Hypocaloric Enteral Nutrition Research Articles

Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trial

Early enteral nutrition is crucial for preventing malnutrition and improving outcomes in patients with severe stroke, but previous trials have provided conflicting results regarding the optimal nutritional strategy. We aimed to compare the efficacy and safety of three enteral feeding strategies in patients with severe stroke. The Optimizing Early Enteral Nutrition in Severe Stroke (OPENS) study was a multicentre, investigator-initiated, prospective, open-label, randomised controlled trial, with blinded outcome assessment, in 16 tertiary and district general hospitals in the west of China. Adult patients with acute severe ischaemic or haemorrhagic stroke (Glasgow Coma Scale score ≤12 or National Institutes of Health Stroke Scale score ≥11 on admission) who were expected to receive enteral nutrition for more than 7 days were randomly assigned (1:1:1) to full enteral nutrition (70-100% of estimated caloric requirements), modified full enteral nutrition (full enteral nutrition plus prokinetic agents), or hypocaloric enteral nutrition (40-60% of estimated caloric requirements) via a centralised web-based randomisation system. The assigned nutrition was initiated within 24 h after enrolment and continued for 7 days. The computer-generated randomisation sequence was prepared by a statistician not involved with the rest of the study. Randomisation was done with an automated permuted block size of six. The allocation was unblinded to participants and investigators. The primary efficacy outcome was the proportion of participants with poor outcome (modified Rankin Scale score ≥3) at day 90 and the prespecified primary safety outcome was mortality at day 90, assessed in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT02982668. Between Jan 15, 2017, and Sept 23, 2020, 321 patients were randomly assigned (107 in each group) and 315 patients (175 [56%] men, median age 71 years, IQR 60-78) were included in the final analysis. The study was terminated ahead of schedule on Sept 23, 2020, because a significant difference between groups was detected in mortality. The proportion of participants with poor outcomes at 90 days did not differ (modified full enteral nutrition 86 [82%] of 105 patients vs full enteral nutrition 85 [80%] of 106 patients, adjusted odds ratio [OR] 0·87, 95% CI 0·41-1·86, p=0·721; hypocaloric enteral nutrition 76 [73%] of 104 patients vs full enteral nutrition 0·61, 0·30-1·27, p=0·186; hypocaloric enteral nutrition vs modified full enteral nutrition 0·70, 0·34-1·46, p=0·340). Hypocaloric enteral nutrition showed significantly higher 90-day mortality than did modified full enteral nutrition (35 [34%] of 104 patients vs 18 [17%] of 105 patients, adjusted OR 2·89, 95% CI 1·46-5·72; p=0·0023), whereas the difference was not significant between hypocaloric enteral nutrition and full enteral nutrition (24 [23%] of 106 patients; adjusted OR 1·92, 95% CI 1·00-3·69; p=0·049), and between modified full enteral nutrition and full enteral nutrition (adjusted OR 0·61, 0·29-1·28; p=0·187). The most common adverse event was pneumonia, the incidence of which showed no significant difference among groups (full enteral nutrition 82 [78%] of 105 patients, modified full enteral nutrition 83 [81%] of 103 patients, hypocaloric enteral nutrition 78 [75%] of 104 patients; p=0·625). In the early phase of severe stroke, modified full enteral nutrition or hypocaloric enteral nutrition did not significantly reduce the risk of a poor outcomes compared with full enteral nutrition over a 90-day period. Hypocaloric enteral nutrition might be associated with increased mortality compared with modified full enteral nutrition. Further studies are needed to investigate whether modified full enteral nutrition might be the optimal strategy. Shaanxi province Key Research and Development Project.

Nutrition in acute stroke management: food for thought

Nutrition is crucial in the management of patients with acute stroke. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar Clinical features putting patients at risk of malnutrition include dysphagia, impaired consciousness, perception deficits, and cognitive dysfunction. Being malnourished or at risk of malnutrition on admission to hospital after stroke is linked with poor functional outcomes and mortality, and worsening of nutritional status during the acute stage post-stroke is associated with similar adverse outcomes. 2 Dennis M Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003; 34: 1450-1456 Crossref PubMed Scopus (0) Google Scholar Therefore, guidelines dedicated to acute stroke care generally include nutritional management. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar , 3 Powers WJ Rabinstein AA Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1816) Google Scholar , 4 Boulanger JM Lindsay MP Gubitz G et al. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th edition, update 2018. Int J Stroke. 2018; 13: 949-984 Crossref PubMed Scopus (154) Google Scholar , 5 Burgos R Bretón I Cereda E et al. ESPEN guideline clinical nutrition in neurology. Clin Nutr. 2018; 37: 354-396 Summary Full Text Full Text PDF PubMed Scopus (175) Google Scholar The guideline for the diagnosis and treatment of post-stroke dysphagia from the European Stroke Organization and European Society for Swallowing Disorders, for example, recommends early enteral nutrition via a nasogastric tube if sufficient oral nutrition is not possible. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar This recommendation relies mainly on the second substudy of the Feed or Ordinary Diet (FOOD) trial, in which 859 patients with dysphagia after stroke were randomly assigned to either early tube feeding or delayed feeding starting later than 7 days after random assignment. Allocation to early tube feeding was associated with a non-significant reduction in mortality by 5·8% (there were 182 deaths in 429 patients randomly assigned to early tube feeding vs 207 deaths in 430 patients in the delayed feeding group; p=0·09). There were no differences in other outcomes, including severe disability or death (339 of 429 patients in the early-feeding group vs 344 of 430 patients in the delayed feeding group; p=0·7), pneumonia (132 of 429 patients in the early-feeding group vs 133 of 430 patients in the delayed feeding group; p>0·9), and percutaneous endoscopic gastrostomy placement at follow-up (30 of 429 patients in the early-feeding group vs 23 of 430 patients in the delayed feeding group). 6 Dennis M Lewis S Cranswick G Forbes J FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke. Health Technol Assess. 2006; 10: 1-120 Crossref Google Scholar Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trialIn the early phase of severe stroke, modified full enteral nutrition or hypocaloric enteral nutrition did not significantly reduce the risk of a poor outcomes compared with full enteral nutrition over a 90-day period. Hypocaloric enteral nutrition might be associated with increased mortality compared with modified full enteral nutrition. Further studies are needed to investigate whether modified full enteral nutrition might be the optimal strategy. Full-Text PDF

Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials.

The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.

Effect of hypocaloric enteral nutrition on acute severe traumatic brain injury

Objective To evaluate the clinical efficacy of hypocaloric enteral nutrition in patients with acute severe traumatic brain injury (TBI). Methods A total of 100 patients with severe TBI [Glasgow Coma Scale (GCS) 3-8 points] were enrolled and randomly divided into hypocaloric enteral nutrition group (hypocaloric group, 41.86-62.79 kJ·kg-1·d-1) and traditional caloric enteral nutrition group (traditional caloric group, 104.65-125.58 kJ·kg-1·d-1), 50 patients per group. The enteral nutrition was given at 24-72 hours postoperatively. The changes of total serum protein (TP), serum-albumin (ALB), plasma hemoglobin (Hb), fasting blood glucose (Glu) and major gastrointestinal tract complications were observed and compared at 7 and 14 days after enteral nutrition support. Results Levels of TP, ALB and Hb were lowered in both groups at 7 and 14 days after nutritional support but showed no statistical difference (P>0.05). Glu was (6.37±1.02)mmol/L in hypocaloric calorie group, significantly lower than (7.35±1.70)mmol/L in traditional caloric group at day 7 after nutritional support (P 0.05), but abdominal distension, diarrhea and stomach retention rate in hypocaloric group were significantly lower than those in traditional caloric group (P<0.05). Conclusion Hypocaloric enteral nutrition can significantly reduce the stress hyperglycemia, abdominal distention, diarrhea, gastric retention and other gastrointestinal symptoms in patients with acute severe TBI. Key words: Craniocerebral trauma; Enteral nutrition; Complications

Hypocaloric Enteral Nutrition Protects against Hypoglycemia Associated with Intensive Insulin Therapy Better than Intravenous Dextrose

Intensive insulin therapy treats hyperglycemia but increases the risk of hypoglycemia. Typically, intravenous dextrose is given to prevent hypoglycemia; however, enteral nutrition is preferred. We hypothesized that the provision of hypocaloric enteral nutrition would protect against hypoglycemia. A retrospective analysis was performed evaluating patients treated with intensive insulin therapy comparing the use of enteral nutrition versus a dextrose-only intravenous solution. Nutrition in the 2 hours before each blood glucose test was assessed, and the association with hypoglycemia (50 mg/dL or less) evaluated. Risk of hypoglycemia as a function of nutrition type and rate was estimated by multivariable regression. A total of 26,140 blood glucose tests were collected on 1289 patients. Hypoglycemia occurred in 6.4 per cent of patients. In regression models, enteral nutrition was the strongest protective factor against hypoglycemia (P < 0.001) with the largest risk reduction (steepest portion of the curve) occurring at 60 per cent goal. Hypocaloric enteral nutrition showed a greater risk reduction than a peripheral dextrose-only intravenous solution alone. In the setting of intensive insulin therapy, the provision of enteral nutrition, even if hypocaloric, is sufficient to protect against hypoglycemia. Future prospective studies should evaluate the efficacy of enteral nutrition in reducing the risk of hypoglycemia and whether lower rates of hypoglycemia correspond to improved outcomes.

Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial

Introduction:Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA).Materials and Methods:In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements.Results:There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017).Discussion:Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay.

