|
Table II: Comparison data between Standard ENFs, MPF,
and MF. 
Table III: Comparison data between Standard ENFs,
MPF, and MF.
|
|
Variables
|
Total
(N=326)
|
Standard ENFs (N=110)
|
WP100% (N=102)
|
Specialized MPF
(N=114)
|
P-
Value
|
|
Group I
(N=54)
|
Group II
(N=56)
|
Group III
(N=50 )
|
Group IV
(N=52 )
|
Group V
(N=54)
|
Group VI
(N=60)
|
|
%∆GRV
|
6.8%±2.8%
|
8.2%±0.2%
|
11.2%±2.5%
|
6.3%±0.2%
|
7.1%±0.3%
|
3.4%±0.1%
|
4.4%±0.1%
|
0.00(S)
|
|
TOLR
|
GI Sx (0,1)
|
244 (74.8%)
|
37 (68.5%)
|
33 (58.9%)
|
38 (76%)
|
39 (75%)
|
47 (87%)
|
50 (83.3%)
|
0.00(S)
|
|
GI Sx (≥2)
|
82 (25.2%)
|
17 (31.5%)
|
23 (40.1%)
|
12 (24%)
|
13 (25%)
|
7 (13%)
|
10 (16.7%)
|
|
Enteric
BSI
|
Negative
|
281 (86.2%)
|
45 (83.3%)
|
43 (76.8%)
|
44 (88%)
|
45 (86.5%)
|
50 (92.6%)
|
54 (90%)
|
0.00(S)
|
|
Positive
|
45 (13.8%)
|
9 (16.7%)
|
13 (23.2%)
|
6 (12%)
|
7 (13.5%)
|
4 (7.4%)
|
6 (10%)
|
|
GNB
|
28 (8.59%)
|
6 (11.1%)
|
7 (12.5%)
|
4 (8%)
|
5 (9.6%)
|
3 (5.5%)
|
3 (5%)
|
|
GNB+CAND
|
17 (5.2%)
|
3 (5.6%)
|
6 (10.7%)
|
2 (4%)
|
2 (3.8%)
|
1 (1.9%)
|
3 (5%)
|
|
TF Cost (USD/day)
|
4.37±4.74
|
0.97±0.00
|
0.97±0.00
|
0.83±0.00
|
0.83±0.00
|
10.8±0.00
|
10.8±0.00
|
0.00(S)
|
|
H.ALB Cost (USD/day)
|
19.9±16.0
|
27.9±10.9
|
29.9±16.7
|
21.3±12.1
|
24.7±14.3
|
7.25±12.4
|
9.32±13.3
|
0.00(S)
|
|
CER (USD/ +1 g ALB/dl)
|
66.2±74.5
|
76.7±42.9
|
185.6±100.4
|
33.1±18.1
|
57.9±21.7
|
18.1±12.4
|
24.2±15.9
|
0.00(S)
|
|
MAP (mmHg)
|
75.82±11.89
|
73.38±1.68
|
55.86±16.05
|
80.40±0.99
|
77.26±0.94
|
84.85±0.66
|
83.30±0.645
|
0.00(S)
|
|
HR (bpm)
|
99.35±12.84
|
101.62±1.68
|
120.11±18.86
|
94.60±0.99
|
97.74±0.94
|
90.15±0.66
|
91.70±0.65
|
0.00(S)
|
|
NE rate (µg/min)
|
7.99±5.72
|
7.62±0.29
|
14.86±11.56
|
6.48±0.14
|
6.94±0.14
|
5.86±0.08
|
6.05±0.07
|
0.00(S)
|
|
TF days
|
9.03±1.78
|
8.93±1.57
|
9.40±2.31
|
8.87±1.44
|
9.20±1.81
|
8.71±1.73
|
9.22±2.13
|
0.06(NS)
|
|
Hospital Stay day(s)
|
12.7±3.59
|
15.1±2.49
|
19.0±0.00
|
11.0±0.00
|
12.0±0.00
|
9.0±0.00
|
10.0±0.00
|
0.00(S)
|
|
28-day Hospital Survival
|
275 (84.4%)
|
44 (81.5%)
|
40 (71.4%)
|
45 (90%)
|
42 (80.8%)
|
50 (92.5%)
|
54 (90%)
|
0.00(S)
|
|
Hospital Mortality
|
All 28- day
|
51 (15.6%)
|
10 (19.2%)
|
16 (29.6%)
|
5 (10%)
|
10 (18.5%)
|
4 (7.5%)
|
6 (10%)
|
|
Early (≤14d)
|
18 (5.5%)
|
4 (7.7%)
|
6 (10.7%)
|
2 (4%)
|
3 (5.6%)
|
1 (1.9%)
|
2 (3.3%)
|
|
Late (>14 d)
|
33 (10.1%)
|
6 (11.5%)
|
10 (18.9%)
|
3 (6%)
|
7 (12.9%)
|
3 (5.6%)
|
4 (6.7%)
|
|
Data
are presented as Mean±Standard deviation and are analyzed by using ANOVA test
(at p-value< 0.05).
