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A systematic review of the definitions and prevalence of feeding intolerance in critically ill adults. Clin Nutr ESPEN 2022; 49:92-102. [DOI: 10.1016/j.clnesp.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/08/2022] [Accepted: 04/15/2022] [Indexed: 12/12/2022]
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Zaher S, White D, Ridout J, Branco RG, Meyer R, Pathan N. The effect of nutritional status and inflammatory stimuli on Ghrelin and PYY levels among critically ill children: A prospective and observational study. JPEN J Parenter Enteral Nutr 2022; 46:1298-1306. [DOI: 10.1002/jpen.2339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences Taibah University Saudi Arabia
| | - Deborah White
- Department of Paediatrics University of Cambridge, Hills Road Cambridge UK
| | - Jenna Ridout
- Cambridge University Hospitals NHS Foundation Trust, Hills Road Cambridge UK
| | | | - Rosan Meyer
- Department Paediatrics, Imperial Collage London, UK/Department Nutrition and Dietetics, University of Winchester UK
| | - Nazima Pathan
- Department of Paediatrics University of Cambridge, Hills Road Cambridge UK
- Cambridge University Hospitals NHS Foundation Trust, Hills Road Cambridge UK
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Galiniak S, Podgórski R, Rachel M, Mazur A. Serum levels of hormones regulating appetite in patients with cystic fibrosis - a single-center, cross-sectional study. Front Endocrinol (Lausanne) 2022; 13:992667. [PMID: 36313742 PMCID: PMC9606394 DOI: 10.3389/fendo.2022.992667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Cystic fibrosis (CF), which is the most common inherited genetically determined disease caused by a mutation in the gene for the CF transmembrane conductance regulator protein. Pulmonary failure is the leading cause of death in this population, while the dysregulation of endocrine system creates significant disorders, including malnutrition, underweight, and CF-related diabetes. Therefore, the objective of our study was to determine the following hormones in the serum of patients with CF: ghrelin, putative peptide YY (PYY), Agouti-signaling protein (ASP), and alpha-melanocyte-stimulating hormone (α-MSH). To our knowledge, serum levels of PYY, ASP, and α-MSH have not yet been assessed in CF. For this purpose, we measured hormone levels using enzyme-linked immunosorbent assays in 38 patients from the local CF care center, as well as 16 sex- and age-matched healthy controls. Moreover, we estimated the correlations between the tested hormones and the parameters of the patients' clinical status. In this study, we found sinificantly reduced serum levels of ghrelin and ASP in patients with CF (p<0.01). There was no difference in PYY and α-MSH levels between participants with CF and healthy subjects. Furthermore, there was no difference in hormone levels between females and males with CF. The type of gene mutation (homozygous or heterozygous for ΔF508) had no effect on hormone levels. Ghrelin was negatively correlated with age, body mass index, and C-reactive protein. PYY was negatively associated with the age of the patients. Hormone dysregulation in CF may contribute to decreased appetite, as well as many other disturbed processes. Therefore, ghrelin appears to play a key role in the regulation of energy management of CF. Future multicenter and multidisciplinary studies should focus on an unequivocal understanding of the role of these hormones in CF.
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Leptin, Ghrelin, and Leptin/Ghrelin Ratio in Critically Ill Patients. Nutrients 2019; 12:nu12010036. [PMID: 31877773 PMCID: PMC7020071 DOI: 10.3390/nu12010036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 12/22/2022] Open
Abstract
The objective of this study was to evaluate leptin, ghrelin, and leptin/ghrelin ratio in critically ill patients and association of leptin/ghrelin ratio with outcomes. This is a sub-study of the PermiT trial (ISRCTN68144998). A subset of 72 patients who were expected to stay >14 days in the Intensive care unit were enrolled. Blood samples were collected on days 1, 3, 5, 7, and 14. Samples were analyzed for leptin and active ghrelin in addition to other hormones. Baseline leptin/ghrelin ratio was calculated, and patients were stratified into low and high leptin/ghrelin ratio based on the median value of 236. There was a considerable variation in baseline leptin level: Median 5.22 ng/mL (Q1, Q3: 1.26, 17.60). Ghrelin level was generally low: 10.61 pg/mL (Q1, Q3: 8.62, 25.36). Patients with high leptin/ghrelin ratio compared to patients with low leptin/ghrelin ratio were older, had higher body mass index and more likely to be diabetic. There were no differences in leptin/ghrelin ratio between patients who received permissive underfeeding and standard feeding. Multivariable logistic regression analysis showed that age and body mass index were significant independent predictors of high leptin–ghrelin ratio. Leptin–ghrelin ratio was not associated with 90-day mortality or other outcomes. Age and body mass index are predictors of high leptin/ghrelin ratio. Leptin/ghrelin ratio is not affected by permissive underfeeding and is not associated with mortality.
