- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04101071
Alternative Substrates in the Critically Ill Subject (ASICS)
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Aggressive muscle wasting occurs early in critical illness, and is associated with a greater number of days on a ventilator, increased length of intensive care unit (ICU) and/or hospital stay, and subsequent functional impairment which may last years. Hospital care costs, and ongoing costs of community-based primary healthcare utilisation, are increased. No known interventions prevent this wasting.
Bioenergetic failure in critical illness and the potential for alternative substrate use:
Muscle protein synthesis is highly energy-dependent.The bioenergetic state of the critically-ill patient is compromised leading to decreased Adenosine Tri-Phosphate (ATP) synthesis. Alterations in mitochondrial function have been described repeatedly in the literature which, with other altered cellular processes, impair the utlilisation of metabolic substrates for ATP production.
Carbohydrate utilisation is impaired in critical illness, partly through impaired nuclear-to-membrane translocation of glucose transporter-4 and increased insulin resistance. Hypoxia signalling and inflammation block activity of pyruvate dehydrogenase by upregulation of pyruvate dehydrogenase kinase, increasing glucose availability thus driving pyruvate metabolism to lactate - the Pasteur effect.
The investigator's recently published data suggest that critical illness also impairs mitochondrial oxidation of fatty acids in skeletal muscle, and that the majority of lipids delivered in feed are not utilized for ATP production. This may be of clinical importance, given that lipids contribute 29-43% of the energy content of enteral, and 50% of parenteral, formulae. Lastly, oxidation of amino acids may produce ATP. However, this is not necessarily in the best interest of the patient: these amino acids are then no longer available for muscle protein synthesis. Further, most amino acid oxidation results in pyruvate production and therefore the same issues as those related to carbohydrate metabolism apply. Provision of a new metabolic substrate such as Ketone Bodies (KBs) may address these limitations.
Potential for Muscle Sparing Offered by Ketone Bodies:
During periods of starvation they may provide up to 50% of total body basal energy, enabling the high energy requirement of human brain to be met whilst sparing muscle. Additionally KBs may act as metabolic modulators, improving mitochondrial efficiency (also impaired by critical illness), and reducing reactive oxygen species and free radical formation. They also have anti-inflammatory effects (intramuscular inflammation is a driver of altered protein homeostasis, and anti-apoptotic activity. Together, these additional mechanistic effects may prove useful in ameliorating skeletal muscle wasting. Further, pilot data demonstrate a significant decrease in the plasma concentrations of beta-hydroxybutyrate and acetoacetate in early critical illness, consistent with increased KB uptake and utilisation early in critical illness.
Ketone bodies have diverse extra-mitochondrial metabolic effects. These include immune enhancement functions: specifically, to bacterial infection. Infection and inflammation are drivers of muscle wasting and amelioration of these may impact on this and other outcome measures. Thus, the critically ill patient may benefit from a ketogenic diet which have been used safely in other population groups, including healthy subjects the obese, and in patients with trauma, epilepsy, cardiovascular disease, Type-2 diabetes and Metabolic Diseases.
The objectives/aims are to:
- Show that it is possible to recruit patients to receive a ketogenic feed
- Show that it is possible for researchers to reconstitute the modular ketogenic feed on ICU.
- Show that it is possible to administer ketogenic feed to ICU patients without ill effect.
- Characterise the time-course of ketone generation (and related changes in related metabolic pathways) in response to the ketogenic feed.
- Show that collection of outcome measures relevant for the subsequent substantive study will be feasible.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
-
Bristol, United Kingdom, BS2 8HW
- Bristol Royal Infirmary
-
London, United Kingdom, E1 1BB
- Royal London Hospital
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- 18 years or older
- due to receive enteral nutrition via nasogastric or nasojejunal tube as part of routine care
- mechanically ventilated and likely to remain so for >48 hours
- likely to remain on the ICU for >5 days
- likely to survive for at least 10 days and
- multi-organ failure (Sequential Organ Failure Assessment Score [SOFA] score >2 in 2 or more domains).
Exclusion Criteria:
- primary neuromyopathy or significant neurological impairment at the time of ICU admission that would preclude physical activity
- uni- or bilateral lower limb amputation
- requiring sole or supplemental parenteral nutrition
- need for specialist nutritional intervention
- patients with known inborn errors of metabolism
- participation in another clinical trial
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Other
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Modular ketogenic enteral feed
Ketogenic enteral feed to be administered continuously for 10 days.
|
Dietician prescribed, and consisting of Betaquik® (from Vitaflo, Nutritional company) to provide medium chain triglycerides), Renapro Shot® (protein), Maxijul® (carbohydrate) and multivitamins according to nutritional need (energy and protein requirements) based on clinical status of the participant.
Ketogenic feed to be given continuously via nasogastric tube for 10 days
|
Active Comparator: Standard enteral feed
Standard enteral feed to be administered continuously for 10 days.
|
Standard Enteral feed.
Dietician prescribed based on clinical status of the participant, as per individual Trust protocols.