|
|
ENF: Enteral Nutritional Formula.
MF: Modular Formula.
MPF: Modular Protein Formula.
WP: Whey protein.
TF: Trophic Feeding.
CER:
Cost-effectiveness ratio.
GRV: Gastric
residual volume.
USD: United
states dollar.
MAP: Mean
arterial pressure.
HR: Heart
rate.
NE:
Norepinephrine.
bpm: Beat per
minute.
|
∆: Changes.
S: Significant
(P-Value <0.05).
NS:
Non-significant (P-Value >0.05).
N: Number of
study’s hospitalized patients.
ALB: Albumin
level.
H.ALB: Human
albumin.
GI:
Gastrointestinal.
Sx: Symptoms.
BSI: Blood
stream infection.
GNB: Gram
negative bacteria.
CAND:
Candida.spp.
|
Discussion
This
study included hypoalbumenic hospitalized patients who were intolerated to
partially or fully EN and were tested for their tolerance to early TF dose of
either 10 ml per hour or 20 ml per 2 hours by using three different enteral
formulas of standard ENFs (Ensure® or Resource®Optimum),
reconstituted WP100% powder, and ArgiMent®. To
the best of our knowledge, this is the first study globally which directly
compare the positive clinical and economic impacts of early TF in intolerated
EN hypoalbumenic hospitalized patients using three different classes of
nutritional formulas in order to rehabilitate the GIT gradually for starting
partially or fully EN and in order to delay using total parental nutrition
(TPN) as possible. According to our proposed concept, early
TF may maintain the integrity of enterocytes, rehabilitate GIT, minimize the
risk of enteric GNB and candida translocation, and promote the liver ALB
synthesis by decreasing the GIT associated systemic inflammatory response
syndrome (SIRS) and better utilizing of absorbed amino acids (AAs).[24-26]
Glutamine is
considered one of the most important enterocyte-nutrients which is independent
on probiotics for activation and so not affected by broad spectrum antibiotics
which are commonly used in hospitalized patients especially the wasted
hypoalbumenic patients.[27,28] This glutamine concept
might explain the significant higher GIT tolerance and positive clinical
outcomes in improving the ALB, GIT related enterobacteriaceae sepsis in patients
who were on ArgiMent® regardless of TF dose schedule in compared with patients who were on either WP100% or standard ENFs.[29,30]
WP is well known as protein with high biological value (BV),
hydrolysability and absorbability advantages, and has the highest content of leucine
in compared with other major proteins of casein and soy protein. Most of
standard ENFs are primarily formulated with mixture of these three proteins in
different proportions. Leucine is
considered as the most important AA in the body due to dual essentiality and
anabolic effect.[31-33] Based on aforementioned leucine advantages,
patients who were on reconstituted WP 100% were also had significantly better
clinical and economic impacts compared with patients who were on standard ENFs
regardless of TF schedule.[34,35] Across all analysis variables in
our study, ArgiMent® had the highest significant positive clinical
and economic outcomes due to the unique formulation characteristics of very high
PD (≈26 g/100 Cal),High protein quality (10 g of whey protein (WP)), high CD
(≈2 Cal/ml), and unique specific nutrients
enrichment of glutamine, arginine, vitamin C, zinc, and prebiotic of galcto-oligosaccharides
(GOS or Bimuno).
