) were selected as blood glucose-related indicators. Logistic regression models and the Lowess smoothing curves were used to display the association between significant blood glucose-related indicators and in-hospital mortality. Survivors and non-survivors showed significant differences in Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV (P < 0.05). Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were risk factors for in-hospital mortality in AP patients (OR > 1; P < 0.05). According to the Lowess smoothing curve, the overall trends of blood glucose-related indicators showed a non-linear correlation with in-hospital mortality. Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were associated with in-hospital mortality in critically ill patients with AP.

Association of specialized enteral nutrition with glycemic control and clinical outcomes in critically ill patients: A meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the association of glycemic-control formulae (GCF) with measurements of glycemic control and clinical outcomes compared to standard enteral formulae (SF) in critically ill patients.

DATA SOURCES

MEDLINE, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials were searched from inception up to January, 2021.

STUDY SELECTION

RCTs that assessed the effects of GCF relative to SF in adult critically ill patients.

DATA EXTRACTION

Measurements of glycemic control were the primary outcomes. Secondary outcomes included insulin requirements, mechanical ventilation (MV), length of intensive care unit (ICU) stay and mortality. Two authors independently extracted data and assessed risk of bias using the Cochrane's RoB 2 tool and the GRADE approach was used to assess the quality of evidence.

DATA SYNTHESIS

Ten studies (12 reports, 685 patients) were included. The use of GCFs was associated with lower blood glucose (WMD, -16.06 mg/dL; 95% CI -23.48 to -8.63; I² = 47%) and lower daily administered insulin (WMD, -7.20 IU; 95% CI -13.92 to -0.48; I² = 53%). Glycemic variability, measured by the coefficient of variation, was also associated with the use of GCFs (WMD, -6.84%; 95% CI, -13.57 to -0.11; I² = 95%). In contrast, analyses for length of ICU stay (WMD, -0.12, 95% CI -1.77 to 1.52; I² = 0%), duration of MV (WMD, -0.34 days; 95% CI, -1.72 to 1.04; I² = 0%) and mortality (RR, 1.13; 95% CI 0.82 to 1.56; I² = 0%) were not statistically significant. Quality of evidence ranged from low to very low, and only one study was judged as at low risk of bias.

CONCLUSIONS

In this meta-analysis, GCFs were significantly associated with lower insulin requirements and improved glycemic control. Although results for clinical outcomes were not statistically significant, there is insufficient evidence to confirm or exclude important differences due to serious imprecision in the effect estimates and overall low quality of evidence. The effects of GCFs on clinical outcomes require confirmation in larger randomized trials.

Nutritional Support in the Intensive Care Unit: Implications for Nursing Care From Evidence-Based Guidelines and Supporting Literature

Several nursing practices are related to oral, enteral, or parenteral feeding on the intensive care unit. Nurses are the group of health care professionals who provide 24-hour care for patients. Therefore, they play a key role in not only identifying nutritional problems but also in ensuring the success of nutritional therapy by implementing evidence-based feeding protocols and ongoing care for (par)enteral access devices. Having an up-to-date evidence-based knowledge about nutritional support can increase safety and quality of care and can contribute to better outcomes. In this narrative review, the most recent European intensive care unit nutrition guidelines and related research are highlighted, and where appropriate, specific applications for nursing practice are described.

Low-carbohydrate, high-fat enteral formulas for managing glycemic control in patients who are critically ill: A review of the evidence

Hyperglycemia is associated with increased morbidity and mortality. Low-carbohydrate, high-fat (LCHF) enteral formulas are marketed to improve glycemic control; however, given the multifactorial mechanisms contributing to hyperglycemia in patients who are critically ill, the effect that LCHF formulas may have on improving glycemic control in this patient population is unclear. Current guidelines for the use of LCHF formulas among patients who are critically ill are limited by a lack of evidence. This review explores recent research published in the past 7 years to determine whether LCHF enteral formulas improve glycemic control compared with standard enteral formulas in patients who are critically ill. Four randomized controlled trials met the inclusion criteria for this review. Their results suggest that LCHF formulas may improve glycemic control in patients who are critically ill with diabetes mellitus and/or who are hyperglycemic. Further large-scale randomized controlled trials are warranted to validate these findings among different subgroups of patients with critical illness. The potential benefits of LCHF formulas need to be weighed against specific limitations, including that LCHF formulas typically do not contain sufficient protein to meet the recommended needs of patients who are critically ill.

