Search

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2010.08.011 Byline: Vikram Khoshoo, Shumei S. Sun, Heidi Storm Abstract: The effects of adding fiber to the tolerance of a peptide-based formula have not been studied. The objective of this study was to evaluate the tolerance of a peptide-based formula with insoluble and prebiotic fiber in children with compromised gut function. During January 2005 to June 2006, a 6-week randomized, double-blind, cross-over clinical study was conducted to compare stool frequency, stool consistency, and tolerance (abdominal pain, abdominal distension, vomiting, weight gain, and intake) between a formula with or without 3.5 g fructo-oligosaccharides and 3.8 g insoluble fiber/L. Fourteen children with gastrointestinal dysmotility (n=9), Crohn's disease (n=3), or mild short bowel syndrome (n=2) were randomized to receive one of two formulas for 2 weeks followed by a 5-day washout period and then the second diet for another 2 weeks. Means and standard deviations of daily stool frequency and consistency were calculated and compared using intent-to-treat analysis. Linear mixed models were applied to each outcome variable. Stool frequency did not differ by formula. Stool consistency did differ with more soft "mushy" stools (less hard stools) occurring with use of fiber (P<0.001) and more watery stools occurring with control formula (P<0.01). The extremes of stool consistency were normalized with the fiber formula. No significant differences were observed in vomiting, abdominal pain, feeding intakes, or weight gain between the two formulas. This study showed that a peptide-based formula containing fiber was as well-tolerated as a fiber-free formula in a small population of children with gastrointestinal impairments. Longer-term effects of the fiber formula need to be studied. Article History: Received 2 July 2010

Supplementation of enteral nutritional formulas and parenteral nutrition lipid emulsions with omega-3 fatty acids is a recent area of research in patients with critical illness. It is hypothesized that omega-3 fatty acids may help reduce inflammation in critically ill patients, particularly those with sepsis and acute lung injury. The objective of this article is to review the data on supplementing omega-3 fatty acids during critical illness; enteral and parenteral supplemental nutrition are reviewed separately. The results of the research available to date are contradictory for both enteral and parenteral omega-3 fatty acid administration. Supplementation with omega-3 fatty acids may influence the acute inflammatory response in critically ill patients, but more research is needed before definitive recommendations about the routine use of omega-3 fatty acids in caring for critically ill patients can be made. [c] 2010 International Life Sciences Institute Key words: acute lung injury, critical illness, fish oil, mechanical ventilation, omega-3 fatty acids, sepsis doi:10.1111/j.1753-4887.2010.00313.x

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jada.2009.12.001 Byline: Joanne Frederike Olieman, Corine Penning, Hanneke IJsselstijn, Johanna C. Escher, Koen F. Joosten, Jessie M. Hulst, Dick Tibboel Abstract: The optimal enteral feeding regimen in children with short-bowel syndrome (SBS) is debated by clinicians. The purpose of this article is to present an overview of published data on feeding strategies in children with SBS. A structured literature search (years 1966 through 2007) was done to identify human studies in children directly addressing nutrition (or specified nutrients) in relation to SBS. Eight relevant studies retrieved were graded by seven experts according to the Scottish Intercollegiate Guidelines Network criteria. This grading system is based on the study design and methodological quality of individual studies. Recommendations were made based on the outcome according to the Scottish Intercollegiate Guidelines Network if appropriate and on expert opinion otherwise. The most important recommendations are: acents Enteral nutrition should be initiated as soon as possible after bowel resection to promote intestinal adaptation. acents Enteral nutrition should be administered in a continuous fashion. acents Breast milk or standard polymeric formula (depending on the child's age) is recommended as preferred type of nutrition. acents Bottle-feeding (small volumes) should be started as soon as possible in neonates to stimulate the suck and swallow reflexes. Solid food can be introduced at the age of 4 to 6 months (corrected for gestational age if necessary) to stimulate oral motor activity and to avoid feeding aversion behavior. The team of experts concluded that high-quality research on the preferred types of enteral and oral nutrition in children with SBS is scarce. Multicenter prospective studies on the effects of feeding strategies on bowel adaptation, fecal production, linear growth, and clinical outcome are required to find the optimal feeding regimen in children with SBS. Article History: Accepted 31 July 2009

Byline: Ulrike Holzinger (1), Reinhard Kitzberger (1), Andja Bojic (2), Marlene Wewalka (1), Wolfgang Miehsler (1), Thomas Staudinger (2), Christian Madl (1) Keywords: Jejunal feeding tube; Critical illness; Enteral nutrition Abstract: Objective To compare the success rate of correct jejunal placement of a new self-advancing jejunal tube with the gold standard, the endoscopic guided technique, in a comparative intensive care unit (ICU) patient population. Design Prospective, randomized study. Setting Two medical ICUs at a university hospital. Patients Forty-two mechanically ventilated patients with persisting intolerance of intragastric enteral nutrition despite prokinetic therapy. Methods Patients were randomly assigned to receive an unguided self-advancing jejunal feeding tube (Tiger Tube[TM]) or an endoscopic guided jejunal tube (Freka.sup.(r) Trelumina). Primary outcome measure was the success rate of correct jejunal placement after 24 h. Results Correct jejunal tube placement was reached in all 21 patients using the endoscopic guided technique whereas the unguided self-advancing jejunal tube could be placed successfully in 14 out of 21 patients (100% versus 67% P = 0.0086). In the remaining seven patients, successful endoscopic jejunal tube placement was performed subsequently. Duration of tube placement was longer in the unguided self-advancing tube group (20 +- 12 min versus 597 +- 260 min P < 0.0001). Secondary outcome parameters (complication rate, number of attempts, days in correct position with accurate functional capability, days with high gastric residual volume, length of ICU stay, ICU mortality) were not statistically different between the two groups. No potentially relevant parameter predicting the failure of correct jejunal placement of the self-advancing tube could be identified. Conclusions Success rate of correct jejunal placement of the new unguided self-advancing tube was significantly lower than the success rate of the endoscopic guided technique. Author Affiliation: (1) Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Intensive Care Unit 13H1, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria (2) Department of Internal Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria Article History: Registration Date: 28/05/2009 Received Date: 25/02/2009 Accepted Date: 22/05/2009 Online Date: 16/06/2009

