Abstract
IntroductionAlthough standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV).MethodsThis was a prospective, open-label, randomized (web-based, blinded) study conducted at nine Spanish ICUs. The patient groups established according to the high-protein formula received were: group A, new-generation diabetes-specific formula; group B, standard control formula; group C, control diabetes-specific formula. Inclusion criteria were: expected enteral nutrition ≥5 days, MV, baseline glucose >126 mg/dL on admission or >200 mg/dL in the first 48 h. Exclusion criteria were: APACHE II ≤10, insulin-dependent diabetes, renal or hepatic failure, treatment with corticosteroids, immunosuppressants or lipid-lowering drugs and body mass index ≥40 kg/m2. The targeted glucose level was 110–150 mg/dL. Glycemic variability was calculated as the standard deviation, glycemic lability index and coefficient of variation. Acquired infections were recorded using published consensus criteria for critically ill patients. Data analysis was on an intention-to-treat basis.ResultsOver a 2-year period, 157 patients were consecutively enrolled (A 52, B 53 and C 52). Compared with the standard control formula, the new formula gave rise to lower insulin requirement (19.1 ± 13.1 vs. 23.7 ± 40.1 IU/day, p <0.05), plasma glucose (138.6 ± 39.1 vs. 146.1 ± 49.9 mg/dL, p <0.01) and capillary blood glucose (146.1 ± 45.8 vs. 155.3 ± 63.6 mg/dL, p <0.001). Compared with the control diabetes-specific formula, only capillary glucose levels were significantly reduced (146.1 ± 45.8 vs. 150.1 ± 41.9, p <0.01). Both specific formulas reduced capillary glucose on ICU day 1 (p <0.01), glucose variability in the first week (p <0.05), and incidences of ventilator-associated tracheobronchitis (p <0.01) or pneumonia (p <0.05) compared with the standard formula. No effects of the nutrition formula were produced on hospital stay or mortality.ConclusionsIn these high-risk ICU patients, both diabetes-specific formulas lowered insulin requirements, improved glycemic control and reduced the risk of acquired infections relative to the standard formula. Compared with the control-specific formula, the new-generation formula also improved capillary glycemia.Trial registrationClinicaltrials.gov NCT1233726.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1108-1) contains supplementary material, which is available to authorized users.
Highlights
Standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial
This study shows that a diabetes-specific high-protein enteral nutrition (EN) formula containing monounsaturated fatty acids (MUFA), slowly absorbed carbohydrates and omega-3 polyunsaturated fatty acids (PUFA) enriched with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and fiber gives rise to better glycemic homeostasis than a standard high-protein formula and may reduce the risk of acquired infections in intensive care unit (ICU) patients
The use of a high-protein diabetes-specific EN formula in hyperglycemic critically ill patients on mechanical ventilation leads to lower insulin requirements, reduces plasma and capillary blood glucose levels and glycemic variability, and could reduce the risks of ICU
Summary
Standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV). Ill patients show a stereotype metabolic response to injury that affects carbohydrate metabolism [1, 2], causing hyperglycemia, which is boosted by the actions of counterregulatory hormones [3, 4]. This metabolic response makes the critically ill patient especially susceptible to infection and increases morbidity and mortality [5,6,7]. To date no consensus has been reached on the optimal target glucose range [16,17,18,19]
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