Should we use a diabetes-specific tube feeding formula in the ICU? In this video, I'll address this question by weighing the potential advantages and disadvantages of these formulas and discussing the body of literature and the position of professional organizations. Diabetes-specific tube feeding formulas are designed to improve improve glycemic control and reduce insulin requirements. Compared to standard tube feeding formulas, they tend to be lower in total carbohydrates and higher in fiber and fat.
The lower carbohydrate load reduces the amount of carbohydrates infused each day. The higher fiber and fat content increases the gastric emptying time, resulting in a slower release of carbohydrates into the small intestine and bloodstream. One potential advantage of using a diabetes-specific formula in the ICU is it may reduce the burden of hyperglycemia. Patients who are critically ill are prone to hyperglycemia, whether they have diabetes or not. Critical illness can increase the production of stress hormones and pro-inflammatory cytokines like cortisol, glucagon, interleukin-1, and interleukin-6.
Together, these decrease insulin release. increase hepatic glycogenesis and gluconeogenesis, and promote insulin resistance, all of which increase blood sugar content. Critical illness may also require treatment with vasopressors and steroids, which have similar effects.
Vasopressors are stress hormones, and steroids promote insulin resistance. Thus, hyperglycemia can be a natural part of the body's response to illness and affect it. physician's attempt to save the patient. When it's mild and short-term hyperglycemia, it's not a significant threat.
But when it's severe and persistent hyperglycemia, it is a significant threat. That's because it's associated with a higher ICU mortality risk. It can also increase the patient's risk of infection by impairing the immune system, and it can impair wound healing if the patient underwent a surgical procedure or has a pressure injury.
Another potential advantage of using a diabetes-specific formula in the ICU is it may minimize the risk of hypoglycemia. The formula would achieve this advantage if it contributed to lower insulin requirements. Since severe and persistent hyperglycemia is undesirable, physicians will use intravenous or subcutaneous insulin therapy to bring it down. Even though this is safe with careful titration and close monitoring of the patient's response, there's always a chance that the insulin dose overshoots the actual need for it.
The higher the insulin dose climbs, the more consequential overshooting the actual need becomes. Severe hypoglycemia can result in seizures, coma, and death quickly. Between these two potential advantages, you can see how a diabetes-specific formula may be a desirable option for the registered dietitian in the ICU. Nevertheless, we must weigh the potential disadvantages.
One potential disadvantage of using a diabetes-specific formula in the ICU is the high fat and fiber content. Although this feature may enhance glycemic control because it slows the release of carbohydrate into the small intestine and bloodstream, The fact that it's designed to sit in the stomach for an extended period may be dangerous for patients at high risk of pulmonary aspiration, bowel ischemia, and bowel necrosis. Many patients who are critically ill are at an increased risk of these complications because of factors like hemodynamic instability, including the need for vasopressor support, the need for mechanical ventilation, and sedation.
the presence of a nasogastric or orogastric feeding tube, and comorbidities like gastroparesis and GERD. By avoiding a high-fat, high-fiber formula and selecting one with low-fat content that has either a standard fiber content or is fiber-free, the hope is that the formula will pass through the stomach rapidly without complications. A second potential disadvantage of using a diabetes-specific formula in the ICU is related to the protein content.
The protein content of these formulas varies, but generally speaking, it's either comparable to a standard formula or lower than a standard formula. This may be undesirable for a patient who is critically ill because their medical condition typically results in an increased demand for protein. Finally, the cost is a third potential disadvantage of using a diabetes-specific formula in the ICU. A diabetes-specific formula is considerably more expensive than a standard tube feeding formula.
If you can achieve glycemic control and meet the estimated nutritional needs with a standard formula, then using the standard formula is the more fiscally responsible option. If you're enjoying this video so far, make sure you hit the like button, share it with a friend, and shop for more free and exclusive content by clicking the link down in the video description. Turning to the body of literature and positions of professional organizations, we'll first look at a review of the evidence published by Burslem et al. in 2022. Using data from four randomized controlled trials comparing a low-carbohydrate, high-fat formula to a standard formula among patients who were critically ill, they found mixed results. Two studies found an improvement in glycemic control with the diabetes-specific formula, one saw an improvement but with no statistical significance, and one found no improvement at all. Of note, none of the studies reported differences for tolerance between the standard and low carbohydrate high-fat formulas, which is encouraging.
The author said there might be a benefit to using a low-fat, high-carbohydrate formula in patients who are critically ill and have a history of diabetes or hyperglycemia. Still, there's insufficient evidence to definitively recommend them, and larger, randomized trials are needed. We can extrapolate additional support for the safety and tolerance of a diabetes-specific formula from a systematic review and meta-analysis published by K- Cara et al. in 2021. This paper focused exclusively on the safety of using fiber-containing formulas in the ICU. The authors found no increased risk of gastrointestinal complications when a fiber-containing formula was used.
That included vomiting, regurgitation, abdominal distension, and pulmonary aspiration. They also found that the data for patients at high risk of balischemia and severe dysmotility is lacking, and more research is needed in that area. That encompasses patients with hemodynamic instability, including those on vasopressors. Regarding professional organizations, the only formal position on this topic that I could find comes from the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine.
In their Joint Clinical Guidelines from 2016, they suggest avoiding the routine use of all specialty formulas in critically ill patients in a medical ICU and disease-specific formulas in the surgical ICU, and to only use them rarely on a case-by-case basis. They also suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility, which, as stated previously, encompasses patients with hemodynamic instability, including those on vasopressors. Notably, three of the four randomized control trials featured in the review by Burslem et al. were published after these clinical guidelines, as were at least two of the studies used to assess fiber-containing formulas and gastrointestinal complications in the review by Cara et al.
The new evidence may change the position of these organizations, but we won't know for sure without an official publication that addresses it. So, should we use a diabetes-specific tube feeding formula in the ICU? I really don't feel there's a clear yes or no answer here. There's no rule that patients in the ICU who have diabetes or hyperglycemia must receive a diabetes-specific formula, just as there's no rule that patients with diabetes or hyperglycemia can't receive a diabetes-specific formula. In the end, selecting a formula for your patients is all about weighing the potential benefits and risks involved, and in this case, neither the potential benefits or risks appear to be very strong.
On the one hand, there's no clear consistent evidence that diabetes-specific formulas improve glycemic control or reduce insulin requirements in the ICU. On the other hand, the concern over gastrointestinal complications and aspiration seems to be more anecdotal and theoretical than what typically occurs. In my own practice, I almost never make a diabetes-specific formula my first choice for a patient with diabetes or hyperglycemia in the ICU, and tend to gravitate toward formulas that are lower in fiber and higher in protein.
Nevertheless, I'm always willing to transition to a diabetes-specific formula if I feel the physicians have given an honest attempt to manage hyperglycemia with insulin, but have had limited success. Thank you for watching. Don't forget to like the video and subscribe to the channel.