Macronutrient Delivery Research Articles

A simple step to improve fat and energy delivery of human milk delivered via bottle-feeding pump: An experimental study.

Enteral feeding pump systems deliver decreased amounts of macronutrients in human milk to neonates. This study determined the macronutrient loss associated with a bottle-feeding pump system and the effect of manually mixing the human milk during extended feeds. Macronutrient content from samples of donor human milk was analyzed after simulated extended feeds with a bottle-feeding pump system, using a human milk analyzer. Simulations were repeated using manual mixing of the bottle every 30 min during feeding. The percentage of the baseline was calculated, and one-sample t tests and analysis of variance compared the effect of manual mixing and the duration of feeding on macronutrient delivery. The delivery of fat and energy was lower over time, but manual mixing considerably improved retention. The length of feeding impacted fat delivery, with less fat delivered over time (P < 0.001). Manually mixing significantly increased fat delivery (P < 0.001). Similar results were found for energy, with a significant reduction in energy delivery over time (P < 0.001) and significantly more energy delivered with mixing (P < 0.001). Mixing and the duration of feeding had minimal effect on protein or carbohydrate delivery. Bottle-feeding pump systems are associated with a significant reduction in the delivery of fat and energy of donor human milk. The manual mixing of donor human milk during prolonged feeds is a simple way to improve fat and energy delivery to the neonate.

Ceramides Increase Fatty Acid Utilization in Intestinal Progenitors to Enhance Stemness and Increase Tumor Risk

Cancers of the alimentary tract, including esophageal adenocarcinomas, colorectal cancers, and cancers of the gastric cardia, are common comorbidities of obesity. Prolonged, excessive delivery of macronutrients to the cells lining the gut can increase one's risk for these cancers by inducing imbalances in the rate of intestinal stem cell proliferation vs differentiation, which can produce polyps and other aberrant growths. We investigated whether ceramides, which are sphingolipids that serve as a signal of nutritional excess, alter stem cell behaviors to influence cancer risk. We profiled sphingolipids and sphingolipid-synthesizing enzymes in human adenomas and tumors. Thereafter, we manipulated expression of sphingolipid-producing enzymes, including serine palmitoyltransferase (SPT), in intestinal progenitors of mice, cultured organoids, and Drosophila to discern whether sphingolipids altered stem cell proliferation and metabolism. SPT, which diverts dietary fatty acids and amino acids into the biosynthetic pathway that produces ceramides and other sphingolipids, is a critical modulator of intestinal stem cell homeostasis. SPT and other enzymes in the sphingolipid biosynthesis pathway are up-regulated in human intestinal adenomas. They produce ceramides, which serve as prostemness signals that stimulate peroxisome-proliferator activated receptor-α and induce fatty acid binding protein-1. These actions lead to increased lipid utilization and enhanced proliferation of intestinal progenitors. Ceramides serve as critical links between dietary macronutrients, epithelial regeneration, and cancer risk.

Innovative hydrogels made from babassu mesocarp for technological application in agriculture

The controlled release of macronutrients via hydrogels using biopolymers is a solution for agricultural production. Two superabsorbent hydrogels (SAH) were synthesized by the graft copolymerization reaction of babassu mesocarp (MB) and polyacrylamide (PAM). Both were distinguished by the presence (HMBP) or absence (HMB) of potassium phosphate fertilizer, which can be used as nutrient carriers and soil’s conditions correctives as well. These materials were characterized by X-ray diffraction (XRD). The hydrogels presented crystallographic characteristics different from their precursors, which indicated interactions among the fertilizers and macromolecular chains. Through Fourier transform infrared spectroscopy (FTIR), a band at 1,121 cm−1 differentiates the HMBP and HMB hydrogels and was attributed to the incorporation of potassium phosphate. Thermogravimetric analyzes (TG and DTG) showed the thermal stability of the obtained materials. The swelling tests showed a superabsorbent capacity of the materials since they had swelling capacity ranging from 250 to 300 (g/g) at the expense of the pH of the medium. Regarding the toxicity of these materials, a study using Artemia showed that the developed products do not present risks. Furthermore, hydrogels containing potassium phosphate have great potential to control macronutrient delivery systems. Therefore, they are a promising input as soil conditioners and nutrient carriers for agricultural applications.