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Martinez EE, Panciotti C, Pereira LM, Kellogg MD, Stylopoulos N, Mehta NM. Gastrointestinal Hormone Profiles Associated With Enteral Nutrition Tolerance and Gastric Emptying in Pediatric Critical Illness: A Pilot Study. JPEN J Parenter Enteral Nutr 2019; 44:472-480. [PMID: 31304610 DOI: 10.1002/jpen.1678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/19/2019] [Accepted: 06/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Enteral nutrition (EN) intolerance and delayed gastric emptying are prevalent in pediatric critical illness and limit EN delivery. Gastrointestinal (GI) hormones may be associated with EN intolerance and delayed gastric emptying in this cohort. METHODS We determined GI hormone levels, time to achieve 50% of EN goal, and gastric emptying in critically ill children. Total amylin, active ghrelin, total glucagon-like peptide-1 (GLP-1), total gastric inhibitory polypeptide, glucagon, and total peptide-YY (PYY) were measured by multiplex assay and cholecystokinin by ELISA. Lower concentrations of acetaminophen at 1 hour (C1h, µg/mL) using the acetaminophen absorption test defined delayed gastric emptying. Correlation, regression analyses, and a principal component analysis were used to examine the association between GI hormones and time to 50% EN goal and C1h. RESULTS GI hormones were measured in 14 of 21 patients with gastric emptying testing; median age of 11.2 years (6.74-16.3) and 50% male. Increasing hormone levels from GI hormone profile 1 (GLP-1, glucagon, and amylin) correlated with greater time to reach 50% EN goal (R2 = 0.296, P = 0.04). Decreasing hormone levels from GI hormone profile 2 (PYY and ghrelin) correlated with lower C1h and slower gastric emptying (R2 = 0.342, P = 0.02). CONCLUSION GI hormone profiles are associated with time to achieve 50% of EN goal and gastric emptying in critically ill children. We have described a feasible model to study the role of GI hormones in this cohort, including the potential clinical applicability of GI hormone measurement in the management of delayed gastric emptying.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney Panciotti
- Department of Medicine, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Luis M Pereira
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Stylopoulos
- Department of Medicine, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Deng J, Zhong Y. [Research advances in nutritional support for critically ill children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:1075-1078. [PMID: 30573001 PMCID: PMC7389499 DOI: 10.7499/j.issn.1008-8830.2018.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/06/2018] [Indexed: 06/09/2023]
Abstract
Most critically ill children are in a state of serious stress and tend to develop malnutrition, which may reduce the body's ability to fight against diseases and repair damaged tissues and thus aggravate their conditions. Reasonable and effective nutritional support for critically ill children can improve their nutritional status and prognosis, and so it is necessary to offer nutritional support for critically ill children. This article reviews the research on nutritional support for critically ill children and the current status of clinical application. It also introduces the main methods for nutritional support, including enteral nutrition and parenteral nutrition, and elaborates on the new methods for nutritional support, such as early enteral nutrition, enteral immunonutrition, and supplementary parenteral nutrition, in order to provide a reference for nutritional support for critically ill children.
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Affiliation(s)
- Jie Deng
- Pediatric Academy, University of South China/Institute of Children's Healthcare, Hunan Children's Hospital, Changsha 410007, China.
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Deng J, Zhong Y. [Research advances in nutritional support for critically ill children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:1075-1078. [PMID: 30573001 PMCID: PMC7389499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/06/2018] [Indexed: 03/30/2024]
Abstract
Most critically ill children are in a state of serious stress and tend to develop malnutrition, which may reduce the body's ability to fight against diseases and repair damaged tissues and thus aggravate their conditions. Reasonable and effective nutritional support for critically ill children can improve their nutritional status and prognosis, and so it is necessary to offer nutritional support for critically ill children. This article reviews the research on nutritional support for critically ill children and the current status of clinical application. It also introduces the main methods for nutritional support, including enteral nutrition and parenteral nutrition, and elaborates on the new methods for nutritional support, such as early enteral nutrition, enteral immunonutrition, and supplementary parenteral nutrition, in order to provide a reference for nutritional support for critically ill children.