Enteral nutrition has a primary therapeutic effect in active Crohn's disease. It is unknown which nutrient(s) account for this action, but a role for both the amount and type of dietary fat has been postulated. Some clinical and experimental data suggest that medium-chain triglycerides (MCT) may reduce intestinal inflammation. We aimed to assess the effect of replacing part of the dietary fat with MCT on the incidence and severity of colitis in interleukin (IL)-10(-/-) mice under specific pathogen-free conditions. Twenty-four IL-10(-/-) 4-wk-old mice were randomized to receive a control diet based on sunflower oil [(n-6) fatty acids (FA)] and an experimental isocaloric, isonitrogenous diet with 50% sunflower and 50% coconut oil (MCT diet). When the mice were 12 wk old, they were killed and the colon was examined for the presence of colitis, lymphocyte subpopulations and apoptosis, ex vivo cytokine production in supernatant of colon explants, toll- like receptor (TLR)-2 and TLR-9 mRNA, and FA profile in colonic tissue homogenates. Colitis incidence was lower in the IL-10(-/-) mice fed the MCT diet (1/12) than in the mice fed the control diet (8/12; P = 0.03). The histological damage score was also lower in the former (P < 0.0005). Feeding the MCT diet resulted in fewer total and apoptotic intraepithelial CD3+ and lamina propria CD3+CD4+ lymphocytes, as well as downregulated production of IL-6 and interferon-[gamma], and reduced TLR-9 mRNA. We conclude that partial replacement of dietary (n-6) FA with MCT decreases the incidence of colitis in a model of spontaneous intestinal inflammation and provide experimental arguments for a possible primary therapeutic effect of MCT in human Crohn's disease.

Byline: Arnaud Desachy (1), Marc Clavel (2,3), Albert Vuagnat (1), Sandrine Normand (2), Valerie Gissot (1), Bruno Francois (2,3) Keywords: Early enteral nutrition; Calorie requirements; Residual gastric volume; Mechanical ventilation; Intensive care unit Abstract: Objective To compare the initial (D7) calorie intake and tolerability of two early enteral nutrition protocols in which the optimal flow rate was introduced either immediately or gradually. Design Open, prospective, randomized study. Setting Two medical-surgical intensive care units. Patients One hundred consecutive intubated and mechanically ventilated patients. Interventions Early enteral nutrition was started within 24a-h following intubation, and the optimal flow rate (25a-Kcal/kga-day.sup.-1) was either introduced immediately or reached in increments. Flow rate of the nutritional solution was adapted to the residual gastric volume, measured every 8a-h, and the use of prokinetic agents was encouraged. Vomiting, regurgitation, colectasia, and suspected aspiration were defined as serious adverse events requiring withdrawal of enteral nutrition. Measurements and results When introduced immediately at optimal flow rate, early enteral nutrition led to a significant improvement in actual calorie supply (pa-a-300a-ml) was more frequent when optimal flow rate was introduced immediately (a-pa-=a-0.04), frequency of serious adverse events necessitating withdrawal of enteral nutrition was similar in the two groups (pa-=a-0.64). Conclusions When residual gastric volume is measured regularly and prokinetic agents are used, enteral nutrition can be started early and be introduced at optimal dose regimen, thereby providing better calorie intake. Serious adverse events required early enteral nutrition withdrawal in only 15a-patients, with no difference in frequency between the groups. Author Affiliation: (1) Service de Reanimation Polyvalente, Centre Hospitalier d'Angouleme, 16470, Saint Michel, France (2) Medical-Surgical Intensive Care unit, Hopital Universitaire Dupuytren, Limoges, France (3) Clinical Research Center, Hopital Universitaire Dupuytren, Limoges, France Article History: Registration Date: 12/12/2007 Received Date: 22/08/2007 Accepted Date: 29/11/2007 Online Date: 22/01/2008

Objective: To study the risk factors for gastrointestinal complications related to enteral nutrition in critically ill children. Design: A prospective, observational study. Setting: Pediatric intensive care unit Subjects: Five hundred [...]