Conclusion
In
summary, using early TF dose at rate of either 10 ml per hour
or 20 ml per 2 hours for 16 hours per day of any enteral formulas (EFs) may
have positive clinical and economic outcomes of increasing ALB level, lower
H.ALB requirement, lower LOS, lower mortality, and lower risk of enteral
pathogen translocation with acceptable GIT tolerance in EN intolerated
hypoalbumenic critically or non-critically medical and surgical hospitalized
patients especially if the EFs have higher glutamine, leucine, PD, CD, specific
nutrients enrichments. This study is limited by its retrospective design and
the use of single-centre data. Nonetheless, our centre is an experienced and
high-volume unit, so our data may be useful for other centres. A larger, multisite, prospective study is needed to
control for multiple confounders.
References
1. Guenter P, Silkroski M. Tube
Feeding: Practical Guidelines and Nursing Protocols. Gaithersburg, MD: Aspen Publishers; 2001.
2.Pullen RL., Jr Measuring gastric
residual volume. Nursing. 2004;34(4):18.
3. Mayer AP, Durward A, Turner C, et
al. Amylin is associated with delayed gastric emptying in critically ill
children. Intensive Care Med. 2002;28(3):336–340.
4 . Kompan L,
Vidmar G, Spindler-Vesel A, Pecar J. Is early enteral nutrition a risk factor
for gastric intolerance and pneumonia? Clin Nutr. 2004;23(4):527–532.
5. Mihatsch WA, von Schoenaich P, Fahnenstich H, et al.
The significance of gastric residuals in the early enteral feeding advancement
of extremely low birth weight infants. Pediatrics. 2002;109(3):457–459.
6. Mostafa SM, Bhandari S, Ritchie G et
al. Constipation and its implications in the critically ill
patient. Br J Anaesth 2003;91:815–19. 10.1093/bja/aeg275
7. Gacouin A, Camus C, Gros A et al. Constipation
in long-term ventilated patients: associated factors and impact on intensive
care unit outcomes. Crit Care Med 2010;38:1933–8.
8. Meissner W, Dohrn B, Reinhart K. Enteral
naloxone reduces gastric tube reflux and frequency of pneumonia in critical
care patients during opioid analgesia. Crit Care Med 2003;31:776–80.
9.Ukleja A. Altered GI motility in critically
ill patients: Current understanding of pathophysiology, clinical impact, and
diagnostic approach. Nutr Clin Pract. 2010;25(1):16-25.
10. McClave SA, Martindale RG, Vanek VW, et al.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the
Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN
J Parenter Enteral Nutr. 2009;33(3):277-316.
11. Taylor SJ, Manara AR, Brown J. Treating delayed
gastric emptying in critical illness:
Metoclopramide, erythromycin and bedside (Cortrak) nasointestinal tube
placement. JPEN J Parenter Enteral Nutr. 2010;34(3):289-294.
12. Poulard F, Dimet J,
Martin-Lefevre L, et al. Impact of not measuring residual gastric volume in
mechanically ventilated patients receiving early enteral feeding: A prospective
before-after study. JPEN J Parenter Enteral Nutr.
2010;34(2):125-130.
13. 5.Btaiche IF, Chan LN, Pleva M,
Kraft MD. Critical illness, gastrointestinal complications, and medication
therapy during enteral feeding in critically ill adult patients. Nutr
Clin Pract. 2010;25(1):32-49
14. Arias C.A., Murray B.E. Antibiotic-resistant bugs in
the 21st century—A clinical super-challenge. N. Engl. J.
Med. 2009;360:439–443. doi: 10.1056/NEJMp0804651.
15. Chaudhary U., Aggarwal R. Extended
spectrum-lactamases (ESBL)—An emerging threat to clinical
therapeutics. Indian J. Med. Microbiol. 2004;22:75–80.
16. Pitout J.D.D., Laupland K.B. Extended-spectrum
beta-lactamase-producing Enterobacteriaceae: An emerging public-health
concern. Lancet Infect. Dis. 2008;8:159–166. doi:
10.1016/S1473-3099(08)70041-0.