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Affiliation(s)
- Jie Deng
- Pediatric Academy, University of South China/Institute of Children's Healthcare, Hunan Children's Hospital, Changsha 410007, China.
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Plummer MP, Kar P, Cousins CE, Hausken T, Lange K, Chapman MJ, Jones KL, Horowitz M, Deane AM. Critical Illness Is Associated With Impaired Gallbladder Emptying as Assessed by 3D Ultrasound. Crit Care Med 2016; 44:e790-6. [PMID: 27071067 DOI: 10.1097/ccm.0000000000001715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To quantify gallbladder dysfunction during critical illness. DESIGN Prospective observational comparison study of nutrient-stimulated gallbladder emptying in health and critical illness. SETTING Single-centre mixed medical/surgical ICU. PATIENTS Twenty-four mechanically ventilated critically ill patients suitable to receive enteral nutrition were compared with 12 healthy subjects. INTERVENTIONS Participants were studied after an 8-hour fast. Between 0 and 120 minutes, high-fat nutrient (20% intralipid) was infused via a postpyloric catheter into the duodenum at 2 kcal/min. MEASUREMENTS AND MAIN RESULTS Three-dimensional images of the gallbladder were acquired at 30-minute intervals from -30 to 180 minutes. Ejection fraction (%) was calculated as changes between 0 and 120 minutes. Blood samples were obtained at 30-minute intervals for plasma cholecystokinin. Data are mean (SD) or median [interquartile range]. In the critically ill, fasting gallbladder volumes (critically ill, 61 mL [36-100 mL] vs healthy, 22 mL [15-25] mL; p < 0.001] and wall thickness (0.45 mm [0.15 mm] vs 0.26 mm [0.08 mm]; p < 0.001] were substantially greater, and sludge was evident in the majority of patients (71% vs 0%). Nutrient-stimulated emptying was incomplete in the critically ill after 120 minutes but was essentially complete in the healthy individuals (22 mL [9-66 mL] vs 4 mL [3-5 mL]; p < 0.01]. In five critically ill patients (21%), there was no change in gallbladder volume in response to nutrient, and overall ejection fraction was reduced in the critically ill (50% [8-83%] vs 77 [72-84%]; p = 0.01]. There were no differences in fasting or incremental cholecystokinin concentrations. CONCLUSIONS Fasted critically ill patients have larger, thicker-walled gallbladders than healthy subjects and nutrient-stimulated gallbladder emptying is impaired with "gallbladder paresis" occurring in approximately 20%.
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Affiliation(s)
- Mark P Plummer
- 1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Medicine, Haukeland University Hospital, Bergen, Norway.4Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
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Kar P, Plummer MP, Chapman MJ, Cousins CE, Lange K, Horowitz M, Jones KL, Deane AM. Energy-Dense Formulae May Slow Gastric Emptying in the Critically Ill. JPEN J Parenter Enteral Nutr 2016; 40:1050-6. [PMID: 26038421 DOI: 10.1177/0148607115588333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/11/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. "Energy-dense formulae" (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy-dense formulae in critically ill patients. METHODS In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100-mL "meal" containing either standard calories (1 kcal/mL) or concentrated calories (energy-dense formulae; 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. RESULTS Forty patients were studied (n = 18, energy-dense formulae; n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy-dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy-dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. CONCLUSIONS In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.
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Affiliation(s)
- Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | | | - Kylie Lange
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
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Abstract
OBJECTIVE We aimed to review gastric dysmotility in critically ill children: 1) its pathophysiology, with a focus on critical care diseases and therapies that affect gastric motility, 2) diagnostic methodologies, and 3) current and future potential therapies. DATA SOURCES Eligible studies were identified from PubMed and MEDLINE. STUDY SELECTION Literature search included the following key terms: "gastric emptying," "gastric motility/dysmotility," "gastrointestinal motility/dysmotility," "nutrition intolerance," and "gastric residual volume." DATA EXTRACTION Studies since 1995 were extracted and reviewed for inclusion by the authors related to the physiology, pathophysiology, diagnostic methodologies, and available therapies for gastric emptying. DATA SYNTHESIS Delayed gastric emptying, a common presentation of gastric dysmotility, is present in up to 50% of critically ill children. It is associated with the potential for aspiration, ventilator-associated pneumonia, and inadequate delivery of enteral nutrition and may affect the efficacy of enteral medications, all of which may be result in poor patient outcomes. Gastric motility is affected by critical illness and its associated therapies. Currently available diagnostic tools to identify gastric emptying at the bedside have not been systematically studied and applied in this cohort. Gastric residual volume measurement, used as an indirect marker of delayed gastric emptying in PICUs around the world, may be inaccurate. CONCLUSIONS Gastric dysmotility is common in critically ill children and impacts patient safety and outcomes. However, it is poorly understood, inadequately defined, and current therapies are limited and based on scant evidence. Understanding gastric motility and developing accurate bedside measures and novel therapies for gastric emptying are highly desirable and need to be further investigated.