Medical Foods: Science, Regulation, and Practical Aspects. Summary of a Workshop

On August 13-14, 2019, the Healthcare Nutrition Council and the ASN held the Medical Foods Workshop: Science, Regulation, and Practical Aspects. Medical food products help patients manage their disease and improve their quality of life. Yet many hurdles exist to getting patients new products. In this workshop, participants addressed some of these hurdles, with specific emphasis on topics like the statutory term distinctive nutritional requirements, the regulatory term modification of the diet alone, the role of clinical guidelines, the requirement that medical foods be used under medical supervision, and differentiation of foods for special dietary use from medical foods, as well as product innovation and future research. Real-world examples were discussed for intractable epilepsy, diabetes, end-stage renal disease, and inflammatory bowel disease.

[The XI SENPE Jesús Culebras Lecture. Enteral nutrition in critically ill patients. History of an evolution]

Introduction

Enteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

Diabetes-Specific Nutrition Formulas in the Management of Patients with Diabetes and Cardiometabolic Risk

Food-based dietary management, enhanced with evidence-based commercial products, such as diabetes-specific nutrition formulas (DSNFs), can help control the development, progression, and severity of certain chronic diseases. In this review, evidence is detailed on the use of DSNFs in patients with or at risk for diabetes and cardiometabolic-based chronic disease. Many DSNF strategies target glycemic excursions and cardiovascular physiology, taking into account various elements of healthy eating patterns. Nevertheless, significant research, knowledge, and practice gaps remain. These gaps are actionable in terms of formulating and testing relevant and pragmatic research questions, developing an educational program for the uniform distribution of information, and collaboratively writing clinical practice guidelines that incorporate the evidence base for DSNF. In sum, the benefits of DNSF as part of validated clinical practice algorithms include mitigation of chronic disease progression, cost-savings for the healthcare system, and applicability on a global scale.

Practice of Hyperglycaemia Control in Intensive Care Units of the Military Hospital, Sudan – Needs of a Protocol.. [DOI: 10.1101/2020.08.17.20176453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Hyperglycaemia is a major risk factor in critically ill patients as it leads to adverse outcomes and mortality in diabetic and non-diabetic patients. The target blood glucose remained controversial; this study aimed to contribute in assessing the practice of hyperglycaemia control in intensive care units of Khartoum Military Hospital. Furthermore, it proposed a protocol for hyperglycaemia control based on findings. A hospital-based cross-sectional study assessed the awareness and practice towards hyperglycaemia management in a sample of 83 healthcare staff selected through stratified random sampling technique. In addition, 55 patients were enrolled, through quota sampling, after excluding those with diabetic ketoacidosis, hyperosmolar-hyperglycaemic state and patients < 18 years. A self-administrated questionnaire enabled to collect data from healthcare staff, patients data were extracted from medical records. SPSS 23 was used to analyse the collected data. Chi-square and ANOVA tests assessed the association among variables. All statistical tests were considered statistically significant when p < 0.05. The training on hyperglycaemia control differed statistically (p = 0.017) among healthcare staff. The target glycaemic level (140-180 mg/dl) was knew by 11.1% of the study participants. Neither the knowledge nor the practice of hyperglycaemia control methods differed among staff (p> 0.05). The use of sliding scale was 79.3% across the ICUs with a statistically significant difference (p = 0.002). 31.5% of patients had received glycaemic control based on different methods and 11.8% were in the targeted blood glucose level. Sliding scale was the prevalent method used by doctors (71.4%) and nurses (81.6%). A patient benefited from insulin infusion method, which achieved the NICE-SUGAR target. The poor knowledge and lack of awareness towards hyperglycaemia monitoring led to inappropriate implementation of glycaemia control methods across the Military Hospital ICUs. Sustained training programs on hyperglycaemia control to ICU staff and the availability of a protocol on glycaemia control are highly required.

