740 Asia Pac J Clin Nutr 2016;25(4):740-746

Original Article

Enteral nutrition preference in critical care:

fibre-enriched or fibre-free?

Hatice Yagmurdur MD, Figen Leblebici MD

Department of Anesthesiology and Intensive Care, Ankara Numune Education and Research Hospital,
Ankara, Turkey

Background and Objectives: This study’s main aim was to observe the effects of a fibre-enriched nutrition solu-
tion on requisite feeding volume, which is directly proportional to energy intake in mechanically ventilated pa-
tients with enteral nutrition. Methods and Study Design: Some 120 patients who required mechanical ventila-
tion and enteral nutrition with a nasogastric tube were studied. Upon ICU admission, the patient’s age, gender,
weight, height, comorbidities, diagnosis and APACHE II score were recorded. We assigned two diets to the pa-
tients randomly. The control group received the fibre-free nutrition solution. The study group, received the fibre-
enriched nutrition solution. Prescribed feeding volume and administered feeding volume, gastric residual volume
(GRV), volume ratio (VR), diarrhoea score and gastrointestinal complications (GIC) were recorded, along with
daily biochemistry. Results: The two groups did not differ with respect to age, sex, weight, BMI, APACHE II
score, target caloric intake or GRV (p>0.05). On days four and five, the study group had higher VR values
(p<0.05). Seventy-one (59%) patients had at least one gastrointestinal complication; 44 (73%) of them were con-
trols and 27 (45%) of them study patients. The most commonly observed GIC was diarrhoea. Thirty-eight pa-
tients had diarrhoea in control group, and twenty-two patients had diarrhoea in study group, and this difference
was statistically significant (p<0.001). There were no significant differences between the groups about vomiting
and regurgitation. Conclusions: We suggest that ICU staff initiate enteral nutrition with fibre-enriched formulas
rather than fibre-free formulas to avoid frequent feeding interruptions that cause protein energy malnutrition in
ICU patients.

Key Words: fibre-enriched nutrition, volume ratio, diarrhoea, enteral nutrition, gastric residual volume

INTRODUCTION mechanically ventilated patients with enteral nutrition.