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Biberoglu E, Kirbas A, Iskender C, Dirican A, Daglar H, Demirtas C, Doganay B, Uygur D, Biberoglu K. Disturbed release of cholecystokinin in pregnant women with hyperemesis gravidarum. J Obstet Gynaecol Res 2014; 41:505-11. [PMID: 25331205 DOI: 10.1111/jog.12562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/06/2014] [Indexed: 01/15/2023]
Abstract
AIMS We aimed to investigate cholecystokinin (CCK) release in pregnant women with and without hyperemesis gravidarum (HG). MATERIAL AND METHODS In this case-control study including 40 pregnant women with HG and 40 women with healthy uncomplicated pregnancies, serum CCK levels in addition to hematological, biochemical and hormonal parameters were investigated. RESULTS Serum CCK values were found to be significantly lower in pregnant women with HG (P < 0.001). Additionally, while serum blood urea nitrogen and free thyroxine levels were significantly higher, sodium, potassium, and thyroid stimulating hormone levels were significantly lower in women with HG than in control women. No correlation was detected between CCK and other parameters like ketonuria and thyroid function tests. CONCLUSIONS CCK release has been found to be halved in pregnant women with HG, which supports the hypothesis that gastrointestinal motility is increased in pregnant women with HG. A causal effect remains to be confirmed.
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Affiliation(s)
- Ebru Biberoglu
- Department of Obstetrics and Gynecology, High Risk Pregnancy Unit, Dr. Zekai Tahir Burak Women's Health Care, Education and Research Hospital, Ankara, Turkey
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Nguyen NQ. Pharmacological therapy of feed intolerance in the critically ills. World J Gastrointest Pharmacol Ther 2014; 5:148-55. [PMID: 25133043 PMCID: PMC4133440 DOI: 10.4292/wjgpt.v5.i3.148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/24/2014] [Accepted: 05/31/2014] [Indexed: 02/06/2023] Open
Abstract
Feed intolerance in the setting of critical illness is associated with higher morbidity and mortality, and thus requires promptly and effective treatment. Prokinetic agents are currently considered as the first-line therapy given issues relating to parenteral nutrition and post-pyloric placement. Currently, the agents of choice are erythromycin and metoclopramide, either alone or in combination, which are highly effective with relatively low incidence of cardiac, hemodynamic or neurological adverse effects. Diarrhea, however, can occur in up to 49% of patients who are treated with the dual prokinetic therapy, which is not associated with Clostridium difficile infection and settled soon after the cessation of the drugs. Hence, the use of prokinetic therapy over a long period or for prophylactic purpose must be avoided, and the indication for ongoing use of the drug(s) must be reviewed frequently. Second line therapy, such as total parenteral nutrition and post-pyloric feeding, must be considered once adverse effects relating the prokinetic therapy develop.