Byline: N. Q. Nguyen (1,3), S. W. Lam (2), K. Ching (1), M. Chapman (2), R. J. Fraser (3,4), R. H. Holloway (1,3) Keywords: Diabetes mellitus; Gastric feed intolerance; Critically ill Abstract: Objective To examine the occurrence of feed intolerance in critically ill patients with previously diagnosed type II diabetes mellitus (DM) who received prolonged gastric feeding. Design and setting Retrospective study in a levela-3 mixed ICU. Patients All mechanically ventilated, enterally fed patients (na-=a-649), with (na-=a-118) and without type II DM (na-=a-531) admitted between January 2003 and July 2005. Interventions Patients with at least 72a-h of gastric feeding were identified by review of case notes and ICU charts. The proportion that developed feed intolerance was determined. All patient received insulin therapy. Results The proportion of patients requiring gastric feeding for at least 72a-h was similar between patients with and without DM (42%, 50/118, vs. 42%, 222/531). Data from patients with DM were also compared with a group of 50 patients matched for age, sex and APACHE II score, selected from the total non-diabetic group. The occurrence of feed intolerance (DM 52% vs. matched non-DM 50% vs. unselected non-diabetic 58%) and the time taken to develop feed intolerance (DM 62.6a-+-a-43.8a-h vs. matched non-DM 45.3a-+-a-54.6 vs. unselected non-diabetic 50.6a-+-a-59.5) were similar amongst the three groups. Feed intolerance was associated with a greater use of morphine/midazolam and vasopressor support, a lower feeding rate and a longer ICU length of stay. Conclusions In critically ill patients who require prolonged enteral nutrition, a prior history of DM type II does not appear to be a further risk factor for feed intolerance. Author Affiliation: (1) Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia (2) Department of Intensive Care, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia (3) University Department of Medicine, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia (4) Department of Gastroenterology, Repatriation General Hospital, 5041, Adelaide, SA, Australia Article History: Registration Date: 03/05/2007 Received Date: 30/06/2006 Accepted Date: 02/05/2007 Online Date: 07/06/2007 Article note: This research was supported by the National Health and Medical Research Council of Australia An erratum to this article can be found at http://dx.doi.org/10.1007/s00134-007-0777-x

Artificial nutrition is widely advocated as adjunctive care in patients with a variety of underlying diseases. In recent years more emphasis has been placed on delivering it directly into the gastrointestinal tract through tubes in the stomach or proximal small intestine (enteral nutrition). Because the efficacy of any therapeutic intervention is best established by demonstrating it in one or more randomized controlled trials, this review focuses on data from such studies. The specific issue to be assessed is the ability of enteral nutrition to influence the mortality and morbidity of various diseases, a question that was addressed in depth in a recent systematic review. This article presents the highlights of that systematic review and puts it in context with the perspective of a practicing food and nutrition professional. Using established search strategies, 30 randomized controlled trials were identified that compared enteral nutrition to no artificial nutrition. In addition, other randomized controlled trials were identified that did provide some insight into the clinical utility of enteral nutrition. The randomized controlled trials were stratified by the underlying disease state. No high-quality evidence indicated that enteral nutrition had any beneficial effect on clinical outcome. Low-quality evidence, which tends to overestimate the treatment effect, suggested that enteral nutrition may be useful in reducing the incidence of postoperative complications and infection rates in intensive care units, improving mortality in chronic liver disease, and reducing length of stay when provided as trophic feeding to low-birth-weight neonates who are also receiving intravenous artificial nutrition. Enteral nutrition was not helpful when given during the first week to patients with dysphagic strokes. Thus, the randomized controlled trials that have compared enteral nutrition to no artificial nutrition have only found benefit when the methodologic rigor of the studies is inadequate to prevent bias from interfering with the interpretation of the data. No high-quality data are available to prove that enteral nutrition is of benefit.

The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically ill patients. The data sources consisted of an intensive literature review from five databases, using standardized search terms. Randomized controlled clinical trials, meta-analyses, consensus statements, reviews, US Food and Drug Administration alerts, and case reports were selected for study. Research reports were abstracted in detail and evaluated for research quality using the criteria developed by the American Dietetic Association. Consensus statements regarding the influence of specific enteral feeding methods on key clinical outcomes (ie, infectious complications, cost, length of hospital stay, and mortality) were developed and graded based on the quality of the available evidence. The data support the use of enteral over parenteral nutrition to reduce infectious complications and cost, and the initiation of enteral feedings within 24 to 48 hours of injury or admission to an intensive care unit to reduce infectious complications and length of hospital stay in head injury and trauma patients. Postpyloric tube placement is associated with reduced gastric residual volume and reflux, but adequately powered trials are not available to support prevention of aspiration pneumonia. Acceptance of gastric residual volumes of up to 250 mL may increase volume of formula delivered. Promotility agents are associated with reduced gastric residual volume. Feeding patients in the semirecumbent rather than supine position is associated with reduced aspiration pneumonia and pharyngoesophageal formula reflux. Actual delivery of 14 to 18 kcal/kg/day or 60% to 70% of goal is associated with improved outcomes, whereas greater intake may not be in some populations. Blue food coloring should not be used with enteral feedings due to its limited sensitivity for aspiration and some risk of mortality. Well-designed, adequately powered, randomized controlled clinical trials are needed to evaluate any benefit of tube tip position on aspiration pneumonia or mortality, and of early enteral feedings on mortality.

Background. Although enteral feeding in end-stage dementia is thought by many clinicians to be 'futile,' it is still widely used. We examined rates of robe feeding (gastrostomy or nasogastric) in end-stage dementia in hospitals in both Canada and Israel, and hypothesized that Canadian non-Jewish affiliated hospitals would have the lowest (and Israeli institutions the highest), with Canadian Jewish hospitals exhibiting intermediate rates. Methods. We conducted a cross-sectional survey of six geriatric long-term hospitals: two in Israel and four in Canada (two Jewish affiliated, two not; two m Ontario, two in Quebec province). Patients with end-stage dementia were assessed and further analyzed for type of feeding. Results. In the six hospitals, 2287 long-term beds were surveyed, of which 1358 (59.4%) were used by demented patients of whom 376 (27.7%) were severely demented (Global Deterioration Scale-level 7). Of these, 24.5% (92) were fed by nasogastric tube or gastrosnomy tube. Significant differences in tube-feeding prevalence were found between Canada (11%) and Israel (52.9%), with only 4.7% seen in non Jewish Canadian institutions. Jewish affiliated hospitals in Canada exhibited an intermediate rate of 19.6%. However, for within-country dyads, wide differences were also found. When we examined patient religion, we found that Canadian non-Jewish patients had the lowest rates (3.2%), Israeli Jewish patients the highest (51.7%), and Canadian Jewish patients exhibited an intermediate rate (19.0%) of tube use. Conclusions. Despite reservations concerning its utility, feeding tube use is reasonably widespread in patients who have reached the stage of severe dementia. Canadian institutions exhibited a lower prevalence of feeding tube use than did Israeli hospitals. Between-country and between-province differences in practice may be explained by some combination of administrative and/or financial incentives, religion, and culture: within country and within ethnic group differences may be caused, at least in part, by differing institutional cultures.