Studies have shown that enteral nutrition is essential for
the feeding of intensive care unit (ICU) patients with
healthy gastrointestinal systems.1 Inefficient nutrition
volume administrations cause low daily caloric intake,
which is correlated with destructive complications, such
as immunosuppression, increased risk of infections and
high mortality.2-5 Thus, uninterrupted, efficient nutrition
is crucial in ICU patients. However, conflicting infor-
mation exists in the literature regarding the preference of
enteral feeding solutions. Research on osmolality, fat con-
tent, caloric intensity and fibre content of the formulas is
ongoing, and a notable amount of studies have focused on
fibre content. In regards to fibres that exist in nutrition
solutions, oligofructose or fructo-oligosaccharide (FOS)
is a short-chain fructan that naturally exists in plants, and
it is a soluble, highly fermentable, prebiotic fibre. Inulin
is another fructan that is soluble and fermentable and has
prebiotic effects. Acacia fibre, which has the same chem-
ical structure as arabic gum, is a soluble and fermentable
fibre. Soy polysaccharide is an insoluble fermentable fi-
bre, and resistant starch and alpha cellulose are insoluble
and non-fermentable fibres.
The main aim of this study was to observe the effects
of a fibre-enriched nutrition solution on requisite feeding
volume, which is directly proportional to caloric intake in
Administering the necessary feeding volume depends on
gastrointestinal system function; thus, the secondary goal
of this study was to investigate the incidence of gastroin-
testinal complications. Biochemical parameters were
evaluated as a prediction of nutrition insufficiency.
METHODS
This study was conducted in a 25-bed adult medical ICU
in an education and research hospital. The study was ap-
proved by the Institutional Review Board of the hospital.
Written informed consent was obtained from the patients’
next of kin before beginning the study.
This study included 120 participants who were between
35-90 years of age and were of both genders. All patients
were chosen from individuals admitted to our ICU with
Corresponding Author: Dr Hatice Yagmurdur, Ankara Nu-
mune Education and Research Hospital, Anesthesiology and
Intensive Care Department, Talatpasa Avenue N:5, 06110, Al-
tindag, Ankara, Turkey.
Tel: 05056527365; Fax: +90312 311 43 40
Email: hyagmurdur@yahoo.com
Manuscript received 14 March 2015. Initial review completed
18 June 2015. Revision accepted 14 July 2015.
doi: 10.6133/apjcn.122015.12
 Fibre-enriched nutrition in ICU
acute cerebrovascular disease (e.g. ischemia, haemor-
rhage) who required mechanical ventilation and enteral
nutrition with a nasogastric tube. Upon ICU admission,
the patient’s age, gender, weight, height, comorbidities,
diagnosis and APACHE II (Acute Physiology and Chron-
ic Health Evaluation) score were recorded. Patients who
were fed within 48 h after ICU admission were included
in the study. The exclusion criteria were the following:
unstable haemodynamic values, sepsis, contraindications
for enteral feeding (gastrointestinal tract obstruction,
haemorrhage and ileus), pancreatitis, gastrointestinal dis-
eases (ulcerative colitis, Chron’s disease and ischaemic or
infectious colitis), obese patients (body mass index (BMI)
>35 kg/m2), malnutrition syndromes, immunosuppressed
patients and severe biochemical results on admission day.
Additionally, patients who were given broad-spectrum
antibiotics for a severe infection, whether gastrointestinal
or not, were excluded from study.
After ICU admission, a nasogastric tube (12 or 14 Fr,
Compat Soft Y; Nestle Nutrition; Germany) was inserted
in all patients who were mechanically ventilated and
could not be fed orally. Every day, the positioning of the
tube was checked radiologically. All patients were man-
aged in the semi-recumbent position (30-45°) to decrease
pneumonia incidence. Mechanical ventilation settings
were adjusted according to the patients’ artery blood gas
results.
Sealed, numbered envelopes were used for randomiza-
tion. The medical staff who performed the GI measure-
ments and assessed GI complications were blind to the
study. We assigned two diets to the patients randomly.
The control group, Group FF, received the fibre free nu-
trition solution Nutrison (500 mL, Nutricia Advanced
Medical Nutrition; Netherlands). The study group, Group
FE, received the fibre-enriched nutrition solution Nu-
trison multifibre (500 mL, Nutricia Advanced Medical
Nutrition; Netherlands). The characteristics of 500 mL of
Nutrison/Nutrison multifibre are as follows: energy 500
kcal/515 kcal, protein 20 g/20 g, carbohydrate 61.5 g/61.5
g, fat 19.5/19.5 g and osmolarity 255 mOsmL-1/300
mOsmL-1. Nutrison multifibre contains both soluble and
insoluble fibres in approximately a 1:1 ratio, 0.7 g and 0.8
g per 100 mL, respectively. The content of the six fibres
in the solution are 32% soy polysaccharides, 24% arabic
gum, 12.5% inulin, 12% alpha-cellulose, 10.5% oli-
gofructose and 9% resistant starch. All patients were giv-
en the nutrition solution using an enteral feeding pump
(Kangaroo Enteral Feeding Pump; Covidien; USA). None
of the patients received any broad-spectrum antibiotics or
antidiarrhoeal or laxative agents such as lactulose, sorbi-
tol or glycerin suppositories. Metoclopramide was admin-
istered twice a day to all patients as a prokinetic agent.
Energy administration was aimed at 25-35 kcal/kg/day
and was given from 18-24 h every day at a constant rate.
On the first day, 50% of the required energy intake was
administered, followed by 75% on the second day and
100% on the third day. Enteral nutrition was started at a
rate of 20 mL/h and increased at six hour intervals to 40
mL/h, 80 mL/h, 100 mL/h and, if needed, to 120 mL/h. If
the patient did not tolerate the nutrition feeds according to
the gastric residual volume (GRV) values mentioned be-
low at any time of the day, nutrition rate was decreased to
741
the previous rate. Tolerance to nutrition was assessed
daily as the GRV. During the first day of enteral nutrition,
GRV was measured every 6 h. On the second day, GRV
was measured every 8 h, and for the patients who tolerat-
ed the enteral nutrition well, GRV was measured once a
day after the third day. GRV was measured by connecting
a drainage bag to the nasogastric tube and waiting 15
mins for gravity drainage. The patients were considered
to have tolerated the enteral nutrition well when the GRV
was <500 mL daily, and those who consumed at least 750
mL of enteral nutrition with <500 mL GRV a day, were
included in the study protocol.
The efficiency of the enteral nutrition was measured
daily by volume ratio (%).
VR (%) = (administered volume of nutrition / prescribe
volume of nutrition) x 100.
During the study, prescribed feeding volume and ad-
ministered feeding volume, GRV, RV, diarrhoea scores
and gastrointestinal complications (GIC) (distension,
vomiting, regurgitation and constipation) were recorded.
The definitions and managements of the gastrointestinal
complications were as follows:
1. Abdominal distention was defined as the presence of
excessive amounts of gases in the stomach or intestine.
It was diagnosed with tympany or the absence of bow-
el sounds during physical examination. After ruling out
intraabdominal pathologies, nutrition was decreased to
half the normal rate when distention was detected. In
the following 12 h, if the distension disappeared, nutri-
tion was increased to the original rate, and if it persist-
ed, nutrition was ruled out as its cause.
2. Regurgitation was defined as the observation of enteral
formula in the oral cavity. If regurgitation was detect-
ed, intraabdominal pathologies were searched for by
radiological examination. If a pathology was found,
such as ileus or tract obstruction, nutrition was with-
drawn, and if GI functioning was normal, nutrition was
continued.
3. Vomiting was defined as ejection of the enteral formu-
la through the mouth. The management of the vomiting
was same as that for regurgitation.
4. Constipation was defined as the absence of defecation
for more than three days. If constipation was observed,
the nutrition infusion route was not changed, but a lax-
ative or enema was administered.
5. Diarrhoea was assessed according to a score defined
by Hart and Dobb6 (Table 1). Each stool of the patient
was scored according to its estimated volume and con-
sistency. The sum of the scores in 24 h was the diar-
rhoea score of the patient. Diarrhoea was defined as a
daily score ≥12. If liquid stools were observed more
than five times a day or the total estimated volume of
the stools was ≥2,000 mL/day, the patient was exam-
Table 1. Diarrhoea score as proposed by Hart and
Dobb6
Estimated volume (mL)
Consistency
<200 200-250 >250
Formed 1 2 3
Semi-solid 3 6 9
Liquid 5 10 15
742 H Yagmurdur and F Leblebici

Table 2. Patient characteristics

Fibre-free group (n=60) Fibre-enriched group (n=60)

Age (yr) (mean±SD) 70±15 71±14
Gender (m/f) (n) 26/34 24/36
Weight (kg) (mean±SD) 76.7±9.8 76±10.6
BMI (kg/m2) (mean±SD) 27.2±3.7 27±4.5
APACHE II Score (mean±SD) 15.7±2.6 15.7±2.9
Target energy intake(kcal/kg/day) (mean±SD) 2272±273 2282±295