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Bartz S, Mody A, Hornik C, Bain J, Muehlbauer M, Kiyimba T, Kiboneka E, Stevens R, Bartlett J, St Peter JV, Newgard CB, Freemark M. Severe acute malnutrition in childhood: hormonal and metabolic status at presentation, response to treatment, and predictors of mortality. J Clin Endocrinol Metab 2014; 99:2128-37. [PMID: 24606092 PMCID: PMC4037734 DOI: 10.1210/jc.2013-4018] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Malnutrition is a major cause of childhood morbidity and mortality. To identify and target those at highest risk, there is a critical need to characterize biomarkers that predict complications prior to and during treatment. METHODS We used targeted and nontargeted metabolomic analysis to characterize changes in a broad array of hormones, cytokines, growth factors, and metabolites during treatment of severe childhood malnutrition. Children aged 6 months to 5 years were studied at presentation to Mulago Hospital and during inpatient therapy with milk-based formulas and outpatient supplementation with ready-to-use food. We assessed the relationship between baseline hormone and metabolite levels and subsequent mortality. RESULTS Seventy-seven patients were enrolled in the study; a subset was followed up from inpatient treatment to the outpatient clinic. Inpatient and outpatient therapies increased weight/height z scores and induced striking changes in the levels of fatty acids, amino acids, acylcarnitines, inflammatory cytokines, and various hormones including leptin, insulin, GH, ghrelin, cortisol, IGF-I, glucagon-like peptide-1, and peptide YY. A total of 12.2% of the patients died during hospitalization; the major biochemical factor predicting mortality was a low level of leptin (P = .0002), a marker of adipose tissue reserve and a critical modulator of immune function. CONCLUSIONS We have used metabolomic analysis to provide a comprehensive hormonal and metabolic profile of severely malnourished children at presentation and during nutritional rehabilitation. Our findings suggest that fatty acid metabolism plays a central role in the adaptation to acute malnutrition and that low levels of the adipose tissue hormone leptin associate with, and may predict, mortality prior to and during treatment.
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Affiliation(s)
- Sarah Bartz
- Division of Pediatric Endocrinology and Diabetes (S.B., A.M., M.F.), the Pediatric Division of Quantitative Sciences and the Duke Clinical Research Institute (C.H.), the Sarah W. Stedman Nutrition and Metabolism Center (J.B., M.M., R.S., C.B.N., M.F.), and the Duke Global Health Institute (J.B., M.F.), Duke University Medical Center, Durham North Carolina 27705; the Mwanamugimu Nutrition Unit (T.K., E.K.), Mulago Hospital Complex, Kampala, Uganda; and Department of Global Research and Development (J.V.S.P.), Long Term Research, PepsiCo, Inc, Purchase, New York 10577
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Abstract
PURPOSE OF REVIEW To highlight the recent developments in nutritional support for critically ill patients. RECENT FINDINGS Increasing data support the benefits of early initiation of enteral nutrition, with improvements in small intestinal absorption and clinical outcomes. In contrast to the previous belief, recent data suggest caloric administration of greater than 65-70% of daily requirement is associated with poorer clinical outcomes, especially when supplemental parenteral nutrition is used to increase the amount of caloric delivery. The role of supplementary micronutrients and anti-inflammatory lipids has been further evaluated but remains inconclusive, and is not currently recommended. SUMMARY Together, current findings indicate that intragastric enteral nutrition should be initiated within 24 h of admission to ICU and supplementary parenteral nutrition should be avoided. Future research should aim to clarify the optimal energy delivery for best clinical outcomes, and the role of small intestinal function and its flora in nutritional care and clinical outcomes.
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Abnormal plasma peptide YY(3-36) levels in patients with liver cirrhosis. Nutrition 2012; 27:880-4. [PMID: 21819934 DOI: 10.1016/j.nut.2010.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 12/14/2010] [Accepted: 12/14/2010] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Peptide YY(3-36) (PYY(3-36)) is a gut hormone with anorectic action that also affects energy expenditure. Anorexia and malnutrition are often observed in patients with decompensated liver cirrhosis (LC), whereas patients with LC after insertion of transjugular portosystemic stent shunts (TIPS) show normal eating behavior. The underlying mechanism of anorexia in decompensated LC and its resolution in patients with TIPS is still unclear. We thus investigated fasting and postprandial PYY(3-36) serum levels in patients with decompensated LC, patients with compensated LC with in situ TIPS, and healthy controls. METHODS We analyzed fasting PYY(3-36) levels in six patients with decompensated LC (four men and two women, 55 ± 11 y of age), nine patients with TIPS (seven men and two women, 48 ± 11 y of age), and 10 controls (eight men and two women, 43 ± 9 y of age) postprandially after a standardized meal of 300 kcal and during 1-h continuous parenteral nutrition. Energy expenditure was determined by indirect calorimetry. RESULTS At baseline PYY(3-36) was comparable in controls and patients with TIPS (91 ± 10 and 89 ± 25 ng/L) but was increased in patients with decompensated LC (165 ± 44 ng/L, P < 0.01). Although the cumulative postprandial PYY(3-36) increase was similar in controls (mean 2089 ng/240 min per liter) and patients with decompensated LC (mean 1735 ng/240 min per liter), no postprandial PYY(3-36) increase was observed in patients with TIPS (mean -579 ng/240 min per liter). Parenteral nutrition did not significantly affect PYY(3-36) levels in any group. Fasting PYY(3-36) values were negatively related to resting energy expenditure (r = -0.443, P = 0.030). PYY(3-36) was not associated to liver parameters (e.g., bilirubin, alanine aminotransferase). CONCLUSION Our results demonstrate an abnormal neuroendocrine regulation of PYY(3-36) in patients with decompensated LC and those with TIPS.
