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Di Bartolomeo AE, Chapman MJ, V Zaknic A, Summers MJ, Jones KL, Nguyen NQ, Rayner CK, Horowitz M, Deane AM. Comparative effects on glucose absorption of intragastric and post-pyloric nutrient delivery in the critically ill. Crit Care 2012; 16:R167. [PMID: 22985684 PMCID: PMC3682265 DOI: 10.1186/cc11522] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 09/14/2012] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Studies in the critically ill that evaluate intragastric and post-pyloric delivery of nutrient have yielded conflicting data. A limitation of these studies is that the influence in the route of feeding on glucose absorption and glycaemia has not been determined. METHODS In 68 mechanically ventilated critically ill patients, liquid nutrient (100 ml; 1 kcal/ml containing 3 g of 3-O-Methyl-D-glucopyranose (3-OMG), as a marker of glucose absorption), was infused into either the stomach (n = 24) or small intestine (n = 44) over six minutes. Blood glucose and serum 3-OMG concentrations were measured at regular intervals for 240 minutes and the area under the curves (AUCs) calculated for 'early' (AUC60) and 'overall' (AUC240) time periods. Data are presented as mean (95% confidence intervals). RESULTS Glucose absorption was initially more rapid following post-pyloric, when compared with intragastric, feeding (3-OMG AUC60: intragastric 7.3 (4.3, 10.2) vs. post-pyloric 12.5 (10.1, 14.8) mmol/l.min; P = 0.008); however, 'overall' glucose absorption was similar (AUC240: 49.1 (34.8, 63.5) vs. 56.6 (48.9, 64.3) mmol/l.min; P = 0.31). Post-pyloric administration of nutrients was also associated with greater increases in blood glucose concentrations in the 'early' period (AUC60: 472 (425, 519) vs. 534 (501, 569) mmol/l.min; P = 0.03), but 'overall' glycaemia was also similar (AUC240: 1,875 (1,674, 2,075) vs. 1,898 (1,755, 2,041) mmol/l.min; P = 0.85). CONCLUSIONS In the critically ill, glucose absorption was similar whether nutrient was administered via a gastric or post-pyloric catheter. These data may have implications for the perceived benefit of post-pyloric feeding on nutritional outcomes and warrant further investigation.
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Affiliation(s)
- Anna E Di Bartolomeo
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
- National Health and Medical Research Council of Australia, Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Antony V Zaknic
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Matthew J Summers
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Karen L Jones
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
| | - Nam Q Nguyen
- Department of Gastroenterology, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Christopher K Rayner
- National Health and Medical Research Council of Australia, Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
| | - Michael Horowitz
- National Health and Medical Research Council of Australia, Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
- National Health and Medical Research Council of Australia, Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
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Deane AM, Wong GL, Horowitz M, Zaknic AV, Summers MJ, Di Bartolomeo AE, Sim JA, Maddox AF, Bellon MS, Rayner CK, Chapman MJ, Fraser RJ. Randomized double-blind crossover study to determine the effects of erythromycin on small intestinal nutrient absorption and transit in the critically ill. Am J Clin Nutr 2012; 95:1396-402. [PMID: 22572649 DOI: 10.3945/ajcn.112.035691] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The gastrokinetic drug erythromycin is commonly administered to critically ill patients during intragastric feeding to augment small intestinal nutrient delivery. However, erythromycin has been reported to increase the prevalence of diarrhea, which may reflect reduced absorption and/or accelerated small intestinal transit. OBJECTIVE The objective was to evaluate the effects of intravenous erythromycin on small intestinal nutrient absorption and transit in the critically ill. DESIGN On consecutive days, erythromycin (200 mg in 20 mL 0.9% saline) or placebo (20 mL 0.9% saline) were infused intravenously between -20 and 0 min in a randomized, blinded, crossover fashion. Between 0 and 30 min, a liquid nutrient containing 3-O-methylglucose (3-OMG), [13C]triolein, and [(99m)Tc]sulfur colloid was administered directly into the small intestine at 2 kcal/min. Serum 3-OMG concentrations and exhaled (13)CO2 (indices of glucose and lipid absorption, respectively) were measured. Cecal arrival of the infused nutrient was determined by scintigraphy. Data are medians (ranges) and were analyzed by using Wilcoxon's signed-rank test. RESULTS Thirty-two mechanically ventilated patients were studied. Erythromycin increased small intestinal glucose absorption [3-OMG AUC360: 105.2 (28.9-157.0) for erythromycin compared with 91.8 (51.4-147.9) mmol/L · min for placebo; P = 0.029] but tended to reduce lipid absorption [cumulative percentage dose (13)CO2 recovered: 10.4 (0-90.6) compared with 22.6 (0-100) %; P = 0.06]. A trend to slower transit was observed after erythromycin [300 (39-360) compared with 228 (33-360) min; P = 0.07]. CONCLUSIONS Acute administration of erythromycin increases small intestinal glucose absorption in the critically ill, but there was a tendency for the drug to reduce small intestinal lipid absorption and slow transit. These observations have implications for the use of erythromycin as a gastrokinetic drug in the critically ill. This trial was registered in the Australian New Zealand Clinical Trials Registry as ACTRN 12610000615088.