Associations of Macronutrient Intake Determined by Point-of-Care Human Milk Analysis with Brain Development among very Preterm Infants.

Point-of-care human milk analysis is now feasible in the neonatal intensive care unit (NICU) and allows accurate measurement of macronutrient delivery. Higher macronutrient intakes over this period may promote brain growth and development. In a prospective, observational study of 55 infants born at <32 weeks’ gestation, we used a mid-infrared spectroscopy-based human milk analyzer to measure the macronutrient content in repeated samples of human milk over the NICU hospitalization. We calculated daily nutrient intakes from unfortified milk and assigned infants to quintiles based on median intakes over the hospitalization. Infants underwent brain magnetic resonance imaging at term equivalent age to quantify total and regional brain volumes and fractional anisotropy of white matter tracts. Infants in the highest quintile of energy intake from milk, as compared with the lower four quintiles, had larger total brain volume (31 cc, 95% confidence interval [CI]: 5, 56), cortical gray matter (15 cc, 95%CI: 1, 30), and white matter volume (23 cc, 95%CI: 12, 33). Higher protein intake was associated with larger total brain (36 cc, 95%CI: 7, 65), cortical gray matter (22 cc, 95%CI: 6, 38) and deep gray matter (1 cc, 95%CI: 0.1, 3) volumes. These findings suggest innovative strategies to close nutrient delivery gaps in the NICU may promote brain growth for preterm infants.

Value of fish oil in nutrition therapy in Covid-19 illness

Our expertise in the medical treatment of COVID-19 infections has grown with time and experience, resulting in the development of a cohesive overall therapeutic strategy for control of the viral infection from supportive measures for mild to moderate illness, to the full range of relevant organ support in critical illness in ICU. In parallel, our strategies for providing nutrition therapy have also evolved beyond the mere delivery of macronutrients (calories and protein) to the utilization of specific nutritional substrates that may play an important role in modifying the course of the disease and optimizing clinical outcomes.

Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children

Optimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery. We aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children. We conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated "adequacy" as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN+PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs). From 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n=97). The average adequacies of delivery via EN+PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P=0.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P=0.027) delivery. There were no clinically significant differences in infections or VFDs between groups. Achieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.

The association of macronutrient deficit with functional status at discharge from the intensive care unit: a retrospective study from a single-center critical illness registry.

Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge. We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables. Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs. <300 g with each unit decrement in FSS-ICU. In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.

Glaciers and Nutrients in the Canadian Arctic Archipelago Marine System

AbstractThe Canadian Arctic Archipelago (CAA) is vulnerable to climate warming, and with over 300 tidewater glaciers, is a hotspot for enhanced glacial retreat and meltwater runoff to the ocean. In contrast to Greenlandic and Antarctic systems, CAA glaciers and their impact on the marine environment remain largely unexplored. Here, we investigate how CAA glaciers impact nutrient delivery to surface waters. We compare water column properties in the nearshore coastal zone along a continuum of locations, spanning those with glaciers (glacierized) to those without (non‐glacierized), in Jones Sound, eastern CAA. We find that surface waters of glacierized regions contain significantly more macronutrients (nitrogen, silica, phosphorus) and micronutrients (iron, manganese) than their non‐glacierized counterparts. Water column structure and chemical composition suggest that macronutrient enrichments are a result of upwelling induced by rising submarine discharge plumes, while micronutrient enrichments are delivered directly by glacial discharge. Generally, the strength of upwelling and associated macronutrient delivery scales with the subglacial meltwater discharge. Glacier‐driven delivery of the limiting macronutrient, nitrate, is of particular importance for local productivity, while metal delivery may have consequences for regional micronutrient cycling given Jones Sound's important role in modifying water masses flowing into the North Atlantic. Finally, we use the natural variability in glacier characteristics observed in Jones Sound to consider, how nutrient delivery may be affected as glaciers retreat. The impacts of melting glaciers on marine ecosystems through both these mechanisms will likely be amplified with increased meltwater fluxes in the short term, but eventually muted as CAA ice masses diminish.

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis.

Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence. This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes. Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P= .99), hospital LOS (mean difference, -1.44; CI,-5.59 to 2.71; P =.50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials. A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.

Timing of parenteral nutrition is associated with adequacy of nutrient delivery and anthropometry in critically ill children: A single-center study.