ined for GI problems. If a problem was detected, nutri- Table 3.Gastrointestinal tolerance over five days
tion was withdrawn. If no problem was detected, the
nutrition infusion rate was decreased to half of the Daily GRV Fibre-free group Fibre-enriched
p value
(mean±SD) (n=60) group (n=60)
normal rate, and the patient was observed for diar-
Day 1 138±100 113±96 0.205
rhoea for 8 h. After 8 h, if the diarrhoea decreased, nu- Day 2 136±115 127±116 0.748
trition infusion was returned to the original rate. If the Day 3 114±91 126±98 0.764
severity of the diarrhoea persisted, the nutrition prod- Day 4 117±114 129±100 0.819
uct was changed, and the patient was withdrawn from Day 5 97±72 122±93 0.240
the study.
The patients were considered as tolerant of the enteral Table 4. Daily volume ratio (%) (mean±SD) accord-
nutrition well if the nutrition feeds did not need any inter- ing to groups and gastrointestinal complications (GIC)
ruption as a consequence of the complications defined
above. Fibre-free group Fibre-enriched
p value
As an important complication, pulmonary aspiration (n=60) group (n=60)
was also taken into account. It was diagnosed when en- Day 1 78.5±12.3 75.9±11.0 0.108
Day 2 81.4±11.9 83.4±11.2 0.310
teral formula was found in the tracheal aspirate. Pulmo-
Day 3 82.0±13.6 85.9±11.9 0.096
nary aspirated patients were excluded from the study and Day 4 81.0±13.5 86.4±12.6 0.021
managed according to a special aspiration pneumonia Day 5 80.8±14.3 89.4±12.4 0.000
treatment protocol. Mean 80.8±9.6 84.2±9.8 0.035
Daily biochemical parameters (haemoglobulin, total
protein, albumin, prealbumin, total cholesterol, calcium, Table 5. Daily volume ratio (%) (mean±SD) accord-
phosphate, magnesium, sodium, potassium, glucose, urea, ing to gastrointestinal complications (GIC)
creatinine, alanine aminotransferase and aspartate amino
transferase) were recorded. The statistical package SPSS Patients with Patients without
p value
20.0 for Windows (SPSS Inc, Chicago, IL) was used for GIC (n=71) GIC (n=49)
the statistical analysis. All values are expressed as the Day 1 72.8±12.2 83.6±7.3 <0.0001
means ± standard deviation. Qualitative data were ana- Day 2 76.5±10.9 90.9±5.8 <0.0001
Day 3 78.1±13.0 92.3±6.4 <0.0001
lysed by the chi-square test. Quantitative data were ana- Day 4 76.7±12.6 93.9±4.9 <0.0001
lysed by analysis of variance or the Mann-Whitney U- Day 5 77.5±13.2 96.2±4.3 <0.0001
test. The haemodynamic parameters obtained at various Mean 76.3±7.6 91.4±4.1 <0.0001
time intervals within the same group were compared with
the baseline values using the paired t-test. As both param- higher VR values, and this difference was statistically
eters were normally distributed, the correlation coeffi- significant (p<0.05) (Table 4, 5). The data analysis of all
cients and their significance were calculated using the patients collectively showed that VR was higher in the
Pearson test. A p-value of ≤0.05 was deemed significant. patients lacking GICs (p<0.001), and this relationship was
consistent throughout the entire study. Seventy-one (59%)
RESULTS patients had at least one gastrointestinal complication; 44
A total of 120 patients were studied. After the initiation of (73%) of them were in Group FF, and 27 (45%) of them
the study, none of the patients were excluded from the were in Group FE. This difference was statistically signif-
study for the indications outlined in the methods section. icant and was the second main result of the study
The two groups did not differ with respect to age, sex, (p<0.01). The most commonly observed gastrointestinal
weight, BMI, APACHE II score or target caloric intake complication in this study was diarrhoea. Sixty patients
(Table 2). (50%) had diarrhoea for at least one day of the study; 38
There was no difference between the groups in the dai- of them were in Group FF, and 22 of them were in Group
ly GRV measurements (Table 3). Only four patients’ FE, and this difference was statistically significant
GRV values exceeded 500 mL for one day; three of those (p<0.001). The daily diarrhoea score was used to obtain
patients were in Group FF, and one was in Group FE. more information about the diarrhoea. In the first two
The main goal of this study was to assess the efficiency days, there was not a significant difference in the daily
of the nutrition solutions. This was established with daily diarrhoea score between the groups. However, in last
VR measurements. In the first three days of the study, three days, Group FF had higher diarrhoea scores, and
there was no difference in the VR values between the this difference was statistically significant (p<0.01). The
groups. However, on days four and five, Group FE had mean diarrhoea scores over the five days of the study in
 Fibre-enriched nutrition in ICU
Table 6. Gastrointestinal complications over five days
Fibre-free group (n=60)
Daily diarrhoea score (mean±SD)
Day 1
Day 2
Day 3
Day 4
Day 5
Diarrhoea score for five days (mean±SD)
Patients at least 1 day with diarrhoea (n)
Regurgitation (n)
Vomiting (n)
Distension (n)
Constipation
Group FF and Group FE were 10.2±5.4 and 7.5±4.7, re-
spectively, and this difference was statistically significant
(p<0.001). Severe diarrhoea, as defined above, was not
observed in any patients. There were no significant dif-
ferences between the groups for the other gastrointestinal
complications (vomiting, regurgitation, distention and
constipation) (Table 6). Nine patients (15%) in Group FF
and ten patients (16%) in Group FE had regurgitation.
Ten patients (16%) in Group FF and nine patients (15%)
in Group FE vomited. 18 patients (30%) in Group FF and
25 patients (42%) in Group FE had abdominal distention.
Two patients (3%) in each group were constipated, and
all of them were treated successfully with an enema or
laxatives. Other complications were not severe and were
managed with the protocols described above. The bio-
chemical parameters on day one and day five were com-
pared. There were no statistically significant differences
in any of the biochemical parameters between the groups.
DISCUSSION
The patients studied were admitted to the ICU with acute
cerebrovascular disease. We excluded patients with intes-
tinal pathologies and infectious diseases, such as sepsis,
as these comorbidities and the therapies used to treat them
could affect intestinal function. The main outcome of the
study was that of preferred nutrition feed for gastrointes-