Objective. To evaluate the complications associated with the image-guided insertion of gastrostomy (G) and gastrojejunostomy (GJ) tubes in children, performed by the retrograde percutaneous route. Methods. A convenience sample of 208 charts of 840 patients recorded as having G and/or GJ tubes placed by the interventional radiology service in a 4-year period (1995-1999) at the Hospital for Sick Children in Toronto, Canada, were selected for review. Complications were categorized as major (including subcutaneous abscess, peritonitis, septicemia, gastrointestinal bleeding, and death) or minor. Results. In total, 253 tubes (208 G tubes, 41 GJ tubes, 4 G and GJ tubes) were placed in the 208 patients reviewed. The median age at the time of insertion was 15 months (range: 7 days-18 years). The most common diagnostic category was neurologic disease (47%). The main indications for tube insertion were recorded as failure to thrive (57%) and risk of aspiration (47%). Major complications were seen in 5% of patients. Peritonitis was noted in 3%, and there was 1 death related to tube insertion (0.4%). Minor complications were found in 73% of patients, including tube dislodgement (37%), tube leakage (25%), and G-tube site skin infection (25%). GJ tubes had a higher rate than G tubes of obstruction, migration, dislodgement, leakage, and intussusception. Site infection, gastroesophageal reflux, and bleeding from the site were seen less frequently in patients with GJ tubes compared with G tubes. Conclusion. G and GJ tubes placed by the image-guided retrograde percutaneous method are associated with a wide range of complications. The majority of these are minor and are predominantly related to tube maintenance, but major complications, including death, do occur. Pediatrics 2004;114:458-461; gastrostomy tube, gastrojejunostomy tube, image-guided, complications., ABBREVIATIONS. G tube, gastrostomy tube; GJ tube, gastrojejunostomy tube; PEG, percutaneous endoscopic gastrostomy; GER, gastroesophageal reflux. The placement of gastrostomy tubes (G tubes) and gastrojejunostomy tubes (GJ tubes) has become [...]

* BACKGROUND Underfeeding of patients reliant on enteral tube feedings most likely is due primarily to interruptions in the infusions. Strategies to improve energy intake require an understanding of such [...]

Byline: Barbara J. Philips (1), Jean-Xavier Meguer (2), Jonathan Redman (1), Emma H. Baker (2) Keywords: Airways; Diabetes mellitus; Viral rhinitis; Glucose; Infection; Intensive care Abstract: Objectives (a) To describe the glucose content of normal human airways secretions (b) to observe the effects of hyperglycemia and airways inflammation on airways glucose. Design Observational studies. Settings (a) St George's Hospital Medical School (b) diabetes mellitus outpatient clinics (c) adult general intensive care unit. Patients Nineteen healthy volunteers, 24 volunteers with acute rhinitis, 20 patients with diabetes mellitus, and 60 patients admitted to a general adult intensive care unit. Measurements (a) Non-ventilated patients: simultaneous measurement of blood and nasal glucose concentrations (b) ICU patients: simultaneous blood, nasal, and endotracheal (ET) glucose concentrations. Results Nasal glucose was undetectable in all healthy volunteers. Glucose was detected in 12/24 volunteers with acute viral rhinitis [1 (1--2) mmol l.sup.-1] and 18/20 people with diabetes [4 (2--7) mmol l.sup.-1]. Glucose was detected in the ET secretions of 31/60 ventilated patients on ICU. Patients with ET glucose had significantly higher blood glucose (9.8+-0.4 mmol l.sup.-1) than patients without ET glucose (7.2+-0.3 mmol l.sup.-1, P10.1 mmol l.sup.-1 had glucose in ET secretions. Enteral nutrition did not affect the presence or concentration of glucose in ET secretions. Conclusions Glucose is not normally present in airways secretions, but appears where hyperglycaemia or epithelial inflammation occur. The detection of glucose cannot reliably be used to detect enteral feed aspiration. Author Affiliation: (1) Department of Anaesthesia and Intensive Care, St George's Hospital Medical School, Cranmer Terrace, London, SW17 0RE, UK (2) Department of Physiological Medicine, St George's Hospital Medical School, London, UK Article History: Received Date: 12/03/2002 Accepted Date: 21/07/2003 Online Date: 28/08/2003

Tube feeding (TF) provides a model with which to study appetite when nutrient delivery bypasses the upper gastrointestinal (GI) tract and associated cephalic phase response. Nocturnal, diurnal and 24-h TF schedules are used clinically, but their effects on satiety have not been distinguished. This study tested two hypotheses: 1) bypassing the upper GI tract with TF has little satiating effect, and 2) diurnal TF suppresses appetite and food intake more than nocturnal or 24-h schedules. Six healthy men, residing in a metabolic suite, each received three continuous TF schedules (diurnal 12-h, nocturnal 12-h and 24-h; 6.86 [+ or -] 0.51 MJ/d) in random order for 3 d over separate 10-d periods. Two days before and after TF, a placebo feed ( KEY WORDS: * tube feeding * appetite * food intake * healthy men