The optimal timing of supplemental parenteral nutrition (PN) use in the pediatric intensive care unit (ICU) is unclear. We aimed to describe patterns of PN use in the ICU and the association between the timing of PN initiation and macronutrient delivery and anthropometry. We enrolled patients (aged <18 years) with an ICU stay >3 days were started on PN in the ICU. Initiation within 48 hours of admission was deemed as early, and duration <5 days was deemed as short. We used multivariable analysis to examine the association between PN timing and macronutrient delivery adequacy (percentage of the prescribed target that was actually delivered) and weight-for-age z-score (WAZ) over hospital stay. Ninety-five patients were included. Median (interquartile range [IQR]) time to initiate PN was 4 (1, 6) days, and in 33%, PN was initiated early. Median (IQR) PN duration was 8 (5, 14) days, and in 16.8%, duration was short. Median (IQR) adequacies for total energy and protein delivery were 55% (40, 74) and 72% (44, 81) in the early PN group compared with 29% (3, 50) and 31% (4, 47), respectively, in the late PN group (P < .001). The late PN group had a 0.50-unit greater decline in mean WAZ compared with the early PN group (95% CI, 0.11-0.89; P = .012). Late PN initiation was associated with significantly lower adequacy of macronutrient delivery and greater decline in WAZ in critically ill children. The relationship between PN timing patient outcomes must be further examined.

The role of nanoparticle structure and morphology in the dissolution kinetics and nutrient release of nitrate-doped calcium phosphate nanofertilizers

Bio-inspired synthetic calcium phosphate (CaP) nanoparticles (NPs), mimicking the mineral component of bone and teeth, are emergent materials for sustainable applications in agriculture. These sparingly soluble salts show self-inhibiting dissolution processes in undersaturated aqueous media, the control at the molecular and nanoscale levels of which is not fully elucidated. Understanding the mechanisms of particle dissolution is highly relevant to the efficient delivery of macronutrients to the plants and crucial for developing a valuable synthesis-by-design approach. It has also implications in bone (de)mineralization processes. Herein, we shed light on the role of size, morphology and crystallinity in the dissolution behaviour of CaP NPs and on their nitrate doping for potential use as (P,N)-nanofertilizers. Spherical fully amorphous NPs and apatite-amorphous nanoplatelets (NPLs) in a core-crown arrangement are studied by combining forefront Small-Angle and Wide-Angle X-ray Total Scattering (SAXS and WAXTS) analyses. Ca2+ ion release rates differ for spherical NPs and NPLs demonstrating that morphology plays an active role in directing the dissolution kinetics. Amorphous NPs manifest a rapid loss of nitrates governed by surface-chemistry. NPLs show much slower release, paralleling that of Ca2+ ions, that supports both detectable nitrate incorporation in the apatite structure and dissolution from the core basal faces.

Further optimization of macronutrient delivery for subirrigated greenhouse-grown chrysanthemums: calcium and magnesium

Moderate levels of calcium or magnesium were applied to two cultivars of subirrigated, potted, pinched chrysanthemums during vegetative growth. Market-quality plants were produced with sufficient leaf-calcium or leaf-magnesium even though the delivery of the respective nutrient could be reduced by approximately 87.5%, compared with industry standards. This practice could contribute to low-input production of floricultural crops.

The Maternal Nutritional Buffering Model: an evolutionary framework for pregnancy nutritional intervention.

Evidence that fetal nutrition influences adult health has heightened interest in nutritional interventions targeting pregnancy. However, as is true for other placental mammals, human females have evolved mechanisms that help buffer the fetus against short-term fluctuations in maternal diet and energy status. In this review, we first discuss the evolution of increasingly elaborate vertebrate strategies of buffering offspring from environmental fluctuations during development, including the important innovation of the eutherian placenta. We then present the Maternal Nutritional Buffering Model, which argues that, in contrast to many micronutrients that must be derived from dietary sources, the effects of short-term changes in maternal macronutrient intake during pregnancy, whether due to a deficit or supplementation, will be minimized by internal buffering mechanisms that work to ensure a stable supply of essential resources. In contrast to the minimal effects of brief macronutrient supplementation, there is growing evidence that sustained improvements in early life and adult pre-pregnancy nutrition could improve birth outcomes in offspring. Building on these and other observations, we propose that strategies to improve fetal macronutrient delivery will be most effective if they modify the pregnancy metabolism of mothers by targeting nutrition prior to conception and even during early development, as a complement to the conventional focus on bolstering macronutrient intake during pregnancy itself. Our model leads to the prediction that birth weight will be more strongly influenced by the mother’s chronic pre-pregnancy nutrition than by pregnancy diet, and highlights the need for policy solutions aimed at optimizing future, intergenerational health outcomes.Lay summary: We propose that strategies to improve fetal macronutrient delivery will be most effective if they modify the pregnancy metabolism of mothers by targeting nutrition prior to conception and even during early development, as a complement to the conventional focus on bolstering macronutrient intake during pregnancy itself.

