低热量高蛋白质肠内营养可改善重症患者葡萄糖控制
在美国，大约46%的重症监护病房（ICU）患者在入住24小时内会出现高血糖。限制糖类摄入量、优化蛋白质种类及比例有助于血糖控制。为此，美国雀巢健康科学、维克弗斯特大学、肯塔基大学、埃默里大学、芝加哥大学、明尼苏达州圣保罗地区医院、范德堡大学、加拿大金斯顿医院、瑞士洛桑雀巢技术、英国伦敦高知特开展了一项前瞻随机多中心临床研究，探讨低热量高蛋白质肠内营养（EN）是否有助于改善ICU患者的血糖控制。
该研究入组美国7家医学中心98例机械通气合并肥胖ICU患者，随机分为低热量组（低热量高蛋白质EN制剂）、对照组（正常热量高蛋白质EN制剂）。
结果显示，与对照组相比，低热量组血糖水平显著较低（P=0.0443），其中血糖水平81～110mg/dL的患者较多，而150mg/dL以上的患者较少。此外，低热量组胰岛素使用率较对照组显著减少（P=0.044）。
因此，低热量高蛋白质制剂可有效控制血糖水平，降低ICU患者高血糖发生率和胰岛素使用率。
JPEN J Parenter Enteral Nutr. 2017;41(2):289-290.
Hypocaloric high-protein enteral nutrition improves glucose management in critically ill patients.
Juan Ochoa, Maureen Huhmann, Daniel C. Files, John Drover, Andrew Bernard, Thomas Ziegler, John Kress, Kealy Rae Ham, Dominik Grathwol, Harshad Kulkarni, Todd Rice.
Nestlé Health Science, Florham Park, New Jersey, USA; Clinical Sciences, Nestlé Health Science, Florham Park, New Jersey, USA; Wake Forest University, Winston-Salem, North Carolina, USA; Kingston Hospital, Kingston, Ontario, Canada; University of Kentucky, Lexington, Kentucky, USA; Emory University, Atlanta, Georgia, USA; Medicine, University of Chicago, Hinsdale, Illinois, USA; Pulmonary Medicine, Regions Hospital, St Paul, Minnesota, USA; Clinical Development Unit, Nestec, Lausanne, Switzerland; Cognizant, London, United Kingdom; Vanderbilt University, Nashville, Tennessee, USA.
PURPOSE: Hyperglycemia in critically ill patients is associated with increased morbidity, mortality, length of hospital stay, utilization of healthcare resources, and cost. Approximately 46% of patients admitted to the intensive care unit (ICU) in the United States have hyperglycemia in the first 24 hours of admission. Twenty-seven percent of these patients have a previous diagnosis of diabetes mellitus. Carbohydrate restriction has been used as a means to improve glucose control in critically ill patients. Quantity and perhaps type of protein also appear to play a role in glucose management. The objective of this study was to compare blood glucose control with a hypocaloric, high-protein enteral tube feeding formulation vs a normocaloric, high-protein formulation in overweight or obese ICU patients.
METHODS: In this prospective, randomized, multicenter clinical trial, mechanically ventilated critically ill, obese, and overweight subjects requiring enteral nutrition (EN) were recruited from 7 academic medical centers. Subjects were randomly assigned to the hypocaloric group, which used Peptamen Intense VHP, or the normocaloric group, which used Replete. The assigned formula was delivered to provide protein at 1.5 g/kg ideal body weight. Serial blood glucose concentrations, markers of nutrition status and inflammation, insulin, and dextrose were determined. The primary end point was defined as number of glycemic events in the first 7 days in ICU >150 mg/dL or <110 mg/dL. A sample size of 100 subjects per arm was calculated based on the primary end point with an absolute effect size of a 10% reduction in the proportion of “out-of-range” glycemic events between the control and the treatment groups and a standard deviation of 24. An interim analysis was undertaken when 40 subjects completed at least 5 days of data collection. We present here a preliminary analysis of the intention-to-treat data.
RESULTS: Ninety-eight subjects were randomized into the study at the time of interim analysis. Of these subjects, 40 had at least 5 days of data collected. The remaining subjects withdrew primarily due to removal of the feeding tube. The mean glucose level was significantly lower in the hypocaloric group (128 [114, 143] vs 140 [125, 158], P = .0443). Mean daily glucose levels were significantly lower in the hypocaloric group on days 2, 3, and 4 (P < .05). There was no significant difference between groups in glucose variability. Subjects receiving the hypocaloric formulation had significantly more blood glucose levels between 81 and 110 mg/dL and significantly less values >150 mg/dL. There was no significant difference in hypoglycemia (blood glucose <81 mg/dL) between groups. There was a significant decrease in the incidence of insulin administration in the hypocaloric group (delta = -12%, P = .044). There was 1 death in the hypocaloric group and 6 in the normocaloric group (P = .11).
CONCLUSIONS: A hypocaloric hyperproteic diet, while not reducing variability, facilitates blood glucose management by decreasing episodes of hyperglycemia, decreasing insulin utilization, and normalizing blood glucose levels in adult ICU patients.
FINANCIAL SUPPORT: Nestlé Health Science.
DOI: 10.1177/0148607116686023