FERMENTABLE CARBOHYDRATES AND ENTERAL NUTRITION INTOLERANCE: A RETROSPECTIVE STUDY IN CRITICALLY ILL PATIENTS
Abstract
Objective. The aim of our study is to observe whether FODMAP content of EN is associated with either diarrhea, distention or gastric residual volumes in critically ill patients. Background. The role of enteral nutrition (EN) in the critically ill patient has been well established as it maintains gut integrity and is associated with improved outcomes and decreased morbidity. Intolerance to enteral nutrition (EN) is a common problem and is usually manifested as diarrhea, distention and elevated gastric residual volume. When this occurs, EN is often held or infused at a lower rate which causes calorie deficits, further compromising outcomes. Multiple factors including osmolality and ingredients of enteral formula need to be considered when assessing EN intolerance. Recently short chain carbohydrates known as FODMAPs (Fermentable Olgio Di- Mono- Saccharides And Polyols) has been shown to be associated with increased risk of intolerance. In colonic bacterial environment the FODMAPs produce rapidly fermentable substrate generating excessive amount of gas with characteristic symptoms including abdominal pain, discomfort, bloating, distention and altered bowel habits. Hamos et al demonstrated that hospitalized patients receiving Isosource 1.5 (an enteral formula with a lower FODMAP content) had a considerable reduction in risk of developing diarrhea. Methods. This retrospective observational study was approved by the Intstitutional Review Board of Mount Sinai Medical Center, Miami Beach Florida. The electronic health record, of all ICU admissions that were either on Peptamen AF ® or Replete ® from July 2012 through September 2013 were reviewed. Patients on EN for three or more consecutive days were included. Diarrhea was defined as one episode of loose or watery stool and/ or three or more stools within a twenty four hour period regardless of consistency. Distension was defined as a distended and/ or firm abdomen as reported in the nursing or dietitian record. Gastric residual was counted if the volume was greater than 250 cc on at least one occasion. Formulas were assigned to patients based on the preference of the physician or dietitian. Peptamen AF ® contains 5.2 g/ L of FODMAPs which consist of inulin (1.6 g/ L) and fructooligosaccharides (3.6 g/ L), while Replete ® does not contain any. Results. Among 221 patients the incidence of gastric residuals was higher in the Peptamen AF® group (18.9% vs 9.2%, P < 0.05, odds ratio (OR) of 2.31). There was no significant difference in the occurrence of either diarrhea (P=0.847) or distension (P=0.087). We observed increased occurrence of diarrhea with longer duration of EN (P<0.05, OR 1.05). Abdominal distension was associated with renal replacement therapy (RRT) (P<0.05, OR 2.906), and gastric residuals was predicted by inotropes (P<0.05, OR 4.047) and RRT (P=0.05, OR 3.014). Logistic regression failed to show any significant differences in diarrhea, distension, or gastric residuals between the two groups. Conclusion. Duration of enteral nutrition, RRT and inotropes were significant independent predictors of EN intolerance. Although FODMAPs have been associated with diarrhea, it does not influence EN intolerance in critically ill patients. This observation may be influenced by multiple variables increasing the risk for gastric intolerance. Further prospective studies are warranted in this unique population to evaluate the causes of intolerance. Grants. No grants to disclose
FERMENTABLE CARBOHYDRATES AND ENTERAL NUTRITION INTOLERANCE: A RETROSPECTIVE STUDY IN CRITICALLY ILL PATIENTS
POSTER PRESENTATIONS
Objective. The aim of our study is to observe whether FODMAP content of EN is associated with either diarrhea, distention or gastric residual volumes in critically ill patients. Background. The role of enteral nutrition (EN) in the critically ill patient has been well established as it maintains gut integrity and is associated with improved outcomes and decreased morbidity. Intolerance to enteral nutrition (EN) is a common problem and is usually manifested as diarrhea, distention and elevated gastric residual volume. When this occurs, EN is often held or infused at a lower rate which causes calorie deficits, further compromising outcomes. Multiple factors including osmolality and ingredients of enteral formula need to be considered when assessing EN intolerance. Recently short chain carbohydrates known as FODMAPs (Fermentable Olgio Di- Mono- Saccharides And Polyols) has been shown to be associated with increased risk of intolerance. In colonic bacterial environment the FODMAPs produce rapidly fermentable substrate generating excessive amount of gas with characteristic symptoms including abdominal pain, discomfort, bloating, distention and altered bowel habits. Hamos et al demonstrated that hospitalized patients receiving Isosource 1.5 (an enteral formula with a lower FODMAP content) had a considerable reduction in risk of developing diarrhea. Methods. This retrospective observational study was approved by the Intstitutional Review Board of Mount Sinai Medical Center, Miami Beach Florida. The electronic health record, of all ICU admissions that were either on Peptamen AF ® or Replete ® from July 2012 through September 2013 were reviewed. Patients on EN for three or more consecutive days were included. Diarrhea was defined as one episode of loose or watery stool and/ or three or more stools within a twenty four hour period regardless of consistency. Distension was defined as a distended and/ or firm abdomen as reported in the nursing or dietitian record. Gastric residual was counted if the volume was greater than 250 cc on at least one occasion. Formulas were assigned to patients based on the preference of the physician or dietitian. Peptamen AF ® contains 5.2 g/ L of FODMAPs which consist of inulin (1.6 g/ L) and fructooligosaccharides (3.6 g/ L), while Replete ® does not contain any. Results. Among 221 patients the incidence of gastric residuals was higher in the Peptamen AF® group (18.9% vs 9.2%, P < 0.05, odds ratio (OR) of 2.31). There was no significant difference in the occurrence of either diarrhea (P=0.847) or distension (P=0.087). We observed increased occurrence of diarrhea with longer duration of EN (P<0.05, OR 1.05). Abdominal distension was associated with renal replacement therapy (RRT) (P<0.05, OR 2.906), and gastric residuals was predicted by inotropes (P<0.05, OR 4.047) and RRT (P=0.05, OR 3.014). Logistic regression failed to show any significant differences in diarrhea, distension, or gastric residuals between the two groups. Conclusion. Duration of enteral nutrition, RRT and inotropes were significant independent predictors of EN intolerance. Although FODMAPs have been associated with diarrhea, it does not influence EN intolerance in critically ill patients. This observation may be influenced by multiple variables increasing the risk for gastric intolerance. Further prospective studies are warranted in this unique population to evaluate the causes of intolerance. Grants. No grants to disclose