Dietary management of blood glucose in medical critically ill patients with overweight/obesity

PURPOSE OF REVIEW

As the obesity epidemic continues, there is a greater proportion of patients with overweight, obesity, and other forms of adiposity-based chronic disease that require intensive care. Nutrition therapy in the ICU is a vital part of critical care but can be challenging in this setting because of the increased risk of stress hyperglycemia and adverse impact of obesity- and diabetes-related complications.

RECENT FINDINGS

Current guidelines favor early nutritional therapy with a hypocaloric, high-protein diet in patients with overweight/obesity. More aggressive protein intake may be useful in those with greater severity of overweight/obesity with an upper limit of 3 g/kg ideal body weight per day. Although there is no specific recommendation, choosing enteral formulas with higher fat content and slower digesting carbohydrates may assist with glucose control. Supplementation with immunonutrients is recommended, given their known benefits in obesity and in reducing inflammation, but must be done in an individualized manner.

SUMMARY

Aggressive nutritional therapy is crucial in patients with overweight/obesity to support ongoing metabolic demands. Although a hypocaloric high-protein feeding strategy is a starting point, nutritional therapy should be approached in an individualized manner taking into account age, weight and BMI, basal metabolism, nutrition status, complications, and comorbidities.

Sugar-Lowering Drugs for Type 2 Diabetes Mellitus and Metabolic Syndrome-Strategies for In Vivo Administration: Part-II

Diabetes is a complex disease characterized by hyperglycemia, together with polyuria, polydipsia, and polyphagia. While Type 1 diabetes mellitus (T1DM) results from genetic, environmental, or immune dysfunction factors leading to pancreatic β-cell destruction depriving the organism from endogenous insulin, Type 2 diabetes mellitus (T2DM) is characterized by peripheral insulin resistance. Depending on the type of diabetes mellitus and drug mechanism to study, the animal model should be carefully selected among the wide variety of the currently available ones. This review discusses the most common animal models currently employed to study T1DM and T2DM. Moreover, an overview on the administration routes that could be used is also discussed.

The Effect of Diabetes-Specific Enteral Nutrition Formula on Cardiometabolic Parameters in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

The prevalence of diabetes is on the increase in the UK and worldwide, partly due to unhealthy lifestyles, including poor dietary regimes. Patients with diabetes and other co-morbidities such as stroke, which may affect swallowing ability and lead to malnutrition, could benefit from enteral nutrition, including the standard formula (SF) and diabetes-specific formulas (DSF). However, enteral nutrition presents its challenges due to its effect on glycaemic control and lipid profile.

AIM

The aim of this review was to evaluate the effectiveness of diabetes-specific enteral nutrition formula versus SF in managing cardiometabolic parameters in patients with type 2 diabetes.

METHOD

This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses. Three databases (Pubmed, EMBASE, PSYCInfo) and Google scholar were searched for relevant articles from inception to 2 January 2019 based on Population, Intervention, Comparator, Outcomes and Study designs (PICOS) framework. Key words, Medical Subject Heading (MeSH) terms, and Boolean operators (AND/OR) formed part of the search strategy. Articles were evaluated for quality and risks of bias.

RESULTS

Fourteen articles were included in the systematic review and five articles were selected for the meta-analysis. Based on the findings of the review and meta-analysis, two distinct areas were evident: the effect of DSF on blood glucose parameters and the effect of DSF on lipid profile. All fourteen studies included in the systematic review showed that DSF was effective in lowering blood glucose parameters in patients with type 2 diabetes compared with SF. The results of the meta-analysis confirmed the findings of the systematic review with respect to the fasting blood glucose, which was significantly lower (p = 0.01) in the DSF group compared to SF, with a mean difference of -1.15 (95% CI -2.07, -0.23) and glycated haemoglobin, which was significantly lower (p = 0.005) in the DSF group compared to the SF group following meta-analysis and sensitivity analysis. However, in relation to the sensitivity analysis for the fasting blood glucose, differences were not significant between the two groups when some of the studies were removed. Based on the systematic review, the outcomes of the studies selected to evaluate the effect of DSF on lipid profile were variable. Following the meta-analysis, no significant differences (p > 0.05) were found between the DSF and SF groups with respect to total cholesterol, LDL cholesterol and triglyceride. The level of the HDL cholesterol was significantly higher (p = 0.04) in the DSF group compared to the SF group after the intervention, with a mean difference of 0.09 (95% CI, 0.00, 0.18), although this was not consistent based on the sensitivity analysis. The presence of low glycaemic index (GI) carbohydrate, the lower amount of carbohydrate and the higher protein, the presence of mono-unsaturated fatty acids and the different amounts and types of fibre in the DSF compared with SF may be responsible for the observed differences in cardiometabolic parameters in both groups.

