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Comparison of the Effect of Enteral Feeding through the Bolus and Continuous Methods on Serum Phosphorus and Glucose Levels in Patients with Mechanical Ventilation: A Randomized Clinical Trial

Comparison of the Effect of Enteral Feeding through the Bolus and Continuous Methods on Serum... Hindawi Journal of Nutrition and Metabolism Volume 2020, Article ID 6428418, 6 pages https://doi.org/10.1155/2020/6428418 Research Article ComparisonoftheEffectofEnteralFeedingthroughtheBolusand Continuous Methods on Serum Phosphorus and Glucose Levels in Patients with Mechanical Ventilation: A Randomized Clinical Trial 1 2 3 4 Javad Seyyedi , Zahra Rooddehghan , Mostafa Mohammadi, and Shima Haghani Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran MSc in Biostatistics Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran Correspondence should be addressed to Zahra Rooddehghan; zrooddehghan@yahoo.com Received 7 February 2020; Revised 1 August 2020; Accepted 28 August 2020; Published 8 September 2020 Academic Editor: Mohammed S. Razzaque Copyright © 2020 Javad Seyyedi et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Patients who are under mechanical ventilation in intensive care units need to have nutritional support. Also, feeding methods affect serum phosphorus and glucose levels, which are very important in weaning patients off the ventilator. )us, this study is to compare the effects of both bolus and continuous enteral feeding methods on serum phosphorus and glucose levels in patients with mechanical ventilation. Methods. In this clinical trial study, 34 patients in the intensive care unit of Imam Khomeini Hospital affiliated to the Tehran University of Medical Sciences satisfied inclusion criteria and were randomly divided into control and intervention groups. Sampling was done between October and February 2018. )e intervention group received continuous enteral feeding for one week, and the control group received nutrition by the bolus method. )e blood glucose level was measured every six hours, and the serum phosphorus level was recorded at the beginning and the end of the intervention, based on the data entry form with respect to all ethical considerations. Data analysis was done by SPSS-20 software. Results. )e serum phosphorus level was significantly increased in the intervention group (P � 0.004) and in the control group (P<0.001) and was compared with the previous intervention. No significant difference was found between the intervention and control groups before and after the intervention (P � 0.22) and also one week after the intervention (P � 0.14). )ere was also no significant difference between the glucose levels from day 1 to day 7 in the control group (P � 0.33) and the intervention group (P � 0.086). Discussion. Nutritional support in both bolus and continuous methods increased the serum phosphorus level. It indicates the importance of the nu- tritional method in controlling the phosphorus level in critically ill patients. However, there was no difference between the effects of dietary methods on blood glucose control. and trauma, stroke, rib fracture, chronic pulmonary ob- 1. Introduction struction associated with respiratory failure such as asthma Intensive care unit is one of the most important sections in and emphysema, and general illnesses such as myasthenia any hospital, where patients with acute and critical condi- gravis, Guillen–Barre syndrome, and tetanus [2–4]. De- tions receive care and treatment [1]. One of the important scriptive findings show that patients who have been groups of the patients admitted to intensive care units is the mechanically ventilated for a long time are nutritionally ones with respiratory disorders who require artificial airway weak [5] and that gradually during their treatment, they and mechanical ventilation for survival. Respiratory disor- develop hypercatabolism and increased metabolism due to ders include postoperative respiratory failure, head injury physiological conditions and psychosocial stressors that are 2 Journal of Nutrition and Metabolism management [27]. In the study of Shahriari et al. that mostly caused by their acute illness. Subsequently, patients will become malnourished if nutritional support is not sufficient concentrated on nonintubated patients, the mean blood glucose level was recognized to be lower in the patients with to provide for body’s demands [6]. Nutritional support in these patients is either enteral nutrition or total parenteral continuous feeding [28]. Given these assumptions and nutrition [7]. Enteral nutrition is mainly performed in two considering the importance of glucose and phosphate in methods of continuous feeding over a period of 16–24 hours weaning patients off the ventilator, the selection of a correct and bolus feeding for 4–6 times per day [8]. In the con- nutritional method is an important factor