Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.
Danone Nutricia Research, Specialized Nutrition, Utrecht, the Netherlands.
Clin Nutr. 2021 May;40(5):2663-2672. doi: 10.1016/j.clnu.2021.03.021. Epub 2021 Apr 2.
BACKGROUND & AIMS: Enteral nutrition with polymeric intact protein formula is the preferred medical nutrition strategy in critically ill patients when oral intake is insufficient. Enteral nutrition formulas are often rich in casein protein, which has coagulating properties. Coagulation in the stomach impedes gastric emptying and might result in high gastric residual volumes which are a clinical sign of gastrointestinal intolerance and a major reason to decrease or to discontinue enteral feeding. In this study the impact of protein composition of enteral formula on gastric content volume (GCV) during and after continuous feeding was tested in healthy volunteers in whom gastrointestinal conditions of critically ill patients were mimicked.
An enteral formula including 4 proteins (P4) with non-coagulating properties was compared to a casein-dominant formula (Cas) with coagulating properties. Esomeprazole and codeine were administered to mimic stress ulcer prophylaxis and induce gastroduodenal motor dysfunction, both being hallmarks of critically ill patients. GCV was measured with magnetic resonance imaging during and after continuous enteral feeding (100 mL/h for 4h) in a randomized single-center cross-over study. Results are provided as mean (SD). Significance level of p < 0.05 was applied.
Twenty subjects completed the study (14 women, 6 men, 25.8 (4.6) years old, BMI: 22.5 (1.5) kg/m). The GCV as change from baseline at T = 240 (primary endpoint) did not differ between study products (P4: 124.3 (83.4) vs. Cas: 137.1 (102.0) mL, 95% CI: -57.4, 27.0, p = 0.457). During feeding and after cessation of feeding, the area under the GCV-curve (AUC GCV) for P4 and Cas was 44631.1 (15546.1) and 52822.2 (19686.1) mL∗min, respectively (p = 0.061). During feeding the GCV was lower at T = 180 min (175.4 (64.8) vs. 205.2 (75.4) mL, p = 0.038) and after cessation of feeding at T = 300 min (81.3 (71.1) vs. 116.3 (84.3) mL, p = 0.004) and T = 330 min (39.9 (53.9) vs. 73.6 (81.1) mL, p = 0.031). With P4 it took less time to reach half of the GCV at T = 240 min compared to Cas (52.8 (27.6) vs. 65.4 (29.9) min, p = 0.020).
In this study in which healthy volunteers received esomeprazole and codeine to mimic gastrointestinal conditions of critically ill patients, observations of secondary endpoints suggest faster gastric emptying with P4 compared to Cas, and less gastric accumulation, possibly due to the non-coagulating properties of the P4 protein blend. Considering the small effect and the possible clinical relevance of reduced intragastric accumulation of enteral nutrition, the potential impact of protein coagulation should be further investigated in relevant study populations. Registered under Netherlands Trial Register identifier no. NTR6423.
在口服摄入不足的情况下，肠内营养采用聚合完整蛋白配方是危重症患者首选的医学营养策略。肠内营养配方通常富含酪蛋白，具有凝结特性。胃中的凝结会阻碍胃排空，并可能导致高胃残留量，这是胃肠道不耐受的临床标志，也是减少或停止肠内喂养的主要原因。在这项研究中，我们在模拟危重症患者胃肠道状况的健康志愿者中测试了肠内配方的蛋白质组成对连续喂养期间和之后胃内容物量（GCV）的影响。
将一种包含 4 种非凝结特性蛋白质的肠内配方（P4）与具有凝结特性的酪蛋白主导配方（Cas）进行比较。给予埃索美拉唑和可待因以模拟应激性溃疡预防和诱导胃十二指肠动力障碍，这两者都是危重症患者的特征。在一项随机单中心交叉研究中，通过磁共振成像（MRI）在连续肠内喂养（4 小时内 100 mL/h）期间和之后测量 GCV。结果以平均值（标准差）表示。p < 0.05 为显著性水平。
20 名受试者完成了这项研究（14 名女性，6 名男性，年龄 25.8（4.6）岁，BMI：22.5（1.5）kg/m²）。主要终点 T=240 时的 GCV 与基线相比没有差异（P4：124.3（83.4）vs. Cas：137.1（102.0）mL，95%CI：-57.4，27.0，p=0.457）。在喂养期间和停止喂养后，P4 和 Cas 的 GCV 曲线下面积（GCV-AUC）分别为 44631.1（15546.1）和 52822.2（19686.1）mL*min，差异无统计学意义（p=0.061）。在 T=180 分钟时，GCV 较低（175.4（64.8）vs. 205.2（75.4）mL，p=0.038），在 T=300 分钟时（81.3（71.1）vs. 116.3（84.3）mL，p=0.004）和 T=330 分钟时（39.9（53.9）vs. 73.6（81.1）mL，p=0.031）。与 Cas 相比，P4 达到 GCV 一半所需的时间更短，T=240 分钟时为 52.8（27.6）分钟，T=65.4（29.9）分钟，p=0.020）。
在这项研究中，健康志愿者接受埃索美拉唑和可待因以模拟危重症患者的胃肠道状况，观察次要终点的结果表明，与 Cas 相比，P4 使胃排空更快，胃内积聚减少，这可能是由于 P4 蛋白质混合物的非凝结特性所致。考虑到减少肠内营养胃内积聚的小效应和可能的临床相关性，应在相关研究人群中进一步研究蛋白质凝结的潜在影响。在荷兰试验注册处注册，编号为 NTR6423。
