Use of dietary fibers in enteral nutrition of critically ill patients: a systematic review

Reis, Audrey Machado dos; Fruchtenicht, Ana Valéria; Loss, Sérgio Henrique; Moreira, Luis Fernando

doi:10.5935/0103-507X.20180050

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Revista Brasileira de Terapia Intensiva

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REVIEW ARTICLE • Rev. bras. ter. intensiva 30 (3) • Jul-Sept 2018 • https://doi.org/10.5935/0103-507X.20180050 copy

Use of dietary fibers in enteral nutrition of critically ill patients: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

To meet the nutritional requirements of patients admitted to intensive care units, it is necessary to establish a diet schedule. Complications associated with enteral nutrition by tube feeding are not uncommon and may reduce the delivery of required nutrient to patients in intensive care units. Research on the osmolality, fat content, caloric intensity and fiber content of formulas are under way, and a substantial number of studies have focused on fiber content tolerability or symptom reduction. We conducted a systematic review of dietary fiber use and safety in critically ill patients in 8 studies based on diarrhea, other gastrointestinal symptoms (abdominal distension, gastric residual volume, vomiting and constipation), intestinal microbiota, length of stay in the intensive care unit and death. We discussed the results reported in the scientific literature and current recommendations. This contemporary approach demonstrated that the use of soluble fiber in all hemodynamically stable, critically ill patients is safe and should be considered beneficial for reducing the incidence of diarrhea in this population.

Keywords:
Dietary fiber/metabolism; Enteral nutrition; Intensive care; Critical care; Critically ill

Author, country	Study	Sample	Sample exclusion criteria	Diet
Yagmurdur et al.,⁽²2 Yagmurdur H, Leblebici F. Enteral nutrition preference in critical care: fibre-enriched or fibre-free? Asia Pac J Clin Nutr. 2016;25(4):740-6.⁾ Turkey	Prospective, randomized	120 critically ill adults; cerebrovascular disease	Hemodynamic instability; sepsis; contraindications for enteral feeding; pancreatitis; gastrointestinal diseases; obesity; malnutrition syndrome; immunodeficiency; severe biochemical results on admission day; and patients who were given broad-spectrum antibiotics for a severe infection	Treatment group: diet with 15g/liter of mix fibers; Control group: Standard isocaloric and isonitrogenous diet
Simakachorn et al.,⁽³3 Simakachorn N, Bibiloni R, Yimyaem P, Tongpenyai Y, Varavithaya W, Grathwohl D, et al. Tolerance, safety, and effect on the faecal microbiota of an enteral formula supplemented with pre- and probiotics in critically ill children. J Pediatr Gastroenterol Nutr. 2011;53(2):174-81.⁾ Thailand	Prospective, multicenter, randomized, double-blinded	94 critically ill children (1 - 3 years old) under mechanic ventilation	Enteral feeding contraindicated; recent surgery or other gastrointestinal disorders and immunodeficiency	Treatment group: diet with 2 probiotics and oligofructose/inulin fiber 2.6g/lL Control group: Standard isocaloric and isonitrogenous diet
O’Keefe et al.,⁽⁶6 O'Keefe SJ, Ou J, Delany JP, Curry S, Zoetendal E, Gaskins HR, et al. Effect of fiber supplementation on the microbiota in critically ill patients. World J Gastrointest Pathophysiol. 2011;2(6):138-45.⁾ United States	Clinical trial	13 critically ill adults; predominantly necrotizing pancreatitis (9 controls; 4 with diarrhea and ventilated patients - study group)	No exclusion criteria related	Both groups received mix fibers progressively up to maximum of 12g tid
Caparrós et al.,⁽⁸8 Caparrós T, Lopez J, Grau T. Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. JPEN J Parenter Enteral Nutr. 2001;25(6):299-308; discussion 308-9.⁾ Spain	Multicenter, prospective, single-blinded	220 critically ill adults (122 cases; 98 controls)	APACHE II score < 8; MOD score > 5; pregnancy; terminals; cardiopulmonary resuscitation patients; diabetics; chronic gastrointestinal disease; renal or liver failure; cancer; immunodeficiency or previous use of corticosteroid salicylates; anti-inflammatory or immunosuppressive drugs	Treatment: 75g protein/liter, 11.8% arginine, 40% medium chain triglycerides; 8.9g mix fiber/liter Controls: Standard isocaloric, 62.5g protein/liter
Spapen et al.,⁽⁹9 Spapen H, Diltoer M, Van Malderen C, Opdenacker G, Suys E, Huyghens L. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, double-blind, randomized, and controlled trial. Clin Nutr. 2001;20(4):301-5.⁾ Belgium	Prospective, randomized, double-blinded	25 adults; severe sepsis or septic chock	Terminal patients; inability to perform gastrointestinal treatment; pancreatitis; known diarrheal diseases or diarrhea up to 72 hours prior to inclusion; treatment modifying gastrointestinal transit; albuminemia; diabetes or any immunodeficiency	Treatment: diet supplemented with 22g of gum guar Controls: Standard isocaloric and isonitrogenous diet
Rushdi et al.,⁽¹⁰10 Rushdi TA, Pichard C, Khater YH. Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin Nutr. 2004;23(6):1344-52.⁾ Egypt	Prospective, randomized	20 critically ill adults	Patients with short bowel syndrome; acute bacterial infection; enteral feeding contraindicated; sepsis or hyperthyroidism	Treatment: diet with 22g of gum guar/liter; Controls: Standard isocaloric and isonitrogenous diet
Spindler-Vesel et al.,⁽¹¹11 Spindler-Vesel A, Bengmark S, Vovk I, Cerovic O, Kompan L. Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients. JPEN J Parenter Enteral Nutr. 2007;31(2):119-26.⁾ Slovenia	Prospective, randomized	113 critically ill adults; trauma patients	No exclusion criteria stated	Group A: 4460mg arginine/liter; Group B: 22g guar gum/liter; Group C: standard diet; Group D: supplement of symbiotic 10¹⁰.
Chittawatanarat et al.,⁽¹²12 Chittawatanarat K, Pokawinpudisnun P, Polbhakdee Y. Mixed fibers diet in surgical ICU septic patients. Asia Pac J Clin Nutr. 2010;19(4):458-64.⁾ Thailand	Prospective, randomized, double-blinded	34 critically ill adults; surgical septic patients	Hemodynamic instability; enteral feeding contraindicated; pancreatitis; post-endoscopy < 24 hours bowel resection and anastomosis < 24 hours; gut diseases and enteric fistula	Treatment group: diet with 15.1g of mix fiber/liter; Control group: Standard isocaloric and isonitrogenous diet