in caring the tinuous method, feeding starts through a feeding pump at patients under mechanical ventilation. )us, we decided to 20–50cc/h and continues 24 hours a day. )is method is conduct a study with the aim of examining the effects of both continuous and bolus feeding methods on the phosphate more common in patients with respiratory failure as it re- duces the risk of aspiration in these patients [9]. )is method and blood glucose levels in patients being treated under mechanical ventilation. also provides a greater opportunity for absorption of micronutrients than other methods [10]. In the bolus method, nutrient (formula) is given to patients 4–6 times a 2. Materials and Methods day through a 50mL syringe over a short interval of 4 –10 minutes [9]. )is method is inexpensive and resembles the )is study is a clinical trial that was conducted on two people’s normal eating pattern. It also shortens the feeding groups of intervention and control following the code of time and is a good choice for patients with good digestive ethics: IR.TUMS.FNM.REC. Sampling has been done be- function, but the risk of aspiration is higher in this method tween October 2018 and February 2018 in the intensive care than others due to delayed gastric emptying [10]. unit of one of the teaching hospitals of the Tehran University Nutritional methods also influence laboratory parame- of Medical Sciences. )e data were collected in two stages: ters [11–13]. Hypophosphatemia, which is defined as before and one week after the intervention. Inclusion criteria P≤2.5mg/dL [14], is one of the most common electrolyte were restricted to the patients aged between 18 and 85 years, abnormalities in ICUs, with 80% prevalence in the ICU who did not suffer from any gastrointestinal problems such patients. In fact, malnutrition with catecholamines, insulin, as diarrhea, ileus, ostomy, obstruction, or chronic renal diuretics, alkalosis, diabetic ketoacidosis, and sepsis can failure. )ey also did not have any history of intestinal predispose patients with acute conditions to hypo- feeding. )e case study patients were admitted to the ICU phosphatemia [15, 16]. Hypophosphatemia can occur in while they had been intubated in the unit. We have also ICU patients by three different mechanisms, including de- received the patients’ families’ consent to be included in the creased intestinal absorption, increased renal excretion of study. Exclusion criteria included the patient’s death, any phosphate, and redistribution of inorganic phosphate changes in feeding method, and feeding intolerance or [17, 18]. Impairment of cellular energy storage as well as termination. tissue hypoxia can lead to various clinical manifestations of Of 64 patients eligible for the study, 13 were excluded hypophosphatemia [19], including myocardial dysfunction, from the study (6 due to family disapproval, 2 due to gas- diaphragm weakening, convulsions, coma, rhabdomyolysis, trointestinal surgery, 2 due to diarrhea at baseline, and 3 due and RBCs’ dysfunction [16]. Hypophosphatemia lowers the to chronic renal failure). Informed consent was obtained 2-3 levels of diphosphoglycerate in red blood cells, which from the family of patients who met the inclusion criteria, shifts the oxyhemoglobin dissociation curve to left and and then, the patients were randomly divided into two increases hemoglobin tendency towards oxygen and sub- groups of intervention and control according to the hospital sequently reduces oxygen delivery to the tissues [20]. Studies number. )e data collection methods were observation and have shown that hypophosphatemia disrupts weaning pa- measurement. )e data collection tools included the patient tients off the ventilator [21] and has been reported as one of record checklist and the data measurement checklist. )e the complications of intravenous nutrition [22]. However, validity of the data collection tools was confirmed by 10 changes in hypophosphatemia during continuous intestinal faculty members, and in order to ensure their reliability, the feeding have not been studied yet. fixed glucometer kit and serum phosphorus measurement Hyperglycemia is another common disorder in ICUs, were used. To collect data in both groups, first baseline which is common even in nondiabetic patients [23]. information such as age, sex, marital status, admission Complications such as pneumonia, urinary tract infection, records, disease records, medications used, BMI, diagnosed and surgical site infection are also associated with increased disease, and level of consciousness were obtained from the blood sugar [24–26]. Studies have shown that the blood patients’ record and then were recorded in the baseline glucose level affects the process of weaning patients off the record sheet. At the beginning of the intervention, the serum ventilator and may be an indicator of the poor metabolic phosphorus level was measured by the researcher