tinal function. We showed that fibre-free nutrition gener-
ated higher gastrointestinal complications, especially di-
arrhoea, than fibre-enriched nutrition. To demonstrate the
consequences of the gastrointestinal complications like
diarrhoea, volume ratio was used; it provided a measure
of feed efficiency. The main result of this study was that
fibre-enriched nutrition resulted in less gastrointestinal
complications and higher VR values, which was predic-
tive of more effective patient nutrition.
Montejo et al7 found that the most frequent complica-
tion in enteral nutrition was high gastric residual volume.
This is different from the results of our study and may be
due to the use of a different nutrition solution or different
GRV measurement methods. At present, a clear consen-
sus regarding the measurement method and the limits of
gastric residual volume has not been reached. In our clin-
ical practice, enteral nutrition is started at a rate of 20
mL/h and is increased gradually. If, the gradual increment
is not interrupted on account of intolerance and the pa-
tient receives the prescribed feed volume, daily GRV
measurement is sufficient to anticipate upper gastrointes-
743
Fibre-enriched group (n=60) p value
8.5±6.9 7.1±7.1 0.055
8.7±7.5 7.1±5.6 0.147
10.2±8.0 7.6±6.1 0.009
11.7±7.8 8.6±6.6 0.008
12.0±8.4 7.3±5.9 <0.0001
10.2±5.4 7.5±4.7 <0.0001
38 22 0.006
9 10 1.0
10 9 1.0
18 25 0.253
2 2 1.0
tinal tract tolerance. When this was not the case, during
the first days of enteral nutrition, we measured GRV fre-
quently (three or four times a day). Additionally, the rou-
tine metoclopramide administration in our study may
have been another factor that caused the low gastric re-
sidual volumes that we observed.
Chang et al8 reported that drugs (e.g. antibiotics), infec-
tions, illness severity and enteral feedings are the causes
of diarrhoea in the ICU. Whelan et al9 reported that the
frequency of diarrhoea in enteral-fed patients ranged from
2 to 95% and that this large variation was due to different
definitions of diarrhoea and different measurement meth-
ods. In the present study, the most frequent complication
was diarrhoea, and it occurred in 50% of patients. Enteral
nutrition is a contributing factor to ICU diarrhoea because
it alters gut physiology. Whelan et al10 hypothesized that
enteral feeding changes both transit time, secretory mech-
anisms and the microbiota in the gastrointestinal tract.
Luft et al11 showed the importance of enteral feeding so-
lution and feeding equipment sterility by decreasing the
frequency of diarrhoea using hygiene protocols. The
properties of nutrition solutions that have been examined
for their diarrhoeal effects are temperature, osmolality, fat
content and caloric density, but strict guidelines for these
properties of nutrition solutions have not been made.12
One of the most controversial components of feeding
solutions is fibre. Dietary fibre has been shown to have
various effects by multiple studies. Krusawa et al13 and
Cummings JH14 showed that dietary fibre increases stool
weight allowing for easier defecation. Salmeron et al15
reported glucose regulating effects of dietary fibre. Fibres
that promote beneficial bacterial growth, such as that of
lactobacillus and bifidobacteria, are called prebiotics.
Prebiotics improve gut barrier function and host immuni-
ty and reduce the overgrowth of pathogenic bacteria, such
as clostridia.16 Inulin and FOS are the main prebiotics in
our study solution. As examples of the immunological
support provided by prebiotics, it has been shown that
FOS consumption increases T-lymphocytes in adults,
increases antibody response to vaccines in infants and
reduces antibiotic consumption.17-19 Elia et al20 reported a
systemic review and meta-analysis that proved that fibre-
enriched feeding formulas reduce diarrhoea incidence.
Chittawatanarat et al21 showed that mixed fibre formulas,
like our formula, in particular, can reduce diarrhoea in
septic ICU patients receiving broad spectrum antibiotics.
Soluble fibres (e.g. pectin, FOS, inulin, guar gum) have
744 H Yagmurdur and F Leblebici
antidiarrhoeal mechanisms. Namely, after soluble fibre
fermentation by colonic anaerobic bacteria, short-chain
fatty acids (SCFAs) are produced. SCFAs are beneficial
for colonocytes and stimulate water uptake.21,22 Majid et
al23 reported that fibres reduced diarrhoea incidence and
acted as a type of prebiotic. Rushdi et al24 performed a
study with only one type of fibre, guar gum, and still
found that fibre-enriched nutrition reduced diarrhoeal
episodes. The required amount of fibre needed to de-
crease the incidence of diarrhoea has not yet been deter-
mined. In a meta-analysis, Elia et al20 reported that the
beneficial mean fibre intake amount is approximately 30
g/day in most studies. In the present study, the fibre-
enriched group mean fibre intake was approximately 28 g
per day, which is in agreement with the results of the me-
ta-analysis.
Controversially, there have been studies that did not
show beneficial effects of fibres. Hart et al6 and Dobb et
al25 reported that fibre-enriched nutrition did not reduce
diarrhoea frequency. These conflicting results may be due
to differences in the types of fibres used in those studies.
Jack et al26 reported that the consequences of diarrhoea
are electrolyte imbalance, dehydration, perianal skin
breakdown and wound contamination. In the present
study, low risk ICU patients were examined in respect to
gastrointestinal complications; thus, we did not observe
these consequences of diarrhoea in our short study period.
In our opinion, one of the most important consequences
of diarrhoea is the compulsory cessation of enteral nutri-
tion.
Majid et al thought that diarrhoea may contribute to
malnutrition in ICU patients.27
In the present study, the two groups were similar in re-
gards to the biochemical measurements at the beginning
of the study, and no differences were found at the end of
the study. Rushdi et al24 reported higher calcium and
magnesium levels in a fibre-enriched group compared
with a control group, but did not find a difference in al-
bumin level. These variable results between studies may
be due to the different fibres used or to the small sample
sizes of those studies.
For diarrhoea management in enteral-fed patients, vari-
ous protocols have been used. Decreasing the nutrition
infusion volume and nutrition interruption are the basics