Byline: Guido Bertolini (1), Gaetano Iapichino (3), Danilo Radrizzani (5), Rebecca Facchini (1), Paola Bruzzone (4), Giancarlo Zanforlin (3), Gianni Tognoni (2) Keywords: Critically ill patients Enteral nutrition Parenteral nutrition Immunonutrition Severe sepsis Abstract: Objective. To compare the mortality of critically ill patients given either enteral feeding with an immune-enhancing formula or parenteral nutrition (PN). We report the results of a planned interim analysis on patients with severe sepsis which was undertaken earlier than planned once a meta-analysis suggested excess mortality in patients with severe sepsis given enteral immunonutrition. Design. Randomised multicentre unblinded controlled clinical trial. Setting. Thirty-three General Intensive Care Units in Italy. Patients and participants. Among the 237 recruited patients, 39 had severe sepsis or septic shock 21 of them received PN. Interventions. Eligible patients received either total PN or enteral nutrition, the latter containing extra L-arginine, omega-3 fatty acids, vitamin E, beta carotene, zinc, and selenium. Measurements and results. The primary endpoint for the subgroup analysis on patients with severe sepsis was mortality on Intensive Care Unit (ICU). The ICU mortality of patients with severe sepsis given enteral nutrition (EN) was higher than for those given PN (44.4% vs 14.3% p=0.039). More patients given EN than patients given PN still had severe sepsis when they died (38.9% vs 9.5%, p=0.055). Recruitment of patients with severe sepsis was subsequently stopped. Conclusions. Our results show that enteral immunonutrition, compared to PN, may be associated with excess mortality in patients with severe sepsis. Author Affiliation: (1) GiViTI Coordinating Center, Istituto di Ricerche Farmacologiche 'Mario Negri', Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele DaccA2, Ranica, Bergamo, Italy (2) , Consorzio 'Mario Negri Sud', S. Maria Imbaro, Chieti, Italy (3) Polo Universitario S. Paolo, Istituto di Anestesia e Rianimazione dell'Universita di Milano, Milan, Italy (4) Ospedale Maggiore IRCCS, Polo Universitario S. Paolo, Istituto di Anestesia e Rianimazione dell'Universita di Milano, Milan, Italy (5) Servizio Anestesia e Rianimazione, Azienda Ospedaliera Legnano, Milan, Italy Article History: Received Date: 24/05/2002 Accepted Date: 27/01/2003 Article note: Electronic Publication

Aggressive enteral nutrition and poor intestinal perfusion are hypothesized to play an important pathogenic role in nonocclusive small bowel necrosis. This study tests the hypothesis that glucose and glutaminetransport are differentially regulated during hypoxia regardless of the luminal nutrient present. Sprague-Dawley rats (247 [+ or -] 3 g; n = 16) were randomized to receive 1 h of intestinal hypoxia or serve as normoxic controls. During this hour, jejunal loops were randomized to receive in situ perfusions of mannitol, glucose, or glutamine. When compared with normoxic groups, glucose but not glutamine transport was impaired (P < 0.001) during hypoxia. Messenger RNA abundance of the sodium glucose cotransporter sodium-dependent glucose cotransporter-1 (SGLT-1) and neutral basic amino acid transporter B[degrees] did not differ with hypoxia or nutrient perfused. Jejunal brush-border SGLT-1 abundance was decreased (P = 0.039) with hypoxia; however, total cellular SGLT-1 protein abundance did not differ among treatment groups. These data indicate that SGLT-1 activity is regulated during hypoxia at the posttranslational level. Additional information regarding the mechanisms regulating nutrient transport in the hypoperfused intestine is critical for optimizing the composition of enteral nutrient formulas. sodium-dependent glucose cotransporter-1; nutrient absorption; small intestine

Background. Feeding intolerance is common in very low birth weight (VLBW; Methods. Primary outcome was the time from initiation of milk feeds until full feeds (150 mL/kg birth weight/d) were achieved in infants who received 10% HM (n = 42) were excluded. Milk bolus feeding every 2 to 3 hours was started at the discretion of the attending physician and advanced by 16 mL/kg/d. Preprandial gastric residuals were tolerated up to 5 mL/kg; otherwise, feedings were reduced or withheld. Data are shown as median (5th and 95th percentile). Results. Forty-six and 41 (HPF vs SPF) infants received Conclusion. HPF improved the feeding tolerance and enabled a more rapid establishment of full enteral feeding in VLBW infants compared with SPF. Pediatrics 2002; 110:1199-1203; hydrolyzed protein formula, early enteral nutrition, very low birth weight infant., ABBREVIATIONS. VLBW, very low birth weight; HM, human milk; HPF, hydrolyzed protein preterm infant formula; SPF, standard preterm infant formula; NEC, necrotizing enterocolitis. Feeding intolerance characterized by vomiting, large gastric [...]