using status in critically ill patients. It is also an important factor in para-clinical tests. )e blood sample kit and measurements determining the necessity for ventilation and disconnection were recorded in the laboratory data sheet. )en, feeding the patient from the ventilator [11]. Compared with the began in the intervention group by the continuous feeding intubated patients, the patients who have been successfully method at 25cc/h and in the control group by the routine weaned off the ventilator have lower mean glucose con- bolus method via a nasal gastric (NG) tube at 75cc/3h with centration [11]. Studies have revealed that the speed and the commercial standard solution “Entera meal,” which volume of feeding exert a direct impact on the blood glucose contained 1 kcal of energy per cc (cubic centimeter). )e Journal of Nutrition and Metabolism 3 patients were at semi-seated position during feeding time. groups in terms of glucose level during days 2 to 7 of the On the first day of the patients’ feeding, 50% of the patients’ intervention (P>0.05) except for day 1 (P � 0.02). nutritional goal was met, and the volume of bolus was gradually increased every hour during the next 48 hours to 4. Discussion achieve the ultimate nutritional goal (25kcal/kg/day). )is diet was kept until the end of study. During the sampling )e importance of phosphorus, especially the role that it process, patients’ blood glucose was measured every 6 hours plays in the formation of adenosine triphosphate and 3-2 using a CLEVER-CHEK glucometer and recorded in the diphosphoglycerate, is related to the point that phosphorus patients’ data sheet. According to Figure 1, in total, 17 is a very important component of supportive nutrition for participants left the study due to various reasons (7 due to patients [29]. Refeeding syndrome is one of the important death, 5 due to intolerance, 3 due to stop feeding, and 2 due issues in the feeding of malnourished patients. In these to the change in feeding method). patients, insulin is released after feeding and the absorption Sampling continued until the desired sample size (34 of carbohydrates, which leads to the transfer of phosphate, individuals) was determined based on the study of Shahriari magnesium, and potassium into the cell and thereby low- et al. [28] and the following formula: ering the serum level of these electrolytes [30]. Studies also confirm this process [31–38]. Phosphorus reduction is a 2 2 􏼐z + z 􏼑 × 􏼐σ + σ 􏼑 1− (α/2) 1− β 1 2 major indicator of this syndrome [39], which is defined as (1) n � . refeeding hypophosphatemia. )is disorder is most severe in ICU patients at two intervals. )e first interval is the first 12 When sampling was completed, baseline information hours of hospitalization where the patient has not received such as age, sex, marital status, admission records, disease any nutrition. )e second interval is 3–5 days after the start records, medications used, and diagnosed disease were of the patients’ artificial feeding [39, 40]. Hypophosphatemia analyzed using the SPSS software, version 20, and the hy- has also been reported as one of the side effects of intra- pothesis was tested by paired and independent t-tests. venous feeding [22], as patients who receive intravenous nutrition without phosphorus supplement develop severe hypophosphatemia [29]. However, the results of studies by 3. Results Zeki et al. [41] revealed that the incidence of hypo- After the intervention, baseline data related to 34 patients phosphatemia was higher in patients who had been fed were statistically analyzed using the Chi-square test, Fisher’s through an NG tube compared with the patients who had test, and independent t-tests. According to Table 1, the mean received total parenteral nutrition. In the study of Agostino age of patients was 62.12years in the intervention group and et al. [42], no significant difference was found between the 64.41years in the control group. )e two groups were ho- phosphorus levels of the children being fed through an NG mogenous in terms of age (P � 0.67) and gender (P � 0.49). tube and children who received bolus nutrition. However, a Also, there was no significant relationship between variables study by Co¸skun et al. [43] showed that all three groups of such as history of hospital admission, history of disease and the patients who received intravenous, continuous enteral, diagnosed disease, medication used, body mass index, and and mixed-method nutrition developed hypophosphatemia, level of consciousness between the two groups. and also there was no significant relationship between the As shown in Table 2, the results of the paired t-tests type of feeding and hypophosphatemia. Also, hypomagne- revealed that after intervention, the amount of phosphate in semia and hypokalemia were higher in the patients with the control group (P<0.001) and in the intervention group hypophosphatemia. According to our