Mitochondrial Dysfunction in Critical Illness: Implications for Nutritional Therapy.

This paper will review the evidence for mitochondrial dysfunction in critical illness, describe the mechanisms which lead to multiple organ failure, and detail the implications of this pathophysiologic process on nutritional therapy. Mitochondria are particularly sensitive to increased oxidative stress in critical illness. The functional and structural abnormalities which occur in this organelle contribute further to the excessive production of reactive oxygen species and the reduction in generation of adenosine triphosphate (ATP). To reduce metabolic demand, mitochondrial dysfunction develops (a process likened to hibernation), which helps sustain the life of the cell at a cost of organ system failure. Aggressive feeding in the early phases of critical illness might inappropriately increase demand at a time when ATP production is limited, further jeopardizing cell survival and potentiating the processes leading to multiple organ failure. Several potential therapies exist which would promote mitochondrial function in the intensive care setting through support of autophagy, antioxidant defense systems, and the biogenesis and recovery of the organelle itself. Nutritional therapy should supplement micronutrients required in the mitochondrial metabolic pathways and provide reduced delivery of macronutrients through slower advancement of feeding in the early phases of critical illness. A better understanding of mitochondrial dysfunction in the critically ill patient should lead to more innovative therapies in the future.

Effect of Macronutrient Type and Gastrointestinal Release Site on PYY Response in Normal Healthy Subjects.

Enteroendocrine L cells release satiety inducing hormones in response to stimulation by luminal macronutrients. We sought to profile the differential effect of macronutrient type and site of release on circulating concentrations of the L cell-derived enteroendocrine hormone peptide tyrosine tyrosine (amino acids 1 to 36) (PYY). Eight healthy volunteers were recruited to a randomized, double-blinded, six-way crossover study. At each visit, the participants consumed a 500-kcal drink containing carbohydrate, protein, or fat in either gastric or small intestinal release formulations. Plasma PYY concentrations and hunger ratings were assessed for 3 hours after consumption of the test drink. The food intake was recorded thereafter at an ad libitum lunch. Microcapsular formulations targeting the distal small intestinal delivery of fat, but not carbohydrate or protein, markedly enhance PYY release relative to macronutrient delivery in gastric release formulations. Food intake at an ad libitum meal was lowest after consumption of the formulation releasing fat at the distal small intestine. Targeting of fat to the distal small intestine in delayed release microcapsules enhanced PYY release and was associated with reductions in food intake.

Association between enteral macronutrient delivery and inflammatory response in critically ill children

Background and aimsAn important goal of nutrition support in paediatric critical illness is minimising catabolism. While focussing on providing full energy requirements, macronutrient balance is often neglected. Studies suggest that there is interplay between nutrition and inflammation. We aimed to assess the amount of enteral macronutrients delivered compared to estimated requirements, and the association between delivered macronutrients and systemic inflammation in critically ill children. MethodWe prospectively evaluated energy and macronutrient intake in critically ill children who required at least 72 h of mechanical ventilation. Data on enteral energy and macronutrient intake was collected and expressed as a percentage of the estimated requirements. Circulating levels of inflammatory cytokines were measured by ELISA and association assessed with delivery of macronutrients from the previous 24 h. ResultsA total of 87 children (0–16 years) were included in this study. By day 3 the median (IQR) intake of energy, fat, carbohydrate (CHO) and protein were 75% (50–103), 85% (43–120), 63% (42–102) and 45% (23–65) respectively. We have also shown that delivery of enteral fat and protein was associated with elevation in the levels of tumour necrosis factor alpha (TNF-α) and interleukin-6 (IL-6). ConclusionThe inflammatory response in critically ill children is influenced by the amount of enteral fat and protein delivered. Our data suggests that within the feed delivered, fat is often higher than protein and CHO. It is crucial to take into account the proportion of macronutrients required and not only aim to achieve the energy goal.