of diarrhoea management, and changing the feeding for-
mula is another technique for diarrhoea management.7 In
these circumstances, energy intake and metabolic re-
quirements (glucose, electrolytes and protein) must be
replaced with intravenous solutions. Unnecessary intra-
venous access for parenteral replacement is a cause of
ICU infections. Protein-energy malnutrition causes many
complications in ICU patients, and mortality increases
with these complications, especially infectious complica-
tions and immunosuppression.2-5
In conclusion, gastrointestinal complications have var-
ious harmful consequences in ICU patients. Diarrhoea is
one of the most frequent complications in tube-fed pa-
tients and is a complicating factor for enteral nutrition
management. On the basis of the present study, we sug-
gest that ICU staff initiate enteral nutrition with fibre-
enriched formulas rather than fibre-free formulas to avoid
frequent feeding interruptions which cause protein-energy
malnutrition in ICU patients.
AUTHOR DISCLOSURES
None.
REFERENCES
1. Jolliet P, Pichard C, Biolo G, Chioléro R, Grimble G,
Leverve X et al. Enteral nutrition in intensive care patients: a
practical approach. A position paper. Clin Nutr. 1999;18:47-
56. doi: 10.1054./clnu.1998.0001.
2. Dempsey DT, Mullen JL, Buzby GP. The link between nutri-
tional status and clinical outcome: can nutritional interven-
tion can modify it? Am J Clin Nutr. 1988;47:352-6.
3. Rubinson L, Diett GB, Song X, Brower RG, Krishnan JA.
Low caloric intake is associated with nosocomial blood-
stream infections in patients in the medical intensive care
unit. Crit Care Med. 2004;32:350-7. doi: 10.1097/01.CCM.
0000089641.06306.68.
4. Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux
MC, Delarue J, Berger MM. Negative impact of hypocaloric
feeding and energy balance on clinical outcome in ICU pa-
tients. Clin Nutr. 2005;24:502-9. doi: 10.1016/j.clnu.2005.
03.006.
5. Alberda C, Gramlich L, Jones N, Jeejeebhoy K, day AG,
Dhaliwal R, Heyland DK. The relationship between nutri-
tional intake and clinical outcomes in critically ill patients:
results of an international multicenter observational study.
Intensive Care Med. 2009;35:1728-37. doi: 10.1007/s00134-
009-1567-4.
6. Hart GK, Dobb GJ. Effect of a fecal bulking agent on diar-
rhea during enteral feeding in the critically ill. JPEN J
Parenter Enteral Nutr. 1988;12:465-8. doi: 10.1177/0148607
188 012005465.
7. Montejo JC. Enteral nutrition related gastrointestinal com-
plications in critically ill patients: a multicenter study. Crit
Care Med. 1999;27:8;1447-53. doi: 10.1097/00003246-1999
08000-00006.
8. Chang SJ, Huang HH. Curr Opin Clin Nutr Metb Care.
2013;16:588-94. doi:10.1097/MCO.0b013e328363bcaf.
9. Whelan K. Enteral tube feeding diarrhea: manipulating the
colonic microbiota with probiotics and prebiotics. Proc Nutr
Soc. 2007;66:299-306. doi:10.1017/S0029665107005551.
10. Whelan K, Judd PA, Tuohy KM, Gibson GR, Preedy VR,
Taylor MA. Fecal microbiata in patients receiving enteral
feeding are highly variable and may be altered in those who
develop diarrhea. Am J Clin Nutr. 2009;89:240-7. doi: 10.39
45/ajcn.2008.26219.
11. Luft VC, Beghetto MG, De Mello ED, Polanczyk CA. Role
of enteral nutrition in the incidence of diarrhea among hospi-
talized adult patients. Nutrition. 2008;24:528-35. doi: 10.10
16/j.nut.2008.02.004.
12. Jack L, Coyer F, Courtney M, Venkatesh B. Diarrhoea risk
factors in enterally tube fed critically ill patients: a retro-
spective audit. Intensive Crit Care Nurs. 2010;26: 327-34.
doi: 10.1016/j.iccn.2010.08.001.
13. Krusawa S, Haack VS, Marlett JA. Plant residue and bacte-
ria as a bases for increased stool weight accompanying con-
sumption of higher dietary fibre diets. J Am Coll Nutr. 2000;
19:426-33. doi: 10.1080/07315724.2000.10718942.
14. Cummings JH. The effect of dietary fibre on fecal weight
and composition. In: Spiller GA, ed. CRC Handbook of Die-
tary Fibre in Human Nutrition. Boca Raton, FL: CRC Press;
1993. pp. 263-333.
15. Salmeron J, Manson JE, Stampfer MJ, Colditz GA, Wing
AL, Willet WC. Dietary fibre, glycemic load, and risk of
non-insulin-dependent diabetes mellitus in women. JAMA.
1997;277:472-7. doi: 10.1001/jama.1997.03540300040031.
 Fibre-enriched nutrition in ICU
16. Kolida S, Gibson GR. Prebiotic capacity of inulin type fruc-
tans. J Nutr. 2007;137:2503-6.
17. Guigoz Y, Rochat F, Perruisseau Carrier G, Rochat I,
Schiffrin EJ. Effects of oligosaccharides on the faecal flora
and nonspecific immune system in elderly people. Nutr Res.
2002;22:13. doi: 10.1016/S0271-5317(01)00354-2.
18. Firmansyah A, Pramita G, Fassler C, Haschke F, Link-
Amster H. Improved humoral immun response to measles
vaccine in infants receiving infant cereal with fructo-
oligosaccharides. J Ped Gastr Nutr. 2001;31:251.
19. Saavedra JM, Tschernia A. Human studies with probiotics
and prebiotics: Clinical implications. Br J Nutr. 2002;87:
241-6. doi: 10.1079/BJN/2002543.
20. Elia M, Engfer MB, Green CJ, Silk DBA. Systemic review
and meta-analysis: the clinical and physiological effects of
fibre-containing enteral formulae. Aliment Pharmacol Ther.
2008;27:120-45. doi: 10.1111/j.1365-2036.2007.03544.x.
21. Chittawatanarat K, Pokawinpudisnun P, Polbhakdee Y.
Mixed fibers diet in surgical ICU septic patients. Asia Pac J
Clin Nutr. 2010;19:458-64.
22. Schneider SM. Microbiota and enteral nutrition. Gastroen-
terol Clin Biol. 2010;34:57-61. doi: 10.1016/S0399-8320
745
(10)70022-1.
23. Majid HA, Emry PW, Whelan K. Faecal microbiota and
short-chain fatty acids in patients receiving enteral nutrition
with standard or fructo-oligosaccharides and fibre-enriched
formulas. J Hum Nutr Diet. 2011;24:260-8. doi:10.1111/j.
1365-277X.2011.01154.x.
24. 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:
1344-52. doi:10.1016/j.clnu.2004.04.008.
25. Dobb GJ, Towler SC. Diarrhea during enteral feeding in
critically ill; a comparison of feeds with or without fibre. In-
tensive Care Med. 1990;16:252-5. doi: 10.1007/BF0170516
1.
26. Jack L, Coyer F, Courtney M, Venkatesh B. Probiotics and
diarrhoea management in enterally tube fed critically ill pa-
tients-what is the evidence? Intensive Crit Care Nurs. 2010;
26:314-26. doi: 10.1016/j.iccn.2010.07.001.
27. Majid HA, Emry PW, Whelan K. Definitions, attitudes, and
management practices in relation to diarrhea during enteral
nutrition. Nutr Clin Pract. 2012;27:252-6. doi: 10.1177/0884
533611431986.
746 H Yagmurdur and F Leblebici