data, 52.94% (n �9) (P � 0.004) were significantly different from the previous patients in the control group and 17.64% (n �3) patients in intervention. Before the intervention, the amount of the intervention group had electrolyte disorder as hypo- phosphate in the control group was lower than that in the phosphatemia (P≤2.5) before the start of intervention, intervention group, and in this regard, there was no sig- which is consistent with the results of previous studies. nificant difference between the two groups before and after However, the serum level of phosphorus increased signifi- the intervention. However, the amount of phosphate in both cantly one week after the intervention in both intervention intervention and control groups was significantly increased and control groups compared with preintervention time, after the intervention. )e results of the independent t-tests which is in contradiction with the study results of Ramazan also showed no significant difference between the amount of et al. )is difference may be due to the type of the diet phosphate in the intervention and control groups before the (Entera meal) used in the present study to feed patients, intervention (P � 0.22) and one week after the intervention while the Nutrica formula was used in the study of Ramazan (P � 0.14). et al. to feed the patients. According to Table 3, the results of ANOVA tests related In the other part of study, the mean blood glucose level in to repeated data showed no statistically significant difference the intervention group increased with the increasing bolus in the glucose level from day 1 to day 7 in the control volume from the second day, and then, with leveling bolus (P � 0.33) and intervention (P � 0.86) groups. volume, the mean blood glucose also remained level. In the Results showed that the glucose level in the intervention control group, in the second day, despite the increasing bolus group was lower than the control group, but the results of the volume, the mean blood glucose decreased compared with the independent t-tests showed no difference between the two intervention group and then remained level, but the mean and 4 Journal of Nutrition and Metabolism Assessed for eligibility to enter the study N = 64 N = 13 excluded from the study N = 7 did not met inclusion criteria N = 6 dissaproval to participate in the study N = 0 other reasons N = 51 randomized N = 25 allocated in control group N = 26 allocated in intervention group N = 17 received intervention N = 17 received intervention N = 8 did not receive intervention N = 9 did not receive intervention N = 8 lack of follow-up N = 9 lack of follow-up Reasons: Patient’s death, feeding Reasons: Patient’s death, feeding intolerance, change of feeding method intolerance, change of feeding method N = 17 analyzed N = 17 analyzed Figure 1: Flow diagram of the study. Table 1: Comparison of baseline information between intervention and control groups. Gender Diabetes Insulin received Phosphate received BMI Age Group Male Female Yes No Yes No Yes No 7 (41.2%) 10 (58.8%) 3 (17.6%) 14 (82.4%) 3 (17.6%) 14 (82.4%) 2 (11.8%) 15 (88.2%) 23.51 62.12 Intervention 9 (52.9%) 8 (47.1%) 6 (35.3%) 11 (64.7%) 6 (35.3%) 11 (64.7%) 0 (0%) 17 (100%) 24.14 64.41 Control P � 0.49 P � 0.43 P � 0.43 P � 0.48 P � 0.44 P � 0.67 Table 2: Comparison of phosphate levels in the intervention and control groups one hour before and one week after the intervention, 2018. One hour before the intervention One week after the intervention Group Paired t-test Maximum Maximum Mean SD Mean SD Minimum Minimum − 4.91 2.50 Control 2.62 1.20 4.02 1.11 t � − 4.98 df �16 P<0.001 0.80 6 − 4.50 Intervention 3.04 0.66 3.52 0.79 2 –4.50 t � − 3.31 df �16 P � 0.004 1.90 t � − 1.25 t � − 1.48 Independent t-test df �32 df �32 P � 0.22 P � 0.14 Table 3: Comparison of the glucose level in the intervention and control groups every 6hours, and in the bolus and continuous feeding groups during one week of intervention, 2018. One hour before the One week after the intervention Group intervention Paired t-test Maximum Maximum Glucose level Mean SD Mean SD Minimum Minimum 89.50 91.50 Day 1 174.61 58.10 134.44 36.34 t � − 2.41 df �32 P � 0.02 − 315 − 203 79.25 97 Day 2 166.29 62.98 142.27 4.59 t � − 1.32 df �32 P � 0.19 − 350.50 − 225 Journal of Nutrition and Metabolism 5 Table 3: Continued. One hour before the One week after the intervention Group intervention Paired t-test Maximum Maximum Glucose level Mean SD Mean SD Minimum Minimum 85.50 95.50 Day 3 163.42 54.74 145.95 4.52 t � − 1.05 df �32 P � 0.29 − 318 − 227.25 79.50 95.50 Day 4 167.80 54.85 141.8 43.30 t � − 1.57 df �32 P � 0.12 − 298.50 − 239.25 81.50 96.25 Day 5 162.20 58.67 144.77 44.35 t �0.97 df �32 P � 0.33 − 302.50 − 247.25 84.75 108 Day 6 159 53.17 144.39 39.46 t �0.90 df �32 P � 0.37 − 300.50 − 230 102.2 104 Day 7 163.85 51.76 141.64 39.87 t �1.40 df �32 P � 0.17 − 307.25 − 241.25 F �1.15 F �1.91 ANOVA test of repeated data P � 0.33 P � 0.086 range of blood glucose level varied more than that in the tracheal intubation,” Journal of Research in Medical Sciences: ,e Official Journal of Isfahan University of Medical Sciences, intervention group. Studies have shown that the speed and vol. 18, no. 9, p. 733, 2013. volume of the patients’ feeding have a direct impact on the [2] O. Aghadavoudi, S. Abbasi, P. 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Comparison of the Effect of Enteral Feeding through the Bolus and Continuous Methods on Serum Phosphorus and Glucose Levels in Patients with Mechanical Ventilation: A Randomized Clinical Trial