CONCLUSION

The results provide evidence to suggest that DSF is effective in controlling fasting blood glucose and glycated haemoglobin and in increasing HDL cholesterol, but has no significant effect on other lipid parameters. However, our confidence in these findings would be increased by additional data from further studies.

Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube

OBJECTIVE

To determine whether clinical and patient-reported outcomes differ in children receiving blenderized diets compared with conventional formula.

STUDY DESIGN

We conducted a prospective cohort study of 70 children aged 1-18 years receiving blenderized diets vs conventional formula via feeding tube. We assessed rates of hospitalization and visits to the emergency department (ED) at Boston Children's Hospital in 2017 and Likert scale addressing satisfaction with feeding regimen; Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire; Pediatric Quality of Life Inventory; and Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale.

RESULTS

Participants receiving blenderized diets (n = 42, 60%) did not differ in demographics or comorbid diagnoses from those receiving conventional formula (n = 28, 40%). Rates of total visits to the ED (0.8 ± 1.5 vs 1.4 ± 2.7, P = .05), total admissions (0.8 ± 1.2 vs 1.7 ± 2.3, P = .01), and respiratory-related admissions (0.2 ± 0.5 vs 0.6 ± 0.8, P = .04) per year were significantly lower in participants receiving blenderized diets, and respiratory-related visits to the ED trended toward significance (0.1 ± 0.4 vs 0.4 ± 0.8, P = .08). Compared with those receiving conventional formula, participants on blenderized diets reported greater satisfaction ratings (Likert scale 4.3 ± 1.0 vs 3.3 ± 1.2, P = .001), lower symptom (0.7 ± 0.8 vs 1.2 ± 1.1, P = .03), and total (0.8 ± 0.8 vs 1.2 ± 1.0, P = .02) scores on Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire and greater scores on the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale, indicating less nausea and vomiting (64.0 ± 22.6 vs 49.0 ± 37.9, P = .02), abdominal pain (65.0 ± 26.8 vs 56.4 ± 33.9, P = .04), diarrhea (87.9 ± 15.5 vs 73.6 ± 26.3, P = .004), and fewer total symptoms (70.2 ± 16.3 vs 62.3 ± 19.6, P = .03).

CONCLUSIONS

Blenderized diets are associated with decreased healthcare use, improved symptom scores, and increased patient satisfaction compared with conventional formulas.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial

BACKGROUND

Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol.

METHODS

This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula.

RESULTS

A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53).

CONCLUSIONS

A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.

The effect of a low carbohydrate formula on glycaemia in critically ill enterally-fed adult patients with hyperglycaemia: A blinded randomised feasibility trial

BACKGROUND

Enteral nutrition is a source of carbohydrate that may exacerbate hyperglycaemia. Its treatment, insulin, potentially exacerbates glycaemic variability.

METHODS

This was a prospective, parallel group, blinded, randomised feasibility trial. Patients were eligible if 18 years or over when admitted to the intensive care unit and receiving enteral nutrition (EN) exclusively with two consecutive blood glucose > 10 mmol/L. A standardized glucose management protocol determined administration of insulin. Key outcome measures were insulin administered and glycaemic variability (coefficient of variation) over the first 48 h.