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Chapman MJ, Nguyen NQ, Deane AM. Gastrointestinal dysmotility: clinical consequences and management of the critically ill patient. Gastroenterol Clin North Am 2011; 40:725-39. [PMID: 22100114 DOI: 10.1016/j.gtc.2011.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastrointestinal dysmotility is a common feature of critical illness, with a number of significant implications that include malnutrition secondary to reduced feed tolerance and absorption, reflux and aspiration resulting in reduced lung function and ventilator-associated pneumonia, bacterial overgrowth and possible translocation causing nosocomial sepsis. Prokinetic agent administration can improve gastric emptying and caloric delivery, but its effect on nutrient absorption and clinical outcomes is, as yet, unclear. Postpyloric delivery of nutrition has not yet been demonstrated to increase caloric intake or improve clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia.
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Gastrointestinal Hormone Concentrations Associated With Gastric Feeding in Critically Ill Patients. JPEN J Parenter Enteral Nutr 2011; 36:189-96. [DOI: 10.1177/0148607111413770] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Zeanandin G, Schneider SM, Hébuterne X. Intérêt des fibres en nutrition entérale en réanimation : de la théorie à la pratique. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0270-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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Nguyen NQ, Besanko LK, Burgstad CM, Burnett J, Stanley B, Butler R, Holloway RH, Fraser RJL. Relationship between altered small intestinal motility and absorption after abdominal aortic aneurysm repair. Intensive Care Med 2010; 37:610-8. [DOI: 10.1007/s00134-010-2094-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 10/18/2010] [Indexed: 12/13/2022]
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Khoo J, Rayner CK, Feinle-Bisset C, Jones KL, Horowitz M. Gastrointestinal hormonal dysfunction in gastroparesis and functional dyspepsia. Neurogastroenterol Motil 2010; 22:1270-8. [PMID: 20939851 DOI: 10.1111/j.1365-2982.2010.01609.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Numerous hormones secreted by the gut, during both the fasted state and in response to a meal, influence gastrointestinal motor and/or sensory function, and appear to contribute to the pathogenesis of delayed gastric emptying associated with gastroparesis, functional dyspepsia (FD) and feed intolerance in critical illness. Gut hormones are, accordingly, potential targets for the management of these patients. PURPOSE This article will discuss the hypersensitivity to enteral fat and endogenous (nutrient-stimulated) and exogenous cholecystokinin (CCK) in patients with FD, and the elevation in both fasting and postprandial CCK levels evident in this group. It will review the use of pharmacological agonists of motilin and ghrelin, which accelerate gastric emptying, in the management of gastroparesis and FD. The frequent finding of markedly delayed gastric emptying in the critically ill will be examined; this is associated with elevated plasma CCK and peptide YY in both the fasted and postprandial states, which may account for the increase in small intestinal nutrient inhibitory feedback on gastric motility in this group. The concepts that the rate of gastric emptying is a major determinant of postprandial glycemic excursions in diabetes, and that modulation of gastric emptying may improve glycemic control, will be addressed; in type 1 and insulin-treated type 2 diabetic patients, co-ordination of insulin administration with nutrient delivery and absorption should be optimized, while type 2 patients who are not on insulin are likely to respond to dietary and/or pharmacological interventions which slow gastric emptying.
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Affiliation(s)
- J Khoo
- Centre of Clinical Research Excellence in Nutritional Physiology, School of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, SA, Australia
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Fraser RJL, Bryant L. Current and future therapeutic prokinetic therapy to improve enteral feed intolerance in the ICU patient. Nutr Clin Pract 2010; 25:26-31. [PMID: 20130155 DOI: 10.1177/0884533609357570] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Malnutrition is associated with poor outcomes in critically ill patients, and providing enteral feeding to those who cannot eat is considered best practice. Enteral feeding is often unsuccessful when there is delayed gastric emptying. Recent research has given additional insight into the mechanisms underlying delayed gastric emptying. Pharmacological strategies to improve the success of feeding include prokinetic drugs such as metoclopramide and erythromycin alone or in combination. When drug treatment fails, either parenteral nutrition or direct small intestinal feeding is indicated. Simpler methods to access the duodenum and distal small bowel for feed delivery are under investigation. This review summarizes current understanding of the mechanisms underlying enteral feeding intolerance in critical illness, together with the evidence for current treatment practices. Areas requiring further research are also described.