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Hindawi Publishing Corporation
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Copyright © 2020 Javad Seyyedi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-0724
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2090-0732
DOI
10.1155/2020/6428418
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Hindawi Journal of Nutrition and Metabolism Volume 2020, Article ID 6428418, 6 pages https://doi.org/10.1155/2020/6428418 Research Article ComparisonoftheEffectofEnteralFeedingthroughtheBolusand Continuous Methods on Serum Phosphorus and Glucose Levels in Patients with Mechanical Ventilation: A Randomized Clinical Trial 1 2 3 4 Javad Seyyedi , Zahra Rooddehghan , Mostafa Mohammadi, and Shima Haghani Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran MSc in Biostatistics Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran Correspondence should be addressed to Zahra Rooddehghan; zrooddehghan@yahoo.com Received 7 February 2020; Revised 1 August 2020; Accepted 28 August 2020; Published 8 September 2020 Academic Editor: Mohammed S. Razzaque Copyright © 2020 Javad Seyyedi et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Patients who are under mechanical ventilation in intensive care units need to have nutritional support. Also, feeding methods affect serum phosphorus and glucose levels, which are very important in weaning patients off the ventilator. )us, this study is to compare the effects of both bolus and continuous enteral feeding methods on serum phosphorus and glucose levels in patients with mechanical ventilation. Methods. In this clinical trial study, 34 patients in the intensive care unit of Imam Khomeini Hospital affiliated to the Tehran University of Medical Sciences satisfied inclusion criteria and were randomly divided into control and intervention groups. Sampling was done between October and February 2018. )e intervention group received continuous enteral feeding for one week, and the control group received nutrition by the bolus method. )e blood glucose level was measured every six hours, and the serum phosphorus level was recorded at the beginning and the end of the intervention, based on the data entry form with respect to all ethical considerations. Data analysis was done by SPSS-20 software. Results. )e serum phosphorus level was significantly increased in the intervention group (P � 0.004) and in the control group (P<0.001) and was compared with the previous intervention. No significant difference was found between the intervention and control groups before and after the intervention (P � 0.22) and also one week after the intervention (P � 0.14). )ere was also no significant difference between the glucose levels from day 1 to day 7 in the control group (P � 0.33) and the intervention group (P � 0.086). Discussion. Nutritional support in both bolus and continuous methods increased the serum phosphorus level. It indicates the importance of the nu- tritional method in controlling the phosphorus level in critically ill patients. However, there was no difference between the effects of dietary methods on blood glucose control. and trauma, stroke, rib fracture, chronic pulmonary ob- 1. Introduction struction associated with respiratory failure such as asthma Intensive care unit is one of the most important sections in and emphysema, and general illnesses such as myasthenia any hospital, where patients with acute and critical condi- gravis, Guillen–Barre syndrome, and tetanus [2–4]. De- tions receive care and treatment [1]. One of the important scriptive findings show that patients who have been groups of the patients admitted to intensive care units is the mechanically ventilated for a long time are nutritionally ones with respiratory disorders who require artificial airway weak [5] and that gradually during their treatment, they and mechanical ventilation for survival. Respiratory disor- develop hypercatabolism and increased metabolism due to ders include postoperative respiratory failure, head injury physiological conditions and psychosocial stressors that are 2 Journal of Nutrition and Metabolism management [27]. In the study of Shahriari et al. that mostly caused by their acute illness. Subsequently, patients