Nutrient Uptake During Continuous Enteral Feeding

Uptake of Glucose and Phenylalanine From Continuous Enteral Nutrition in Healthy and Critically Ill Persons

Continuous enteral nutrition is used to feed patients in intensive care who are unable to eat normally. The goal of this observational study is to learn about the uptake of nutrients from feeding formula. The study method will first be applied in healthy persons to establish workability and normal values, then in patients in the intensive care unit to learn how nutrient uptake is affected by critical illness.

The main questions this study aims to answer are:

• what is the time course of uptake of phenylalanine (an amino acid) and glucose (a sugar) from enteral feeding formula given continuously over several hours
• what is the time course of the filling volume of the stomach during continuous enteral feeding

Participants receive feeding formula through a nasogastric feeding tube and blood samples are taken at short intervals to analyse uptake of nutrients into blood. Simultaneously, the filling volume of the stomach is measured by gastric ultrasound.

Study Overview

• Status: Not yet recruiting
• Conditions: Critical Illness
• Intervention / Treatment: Procedure: Continuous enteral feeding

Detailed Description

Background

The investigators have previously studied the uptake of dietary isotope-labeled phenylalanine and plasma amino acid concentrations in critically ill patients and healthy subjects. During continuous feeding, uptake was unexpectedly found to be highly variable over time. Due to infrequent sampling, the time course of variability could not be modeled mathematically. Also, the underlying physiological mechanisms remain unclear, though it is hypothesized that gastric emptying is a major factor determining temporal variability.

The study here described is a follow-up that includes serial abdominal ultrasound studies to measure gastric emptying, additional indicators/tracers to determine more detail of uptake vs. digestion/transport/metabolism, and makes use of more frequent sampling to allow for detailed mathematical modeling of temporal variability.

Experimental protocol

ICU patients:

• Standard care and treatment as per clinical routines
• Pre-experiment ongoing nutrition for ≥ 6 hrs by nasogastric feeding tube or gastrostomy (not postpyloric)
• Bed rest during experiment as feasible

Healthy subjects

• Keep dietary and training habits for ≥ 2 days before experiment start
• Overnight fast
• Bed rest during experiment as feasible
• Nasogastric feeding tube
• Arterial line in radial or ulnar artery

Nutrition, sampling, measurements

• Experimental nutrition by continuous infusion for 10 hrs
• Infusion rate corresponding to 25 kcal/kg body weight/day (calculated including metabolizable tracers/indicators)
• Arterial blood sampling (à 1 ml) every 5 min in pilot study (may adjust to 10 or 15 min depending on results of pilot study)
• Serial abdominal ultrasound for determination of gastric volume (pilot study will determine how often)

Experimental nutrition

• Commercially available feeding formula for ICU use (Fresubin® HP Energy or similar) with added phenylalanine and glucose indicators
• Intrinsically labeled protein: 13C-L-phenylalanine intrinsically labeled milk protein
• Nonmetabolisable phenylalanine analogue: D-phenylalanine
• Free amino acid tracer: stable isotope-labeled phenylalanine tracer (2H5-L-Phe)
• Non-metabolizable glucose analogue: 3-O-Methyl-d-glucose (3-OMG)
• Free glucose tracer: isotope labeled D-glucose

Analyses

• arterial plasma amino acid and glucose tracers as above
• arterial plasma 3-OMG
• arterial plasma aminograms
• arterial plasma glucose, insulin, c peptide

• Study Type: Observational
• Enrollment (Anticipated): 20

Contacts and Locations

• Study Contact: Name: Felix Liebau, MD PhD; Email: felix.liebau@regionstockholm.se
• Study Contact Backup: Name: Olav Rooyackers, Prof Phd; Phone Number: +46702069227 +46702069227; Email: olav.rooyackers@ki.se

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

ICU patients: patients admitted to an intensive care unit at Karolinska University Hospital

Healthy subjects: volunteers from Stockholm metropolitan region

Description

Inclusion Criteria (ICU patients):

- stable enteral nutrition of >80% of measured or calculated energy expenditure by nasogastric feeding tube or gastrostomy

Exclusion Criteria (ICU patients):

• enteral nutrition by postpyloric route such as jejunostomy or postpyloric tube
• remaining ICU stay expected < 12 hrs
• ongoing bleeding that requires surgery/intervention or transfusion of > 2 units red cells/24 hrs
• inability to use feeding tube or arterial line

Inclusion Criteria (healthy subjects):

- healthy volunteer

Exclusion Criteria (healthy subjects)

- any condition or medication affecting nutrition or metabolism

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Healthy subjects; Healthy persons ≥ 18 yrs of age	Procedure: Continuous enteral feeding; Enteral nutrition by continuous infusion for 10 hrs at a dose corresponding to 25 kcal/kg body weight/day; Other Names: Gastric ultrasound
Critically ill patients; Critically ill patients ≥ 18 yrs of age admitted to the ICU	Procedure: Continuous enteral feeding; Enteral nutrition by continuous infusion for 10 hrs at a dose corresponding to 25 kcal/kg body weight/day; Other Names: Gastric ultrasound

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Glucose and phenylalanine indicators	Time series of isotopic and non-isotopic indicators of glucose and phenylalanine from enteral nutrition	0-10 hours
Gastric volume	Time series of gastric volume	0-10 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Plasma metabolites	Time series of plasma aminograms, glucose, insulin and c peptide	0-10 hours

Collaborators and Investigators

• Sponsor: Felix Liebau
• Collaborators: Karolinska University Hospital; Karolinska Institutet
• Investigators: Principal Investigator: Felix Liebau, MD PhD, Karolinska university Hospital

Publications and helpful links

General Publications

• Liebau F, Kiraly E, Olsson D, Wernerman J, Rooyackers O. Uptake of dietary amino acids into arterial blood during continuous enteral feeding in critically ill patients and healthy subjects. Clin Nutr. 2021 Mar;40(3):912-918. doi: 10.1016/j.clnu.2020.06.018. Epub 2020 Jun 30.

Study record dates

Study Major Dates

• Study Start (Anticipated): January 1, 2023
• Primary Completion (Anticipated): December 31, 2026
• Study Completion (Anticipated): December 31, 2026

Study Registration Dates

• First Submitted: November 17, 2022
• First Submitted That Met QC Criteria: November 17, 2022
• First Posted (Actual): November 29, 2022

Study Record Updates

• Last Update Posted (Actual): December 2, 2022
• Last Update Submitted That Met QC Criteria: November 29, 2022
• Last Verified: November 1, 2022

More Information

Terms related to this study

• Keywords: Nutritional support; Intestinal absorption; Enteral nutrition; Gastric volume; Continuous enteral feeding
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Critical Illness
• Other Study ID Numbers: 2022-04200-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No