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Affiliation(s)
- Robert J L Fraser
- Repatriation General Hospital, Daws Road, Daw Park, Adelaide 5041, South Australia.
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Parkman HP, Camilleri M, Farrugia G, McCallum RW, Bharucha AE, Mayer EA, Tack JF, Spiller R, Horowitz M, Vinik AI, Galligan JJ, Pasricha PJ, Kuo B, Szarka LA, Marciani L, Jones K, Parrish CR, Sandroni P, Abell T, Ordog T, Hasler W, Koch KL, Sanders K, Norton NJ, Hamilton F. Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting. Neurogastroenterol Motil 2010; 22:113-33. [PMID: 20003077 PMCID: PMC2892213 DOI: 10.1111/j.1365-2982.2009.01434.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders. PURPOSE This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.
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Affiliation(s)
- H P Parkman
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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Libert N, De Rudnicki S, Cirodde A, Janvier F, Leclerc T, Borne M, Brinquin L. [Promotility drugs use in critical care: indications and limits?]. ACTA ACUST UNITED AC 2009; 28:962-75. [PMID: 19910155 DOI: 10.1016/j.annfar.2009.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 08/20/2009] [Indexed: 02/08/2023]
Abstract
Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.
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Affiliation(s)
- N Libert
- Département d'anesthésie réanimation, hôpital d'instruction des armées du Val-de-Grâce,74, boulevard de Port-Royal, 750005 Paris, France.
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24
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Nguyen NQ, Fraser RJ, Bryant LK, Burgstad C, Chapman MJ, Bellon M, Wishart J, Holloway RH, Horowitz M. The impact of delaying enteral feeding on gastric emptying, plasma cholecystokinin, and peptide YY concentrations in critically ill patients. Crit Care Med 2008; 36:1469-74. [PMID: 18434906 DOI: 10.1097/ccm.0b013e31816fc457] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enteral nutrient (EN) deprivation slows gastric emptying (GE) and increases plasma cholecystokinin (CCK) concentrations in healthy humans and may potentially contribute to the delayed GE in the critically ill. This study examined the impact of delayed feeding on GE, plasma CCK, and peptide YY (PYY) concentrations in the critically ill. DESIGN Randomized controlled trial. SETTING Mixed medical and surgical intensive care unit (ICU). INTERVENTIONS Twenty-eight critically ill patients were randomized to receive EN either within 24 hrs of admission ("early feeding": 54.9 +/- 3.3 yrs; Acute Physiology and Chronic Health Evaluation (APACHE) II = 23.0 +/- 1.8) or on day 4 of admission after GE assessment ("delayed feeding": 56.1 +/- 4.2 yrs, APACHE II = 21.7 +/- 1.8). GE of 100 ml of Ensure was measured using scintigraphy on day 4 of admission. Blood was sampled for measurement of plasma CCK, PYY, and glucose concentrations. RESULTS Demographics, APACHE II score, use of inotrope and morphine sedation were similar between the groups. The mean administered/prescribed caloric ratio in the "early feeding" group was 72 +/- 4%. There were no differences in the retention of meal, intragastric meal distribution, proportion of patients with delayed GE (9/14 vs. 9/14), and plasma CCK and PYY concentrations during fasting and postprandially between the two groups. There was no relationship between the number of calories received and percentage of meal retention at 240 min (p > .05). However, delayed feeding was associated with longer duration of mechanical ventilations (13.7 +/- 1.9 vs. 9.2 +/- .9 days, p = .049) and length of stay in ICU (15.9 +/- 1.9 vs. 11.3 +/- 0.8 days, p = .048), but no difference in mortality. CONCLUSIONS In critical illness, delayed enteral feeding appears to have little impact on either GE or the enterogastric feedback hormones. However, the association between delayed feeding and increased duration of ventilation and length of stay in the ICU supports the current recommendation that enteral nutrition should be commenced early.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, South Australia.