RESULTS

41 patients were randomized to either standard EN (14.1 g/100 mL carbohydrate; n = 20) or intervention EN (7.4 g/100 mL carbohydrate; n = 21). Overall 59% were male, mean (±SD) age of 62.3 years ± 10.4, APACHE II score of 16.5 ± 7.8 and a median (IQR) Body Mass Index 29.0 kg/m² (25.2-35.5). Most patients (73%) were mechanically ventilated. Approximately half (51%) were identified as having diabetes prior to ICU admission. Patients in the intervention arm received less insulin over the 48 h study period than those in the control group (mean insulin units over study period (95% CI) 45.0 (24.4-68.7) vs. 107 (56.1-157.9) units; p = 0.02) and had lower mean glycaemic variability (12.6 vs. 15.9%, p = 0.01). There was a small difference in the mean percentage of energy requirements met (intervention: 72.9 vs. control: 79.1%; p = 0.4) or protein delivered (78.2 vs. 85.4%; p = 0.3).

CONCLUSIONS

A low carbohydrate formula was associated with reduced insulin use and glycaemic variability in enterally-fed critically ill patients with hyperglycaemia. Further large trials are required to determine the impact of this formula on clinical outcomes. Registered under Australian and New Zealand Clinical Trials Registry, ANZCTR number: 12614000166673.

Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario

Background and aim

Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field.

Materials and methods

Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences.

Results

Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered.

Conclusion

This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.

How to cite this article

Mehta Y, Mithal A, Kulkarni A, Reddy BR, Sharma J, Dixit S, et al. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019;23(12):594–603.

The Effects of Gastrointestinal Function on the Incidence of Ventilator-associated Pneumonia in Critically Ill Patients

Objective

To investigate the effect of gastrointestinal function on the incidence of ventilator-associated pneumonia (VAP) in critically ill patients.

Methods

From August 2012 to June 2016, 160 critically ill patients in the ICU (Intensive Care Unit) of our hospital were selected as the research group; patients were divided equally into an observation group and a control group, 80 patients in each group, based on the random draw envelope principle. The control group was given a nasogastric tube for gastric feeding, the observation group was given a dual lumen gastrointestinal enteral device for gastric feeding; the two groups’ enteral nutrition observation time was 7d; any changes in patient condition and prognosis were recorded.

Results

The pH value of gastric juice in the control group and the observation group was 6.13±1.38 and 4.01±1.83, respectively: the pH for the observation group was significantly lower than that of the control group (t=4.982, P<0.05). The incidence of VAP in the observation group and the control group was 2.5% and 12.5%, respectively: the VAP for the observation group was significantly lower than that of the control group (P<0.05). The serum levels of pre-albumin and albumin after feeding in the two groups were significantly higher than before feeding (P<0.05); the serum levels of pre-albumin and albumin in the observation group after feeding were significantly higher than those in the control group (P<0.05). The mechanical ventilation time and ICU length of stay in the observation group were 9.12±2.13 days and 12.76±1.98 days, respectively, significantly lower than those of the control group of 10.56±2.89 days and 16.33±2.11 days (P<0.05).

Conclusion

Obstacles to gastrointestinal function in critically ill ICU patients are common; enteral gastric feeding by dual lumen gastrointestinal for can improve the patient’s nutritional status, promote and maintain the normal pH value of gastric juice, thereby reducing the incidence of VAP through rehabilitation of patients.

ESPEN guideline on clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

Very high-protein and low-carbohydrate enteral nutrition formula and plasma glucose control in adults with type 2 diabetes mellitus: a randomized crossover trial

BACKGROUND AND OBJECTIVES

Standard enteral nutrition (EN) formulas can  worsen hyperglycemia in diabetic patients. We hypothesized that altering the proportion of macronutrients in a formula; increasing protein while decreasing carbohydrate concentrations would improve glycemic response. The objective of this study was to demonstrate that an EN formula containing a very high concentration of protein (in the form of whey peptides) and low concentration of carbohydrate provide better control of postprandial blood glucose relative to a very high-protein/higher-carbohydrate formula.

SUBJECTS AND METHODS

This was a randomized crossover clinical trial of 12 ambulatory adult subjects with type 2 diabetes. The primary outcome was glycemic response following a bolus of isocaloric amounts of two EN formulas; the secondary outcome was insulin response. Subjects were randomized to the experimental or the control formula, on two separate days, 5-7 days apart.