Nutrition Delivery During Pediatric Extracorporeal Membrane Oxygenation Therapy.

Macronutrient delivery during pediatric ECMO therapy can be challenging. We examined predictors of nutrient delivery in the first 2 weeks of extracorporeal membrane oxygenation (ECMO) therapy in the pediatric intensive care unit (ICU). Details of macronutrient delivery were recorded in children (newborn-18 years of age) who survived 24 hours after cannulation to ECMO over a 3-year period (2012-2015). We analyzed data from 54 consecutive eligible patients, 43% female, with median (interquartile range) ECMO duration of 8.5 (6-24) days, age 0.1 (0, 16) months, ICU length of stay 32 (21, 60) days, and 28-day mortality 13%. Median weight for age z score declined from -0.1 at admission to -1.2 at 30 days (P = 0.013). At least 80% goal energy and protein was delivered in 35 (65%) and 33 (61%) patients, respectively, by day 7; 10% of energy and 11% protein goal was delivered enterally. Parenteral nutrition (PN) was utilized in 47 (87%) patients, initiated by day 1 (1, 3). Enteral nutrition (EN) was successfully delivered in 49 (94%) patients (35% postpyloric), initiated by day 6 (2, 16). Younger age (P = 0.01) and venoarterial mode of ECMO (P = 0.0014) were associated with lower EN delivery. Use of umbilical artery catheters or vasoactive infusions did not impede EN delivery. Late PN delivery was associated with cumulative protein deficits (P = 0.019) and failure to achieve nutrient delivery goals by day 7. Optimal nutrient delivery was achieved in most patients by day 7, predominantly via PN. Early EN is feasible in low volumes, but PN may be essential to prevent cumulative energy and protein deficits during the first week of ECMO.

Duodenal and ileal glucose infusions differentially alter gastrointestinal peptides, appetite response, and food intake: a tube feeding study

Background: Activation of the ileal brake through the delivery of nutrients into the distal small intestine to promote satiety and suppress food intake provides a new target for weight loss. Evidence is limited, with support from naso-ileal lipid infusion studies.Objective: The objective of the study was to investigate whether glucose infused into the duodenum and ileum differentially alters appetite response, food intake, and secretion of satiety-related gastrointestinal peptides.Design: Fourteen healthy male participants were randomly assigned to a blinded 4-treatment crossover, with each treatment of single-day duration. On the day before the intervention (day 0), a 380-cm multilumen tube (1.75-mm diameter) with independent port access to the duodenum and ileum was inserted, and position was confirmed by X-ray. Subsequently (days 1-4), a standardized breakfast meal was followed midmorning by a 90-min infusion of isotonic glucose (15 g, 235 kJ) or saline to the duodenum or ileum. Appetite ratings were assessed with the use of visual analog scales (VASs), blood samples collected, and ad libitum energy intake (EI) measured at lunch, afternoon snack, and dinner.Results: Thirteen participants completed the 4 infusion days. There was a significant effect of nutrient infused and site (treatment × time, P < 0.05) such that glucose-to-ileum altered VAS-rated fullness, satisfaction, and thoughts of food compared with saline-to-ileum (Tukey's post hoc, P < 0.05); decreased ad libitum EI at lunch compared with glucose-to-duodenum [-22%, -988 ± 379 kJ (mean ± SEM), Tukey's post hoc, P < 0.05]; and increased glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) compared with all other treatments (Tukey's post hoc, P < 0.05).Conclusions: Macronutrient delivery to the proximal and distal small intestine elicits different outcomes. Glucose infusion to the ileum increased GLP-1 and PYY secretion, suppressed aspects of VAS-rated appetite, and decreased ad libitum EI at a subsequent meal. Although glucose to the duodenum also suppressed appetite ratings, eating behavior was not altered. This trial was registered at www.anzctr.org.au as ACTRN12612000429853.

Role of Insulin-Stimulated Adipose Tissue Perfusion in the Development of Whole-Body Insulin Resistance.

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Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes.

Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.