will become malnourished if nutritional support is not sufficient concentrated on nonintubated patients, the mean blood glucose level was recognized to be lower in the patients with to provide for body’s demands [6]. Nutritional support in these patients is either enteral nutrition or total parenteral continuous feeding [28]. Given these assumptions and nutrition [7]. Enteral nutrition is mainly performed in two considering the importance of glucose and phosphate in methods of continuous feeding over a period of 16–24 hours weaning patients off the ventilator, the selection of a correct and bolus feeding for 4–6 times per day [8]. In the con- nutritional method is an important factor in caring the tinuous method, feeding starts through a feeding pump at patients under mechanical ventilation. )us, we decided to 20–50cc/h and continues 24 hours a day. )is method is conduct a study with the aim of examining the effects of both continuous and bolus feeding methods on the phosphate more common in patients with respiratory failure as it re- duces the risk of aspiration in these patients [9]. )is method and blood glucose levels in patients being treated under mechanical ventilation. also provides a greater opportunity for absorption of micronutrients than other methods [10]. In the bolus method, nutrient (formula) is given to patients 4–6 times a 2. Materials and Methods day through a 50mL syringe over a short interval of 4 –10 minutes [9]. )is method is inexpensive and resembles the )is study is a clinical trial that was conducted on two people’s normal eating pattern. It also shortens the feeding groups of intervention and control following the code of time and is a good choice for patients with good digestive ethics: IR.TUMS.FNM.REC. Sampling has been done be- function, but the risk of aspiration is higher in this method tween October 2018 and February 2018 in the intensive care than others due to delayed gastric emptying [10]. unit of one of the teaching hospitals of the Tehran University Nutritional methods also influence laboratory parame- of Medical Sciences. )e data were collected in two stages: ters [11–13]. Hypophosphatemia, which is defined as before and one week after the intervention. Inclusion criteria P≤2.5mg/dL [14], is one of the most common electrolyte were restricted to the patients aged between 18 and 85 years, abnormalities in ICUs, with 80% prevalence in the ICU who did not suffer from any gastrointestinal problems such patients. In fact, malnutrition with catecholamines, insulin, as diarrhea, ileus, ostomy, obstruction, or chronic renal diuretics, alkalosis, diabetic ketoacidosis, and sepsis can failure. )ey also did not have any history of intestinal predispose patients with acute conditions to hypo- feeding. )e case study patients were admitted to the ICU phosphatemia [15, 16]. Hypophosphatemia can occur in while they had been intubated in the unit. We have also ICU patients by three different mechanisms, including de- received the patients’ families’ consent to be included in the creased intestinal absorption, increased renal excretion of study. Exclusion criteria included the patient’s death, any phosphate, and redistribution of inorganic phosphate changes in feeding method, and feeding intolerance or [17, 18]. Impairment of cellular energy storage as well as termination. tissue hypoxia can lead to various clinical manifestations of Of 64 patients eligible for the study, 13 were excluded hypophosphatemia [19], including myocardial dysfunction, from the study (6 due to family disapproval, 2 due to gas- diaphragm weakening, convulsions, coma, rhabdomyolysis, trointestinal surgery, 2 due to diarrhea at baseline, and 3 due and RBCs’ dysfunction [16]. Hypophosphatemia lowers the to chronic renal failure). Informed consent was obtained 2-3 levels of diphosphoglycerate in red blood cells, which from the family of patients who met the inclusion criteria, shifts the oxyhemoglobin dissociation curve to left and and then, the patients were randomly divided into two increases hemoglobin tendency towards oxygen and sub- groups of intervention and control according to the hospital sequently reduces oxygen delivery to the tissues [20]. Studies number. )e data collection methods were observation and have shown that hypophosphatemia disrupts weaning pa- measurement. )e data collection tools included the patient tients off the ventilator [21] and has been reported as one of record checklist and the data measurement checklist. )e the complications of intravenous nutrition [22]. However, validity of the data collection tools was confirmed by 10 changes in hypophosphatemia during continuous intestinal faculty members, and in order to ensure their reliability, the feeding have not been studied yet. fixed glucometer kit and serum phosphorus measurement Hyperglycemia is another common disorder in ICUs, were used. To collect data in both groups, first baseline