Byline: Paulo da Silva (1), Chiu Paulo (1), Simone de Oliveira Iglesias (1), Werther de Carvalho (1), Flavia Santana e Meneses (1) Keywords: Insufflation Enteral nutrition Intubation Critical care Intensive care units Child Abstract: Abstract Objective. To test air insufflation as an adjunct to placement of enteral feeding tubes and the effectiveness of using a smaller insufflation volume in pediatric patients. Design and setting. A randomized, controlled study in a pediatric intensive care unit in two tertiary hospitals. Patients. A total of 78 children with indication for transpyloric tube feeding were studied. Interventions. An unweighted feeding tube was placed into the stomach through the nares a 20-ml syringe was used to insufflate 10 ml/kg air into the stomach. The tube was advanced an estimated distance into the pylorus or beyond. The control group received the same procedure except for air insufflation. Resident physicians performed all procedures. Abdominal radiography was performed 3 h later. Results. Of 38 tubes in the study group 33 (86.8%) were successfully placed in a single attempt, compared to 18 of 40 tubes (45%) in the control group. Compared with the technique of using 20 ml/kg air for insufflation, no statistically significant difference was observed. No significant complication was observed. Conclusions. The gastric insufflation technique required no expensive equipment, minimal training, and consistently allowed transpyloric passage of feeding tubes. The use of 10 ml/kg air may significantly improve the rate of success without increasing risks. Author Affiliation: (1) Rua das Aroeiras, 30 ap 22. Bairro Jardim, Santo Andre, Sao Paulo, 09090-000, Brazil Article History: Received Date: 17/05/2001 Accepted Date: 03/04/2002 Article note: Electronic Publication

Byline: Jean-Pierre Revelly (1), Luc Tappy (2), Mette M. Berger (1), Philippe Gersbach (3), Christine Cayeux (1), Rene Chiolero (1) Keywords: Carbon dioxide Cardiac surgical procedures Gastric mucosa Lactate Postoperative care Splanchnic circulation Abstract: Objectives: To assess the hemodynamic and metabolic adaptations to enteral nutrition (EN) in patients with hemodynamic compromise. Design and setting: Prospective study in a university hospital surgical ICU, comparing baseline (fasted) with continuous EN condition. Patients: Nine patients requiring hemodynamic support by catecholamines (dobutamine and/or norepinephrine) 1 day after cardiac surgery under cardiopulmonary bypass. Intervention: Isoenergetic EN via a postpyloric tube while catecholamine treatment remained constant. Baseline (fasted) condition was compared to continuous EN condition. Measurements and main results: Cardiac index (CI), mean arterial pressure (MAP), pulmonary and wedge pressures, indocyanine green (ICG) clearance, gastric tonometry, plasma glucose and insulin, and glucose turnover (6[,6.sup.2]H.sub.2-glucose infusion) were determined repetitively every 60 min during 2 h of baseline fasting condition and 3 h of EN. During EN CI increased (from 2.9+-0.5 to 3.3+-0.5 l min.sup.--1 m.sup.--2), MAP decreased transiently (from 78+-7 to 70+-11 mmHg), ICG clearance increased (from 527+-396 to 690+-548 ml/min), and gastric tonometry remained unchanged, while there were increases in glucose (158+-23 to 216+-62 mg/dl), insulin (29+-23 to 181+-200 mU/l), and glucose rate of appearance (2.4+-0.2 to 3.3+-0.2 mg min.sup.--1 kg.sup.--1). Conclusions: The introduction of EN in these postoperative patients increased CI and splanchnic blood flow, while the metabolic response indicated that nutrients were utilized. These preliminary results suggest that the hemodynamic response to early EN may be adequate after cardiac surgery even in patients requiring inotropes. Author Affiliation: (1) Surgical Intensive Care Unit, University Hospital CHUV, 1011 Lausanne, Switzerland (2) Institute of Physiology, University of Lausanne, 1011 Lausanne, Switzerland (3) Department of Cardiovascular Surgery, University Hospital CHUV, 1011 Lausanne, Switzerland Article History: Received Date: 09/05/2000 Accepted Date: 19/12/2000 Article note: Final revision received: 25 October 2000 Electronic Publication

Byline: P. Bauer (1), C. Charpentier (1), C. Bouchet (1), L. Nace (1), F. Raffy (1), N. Gaconnet (1) Keywords: Key words Parenteral nutrition; Enteral nutrition; Nutritional assessment; Clinical trial; Randomized controlled trial; Intensive care Abstract: Objective: To determine whether nutrient intake by early enteral nutrition with parenteral nutrition improves levels of retinol-binding protein and prealbumin (primary endpoint) and reduce morbidity and mortality (secondary endpoint) in ICU patients. Design: Prospective, double-blind, and randomized, placebo-controlled study. Setting: Two intensive care units in a tertiary institution. Patients and participants: 120 patients in two groups of 60.APInterventions: Patients received either enteral plus parenteral nutrition (treatment group) or enteral nutrition plus placebo (placebo group) for 4--7 days after initiation of nutritional support. Measurements and results: Retinol-binding protein (P = 0.0496) and prealbumin (P = 0.0369) increased significantly in the treatment group from day 0 to day 7. There was no reduction in morbidity in ICU. There was no difference in OMEGA score (263 vs. 244) and length of stay in the ICU (16.9 vs. 17.3), but a reduction in length of stay at hospital (31.2 +- 18.5 vs. 33.7 +- 27.7, P = 0.0022). Mortality on day 90 (17 vs. 18) and after 2 years (24 vs. 24) was identical. Conclusions: Although it enhances nutrient intake and corrects nutritional parameters such as RBP and prealbumin more rapidly, within 1 week, supplemental parenteral nutrition has no clinically relevant effect on outcome in ICU patients at the early phase of nutritional support. Author Affiliation: (1) Reanimation Medicale, Hopital Central, 54 035 Nancy, France, FR Article note: Received: 23 August 1999/Final revision received: 27 January 2000/Accepted: 25 February 2000

Objective To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections. Design A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset. Subjects/setting Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period. Intervention Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care. Outcomes A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups. Statistical analysis Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank stun tests were used to determine the cost significance of a nosocomial infection. Results The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group. Conclusion An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective., Health care costs in the United States, which in 1996 accounted for 13.6% of the gross domestic product, have increased at a faster rate than in any other nation (1-4). [...]

