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.
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