which is common even in nondiabetic patients [23]. information such as age, sex, marital status, admission Complications such as pneumonia, urinary tract infection, records, disease records, medications used, BMI, diagnosed and surgical site infection are also associated with increased disease, and level of consciousness were obtained from the blood sugar [24–26]. Studies have shown that the blood patients’ record and then were recorded in the baseline glucose level affects the process of weaning patients off the record sheet. At the beginning of the intervention, the serum ventilator and may be an indicator of the poor metabolic phosphorus level was measured by the researcher using status in critically ill patients. It is also an important factor in para-clinical tests. )e blood sample kit and measurements determining the necessity for ventilation and disconnection were recorded in the laboratory data sheet. )en, feeding the patient from the ventilator [11]. Compared with the began in the intervention group by the continuous feeding intubated patients, the patients who have been successfully method at 25cc/h and in the control group by the routine weaned off the ventilator have lower mean glucose con- bolus method via a nasal gastric (NG) tube at 75cc/3h with centration [11]. Studies have revealed that the speed and the commercial standard solution “Entera meal,” which volume of feeding exert a direct impact on the blood glucose contained 1 kcal of energy per cc (cubic centimeter). )e Journal of Nutrition and Metabolism 3 patients were at semi-seated position during feeding time. groups in terms of glucose level during days 2 to 7 of the On the first day of the patients’ feeding, 50% of the patients’ intervention (P>0.05) except for day 1 (P � 0.02). nutritional goal was met, and the volume of bolus was gradually increased every hour during the next 48 hours to 4. Discussion achieve the ultimate nutritional goal (25kcal/kg/day). )is diet was kept until the end of study. During the sampling )e importance of phosphorus, especially the role that it process, patients’ blood glucose was measured every 6 hours plays in the formation of adenosine triphosphate and 3-2 using a CLEVER-CHEK glucometer and recorded in the diphosphoglycerate, is related to the point that phosphorus patients’ data sheet. According to Figure 1, in total, 17 is a very important component of supportive nutrition for participants left the study due to various reasons (7 due to patients [29]. Refeeding syndrome is one of the important death, 5 due to intolerance, 3 due to stop feeding, and 2 due issues in the feeding of malnourished patients. In these to the change in feeding method). patients, insulin is released after feeding and the absorption Sampling continued until the desired sample size (34 of carbohydrates, which leads to the transfer of phosphate, individuals) was determined based on the study of Shahriari magnesium, and potassium into the cell and thereby low- et al. [28] and the following formula: ering the serum level of these electrolytes [30]. Studies also confirm this process [31–38]. Phosphorus reduction is a 2 2 􏼐z + z 􏼑 × 􏼐σ + σ 􏼑 1− (α/2) 1− β 1 2 major indicator of this syndrome [39], which is defined as (1) n � . refeeding hypophosphatemia. )is disorder is most severe in ICU patients at two intervals. )e first interval is the first 12 When sampling was completed, baseline information hours of hospitalization where the patient has not received such as age, sex, marital status, admission records, disease any nutrition. )e second interval is 3–5 days after the start records, medications used, and diagnosed disease were of the patients’ artificial feeding [39, 40]. Hypophosphatemia analyzed using the SPSS software, version 20, and the hy- has also been reported as one of the side effects of intra- pothesis was tested by paired and independent t-tests. venous feeding [22], as patients who receive intravenous nutrition without phosphorus supplement develop severe hypophosphatemia [29]. However, the results of studies by 3. Results Zeki et al. [41] revealed that the incidence of hypo- After the intervention, baseline data related to 34 patients phosphatemia was higher in patients who had been fed were statistically analyzed using the Chi-square test, Fisher’s through an NG tube compared with the patients who had test, and independent t-tests. According to Table 1, the mean received total parenteral nutrition. In the study of Agostino age of patients was 62.12years in the intervention group and et al. [42], no significant difference was found between the 64.41years in the control group. )e two groups were ho- phosphorus levels of the children being fed through an NG mogenous in terms of age (P � 0.67) and gender (P � 0.49). tube and children who received bolus nutrition. However, a Also, there was no significant relationship between variables study by Co¸skun et