Intensive Care Unit Clinical Trial
Official title:
Citrullinemia for the Prediction of Enteral Nutrition Tolerance Among Critically Ill Patients
The French intensive care societies (SRLF and SFAR), in agreement with the European and
American societies for enteral and parenteral nutrition, recommend to quickly administer an
artificial nutrition to patients admitted to ICU and for which it is expected that they will
not be able to eat normally in the three days of admission.
Enteral nutrition should be used in priority if the gut is functioning. However, intolerance
to enteral nutrition, such as vomiting, regurgitation, increased residual gastric volume, or
diarrhea, occurs in 40% of patients hospitalized in ICU receiving enteral nutrition.
Intolerance to enteral nutrition leads to the risk of not receiving enough nutrition. Feeding
intolerance also exposes to the risk of acute mesenteric ischemia, especially in the most
severe patients under catecholamine for shock. Currently, it is not possible to predict
intolerance to enteral nutrition in ICU patients. Thus, the diagnosis of intolerance is made
a posteriori while enteral nutrition is in progress.
Citrullinemia (normal concentration of 20 to 60 μmol / L), could be a good biomarker of the
function of enterocytes involved in the absorption of food.
The aim of this study is to evaluate the interest of citrullinemia to predict tolerance to
enteral nutrition in ICU patients.
Citrulline is an amino acid mainly produced by enterocytes from glutamine.
Citrullinemia ≤ 20μmol/L is a biomarker of enterocyte mass reduction, secondary to the
reduction of small bowel length or secondary to villous atrophy diseases. A patient with low
citrullinemia is probably at risk of enteral nutrition malabsorption.
Citrulline generation test consists of measuring the course of citrullinemia after an oral or
intravenous administration of glutamine, the main precursor of citrulline. When the small
bowel is functional, administration of glutamine is followed by the elevation of
citrullinemia. On the contrary, when there is enterocyte dysfunction or reduction,
citrullinemia does not vary after glutamine administration. Peeters et al have shown the
feasibility of carrying out the citrulline generation test in patients hospitalized in the
ICU. In this context, intravenous administration of glutamine (20 gr of 10%
N2-L-Alanyl-L-Glutamine, dilution in 200 ml of water for injection, IV infusion over 30
minutes) followed by monitoring of citrullinemia (basal time and then after 90 minutes, on
arterial sampling) is feasible and reproducible.
There is currently no data available on the relationship between citrullinemia measured at
ICU admission and tolerance to enteral nutrition in the days following ICU admission.
Similarly, the value of the citrulline generation test for evaluating enteral nutrition
tolerance is unknown.
The investigators hypothesize that patients with low citrullinemia at ICU admission, as well
as those with a decreased citrullinemia elevation after Dipeptiven bolus, will have less
tolerance to enteral nutrition than patients with normal citrullinemia.
PREDICT is the first study evaluating the interest of citrullinemia and the citrulline
generation test to predict feeding tolerance among critically ill patients.
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