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Affiliation(s)
- Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
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Deane AM, Summers MJ, Zaknic AV, Chapman MJ, Di Bartolomeo AE, Bellon M, Maddox A, Russo A, Horowitz M, Fraser RJL. Glucose absorption and small intestinal transit in critical illness. Crit Care Med 2011; 39:1282-8. [PMID: 21336122 DOI: 10.1097/ccm.0b013e31820ee21f] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although enteral nutrition is standard care for critically ill patients, nutrient absorption has not been quantified in this group and may be impaired due to intestinal dysmotility. The objectives of this study were to measure small intestinal glucose absorption and duodenocecal transit and determine their relationship with glycemia in the critically ill. DESIGN Prospective observational study of healthy and critically ill subjects. SETTING Tertiary mixed medical-surgical adult intensive care unit. SUBJECTS Twenty-eight critically ill patients and 16 healthy subjects were studied. MATERIALS AND MAIN RESULTS: Liquid feed (100 kcal/100 mL), labeled with Tc-sulfur colloid and including 3 g of 3-O-methylglucose, was infused into the duodenum. Glucose absorption and duodenocecal transit were measured using the area under the 3-O-methylglucose concentration curve and scintigraphy, respectively. Data are median (range). RESULTS AND DISCUSSION Glucose absorption was reduced in critical illness when compared to health (area under the concentration curve: 16 [1-32] vs. 20 [14-34] mmol/L·min; p = .03). Small intestinal transit times were comparable in patients and healthy subjects (192 [9-240] vs. 168 [6-240] min; p = .99) and were not related to glucose absorption. Despite higher fasting blood glucose concentrations (6.3 [5.1-9.3] vs. 5.7 [4.6-7.6] mmol/L; p < .05), the increment in blood glucose was sustained for longer in the critically ill (Δ glucose at t = 60; 1.9 [-2.1-5.0] mmol/L vs. -0.2 [-1.3-2.3] mmol/L; p < .01). CONCLUSIONS Critical illness is associated with reduced small intestinal glucose absorption, but despite this, the glycemic response to enteral nutrient is sustained for longer.
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Affiliation(s)
- Adam M Deane
- National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Adelaide, South Australia, Australia.
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Deane AM, Summers MJ, Zaknic AV, Chapman MJ, Fraser RJL, Di Bartolomeo AE, Wishart JM, Horowitz M. Exogenous glucagon-like peptide-1 attenuates the glycaemic response to postpyloric nutrient infusion in critically ill patients with type-2 diabetes. Crit Care 2011; 15:R35. [PMID: 21255422 PMCID: PMC3222072 DOI: 10.1186/cc9983] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 12/14/2010] [Accepted: 01/21/2011] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Glucagon-like peptide-1 (GLP-1) attenuates the glycaemic response to small intestinal nutrient infusion in stress-induced hyperglycaemia and reduces fasting glucose concentrations in critically ill patients with type-2 diabetes. The objective of this study was to evaluate the effects of acute administration of GLP-1 on the glycaemic response to small intestinal nutrient infusion in critically ill patients with pre-existing type-2 diabetes. METHODS Eleven critically ill mechanically-ventilated patients with known type-2 diabetes received intravenous infusions of GLP-1 (1.2 pmol/kg/minute) and placebo from t = 0 to 270 minutes on separate days in randomised double-blind fashion. Between t = 30 to 270 minutes a liquid nutrient was infused intraduodenally at a rate of 1 kcal/min via a naso-enteric catheter. Blood glucose, serum insulin and C-peptide, and plasma glucagon were measured. Data are mean ± SEM. RESULTS GLP-1 attenuated the overall glycaemic response to nutrient (blood glucose AUC30-270 min: GLP-1 2,244 ± 184 vs. placebo 2,679 ± 233 mmol/l/minute; P = 0.02). Blood glucose was maintained at < 10 mmol/l in 6/11 patients when receiving GLP-1 and 4/11 with placebo. GLP-1 increased serum insulin at 270 minutes (GLP-1: 23.4 ± 6.7 vs. placebo: 16.4 ± 5.5 mU/l; P < 0.05), but had no effect on the change in plasma glucagon. CONCLUSIONS Exogenous GLP-1 in a dose of 1.2 pmol/kg/minute attenuates the glycaemic response to small intestinal nutrient in critically ill patients with type-2 diabetes. Given the modest magnitude of the reduction in glycaemia the effects of GLP-1 at higher doses and/or when administered in combination with insulin, warrant evaluation in this group. TRIAL REGISTRATION ANZCTR:ACTRN12610000185066.
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Affiliation(s)
- Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
- National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Matthew J Summers
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Antony V Zaknic
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
- National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Robert JL Fraser
- National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
- Investigation and Procedures Unit, Repatriation General Hospital, Daws Road, Daw Park, South Australia, 5041, Australia
| | - Anna E Di Bartolomeo
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Judith M Wishart
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia
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