17. Paterson D.L., Bonomo R.A.
Extended-spectrum beta-lactamases: A clinical update. Clin. Microbiol.
Rev. 2005;18:657–686. doi: 10.1128/CMR.18.4.657-686.2005.
18. Chong Y., Ito Y., Kamimura T.
Genetic evolution and clinical impact in extended-spectrumβ-lactamase-producing Escherichia coli and Klebsiella
pneumoniae.Infect.Genet.Evol.2011;11:1499–1504.doi:10.1016/j.meegid. 2011.06.001.
19. Roy C. C., Kien C. L., Bouthillier L., Levy E.
2006. Short-chain fatty acids: ready for prime time? Nutr. Clin.
Pract. 21: 351–366.
20. Cook S. I., Sellin J. H.
1998. Review article: short chain fatty acids in health and
disease. Aliment. Pharmacol. Ther. 12: 499–507.
21. 9. Hijova E., Chmelarova A.
2007. Short chain fatty acids and colonic health. Bratisl. Lek.
Listy. 108: 354–358.
22. Srivastava A, Mishra S ,Enrichment and evaluation of galacto-oligosaccharides
produced by whole cell treatment of sugar reaction mixture. 2019
Feb;46(1):1181-1188. doi: 10.1007/s11033-019-04585-1. Epub 2019 Jan 14.
23. Monteagudo-Mera A, Arthur JC, Jobin C, Keku T, Bruno-Barcena JM, Azcarate-Peril MA,High purity galacto-oligosaccharides
enhance specific Bifidobacterium species and their metabolic activity in the
mouse gut microbiome. 2016;7(2):247-64. doi: 10.3920/BM2015.0114. Epub 2016 Feb
3
24. Lord L, Harrington M The A.S.P.E.N. Nutrition
Support Practice Manual. 2. Silver Spring, MD: The American Society for
Parenteral and Enteral Nutrition; 2005.
25. Hardman JG, O’Connor PJ. Predicting gastric contents
following trauma: an evaluation of current practice. Eur J
Anaesthesiol. 1999;16(6):404–409.
26. Mentec H,
Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive
intolerance during enteral nutrition in critically ill patients: frequency,
risk factors, and complications. Crit Care Med. 2001;29(10):1955–1961.
27. Backhed F, Ley RE, Sonnenburg JL, et al.
Host-bacterial mutualism in the human intestine. Science. 2005;307:1915–1920.
28. Ley RE, Peterson DA, Gordon JI. Ecological and
evolutionary forces shaping microbial diversity in the human
intestine. Cell. 2006;124:837–848.
29. Eckburg PB, Bik EM, Bernstein CN, et al. Diversity
of the human intestinal microbial flora. Science. 2005;308:1635–1638.
30. Zoetendal EG, von Wright A, Vilpponen-Salmela T, et
al. Mucosa-associated bacteria in the human gastrointestinal tract are
uniformly distributed along the colon and differ from the community recovered
from feces. Appl Environ Microbiol. 2002;68:3401–3407.
31. Barzel U.S., Massey L.K. (1998) Excess dietary
protein can adversely affect bone. Journal of Nutrition 128,
1051-1053.
32. Boirie Y., Dangin M., Gachon P., Vasson M.P.,
Maubois J.L., Beaufrere B. (1997) Slow and fast dietary proteins
differently modulate postprandial protein accretion. Proclamations of
National Academy of Sciences 94, 14930-14935 .
33. Deutz N.E.P., Bruins M.J., Soeters P.B.
(1998) Infusion of soy and casein protein meals affects interorgan amino
acid metabolism and urea kinetics differently in pigs. Journal of
Nutrition 128, 2435-2445.
34. Ferber-Viart C, Dubreuil C, Vidal PP. Effects of
acetyl-dl-leucine in vestibular patients: a clinical study following neurotomy
and labyrinthectomy. Audiol neuro-otol. 2009;14:17–25.
35. Vibert N, Vidal PP. In vitro effects of
acetyl-dl-leucine (Tanganil) on central vestibular neurons and vestibulo-ocular
networks of the guinea-pig. Eur J Neurosci. 2001;13:735–748.