Original Article

Enteral nutrition preference in critical care:

fibre-enriched or fibre-free?

Hatice Yagmurdur MD, Figen Leblebici MD

Department of Anesthesiology and Intensive Care, Ankara Numune Education and Research Hospital,
Ankara, Turkey

重症监护中的肠内营养选择：富含还是不含膳食纤维?

背景与目的：本研究的主要目的是观察一个富含纤维营养液对必要给与量的
影响，这与机械通气的肠内营养患者能量摄入成正比。研究设计与方法：对
需要机械通气和肠内营养鼻饲管的 120 例患者进行了研究。在进入 ICU 前，
记录患者的年龄、性别、体重、身高、疾病、诊断和 APACHE II 评分。我们
随机将患者分至两种饮食。对照组给予无膳食纤维营养液。研究组给与富含
膳食纤维营养液。在每日生化检测时，记录处方量和实际给予量、胃残留量
（GRV）、体积比（VR）、腹泻评分和胃肠道并发症（GIC）。结果：两组
患者的年龄、性别、体重、BMI、APACHEⅡ评分、热量摄入或 GRV 均无统
计学意义（p>0.05）。在第 4 和 5 天时，研究组的 VR（p<0.05）较高。71
（59%）例患者至少有 1 种胃肠道并发症，其中对照组 44 例（73%），研究
组 27 例（45%）。腹泻是最常见的 GIC。对照组 38 例、研究组 22 例患者有
腹泻（p<0.001）。两组间呕吐和反流的发生率无统计学意义。结论：我们建
议，对 ICU 患者启动肠内营养与富含膳食纤维的配方，而不是无膳食纤维配
方，以避免频繁喂养中断导致蛋白质-能量营养不良。

关键词：富含纤维营养、体积比、腹泻、肠内营养、胃残留量
 CHECKLIST CONSORT PADA PENELITIAN EKSPERIMEN

Enteral Nutrition Preference in Critical Care :

Fibre-Enriched or Fibre-Free ?

Topik Nomor Checklist Dilaporkan

pada halaman
Title and 1a Pada judul penelitian, tidak menyebutkan sebagai 740
Abstrack penelitian randomized trial . Judul dituliskan dalam
bentuk kata tanya, yaitu Enteral Nutrition Preference in
Critical Care : Fibre-Encriched or Fibre-Free?
Fibre-Free ?

1b Pada abstrak, sudah menuliskan ringkasan dari 740

penelitian yang dilakukan secara terstruktur yaitu latar
belakang, metode dan desain penelitian, hasil penelitian
dan kesimpulan, serta kata kunci dari penelitian
tersebut.

Introduction 2a Latar belakang masalah sudah dijelaskan secara ilmiah 740

Background dan rasional berdasarkan sumber penelitian sebelumnya
And Objectives yang diambil dari American Journal Clinical Nutrition,
Intensive Care Medicine,
Medicine, dll. Namun pada paragraph
pertama Pendahuluan, kalimat ketiga dan seterusnya
tidak dituliskan sumber pustaka/referensi penulisannya.

2b Peneliti sudah menuliskan tujuan penelitian dalam 740

paragraf kedua pada bab Pendahuluan
Pendahuluan meliputi tujuan
utama dan tujuan sekunder, dimana tujuan utamanya
adalah untuk mengetahui efek dari pemberian nutrisi
yang diperkaya serat sesuai dengan asupan kalori yang
dibutuhkan pada pasien yang menggunakan ventilator
dengan nutrisi enteral. Sedangkan tujuan sekundernya
adalah untuk meneliti insiden komplikasi
gastrointestinal.
Hipotesis penelitian tidak dituliskan dalam bab
Pendahuluan.

Methods
Trial design 3a Desain penelitian tidak disebutkan secara jelas. Dalam 740-741
bab Metode penelitian disebutkan pasien ICU yang yang
sesuai dengan kriteria inklusi diberikan 2 jenis
 intevensi diet secara acak pada 2 kelompok yaitu
kelompok kontrol (kelompok Fiber-Free) dan
kelompok penelitian (kelompok Fiber-Enriched).
Randomization/ pengacakan dilakukan secara tertutup.
Rasio alokasi atau distribusi kelompok tidak dijelaskan
secara rinci.

Sudah dijelaskan alasan dari penentuan kriteria

3b kelayakan pada subyek penelitian, yaitu selama 741-742
penelitian berjalan, komplikasi gastrointestinal diamati.
Jika terdapat distensi, vomitus, regurgitasi, konstipasi
dan diare seperti yang didefinisikan di Bab Metode
halaman 741, subyek dapat dikeluarkan dari penelitian
atau dapat juga dilanjutkan intervensinya sesuai dengan
hasil pemeriksaan lanjutan.