RESULTS

Mean blood glucose concentrations at 10-180 min post-infusion and mean area under the curve for glucose over 240 min post-infusion were significantly lower with the experimental formula than with the control formula (71.99 ± 595.18 and 452.62 ± 351.38, respectively; p = 0.025). There were no significant differences in the mean insulin concentrations over time, insulinogenic indices, and first-phase insulin measurements.

CONCLUSIONS

An EN formula containing high-protein and low-carbohydrate loads can significantly improve glucose control in subjects with type 2 diabetes in ambulatory settings as evidenced by observed improved glucose control without significant difference in insulin response.

Current evidence on ω-3 fatty acids in enteral nutrition in the critically ill: A systematic review and meta-analysis

Fish oil exerts anti-inflammatory and immunomodulatory properties that may be beneficial for critically ill patients, thus multiple randomized controlled trials and meta-analyses have been performed. However, controversy remains as to whether fish oil-enriched enteral nutrition can improve clinical outcomes in adult critically ill patients in intensive care units (ICUs). The aim of this study was to provide an up-to-date systematic review and meta-analysis of all randomized controlled trials of fish oil-containing enteral nutrition addressing relevant clinical outcomes in critically ill patients. A systematic literature search was conducted. The primary outcome was 28-d mortality. Secondary outcomes were ICU and hospital mortality, ICU and hospital length of stay (LOS), ventilation duration, and infectious complications. Predefined subgroup and sensitivity analyses were performed. Twenty-four trials, enrolling 3574 patients, met the inclusion criteria. The assessment of risk for bias showed that most of included studies were of moderate quality. The overall results revealed no significant effects of enteral fish oil supplementation on 28-d, ICU or hospital mortality. However, ICU LOS and ventilation duration were significantly reduced in patients receiving fish oil supplementation. Furthermore, subgroup analysis revealed a significant reduction in 28-d mortality, ICU LOS, and ventilation duration in patients with acute respiratory distress syndrome but not in other subgroups. When comparing high- and low-quality trials, significant reductions in 28-d mortality and ventilation duration in low-quality trials only were observed. Regarding ICU LOS a significant reduction was observed in high-quality trials; whereas only a trend was observed in low-quality trials. No significant effects on hospital LOS or infectious complications were observed in overall or subgroup analyses. Enteral fish oil supplementation cannot be recommended for critically ill patients, as strong scientific evidence for improved clinical benefits was not found. There is a signal of mortality benefit in patients with acute respiratory distress syndrome; however, results are based on low-quality studies. Further research should focus on the relation between the individual critically ill patients' immune response, the administration of fish oil, and clinical outcomes.

Effect of Home Enteral Nutrition on Diabetes and Its Management

BACKGROUND

Diabetes mellitus (DM) is estimated to affect 9% of Americans and is associated with significant morbidity, mortality, and increased healthcare costs.

METHODS

A retrospective review of a home enteral nutrition (HEN) database of patients seen between March 1, 2004, and April 31, 2014, at our institution was conducted to identify HEN patients who had a diagnosis of DM or were diagnosed within the acute period (4 months) of starting HEN therapy.

RESULTS

174 (3.7%) of 4682 patients in the HEN program had DM. HEN was provided through a gastrostomy tube in 82 patients and through a jejunostomy tube in 92 patients. At 3 months, data were available for 42 gastrostomy patients; 44% had a change in DM management, with 60% undergoing a change to insulin. Similarly, 34 patients with jejunostomy had data available, with 41% undergoing change in medication and 93% being changed to insulin therapy. For patients with available glycated hemogloblin values, at 3 months the gastrostomy patients noted a decrease of 0.5% (7.3% ± 1.1% to 6.8% ± 0.7%, not significant) and the jejunostomy patients noted a decrease of 0.4% (6.9% ± 0.9% to 6.5% ± 1.1%, P = .06).

CONCLUSIONS

Overall, our results suggest that closer follow-up and laboratory assessment are necessary for management of HEN patients with DM. In those with data available, glycemic control can be maintained in patients receiving HEN with appropriate adjustment of DM management and focus on ensuring that patients are not overfed.