Standard feed to be given continuously via nasogastric tube for 10 days
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Feasibility of patient recruitment; number eligible from screening
Time Frame: 15 months
|
Number of patients screened
|
15 months
|
Feasibility of patient recruitment; percentage eligible from screening
Time Frame: 15 months
|
Percentage of patients eligible for recruitment
|
15 months
|
Feasibility of patient recruitment; number from consent process
Time Frame: 15 months
|
Number of eligible patients able to be consented to join the study
|
15 months
|
Feasibility of patient recruitment: percentage from consent process
Time Frame: 15 months
|
Percentage of eligible patients able to be consented to join the study
|
15 months
|
Feasibility of patient retention during the 10 day study period: number of participants
Time Frame: 15 months
|
Number of participants retained for the 10 day study; reasons for withdrawal analysed by descriptive statistics
|
15 months
|
Feasibility of patient retention during the 10 day study period; percentage of participants
Time Frame: 15 months
|
Percentage of participants retained for the 10 day study; reasons for withdrawal analysed by descriptive statistics
|
15 months
|
Feasibility of provision of ketogenic feed: staff-completed questionnaire
Time Frame: 15 months
|
Non-validated questionnaire to be completed by ICU bedside nurses and critical care research nurses within 2 weeks of recruitment completing.
12 questions will ask about ease of reconstituting and using the feed and any side effects encountered.
Each question will be scored on a scale of 0-10 with 0 the worst/lowest score and 10 the best/highest score.
The results for each question will be presented individually using descriptive statistics as mean +/- standard deviation, with a text description adding any comments received.
|
15 months
|
Incidence of Adverse Events/Serious Adverse Events, gastric intolerance, glucose variation
Time Frame: 15 months
|
Percentage of days event occurred out of total possible days (mean +/- 95% confidence interval): pulmonary aspiration; vomiting, diarrhea (Bristol Stool Score T5-T7), prokinetics use, gastric residual volume >300mls; adverse blood glucose levels of >10.1mmol/l and <3.9mmol/l; Daily insulin use.
|
15 months
|
Coefficient of Glucose Variation (scored as mean/standard deviation)
Time Frame: 15 months
|
Coefficient of Glucose Variation (scored as mean/standard deviation)
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed; beta-hydroxybutyrate
Time Frame: 15 months
|
Plasma levels of beta-hydroxybutyrate: mmol/l
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed; acetoacetate
Time Frame: 15 months
|
Plasma levels of acetoacetate mmol/l
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed; pyruvate
Time Frame: 15 months
|
Plasma levels of pyruvate mmol/l
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed, fat
Time Frame: 15 months
|
Plasma levels of fat (ratio of Medium Chain to Long Chain Triglyceride)
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed, glucose
Time Frame: 15 months
|
Plasma levels of glucose mmol/l
|
15 months
|
Timescale for the development and establishment of ketosis during 10 days of intervention or control feed, lactate
Time Frame: 15 months
|
Plasma levels of lactate mmol/l
|
15 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data: blood gases
Time Frame: 15 months
|
Arterial Blood Gases, pH, PaO2 and PaCO2 in kPa
|
15 months
|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data; biochemistry
Time Frame: 15 months
|
Bicarbonate, Base Excess, Lactate, other biochemistry data in mmol/l
|
15 months
|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data; haematology
Time Frame: 15 months
|
Hematology data (Hb in g/l, White cell count and platelets in 10 to power of 9/l)
|
15 months
|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data; bedside physiology
Time Frame: 15 months
|
Bedside Physiology (BP, HR, SOFA score, Fluid Balance)
|
15 months
|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data; nutritional data
Time Frame: 15 months
|
Nutritional data (Protein g/kg/day and Energy kcal/kg/day
|
15 months
|
Feasibility of data collection into electronic database from medical notes and nursing sheets as assessed by completion of >80% of available data; Propofol
Time Frame: 15 months
|
Propofol dose (mg/day)
|
15 months
|
Feasibility of performing quadriceps ultrasound scans: muscle mass
Time Frame: 15 months
|
Ultrasound scans of rectus femoris part of quadriceps muscle as a measure of muscle mass
|
15 months
|
Feasibility of performing functional assessment at hospital discharge by Two- or Six-Minute Walk Test
Time Frame: 15 months
|
Two minute or Six-Minute Walk Test (depending on patient capability) captures all the walking distance that a patient can demonstrate (in metres)
|
15 months
|
Feasibility of performing functional assessment at hospital discharge by Short Physical Performance Battery
Time Frame: 15 months
|
Short Physical Performance Battery (scoring between 0-10; includes results of the gait speed, balance tests and chair stand)
|
15 months
|
Feasibility of performing functional assessment at hospital discharge by CPAx score
Time Frame: 15 months
|
Chelsea Critical Care Physical Assessment Score (CPAx): scoring 0-5 in 10 domains
|
15 months
|
Feasibility of collecting metabolic data on ICU: indirect calorimetry
Time Frame: 15 months
|
non-invasive metabolic data via indirect calorimetry on ICU
|
15 months
|
Feasibility of collecting follow-up data by telephone re quality of life: ED5Q survey
Time Frame: 18 months
|
Use of ED5Q survey to determine health-related quality of life; scoring 1-5 in 5 domains, plus 1-100 in 1 domain
|
18 months
|
Feasibility of collecting follow-up data by telephone re job status: Questions on employment status
Time Frame: 18 months
|
Questions on employment status (full-time: yes/no; part-time: yes/no)
|
18 months
|
Feasibility of collecting follow-up data from medical records: number of GP/nurse visits
Time Frame: 18 months
|
Information on health care resource usage from number of GP/nurse visits during 12 months post-ICU and hospital discharge
|
18 months
|
Biochemical analysis of urine
Time Frame: 18 months
|
To determine urinary concentrations of beta-hydroxybutyrate and total nitrogen (in mmol/l)
|
18 months
|
Biochemical analysis of plasma metabolites, beta-hydroxy butyrate, acetoacetate, leucine, and alanine (all measured in the same Arbitrary Units [AU]).
