Postoperative hypocaloric peripheral parenteral nutrition with branched-chain-enriched amino acids provides no better clinical advantage than fluid management in nonmalnourished colorectal cancer patients.

To assess clinical efficacy of using postoperative branched-chain amino acids (BCAAs)-enriched nutritional support in lower gastrointestinal cancer patients, we conducted a retrospective observational study comparing this regimen with traditional fluid management. Sixty-one eligible colorectal cancer patients consecutively admitted in the Colorectal Surgery Ward to receive postoperative hypocaloric peripheral parenteral nutrition (HPPN) were categorized into dextrose-only control group (n = 20), dextrose plus low-dose BCAA fat group (n = 20), and dextrose plus high-dose BCAA fat group (n = 21). Nutritional, clinical, and biochemical outcomes were collected on the day before and 7 days after surgery. Patients were nonmalnourished. Over the 7-day observation period, the control group had a significantly higher reduction in body mass index than the lower dose and the higher dose BCAA groups (P = 0.023 and P = 0.002, respectively). Compared to high-dose BCAA group, the control group also had a lower nitrogen excretion (P < 0.0001) and less reduction in nitrogen balance (P < 0.0001). There were no differences between study groups in biochemical measures, phlebitis, postoperative hospital stay, and in-hospital mortality. We found no better clinical advantage to the postoperative administration of BCAA-enriched HPPN than fluid management in nonmalnourished colorectal cancer patients.

Diarrhea in enterally fed patients: blame the diet?

PURPOSE OF REVIEW: Diarrhea has great impact on enteral nutrition. The purpose of this review is to identify the factors leading to diarrhea during enteral nutrition and to provide the published updates on diarrhea prevention through nutritional intervention. RECENT FINDINGS: Diarrhea in enteral fed patients is attributed to multiple factors, including medications (major contributor), infections, bacterial contamination, underlying disease, and enteral feeding. Diet management can alleviate diarrhea in enteral feeding. High content of fermentable oligosaccharides, disaccharides, and monosaccharides and polyols (FODMAPs) in enteral formula is postulated to induce diarrhea and lower FODMAPs formula may reduce the likelihood of diarrhea in enterally fed patients. Fiber-enriched formula can reduce the incidence of diarrhea and produce short-chain fatty acids for colonocytes. Ingesting prebiotics, nonviable probiotics or probiotic derivatives, and human lactoferrin may provide alternatives for reducing/preventing diarrhea. SUMMARY: Enteral feeding is not generally considered the primary cause of diarrhea, which is frequently linked to prescribed medications. When diarrhea is apparent, healthcare members should evaluate the possible risk factors and systematically attempt to eliminate the underlying causes of diarrhea before reducing or suspending enteral feeding. Lower FODMAPs formula, prebiotics, probiotic derivatives, and lactoferrin may be used to manage enteral feeding-related diarrhea.

Moderate glucose control results in less negative nitrogen balances in medical intensive care unit patients: a randomized, controlled study.

INTRODUCTION: Hyperglycemia and protein loss are common in critically ill patients. Insulin can be used to lower blood glucose and inhibit proteolysis. The impact of moderate insulin therapy on protein metabolism in critically ill patients has not been evaluated. We compared urinary nitrogen excretion, nitrogen balance, serum albumin concentrations, prealbumin concentrations, and clinical outcomes between patients receiving moderate insulin therapy (MIT) and conventional insulin therapy (CIT) in a medical ICU. METHODS: Patients were randomly divided into groups and treated with MIT (glucose target 120 to 140 mg/dl) or CIT (glucose target 180 to 200 mg/dl). Calories and protein intake were recorded each day. On days 3, 7 and 14, the 24-hour urinary nitrogen excretion, nitrogen balance, and serum albumin and prealbumin concentrations were measured. Clinical outcomes data were collected. RESULTS: A total of 112 medical ICU patients were included, with 55 patients randomized to the MIT group and 57 patients randomized to the CIT group. Patients treated with MIT showed a trend towards increased nitrogen balance (P = 0.070), significantly lower urinary nitrogen excretion (P = 0.027), and higher serum albumin (P = 0.047) and prealbumin (P = 0.001) concentrations than patients treated with CIT. The differences between the two groups were most significant on day 3, when all factors showed significant differences (P < 0.05). CONCLUSIONS: Moderate glucose control results in less negative nitrogen balances in medical ICU patients. Differences are more significant in the early stages compared with the late stages of critical illness. TRIAL REGISTRATION: ClinicalTrial.Gov NCT 01227148.

Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study.

BACKGROUND: Early enteral nutrition is recommended in cases of critical illness. It is unclear whether this recommendation is of most benefit to extremely ill patients. We aim to determine the association between illness severity and commencement of enteral feeding. METHODS: One hundred and eight critically ill patients were grouped as "less severe" and "more severe" for this cross-sectional, retrospective observational study. The cut off value was based on Acute Physiology and Chronic Health Evaluation II score 20. Patients who received enteral feeding within 48 h of medical intensive care unit (ICU) admission were considered early feeding cases otherwise they were assessed as late feeding cases. Feeding complications (gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, length of hospital stay, ventilator-associated pneumonia, hospital mortality, nutritional intake, serum albumin, serum prealbumin, nitrogen balance (NB), and 24-h urinary urea nitrogen data were collected over 21 days. RESULTS: There were no differences in measured outcomes between early and late feedings for less severely ill patients. Among more severely ill patients, however, the early feeding group showed improved serum albumin (p=0.036) and prealbumin (p=0.014) but worsened NB (p=0.01), more feeding complications (p=0.005), and prolonged ICU stays (p=0.005) compared to their late feeding counterparts. CONCLUSIONS: There is a significant association between severity of illness and timing of enteral feeding initiation. In more severe illness, early feeding was associated with improved nutritional outcomes, while late feeding was associated with reduced feeding complications and length of ICU stay. However, the feeding complications of more severely ill early feeders can be handled without significantly affecting nutritional intake and there is no eventual difference in length of hospital stay or mortality between groups. Consequently, early feeding shows to be a more beneficial nutritional intervention option than late feeding in patients with more severe illness.

Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.

OBJECTIVE: To determine whether medical intensive care unit (ICU) patients receiving nasoduodenal (ND) feedings achieve optimal nutritional support and better clinical outcomes compared with patients receiving nasogastric (NG) feedings. DESIGN: A prospective, randomized, clinical study. SETTING: Medical ICU of a university-affiliated tertiary medical center. PATIENTS: One hundred twenty-one medical ICU patients required enteral feeding. INTERVENTIONS: Patients were randomized to receive enteral feeding. One group received ND feedings and the other group received NG feedings. All patients followed the same protocol. MEASUREMENTS AND MAIN RESULTS: The primary outcome of optimal nutritional support was assessed by measurement of time to goal tube feed rate and daily calorie and protein intake. Secondary clinical outcomes included number of ICU, hospital and ventilator days, number of the days in the study, blood-glucose levels, incidence of vomiting, diarrhea, gastrointestinal bleeding, tube replaced, tube clogged, fever, bacteremia, and ventilator-associated pneumonia (VAP), and mortality rate. Results showed that the ND group had a higher average daily calorie and protein intake compared with NG group and achieved nutritional goals earlier. In terms of clinical outcomes, patients in the ND group had a lower rate of vomiting and VAP. The other clinical outcomes such as number of ICU days, hospital days, ventilator days, blood-glucose level, tube replaced or clogged, diarrhea, gastrointestinal bleeding, fever, bacteremia, and mortality rate were not significantly different between two groups. CONCLUSIONS: Patients who received ND feedings achieved nutritional goals earlier than those who received NG feeding. ND feeding group also has a lower rate of vomiting and VAP in the medical ICU setting.

Trace elements, oxidative stress and glycemic control in young people with type 1 diabetes mellitus.

Trace elements and oxidative stress are associated with glycemic control and diabetic complications in type 1 diabetes mellitus. In this study, we analyzed the levels of serum copper, zinc, superoxide dismutase (SOD) activity, and malondialdehyde (MDA) and urinary MDA and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in 33 type 1 diabetic patients with optimal and suboptimal glycemic control (HbA1C<9.0%) and 40 patients with poor glycemic control (HbA1C≥9%) and 27 age- and sex-matched non-diabetic controls to evaluate the differences between these markers in different glycemic control states. Diabetic patients, especially poor-glycemic-control subjects (HbA1C≥9%), exhibited significantly lower levels of serum zinc and increased levels of serum copper (and, therefore, increased serum copper-to-zinc ratios), serum SOD, blood MDA, and urinary MDA and 8-OHdG, relative to non-diabetic subjects. Furthermore, significant correlations existed in these patients between the serum copper, serum copper-to-zinc ratio, and urinary MDA (all p<0.001) and the levels of urinary 8-OHdG (p=0.007) and HbA1C. Our results suggest that high serum copper levels and oxidative stress correlate with glycemic control. Therefore, strict glycemic control, decreased oxidative stress, and a lower copper concentration might prevent diabetic complications in patients with type 1 diabetes mellitus.

Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness.

BACKGROUND: Few trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial. OBJECTIVE: To test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. DESIGN: A 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes. PARTICIPANTS/SETTING: One hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study. INTERVENTION: Patients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as "less severe" and "more severe," with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20. MAIN OUTCOME MEASURES: Daily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin. STATISTICAL ANALYSES PERFORMED: Two-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes. RESULTS: Among less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group. CONCLUSIONS: To optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.

Impact of disease severity on gastric residual volume in critical patients.

AIM: To investigate whether illness severity has an impact on gastric residual volume (GRV) in medical critically ill patients. METHODS: Medical intensive care unit (ICU) patients requiring nasogastric feeding were enrolled. Sequential Organ Failure Assessment (SOFA) score was assessed immediately preceding the start of the study. Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on the first, fourth, seventh, and fourteenth day of the study period. GRV was measured every 4 h during enteral feeding. The relationship between mean daily GRV and SOFA scores and the correlation between mean daily GRV and mean APACHE II score of all patients were evaluated and compared. RESULTS: Of the 61 patients, 43 patients were survivors and 18 patients were non-survivors. The mean daily GRV increased as SOFA scores increased (P < 0.001, analysis of variance). Mean APACHE II scores of all patients correlated with mean daily GRV (P = 0.011, Pearson correlation) during the study period. Patients with decreasing GRV in the first 2 d had better survival than patients without decreasing GRV (P = 0.017, log rank test). CONCLUSION: GRV is higher in more severely ill medical ICU patients. Patients with decreasing GRV had lower ICU mortality than patients without decreasing GRV.

Determination of bile acids in pig liver, pig kidney and bovine liver by gas chromatography-chemical ionization tandem mass spectrometry with total ion chromatograms and extraction ion chromatograms.

An effective method has been developed for quantitative determination of six bile acids including lithocholic acid (LCA), deoxycholic acid (DCA), chenodeoxycholic acid (CDCA), hydodeoxycholic acid (HDCA), cholic acid (CA) and ursodeoxycholic acid (UDCA) in biological tissues including pig liver, pig kidney and bovine liver by gas chromatography-chemical ionization/tandem mass spectrometry (GC-CI/MS/MS). Camphor-10-sulphonic acid (CSA) was proposed as effective catalyst for bile acid derivatization. Reactions were accelerated ultrasonically. The effects of different catalysts and reaction times on derivatization efficiency were evaluated and optimized. Bile acids were determined as methyl ester-trimethylsilyl ether and methyl ester-acetate derivatives. The efficiency of trimethylsilylation and acetylation was evaluated. Trimethylsilylation was done with N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA) as the trimethylsilyl donating reagent in a ultrasonic bath for 20 min. Acetylation was done in pyridine with acetic anhydride at 40-45°C for 4 h. The former reaction was faster than the latter. Thus, trimethylsilylation was employed for the quantitative analysis. Negligible interferences from sterols in biological matrices were observed when the biological samples were treated with solid phase extraction before GC-CI/MS/MS. The linearity, reproducibility, detection limit and recovery were evaluated under the optimized conditions. Satisfactory results were obtained when bile acid derivatives of LCA, CDCA, HDCA, and UDCA were determined with total ion chromatograms (TIC) while DCA and CA were determined with extracted ion chromatograms (EIC), respectively. The detection limits (S/N=3) for six bile acids in biological tissues were ranging from 0.40 to 1.6 ng/mL and the recoveries indicated that the proposed method was feasible for the determination of trace bile acids in the biological samples studied. The experimental results for the animal tissues purchased from five different markets were compared. Interestingly, all of the six bile acids were present in pig liver while only the dihydroxy bile acids, DCA, CDCA and HDCA were found in pig kidney. In addition to DCA and CDCA, trihydroxy bile acid, CA, are the major bile acids in bovine liver.