Author, country	Main results
Yagmurdur et al.,⁽²2 Yagmurdur H, Leblebici F. Enteral nutrition preference in critical care: fibre-enriched or fibre-free? Asia Pac J Clin Nutr. 2016;25(4):740-6.⁾ Turkey	The study group had less diarrhea than the control group (p < 0.001). The authors suggest that enteral nutrition should be initiated with fiber-enriched formulas rather than fiber-free formulas to avoid frequent feeding interruptions that cause protein energy malnutrition in intensive care unit patients
Simakachorn et al.,⁽³3 Simakachorn N, Bibiloni R, Yimyaem P, Tongpenyai Y, Varavithaya W, Grathwohl D, et al. Tolerance, safety, and effect on the faecal microbiota of an enteral formula supplemented with pre- and probiotics in critically ill children. J Pediatr Gastroenterol Nutr. 2011;53(2):174-81.⁾ Thailand	The enteral formula enriched with soluble fiber and probiotic was well tolerated by critically ill children; it was safe and produced an increase in fecal bacterial groups of previously reported beneficial effects
O’Keefe et al.,⁽⁶6 O'Keefe SJ, Ou J, Delany JP, Curry S, Zoetendal E, Gaskins HR, et al. Effect of fiber supplementation on the microbiota in critically ill patients. World J Gastrointest Pathophysiol. 2011;2(6):138-45.⁾ United States	Fiber supplementation resulted in significant increases in fecal short chain fatty acids and microbial counts of specific butyrate producers, with a resolution of diarrhea in 3 of 4 patients. Thus, this supplementation has the potential to improve the microbiota mass and function, thereby reducing the risks of diarrhea as a result of dysbiosis
Caparrós et al.,⁽⁸8 Caparrós T, Lopez J, Grau T. Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. JPEN J Parenter Enteral Nutr. 2001;25(6):299-308; discussion 308-9.⁾ Spain	Patients fed a diet enriched with soluble fiber had a significantly lower catheter-related sepsis rate than patients fed a standard high-protein diet. Patients fed the study diet for > 2 days showed a trend toward decreased mortality
Spapen et al.,⁽⁹9 Spapen H, Diltoer M, Van Malderen C, Opdenacker G, Suys E, Huyghens L. Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, double-blind, randomized, and controlled trial. Clin Nutr. 2001;20(4):301-5.⁾ Belgium	Enteral nutrition supplemented with soluble fiber is beneficial in reducing the incidence of diarrhea in tube-fed full-resuscitated and mechanically ventilated septic patients
Rushdi et al.,⁽¹⁰10 Rushdi TA, Pichard C, Khater YH. Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin Nutr. 2004;23(6):1344-52.⁾ Egypt	Enteral nutrition fiber supplementation was related to a decrease of diarrheal episodes in intensive care unit patients with preexisting diarrhea and a trend towards lower plasma glucose and cholesterol levels
Spindler-Vesel et al.,⁽¹¹11 Spindler-Vesel A, Bengmark S, Vovk I, Cerovic O, Kompan L. Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients. JPEN J Parenter Enteral Nutr. 2007;31(2):119-26.⁾ Slovenia	The group that received soluble fiber and probiotic had significantly less combined infections (p = 0.003) and pneumonias (p = 0.03). Intestinal permeability decreased only in the symbiotic group (p < 0.05). Patients supplemented with symbiotic had lower intestinal permeability and fewer infections
Chittawatanarat et al.,⁽¹²12 Chittawatanarat K, Pokawinpudisnun P, Polbhakdee Y. Mixed fibers diet in surgical ICU septic patients. Asia Pac J Clin Nutr. 2010;19(4):458-64.⁾ Thailand	The fiber group had a lower mean diarrhea score (p = 0.005) and lower global diarrhea “score on the generalized scale (p = 0.005). In summary, a mixed fiber diet formula can reduce the diarrhea score in surgical, critically ill septic patients who received broad spectrum antibiotics

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[1] Corresponding author: Audrey Machado dos Reis, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2.350 - Santa Cecília, Zip code: 90035-903 - Porto Alegre (RS), Brazil, E-mail: audreymreis@gmail.com