In hospitalized patients, a multitude of factors including loss of luminal trophic factors, altered splanchnic blood flow and nutritional deprivation lead to gastrointestinal mucosal atrophy. Clinical orders of nothing per os (NPO)(6) or 'bowel rest' cause intestinal atrophy, which leads to abnormal enteric flora with bacterial, endotoxin or cytokine translocation, altered host immune function and sepsis (Barber et al.1991, Zaloga 1994). The prevention or limitation of intestinal atrophy during small bowel disuse or 'rest' would have clinical significance if fewer hospital days and lower infection rates resulted. Glutamine is the preferred respiratory fuel for enterocytes; administration of 2% glutamine solutions is known to be beneficial in the short term. However, glutamine is more like a conditionally essential amino acid, necessary only during recovery to stimulate DNA synthesis and increase mucosal mass (Lacey and Wilmore 1990). Glutamine administered intravenously (IV) long term to animals with intestinal atrophy has not been adequately investigated in clinically relevant species. Enteral feedings are also known to be beneficial in preventing intestinal disuse. Data in critically injured patients suggest that enteral nutrition had a positive effect on intestinal immune function and leads to decreased infectious morbidity and reduced hospital stay (Heyland et al.1993). Possible advantages of feeding small volumes enterally during prolonged periods of small bowel 'rest' therapy have also not been investigated, but such feeding is quite possible in most hospitalized cases as a means of minimizing intestinal atrophy. The objective of this study was to compare the small intestinal response to intravenous glutamine vs. intermittent small volume enteral feedings, administered for >1 wk as a means of preventing intestinal atrophy. The piglet has become the preferred small intestinal research model because of the homology among the swine, human, canine, feline and equine small bowels. The small intestines of the dog, cat, pig and foal are very similar in morphology and physiology through the first year of life, and the atrophic response to NPO also appears to be similar. The information derived from a swine research model of small intestinal atrophy is, therefore, relevant to the small bowel changes after disuse in dogs, cats and foals. Materials and methods. Five litters of Hampshire x Duroc piglets were selected on the basis of body weight (BW) (1.8-2.7 kg) at 4 d of age. Four litter mates were randomly assigned to one of the following four treatments: 1) 100% enterally fed sow's milk replacer (SMR); 2) total parenteral nutrition (TPN); 3) TPN with 1.7% (wt/v) glutamine (GLN); or 4) 90% of total energy as TPN plus 10% enterally as SMR (PEN). The TPN treatment served as a negative control, whereas SMR served as a positive control. Because of logistical limitations, four litter mates (1 piglet/treatment) completed the 28-d feeding trial at a time. Piglets were maintained in accordance with the Animal Care Committee guidelines at the Johns Hopkins Medical Institutions and the Committee on Care and Use of Laboratory Animals from the Institute of Laboratory Animal Resources. Nutritional treatments. All piglets suckled sow's colostrum/milk until delivered to the laboratory at 4 d of age; they also received an iron dextran injection (100 mg intramuscularly) at 3 and 10 d of age. Catheters (1.0 mm i.d., 2.1 mm o.d., 91 cm) of medical grade silastic tubing (Dow Corning, Midland, MI) were surgically placed in the left and right external jugular veins of all piglets. The catheter tips were inserted into the cranial vena cava; the proximal end of the catheter was tunneled to the dorsum, passing cranially to the shoulder and exiting 5-10 cm posterior to the ear. One catheter was used for parenteral administration, and the second was used for blood sampling. Weekly blood samples were drawn for complete blood cell count with a differential and serum profile.(7) All piglets were individually housed in stainless steel (60 x 60 x 60 [cm.sup.3]) cages with plastic mesh-covered screened floors, and maintained in nylon open mesh vests with an attached stainless steel tether line (Spalding Medical Research Products, Birmingham, AL) and swivel infusion system. All piglets were administered 630 kJ/(kg BW [center dot] d) of their respective nutritional treatments on the basis of daily BW and were maintained on these diets as the sole source of nutrition for 4 wk. TPN solution was formulated to have a nutrient profile recommended (NRC1988) for piglets 4% BW) compared with SMR fed piglets (2.5% BW). During wk 4, serum bilirubin and aspartate aminotransferase were not different between treatment groups; however, alanine aminotransferase and alkaline phosphatase in TPN and GLN serum were significantly greater than SMR serum values, whereas PEN serum values were intermediate. Small intestinal histology (Table 2) was affected by route of nutrition because parenteral administration decreased villous heights by 50% in the jejunum and by 25% in the ileum, and SMR piglets had jejunal and ileal villus:crypt ratios greater than the other three piglet groups. Within parenteral treatment groups, jejunal villous heights in the PEN group were greater than those in the TPN group; however, crypt depths were significantly greater in the PEN and GLN piglets than in the TPN group. Jejunal lactase and sucrase activities for TPN and GLN piglets were significantly less than those of SMR piglets, whereas activities of PEN-treated piglets were intermediate (Table 2). Ileal lactase and sucrase activities in SMR piglets were uniformly greater than those of TPN-, GLN- and PEN-treated piglets. Maltase activity in the jejunum and ileum, however, was not affected by the route of nutritional administration and remained uniform across treatments [150 [+ or -] 63/(min [center dot] g protein)]. Discussion. The 4-wk parenteral administration of nutrients to piglets did produce a small bowel (SB) disuse atrophy and hepatomegaly. Although there were no significant differences in final body weight or gain, TPN-fed piglets had significantly lower SB weights, shorter jejunal and ileal villous heights and lower SB enzyme activity than the positive control SMR-fed piglets. The negative control TPN treatment findings were consistent with previously reported results. In TPN-fed adult rats, glutamine has been shown to prevent decreased intestinal weight, DNA content, villous height, and sucrase and lactase activities when administered IV for 6-7 d. In this 4-wk swine study, SB weights and enzyme activities were not preserved with glutamine added to the TPN solution. Glutamine in the TPN solutions may have spared jejunal crypt cell atrophy; however, villous heights were not spared. The difference between the previous studies demonstrating some advantage in giving glutamine and this study demonstrating no clear advantage may be related to differences in the species (rats vs. pigs), age of the animal models (adult vs. young) but more likely, length of treatment time (1 vs. 4 wk). In dogs, there is an increased requirement for glutamine during the immediate postoperative phase (10 d postsurgery) (Souba et al. 1987 and 1990). The long-term use of IV glutamine was not effective in preventing NPO-induced disuse atrophy. Therefore, given the high cost of IV glutamine fluids and the apparent limited time of efficacy, the use of IV glutamine solutions for dogs, cats and foals recovering from small bowels diseases should be limited to early short-term use. Piglets fed small volume enteral feedings of milk (PEN) did have jejunal villous heights and crypt depths significantly greater than those in the TPN piglets, and jejunal sucrase and lactase activities in the PEN fed piglets were intermediate to those of the SMR and TPN piglets. Piglets are farrowed with negligible amounts of maltase and sucrase activities, which develop during the first few weeks of life; however, lactase activity is high at birth and decreases with age (Ulshen et al.1991). Lactase and sucrase are known to be diet-inducible enzymes, which decreased in TPN-fed piglets, whereas maltase is not a diet-inducible enzyme (Jackson and Grand 1991), and intestinal activity remained high in all piglets. The enteral feedings apparently had minimal effect on ileal parameters, which may indicate small volume feedings of a highly digestible product may not have reached the ileum as a result of proximal bowel digestion and absorption. Apparently, the use of a milk solution, providing only 10% of the total energy intake, resulted in intermediate jejunal lactase and sucrase activities with taller villi and deeper crypts; however, this solution had no effect on overall SB weight. On the basis of these results, we believe that limited enteral milk feeding during SB disuse, if possible, has important clinical ramifications and warrants further investigation. Feeding small volumes of a well-designed enteral product to dogs, cats and foals recovering from small intestinal diseases may be a beneficial alternative to NPO. KEY WORDS: * small intestine * atrophy * glutamine * enteral feedings * swine