Sudah dijelaskan mengenai kriteria sebagai subyek

Participant 4a penelitian meliputi kriteria inklusi dan ekslusi. Kriteria 741
inklusi pada penelitian ini meliputi pasien yang dirawat
di ruang ICU, usia 35-90 tahun, pasien dengan penyakit
cerebrovaskuler akut yang membutuhkan ventilator dan
nutrisi enteral dengan NGT, serta pasien yang
memperoleh feeding dalam 48 jam setelah pengkajian
ICU (usia, jenis kelamin, berat badan, tinggi badan,
komorbiditas, diagnosis dan skor APACHE II).
Sedangkan kriteria eksklusinya adalah pasien dengan
kondisi hemodinamik yang tidak stabil, sepsis,
kontraindikasi pada nutrisi enteral (obstruksi saluran
GI), hemoragik, dan ileus), pancreatitis, penyakit GI
(ulcerative colitis, Chron’s disease, dan iskemik atau
infeksi colitis), pasien obes (BMI > 35 kg.m 2), sindrom
malnutrisi, pasien imunosupresi, dan hasil biokimia
yang sangat parah serta memperoleh antibiotik
spektrum luas.

4b Tidak disebutkan secara jelas lokasi penelitian, dalam 740

Bab Metode paragraf pertama hanya disebutkan
penelitian dilakukan di ruang ICU di sebuah Rumah
sakit pendidikan dan penelitian. Namun dalam artikel
ini, juga dicantumkan alamat korespondensi peneliti
yaitu di Ankara Numune Education and Research
 Hospital, Anesthesiology and Intensive Care
Department, Turki.

Interventions 5 Intervensi yang diberikan pada subyek penelitian sudah 741

dijelaskan secara urut dan rinci serta bagaimana dan
kapan pengambilan datanya, yang dijelaskan di Bab
Metode. Dimana intervensi yang diberikan pada subyek
penelitian adalah sebagai berikut :
1. Semua Pasien ICU yang sudah melalui pengkajian
dan menggunakan ventilator serta tidak dapat
makan/minum per oral, dipasangkan NGT. Setiap
hari dilakukan pengecekan degan radiologi terkait
posisi NGT. Semua pasien diatur dalam posisi semi
telentang (30-45°) untuk mengurangi kejadian
pneumonia. Ventilator diatur sesuai hasil Analisa
gas darah arteri pasien.
2. Secara acak dan tertutup dilakukan pembagian
kelompok menjadi 2 dengan pemberian 2 jenis diet.
3. Kelompok kontrol (FF) menerima Nutrison, solusi
nutrisi bebas serat. Kelompok penelitian (FE)
menerima Nutrison multifiber, solusi nutrisi yang
diperkaya serat. Pemberian nutrisi menggunakan
enteral feeding pump.
4. Pada hari pertama, asupan enteral diatur untuk
memenuhi 50% kebutuhan energi, diikuti hari
kedua 75% dan 100% di hari ketiga.nutrisi enteral
dimulai dari 20 ml/jam dan meningkat pada interval
6 jam menjadi 40 ml/jam, 80 ml/jam, 100 ml/jam
dan jika perlu sampai 120 ml/jam.

Outcomes 6a Sudah dijelaskan secara spesifik mengenai sumber data 741-742

dan cara pengambilan data baik data primer maupun
sekunder serta waktu pengambilan datanya,
diantaranya:
1. Pengukuran GRV (Gastric Residual Volume) untuk
mengetahui toleransi dari pemberian nutrisi enteral.
Pengukuran GRV pada hari pertama dilakukan
setiap 6 jam, pada hari kedua setiap 8 jam dan pada
pasien yang toleransi terhadap nutrisi enteralnya
baik, pengukuran GRV dilakukan 1x sehari setelah
3 hari.
 2. Pengukuran erhadap VR (Volume Ratio (%))
dilakukan setiap hari untuk mengetahui efisiensi
nutrisi enteral.
3. Pengukuran skor diare dan komplikasi pada saluran
cerna seperti distensi, vomitus, regurgitasi dan
konstipasi.
4. Data komplikasi pulmonary aspiration berdasarkan
diagnosa dokter ketika formula enteral ditemukan
pada bunyi aspirasi trachea.
5. Parameter biokimia (hemoglobin, total protein,
albumin, prealbumin, total cholesterol, calcium,
phosphate, magnesium, sodium, potassium,
glucose, urea, creatinine, alanine aminotransferase)
dicatat setiap hari.

6b Tidak menyebutkan ada perubahan protokol penelitian -

selama penelitian berjalan.

Sample size 7a Penentuan besar sampel tidak disebutkan secara jelas. 740
Dalam Bab Metode hanya disebutkan besar sampel
sejumlah 120 pasien ICU yang dirawat, yang
memenuhi kriteria inklusi penelitian, dimana informed
consent diperoleh dari keluarga terdekat pasien sebelum
dilakukan intervensi.

7b Dalam artikel penelitian Bab Metode sudah dijelaskan 742

tentang pedoman penghentian sampel atau
dikeluarkannya sampel sebagai subyek penelitian, yaitu
jika pasien mengalami diare persisten (lebih dari 8 hari)
yang mengindikasikan adanya masalah GI, pasien
dikeluarkan dari subyek penelitian. Namun pada
aplikasinya, peneliti melaporkan di Bab Hasil bahwa
dari 120 pasien, tidak ada yang diekslusi dari
penelitian.

Randomisation:
Sequence 8a Metode random untuk menentukan alokasi sudah 741
generation dijelaskan yaitu secara tertutup, penomoran
dimasukkan dalam amplop tertutup. Staf medis yang
melakukan pengukuran GI dan mengkaji komplikasi GI
tidak mengetahuinya (blind).
 8b Tipe randomisasi tidak dijelaskan secar rinci, dalam 741
bab Metode hanya menyebutkan bahwa random
dilakukan dengan penomoran dalam amplop tertutup.
Allocation
concealment 9 Mekanisme yang digunakan untuk implementasi 741
mechanism random untuk urutan alokasi hanya dijelaskan secara
singkat yaitu secara tertutup. Peneliti memberikan 2
diet pada subyek secara acak, sehingga terbagi menjadi
2 kelompok yaitu kelompok penelitian dan kelompok
kontrol.

