Elsevier

Clinical Nutrition

Volume 22, Issue 3, June 2003, Pages 295-305
Clinical Nutrition

ORIGINAL ARTICLE
Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients

https://doi.org/10.1016/S0261-5614(02)00234-0Get rights and content

Abstract

Aims: To determine whether a specific high-protein enteral formula with a similar caloric percentage of fat and carbohydrates achieves greater control over glycemic levels and reduces insulin requirements in hyperglycemic critically ill patients when compared to a control high-protein enteral formula.

Design: A prospective, randomized, controlled, single-blind trial in two University Hospital Intensive Care Units in Spain.

Methods: We enrolled 50 patients with diabetes mellitus or stress hyperglycemia with basal glycemia ≥160 mg/dl and indication for enteral nutrition ≥5 days. Patients with severe kidney failure, liver failure or obesity were excluded from the study. In the first 48 h of admission, after randomization, 26 patients received the study diet and 24 patients received the control diet. The variables were monitored for 14 days. The Harris–Benedict formula with a fixed stress factor of 1.2 was used to calculate caloric needs. Insulin was administered by continuous infusion. An intention-to-treat analysis was performed.

Results: On admission, there were no differences between the study and control group in plasma glucose levels (mg/dl) (190.9±45 vs 210.3±63) and capillary glucose levels (mg/dl) (226.1±73 vs 213.8±67). After the feeding trial, there were differences between the study and control group in plasma glucose levels (mg/dl) (176.8±44 vs 222.8±47, P=0.001), capillary glucose levels (mg/dl) (163.1±45 vs 216.4±56, P=0.001), insulin requirements/day (IU) 8.73 (2.3–27.5) vs 30.2 (21.5–57.1) (P=0.001), insulin/received carbohydrates (UI/g) 0.07 (0.02–0.22) vs 0.18 (0.11–0.35) (P=0.02) and insulin/received carbohydrates/kg 0.98 (0.26–3.59) vs 2.13 (1.44–4.58) (P=0.04). These differences remain in a day-to-day comparison. There were no differences in the analytical tests, or in digestive or infectious complications. Intensive Care Unit length of stay, mechanical ventilation and mortality were similar in both groups.

Conclusions: Hyperglycemic critically ill patients fed with a high-protein diet with a similar caloric percentage of fat and carbohydrates show a significant reduction in plasma glucose levels, capillary glucose levels and insulin requirements in comparison to patients on a conventional high-protein diet. This better glycemic control do not modify Intensive Care Unit length of stay, infectious complications, mechanical ventilation and mortality.

Introduction

Both enteral and parenteral artificial nutritional support are nowadays common practices in the treatment of critically ill patients. Early enteral nutrition (EN) appears to have advantages over parenteral nutrition because it costs less, causes less atrophy in the structure of the intestinal mucosa, has a lower infection rate and reduces bacterial translocation and sepsis 1., 2., 3., 4., 5., although the frequency of gastrointestinal complications is high 6., 7.. However, although the use of standard products for EN is universally accepted, the role of what is known as disease-specific nutrition is still controversial 8., 9., 10.. Critically ill patients show a stereotyped metabolic response to injury which causes changes in the carbohydrate metabolism 11., 12. with increased gluconeogenesis, enhanced peripheral glucose uptake and utilization, insulin resistance and inversion of the glucagon/insulin ratio, leading to hyperglycemia favored by the action of counterregulatory hormones 13., 14.. There is also an increase in fat oxidation with lipolysis (15) and an increase in proteolysis with loss of nitrogen (16). Thus, in these patients, the stress metabolic response is characterized by hyperglycemia, fat mobilization and protein breakdown.

The composition of enteral formulas for hospitalized diabetic patients is still controversial 17., 18., 19., since it is postulated that standard high-carbohydrate, low-fat diets may not be appropriate in short-to-medium term treatment since they may impair glycemic control. Studies of diets with higher percentage of fat to carbohydrates appear to show improved glycemic control when compared to standard diets 17., 19., 20.. However, the type and amount of fiber needed by diabetic patients on liquid diets has not yet been satisfactorily established (21), and the percentage of monounsaturated fatty acids (MUFA) and total fat that should be recommended remain unclear 22., 23.. There are also very few studies of long-term EN treatment in diabetic patients and even fewer on hyperglycemic critically ill patients 19., 20., 24., 25..

The importance of avoiding overfeeding in the critically ill patient has been postulated (26), but in patients who also have hyperglycemia the role of specific diets in the control of their carbohydrate, lipid and protein metabolism has not yet been demonstrated, especially in long term treatments. We hypothesized that a disease-specific diet in hyperglycemic critically ill patients may allow a better glycemic control than a non-disease-specific diet. Thus, the aim of this study was to evaluate if the administration of a disease-specific high-protein formula with similar caloric percentage of fat and carbohydrates to hyperglycemic critically ill patients achieves greater control of glycemia and reduces insulin requirements when compared to a conventional high-protein formula. The main differences between them were related to the content and type of carbohydrates, the content and type of fat, and the addition or lack of dietary fiber.

Section snippets

Material and methods

A prospective, randomized, controlled, single-blind, clinical trial was conducted in the ICU wards of two university hospitals in Spain. The study protocol was approved by the Institutional Review Board and each patient or the closest relative provided written informed consent to participate.

The primary endpoints for this study were glycemic control, keeping plasma glucose levels between 100 and 200 mg/dl and insulin/day requirements, adapting insulin infusion to capillary glucose levels every 6 

Results

Of the 61 patients initially selected to participate in the study, five refused to give the informed consent, four died before randomization and two suffered acute gastrointestinal bleeding which prevented enteral feeding. Of the remaining 50 patients, 26 were allocated to the study group and 24 to the control group. One patient in the study group and three patients in the control group did not achieve the minimum 5 days of nutrition established in the protocol, in one case due to death and in

Discussion

The use of a high-protein disease-specific formula with a similar caloric percentage of fat and carbohydrates in hyperglycemic critically ill patients improves glycemic metabolism control with lower plasma glucose levels, capillary glucose levels and insulin requirements compared with a control high-protein diet, thus confirming the initial hypothesis. However, Table 5 shows no significant interaction between the effect of the formula and the prognostic variables such as the presence of sepsis

Conclusions

Enteral nutrition in the hyperglycemic critically ill patient with a disease-specific high protein diet, with similar caloric percentage of fat and carbohydrates produces a significant reduction in plasma glucose levels, capillary glucose levels and insulin requirements in comparison with a conventional high-protein diet.

There are no significant differences in the rate of acquired infections, ICU length of stay, days of mechanical ventilation or mortality between the groups. Gastrointestinal

Acknowledgements

We would like to thank Mireia Morera, MD, for her helpful advice and encouragement. The statistical analysis of this research was supported by Novartis Consumer Health, Spain.

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