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Nguyen NQ, Fraser RJ, Bryant LK, Chapman M, Holloway RH. Diminished functional association between proximal and distal gastric motility in critically ill patients. Intensive Care Med 2008; 34:1246-55. [PMID: 18297265 DOI: 10.1007/s00134-008-1036-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 12/27/2007] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study examined the effects of critical illness on the relationship between proximal and distal gastric motor activity during fasting and duodenal nutrient stimulation. DESIGN Prospective, case-controlled study. PATIENTS AND PARTICIPANTS Ten critically ill patients and ten healthy volunteers. INTERVENTIONS Concurrent proximal gastric (barostat) and antro-pyloro-duodenal (manometry) motility were recorded during fasting and during two 60-min duodenal nutrient infusions (Ensure at 1 kcal/min and 2 kcal/min) in random order, separated by a 2-h wash-out period. RESULTS Baseline proximal gastric volumes were similar between the two groups. At 10 min nutrient-induced fundic relaxation was lower in patients than healthy subjects (45 +/- 26 vs. 196 +/- 29 ml). In patients the frequency and volume amplitude of fundic waves were also lower. There were fewer propagated antral waves in patients than in healthy subjects during both fasting and nutrient infusion. These were more retrograde, shorter in length and associated with a pyloric contraction. The proportion of fundic waves followed by a distally propagated antral wave was significantly less in patients (0%, 0-8%) than controls 36% (11-44%). CONCLUSIONS In critical illness, in addition to impairment of proximal and distal gastric motor activity, the association between the two gastric regions is abnormal. This disturbance may interfere with meal distribution and further contribute to slow gastric emptying in these patients.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, SA, Australia.
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Nguyen NQ, Fraser RJ, Bryant LK, Chapman MJ, Wishart J, Holloway RH, Butler R, Horowitz M. The relationship between gastric emptying, plasma cholecystokinin, and peptide YY in critically ill patients. Crit Care 2007; 11:R132. [PMID: 18154642 PMCID: PMC2246231 DOI: 10.1186/cc6205] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Revised: 11/23/2007] [Accepted: 12/21/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cholecystokinin (CCK) and peptide YY (PYY) are released in response to intestinal nutrients and play an important physiological role in regulation of gastric emptying (GE). Plasma CCK and PYY concentrations are elevated in critically ill patients, particularly in those with a history of feed intolerance. This study aimed to evaluate the relationship between CCK and PYY concentrations and GE in critical illness. METHODS GE of 100 mL of Ensure meal (106 kcal, 21% fat) was measured using a 13C-octanoate breath test in 39 mechanically ventilated, critically ill patients (24 males; 55.8 +/- 2.7 years old). Breath samples for 13CO2 levels were collected over the course of 4 hours, and the GE coefficient (GEC) (normal = 3.2 to 3.8) was calculated. Measurements of plasma CCK, PYY, and glucose concentrations were obtained immediately before and at 60 and 120 minutes after administration of Ensure. RESULTS GE was delayed in 64% (25/39) of the patients. Baseline plasma CCK (8.5 +/- 1.0 versus 6.1 +/- 0.4 pmol/L; P = 0.045) and PYY (22.8 +/- 2.2 versus 15.6 +/- 1.3 pmol/L; P = 0.03) concentrations were higher in patients with delayed GE and were inversely correlated with GEC (CCK: r = -0.33, P = 0.04, and PYY: r = -0.36, P = 0.02). After gastric Ensure, while both plasma CCK (P = 0.03) and PYY (P = 0.02) concentrations were higher in patients with delayed GE, there was a direct relationship between the rise in plasma CCK (r = 0.40, P = 0.01) and PYY (r = 0.42, P < 0.01) from baseline at 60 minutes after the meal and the GEC. CONCLUSION In critical illness, there is a complex interaction between plasma CCK, PYY, and GE. Whilst plasma CCK and PYY correlated moderately with impaired GE, the pathogenetic role of these gut hormones in delayed GE requires further evaluation with specific antagonists.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000
| | - Robert J Fraser
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000
- Investigation and Procedures Unit, Repatriation General Hospital, Daw Road, Adelaide, South Australia, 5000
| | - Laura K Bryant
- Investigation and Procedures Unit, Repatriation General Hospital, Daw Road, Adelaide, South Australia, 5000
| | - Marianne J Chapman
- Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, Adelaide, South Australia, 5000
| | - Judith Wishart
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000
| | - Richard H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000
| | - Ross Butler
- Centre for Paediatric and Adolescent Gastroenterology, Children, Youth and Women's Health Service, Adelaide, South Australia, 5000
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000
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