Implementation 10 Dalam Bab Metode, dijelaskan yang melakukan 741

random untuk menentukan alokasi adalah peneliti
sendiri.

Blinding 11a Dalam bab Metode disebutkan bahwa setelah intervensi 741
diet yang diberikan pada subyek penelitian yang sudah
dibagi menjadi 2 kelompok secara acak dan tertutup,
staf medis yang melakukan pengambilan data, tidak
mengetahui tentang alokasinya.

11b Pemberian intervensi pada masing-masing kelompok 741

sudah disebutkan secara rinci dan mendeskripsikan
kesamaan/kemiripan dari intervensi yaitu pemberian
nutrisi enteral, kelompok kontrol berupa nutrisi enteral
bebas serat dan kelompok penelitian berupa nutrisi
enteral yang diperkaya serat.

Metode statistik 12a Sudah menyebutkan metode statistik yang digunakan 742
untuk analisis data primer dan sekunder yaitu uji chi
square untuk analisis data kualitatif, analisis varian
dengan uji Mann-Whitney untuk data kuantitatif..

12b Dalam bab Metode paragraph akhir disebutkan 742

dilakukan analisis untuk parameter hemodinamik
diperoleh dari interval waktu dalam kelompok yang
sama dibandingkan dengan nilai awal intervensi
menggunakan uji Paired t-test. Jika kedua parameter
dalam distribusi normal, koefisien korelasi dan
signifikansinya dihitung menggunakan Pearson test.

Results
Participant 13a Dalam artikel ini, tidak mencantumkan flow diagram 742
flow penelitian. Dalam Bab Hasil, disebutkan total subyek
penelitian adalah 120 pasien, yang dibagi menjadi 2
kelompok yaitu kelompok kontrol (n=60) dan
kelompok penelitian (n=60).

13b Pada Bab Hasil paragraf pertama, peneliti menyebutkan 742

tidak ada pasien yang dieksklusi dari penelitian untuk
indikasi yang sudah dijelaskan di Bab Metode.

Recruitment 14a Tidak disebutkan secara jelas tanggal/waktu penelitian, 742

hanya menjelaskan tentang periode pengambilan data
penelitian pada Bab Hasil selama 5 hari pengamatan.

14b Tidak disebutkan alasan penelitian dihentikan, karena -

penelitian diakhiri setelah semua proses intervensi dan
pengambilan data selesai.

Baseline data 15 Sudah menampilkan tabel tentang karakteristik 742

demografi dan klinis data serta hasil penelitian pada
tiap kelompok seperti karkteristik umur, jenis kelamin,
berat badan, BMI, skor APACHE II dan target asupan
energi yang diperesentasikan dalam mean ± SD.

Number 16 Pada Bab Hasil, sudah disebutkan jumlah data yang 742-743
analysed dianalisis, yaitu 60 pasien tiap kelompok karena tidak
ada data yang missing. Pada pelaksanaan penelitian,
komplikasi GI yang dialami pasien masih dapat
tertangani sesuai dengan protokol penelitian yang sudah
dijelaskan di Bab Metode, sehingga data yang diperoleh
dapat dianalisis.

Outcomes and 17a Sudah menjelaskan presisi untuk tiap data penelitian 742
estimation dari masing-masing kelompok yaitu signifikan pada
nilai p < 0,05 (95% Confidence Interval)

17b Pada penelitian ini tidak mempresentasikan besaran -

efek absolut dan efek relatif

Ancillary 18 Analisis data baik untuk data kualitatif maupun data 743
analyses kuantitatif sudah dilakukan, ditampilkan pada tabel 3,
4, 5 dan 6. Selain itu juga dilakukan analisis untuk
 parameter biokimia dengan membandingkan hasil di
hari 1 dan hari 5, namun hasil analisis tidak ditampilkan
dalam tabel, peneliti hanya menyebutkan tidak ada
perbedaan yang signifikan secara statistik pada
parameter biokimia antar kelompok.

Harms 19 Pada penelitian ini sudah menyebutkan antisipasi resiko 741

negatif yang mungkin muncul akibat dari treatmen
yang diberikan (nutrisi enteral) berupa gangguan
saluran cerna (gastrointestinal complication) yaitu
dengan protokol medis yang sudah dijelaskan pada bab
Metode.

Discussion
Limitation 20 Pada bab Pembahasan, peneliti tidak menyebutkan 744
secara jelas keterbatasan penelitian. Hanya pada
beberapa indikator data yang menunjukkan tidak
adanya perbedaan yang signifikan yaitu pada
pengukuran biokimia, peneliti menyebutkan hal ini
dikarenakan perbedaan serat yang digunakan dan
ukuran sampel yang kecil.

Generalizability 21 Penelitian ini menyebutkan generalisasi dari hasil 743-744

penelitiannya bahwa pada pasien ICU dianjurkan untuk
pemberian nutrisi enteral yang diperkaya serat
dibandingkan yang bebas serat, dengan didukung dari
hasil penelitian lain yang sejenis.

Interpretation 22 Pada Bab Pembahasan, sudah menampilkan interpretasi 743-744

hasil penelitian dengan mempertimbangkan tujuan
penelitian dan bukti yang relevan berupa hasil Analisa
statistik, selain itu sudah mengkaitkan dengan hasil-
hasil dari penelitian sebelumnya.

Other
information 23 Tidak mencantumkan nomor dan nama registrasi -
Registration percobaan

Protocol 24 Tidak menyebutkan alamat dimana dapat memperoleh -

protokol penelitian secara penuh.

Funding 25 Tidak menyebutkan sumber dana penelitian -