Time Frame: 18 months
|
Investigation into beta-hydroxy butyrate, acetoacetate, leucine, and alanine (all measured in the same Arbitrary Units [AU]) by HPLC; NMR spectra will be phased, baseline corrected, zero filled and referenced prior to multivariate analysis.
Multivariate techniques will include principal components analysis (PCA) and prediction and regression using partial least squared discriminant analysis (PLS-DA).
Owing to the high variability expected in this data set, orthogonal projection to latent structures (OPLS) will be utilised to maximise the variation in the intervention under study.
Given the high number of metabolites expected to be seen, statistical total correlation spectroscopy (STOCSY) will be utilised to detect endogenous responses.
|
18 months
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Angela McNelly, PhD, Royal London Hospital
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 266031
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
(i) Where practicable, publicly funded research data should be made available for access, subject to such conditions as are necessary to ensure compliance with legal, data protection, ethical, confidentiality, intellectual property protection, and security/funder obligations.
(ii) The rights of researchers to the exclusive use of research data that they generate as part of a well-defined research project will be protected up until the point of publication or public availability.
(iii) Data arising from this research involving human subjects will be anonymised so that it will not be possible to identify any individuals. Where it appears inappropriate to make such data accessible, e.g. it might lead to identification of research subjects or because seeking consent would reduce the rate of participation in the research, the data will remain confidential.
(iv) For research collaborations, any open access arrangements can only take place with the agreement of all research partners.
IPD Sharing Time Frame
IPD Sharing Access Criteria
IPD Sharing Supporting Information Type
- Study Protocol
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Critical Illness
-
Duke UniversityNational Institute of Neurological Disorders and Stroke (NINDS); National Institutes...CompletedNeonatal Critical Illness | Pediatric Critical IllnessUnited States
-
Yale UniversityNational Institute on Aging (NIA)RecruitingCritical Illness | Illness, CriticalUnited States
-
McMaster UniversityLondon Health Sciences Centre; McMaster Children's Hospital; Canadian Critical...CompletedPediatric Critical IllnessCanada
-
Boston Children's HospitalCompleted
-
St Helens & Knowsley Teaching Hospitals NHS TrustManchester University NHS Foundation TrustCompleted
-
Sándor BeniczkyUniversity of Aarhus; Danish Council for Independent Research; Søster og Verner...CompletedCritical Illness Myopathy | Myopathy Critical IllnessDenmark
-
Hospital de Clinicas de Porto AlegreUnknownCritical Illness PolyneuropathiesBrazil
-
Peking Union Medical College HospitalBaxter Healthcare CorporationUnknownNutrition Therapy for Critical Illness
-
Assistance Publique - Hôpitaux de ParisRecruitingCritical Illness Related Corticosteroids InsufficiencyFrance
-
Yuzuncu Yıl UniversityKahramanmaras Sutcu Imam University; Izmir Ataturk Training and Research HospitalCompleted
Clinical Trials on Modular ketogenic feed
-
University Hospitals Bristol and Weston NHS Foundation...Unknown
-
McMaster Children's HospitalUnknownPostnatal Growth DisorderCanada
-
University of NebraskaAlegent Health Bergan Mercy Medical CenterCompletedProblem With Growth of an InfantUnited States
-
Florida International UniversityAcademy of Nutrition and DieteticsRecruitingObesity, ChildhoodUnited States
-
Hiroshima Kyoritsu HospitalCompleted
-
The Netherlands Cancer InstituteUMC UtrechtCompletedCancer Genetics | Psychosocial IssuesNetherlands
-
Florida International UniversityCompleted
-
University of North Carolina, Chapel HillAmerican Heart Association; Community ServingsRecruiting
-
Boston Children's HospitalRecruiting
-
Shriners Hospitals for ChildrenUniversity of HawaiiCompleted