Doola Ra'eesa, Deane Adam M, Tolcher Debbie M, Presneill Jeffrey J, Barrett Helen L, Forbes Josephine M, Todd Alwyn S, Okano Satomi, Sturgess David J
Mater Health Services, Mater Research Institute, The University of Queensland, Australia.
The Royal Melbourne Hospital, The University of Melbourne, Mater Research Institute, The University of Queensland, Australia.
Clin Nutr ESPEN. 2019 Jun;31:80-87. doi: 10.1016/j.clnesp.2019.02.013. Epub 2019 Mar 11.
Enteral nutrition is a source of carbohydrate that may exacerbate hyperglycaemia. Its treatment, insulin, potentially exacerbates glycaemic variability.
This was a prospective, parallel group, blinded, randomised feasibility trial. Patients were eligible if 18 years or over when admitted to the intensive care unit and receiving enteral nutrition (EN) exclusively with two consecutive blood glucose > 10 mmol/L. A standardized glucose management protocol determined administration of insulin. Key outcome measures were insulin administered and glycaemic variability (coefficient of variation) over the first 48 h.
41 patients were randomized to either standard EN (14.1 g/100 mL carbohydrate; n = 20) or intervention EN (7.4 g/100 mL carbohydrate; n = 21). Overall 59% were male, mean (±SD) age of 62.3 years ± 10.4, APACHE II score of 16.5 ± 7.8 and a median (IQR) Body Mass Index 29.0 kg/m (25.2-35.5). Most patients (73%) were mechanically ventilated. Approximately half (51%) were identified as having diabetes prior to ICU admission. Patients in the intervention arm received less insulin over the 48 h study period than those in the control group (mean insulin units over study period (95% CI) 45.0 (24.4-68.7) vs. 107 (56.1-157.9) units; p = 0.02) and had lower mean glycaemic variability (12.6 vs. 15.9%, p = 0.01). There was a small difference in the mean percentage of energy requirements met (intervention: 72.9 vs. control: 79.1%; p = 0.4) or protein delivered (78.2 vs. 85.4%; p = 0.3).
A low carbohydrate formula was associated with reduced insulin use and glycaemic variability in enterally-fed critically ill patients with hyperglycaemia. Further large trials are required to determine the impact of this formula on clinical outcomes. Registered under Australian and New Zealand Clinical Trials Registry, ANZCTR number: 12614000166673.
肠内营养是碳水化合物的一个来源，可能会加重高血糖。其治疗药物胰岛素可能会加剧血糖变异性。
这是一项前瞻性、平行组、盲法、随机可行性试验。入选患者需满足入住重症监护病房时年满18岁且仅接受肠内营养（EN），同时连续两次血糖>10 mmol/L。采用标准化血糖管理方案来确定胰岛素的给药。主要结局指标为头48小时内的胰岛素给药量和血糖变异性（变异系数）。
41例患者被随机分为标准EN组（碳水化合物含量14.1 g/100 mL；n = 20）或干预EN组（碳水化合物含量7.4 g/100 mL；n = 21）。总体上，59%为男性，平均（±标准差）年龄62.3岁±10.4岁，急性生理与慢性健康状况评分系统（APACHE II）评分为16.5±7.8，体重指数中位数（四分位间距）为29.0 kg/m²（25.2 - 35.5）。大多数患者（73%）接受机械通气。约一半（51%）患者在入住重症监护病房前被确诊患有糖尿病。在48小时研究期间，干预组患者接受的胰岛素量少于对照组（研究期间平均胰岛素单位数（95%置信区间）：45.0（24.4 - 68.7）单位 vs. 107（56.1 - 157.9）单位；p = 0.02），且血糖变异性均值较低（12.6% vs. 15.9%，p = 0.01）。在满足能量需求的平均百分比（干预组：72.9% vs. 对照组：79.1%；p = 0.4）或蛋白质供给量（78.2% vs. 85.4%；p = 0.3）方面存在微小差异。
对于接受肠内营养的高血糖重症患者，低碳水化合物配方与胰岛素使用减少及血糖变异性降低相关。需要进一步开展大型试验来确定该配方对临床结局的影响。在澳大利亚和新西兰临床试验注册中心注册，注册号：ANZCTR number: 12614000166673 。