Nutrition in Pediatric/Neonatology Patients Submitted to Mechanical Ventilation

This review emphasizes the use of nutrition support how an important priority in the management of children with severe respiratory insufficiency. This situation causes metabolic deregulation leading to muscle proteolysis (hypercatabolism) and can cause hospital malnutrition that constitutes important risk factor for increases in morbidity, lethality, length of hospital stay, and medical costs. Sequential evaluation of nutritional status in the patient with acute respiratory disease should be assessed by clinical and laboratory procedures. Although there is general agreement that nutrition is an important element of critical care, there is much less clarity about the exact requirements of children with specific problems, including acute respiratory diseases. Enteral nutrition is the recommended method of artificial feeding in intensive care unit, including in patients with bronchopulmonary dysplasia and ventilator-associated pneumonia. Combined nutritional support is considered an optional tool to avoid energy deficiency during hypocaloric enteral nutrition. The trend towards earlier initiation of adequate metabolic-nutrition support based on protocols can improve the clinical condition of critically ill children with acute respiratory disease.

Adding Supplemental Parenteral Nutrition to Hypocaloric Enteral Nutrition

Adding Supplemental Parenteral Nutrition to Hypocaloric Enteral Nutrition

Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by hypocaloric enteral nutrition

We report a case of acute respiratory failure due to refeeding syndrome caused by hypocaloric enteral tube feeds. A 60-y-old obese man, with a diagnosis of esophageal carcinoma with local metastases, underwent feeding jejunostomy tube insertion. Enteral tube feeding was initiated at small volumes providing 4.4 kcal · kg −1 · d −1 and gradually increased over 48 h to 29 kcal · kg −1 · d −1 (based on adjusted body weight). The patient then developed acute respiratory distress requiring intubation and ventilatory support. Serum phosphorus (P) level was extremely low at <0.7 mg/dL. Serum potassium (K) and magnesium (Mg) levels were also low. It took >4 d to adequately correct the electrolyte derangements. Successful liberation from mechanical ventilation was then possible. In chronically malnourished patients undergoing nutritional support, even hypocaloric feeding should be considered a risk factor for developing refeeding syndrome leading to severe and acute electrolyte fluid-balance and metabolic abnormalities.

Early nutritional therapy: the role of enteral and parenteral routes

Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.

Hypocaloric enteral tube feeding in critically ill obese patients

OBJECTIVE: We respectively compared the nutritional and clinical efficacies of eucaloric and hypocaloric enteral feedings in 40 critically ill, obese patients admitted to the trauma or surgical intensive care unit. METHODS: Adult patients, 18 to 69 years old, with weights greater than 125% of ideal body weight, normal renal and hepatic functions, and who received at least 7 d of enteral tube feeding were studied. Patients were stratified according to feeding group: eucaloric feeding (≥20 kcal/kg of adjusted weight per day; n = 12) or hypocaloric feeding (<20 kcal/kg of adjusted weight per day; n = 28). The goal protein intake for both groups was approximately 2 g/kg of ideal body weight per day. Clinical events and nutrition data were recorded for 4 wk. RESULTS: Patients were similar according to sex, age, weight, body mass index, Second Acute Physiology and Chronic Health Evaluation score, Trauma score, and Injury Severity Score. The hypocaloric feeding group received significantly fewer calories than the eucaloric group ( P ≤ 0.05). The hypocaloric group had a shorter stay in the intensive care unit (18.6 ± 9.9 d versus 28.5 ± 16.1 d, P < 0.03), decreased duration of antibiotic therapy days (16.6 ± 11.7 d versus 27.4 ± 17.3 d, P < 0.03), and a trend toward a decrease in days of mechanical ventilation (15.9 ± 10.8 d versus 23.7 ± 16.6 d, P = 0.09). There was no statistically significant difference in nitrogen balance or serum prealbumin response between groups. CONCLUSION: These data suggest that hypocaloric enteral nutrition support is as least as effective as eucaloric feeding in critically ill, obese patients.

Effect of early feeding on maturation of the preterm infant's small intestine

To determine the response of the preterm infant's intestine to entire feedings at different postnatal ages, we recorded results of manometry of the gastroduodenum and determined fasting plasma concentrations of gastrin, gastric inhibitory peptide, neurotensin, and peptide YY three times in each of two groups: 27 preterm infants were randomly assigned to receive hypocaloric enteral nutrition on postnatal days 3 to 5 (early feeding) or on days 10 to 14 (late feeding). Initial observations (study 1) were performed by the fifth postnatal day; study 2 was performed on days 10 to 14, and study 3 on days 24 to 28. Early-fed infants received hypocaloric feedings immediately after study 1; late-fed infants did not receive enteral feedings until the completion of study 2. Although motor activity and fasting gastrointestinal peptide concentrations did not differ between groups at study 1, at study 2 early-fed infants had significantly more mature motor patterns than did babies not being fed. Early-fed infants also had significantly higher plasma concentrations of gastrin and gastric inhibitory peptide than did late-fed infants; neurotensin and peptide YY values were similar in both groups. By the time of study 3, when late-fed infants had also received enteral feedings, gut development was not different in the two groups. However, early-fed infants were able to tolerate full oral nutrition sooner, had fewer days of feeding intolerance, and had shorter hospital stays. Thus the provision of early hypocaloric nutrition was associated with earlier nutrition of preterm infants' intestinal function and resulted in improved feeding tolerance. These findings support the use of early feedings in preterm infants.