Keywords: Nutrition; Enteral nutrition; Malnutrition; Intensive care; Critical illness Abstract: Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence. Article History: Registration Date: 23/03/2009 Received Date: 07/04/1998 Accepted Date: 24/04/1998 Article note: Reprint requests to the European Society of Intensive Care Medicine, 40 Ave Joseph Wybran, B-1070 Brussels, Belgium E-mail esicm@pophost.eunet.be

To investigate appropriate mode and daily dose of enteral ornithine [Alpha]-ketoglutarate (OKG) administration, 54 burn patients (total burn surface area: 20-50%) were included in a randomized controlled trial and assigned to receive either a supplement of OKG (10, 20 or 30 g/d) as bolus or continuous infusion, or a continuous infusion of an isonitrogenous amount of a soy protein mixture (Protil-1: 10, 20 or 30 g/d) in addition to their enteral diet. The influence of these treatments on clinical outcome and biological indices was evaluated. OKG administration significantly improved nitrogen balance and reduced 3-methylhistidine and hydroxyproline urinary elimination. This was associated with a gradual rise in plasma glutamine over time. Given as a bolus, OKG significantly improved wound healing, assessed both clinically [day of last graft: (mean [+ or -] SEM) OKG bolus 23.7 [+ or -] 2.1 d versus Protil-1, 39.9 [+ or -] 9.9 d; P < 0.05] and by hydroxyproline excretion, and biological markers of nitrogen metabolism, and tended to reduce duration of enteral nutrition (P = 0.12). The higher catabolic status in the patients administered 20 g OKG/d at the onset of the study, despite randomization, precludes any definite conclusion (concerning the dose-effect relationship). However, based on 3-methylhistidine elimination, our data indicate a benefit of 30 g OKG/d administration over 10 g/d. This study further supports OKG supplementation in burn patients. In addition, this is the first trial based on objective data that favors bolus over continuous infusion of OKG in critically ill patients. J. Nutr. 128: 563-569, 1998. KEY WORDS: * ornithine [Alpha]-ketoglutarate * burn injury * enteral nutrition * humans

In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home., Physicians with expertise in many different medical specialties order home enteral and/or parenteral nutrition support (1). Most physicians obtain their knowledge of nutrition support during their residency training. Because the [...]

Research was conducted to measure the source and rate of mucosal glutathione (GSH) synthesis in piglets. Piglets received a 6-h infusion of intragastric [U-13C]glutamate (n = 11) either with (n = 5) or without (n = 6) an intragastric infusion of [1-13C]glycine (0-6h) and [1,2-13C2/(U-13C)glycine (3-6 h). Eight-six percent of the luminal GSH-glutamate and 84% of the labeled mucosal GSH-glutamate was 13C5. Results suggest that in fed piglets, mucosal GSH-glutamate derived largely from the direct metabolism of enteral glutamate rather than from glutamate that was metabolized within the mucosa.