al. [43] showed that all three groups of such as history of hospital admission, history of disease and the patients who received intravenous, continuous enteral, diagnosed disease, medication used, body mass index, and and mixed-method nutrition developed hypophosphatemia, level of consciousness between the two groups. and also there was no significant relationship between the As shown in Table 2, the results of the paired t-tests type of feeding and hypophosphatemia. Also, hypomagne- revealed that after intervention, the amount of phosphate in semia and hypokalemia were higher in the patients with the control group (P<0.001) and in the intervention group hypophosphatemia. According to our data, 52.94% (n �9) (P � 0.004) were significantly different from the previous patients in the control group and 17.64% (n �3) patients in intervention. Before the intervention, the amount of the intervention group had electrolyte disorder as hypo- phosphate in the control group was lower than that in the phosphatemia (P≤2.5) before the start of intervention, intervention group, and in this regard, there was no sig- which is consistent with the results of previous studies. nificant difference between the two groups before and after However, the serum level of phosphorus increased signifi- the intervention. However, the amount of phosphate in both cantly one week after the intervention in both intervention intervention and control groups was significantly increased and control groups compared with preintervention time, after the intervention. )e results of the independent t-tests which is in contradiction with the study results of Ramazan also showed no significant difference between the amount of et al. )is difference may be due to the type of the diet phosphate in the intervention and control groups before the (Entera meal) used in the present study to feed patients, intervention (P � 0.22) and one week after the intervention while the Nutrica formula was used in the study of Ramazan (P � 0.14). et al. to feed the patients. According to Table 3, the results of ANOVA tests related In the other part of study, the mean blood glucose level in to repeated data showed no statistically significant difference the intervention group increased with the increasing bolus in the glucose level from day 1 to day 7 in the control volume from the second day, and then, with leveling bolus (P � 0.33) and intervention (P � 0.86) groups. volume, the mean blood glucose also remained level. In the Results showed that the glucose level in the intervention control group, in the second day, despite the increasing bolus group was lower than the control group, but the results of the volume, the mean blood glucose decreased compared with the independent t-tests showed no difference between the two intervention group and then remained level, but the mean and 4 Journal of Nutrition and Metabolism Assessed for eligibility to enter the study N = 64 N = 13 excluded from the study N = 7 did not met inclusion criteria N = 6 dissaproval to participate in the study N = 0 other reasons N = 51 randomized N = 25 allocated in control group N = 26 allocated in intervention group N = 17 received intervention N = 17 received intervention N = 8 did not receive intervention N = 9 did not receive intervention N = 8 lack of follow-up N = 9 lack of follow-up Reasons: Patient’s death, feeding Reasons: Patient’s death, feeding intolerance, change of feeding method intolerance, change of feeding method N = 17 analyzed N = 17 analyzed Figure 1: Flow diagram of the study. Table 1: Comparison of baseline information between intervention and control groups. Gender Diabetes Insulin received Phosphate received BMI Age Group Male Female Yes No Yes No Yes No 7 (41.2%) 10 (58.8%) 3 (17.6%) 14 (82.4%) 3 (17.6%) 14 (82.4%) 2 (11.8%) 15 (88.2%) 23.51 62.12 Intervention 9 (52.9%) 8 (47.1%) 6 (35.3%) 11 (64.7%) 6 (35.3%) 11 (64.7%) 0 (0%) 17 (100%) 24.14 64.41 Control P � 0.49 P � 0.43 P � 0.43 P � 0.48 P � 0.44 P � 0.67 Table 2: Comparison of phosphate levels in the intervention and control groups one hour before and one week after the intervention, 2018. One hour before the intervention One week after the intervention Group Paired t-test Maximum Maximum Mean SD Mean SD Minimum Minimum − 4.91 2.50 Control 2.62 1.20 4.02 1.11 t � − 4.98 df �16 P<0.001 0.80 6 − 4.50 Intervention 3.04 0.66 3.52 0.79 2 –4.50 t � − 3.31 df �16 P � 0.004 1.90 t � − 1.25 t � − 1.48 Independent t-test df �32 df �32 P � 0.22 P � 0.14 Table 3: Comparison of the glucose level in the intervention and control groups every 6hours, and in the bolus and continuous feeding groups during one week of intervention, 2018. One hour before the One week after the intervention Group intervention Paired t-test Maximum Maximum Glucose level Mean SD Mean SD Minimum Minimum 89.50 91.50 Day 1 174.61 58.10 134.44 36.34 t � − 2.41 df �32 P � 0.02 − 315 − 203 79.25 97 Day 2 166.29 62.98 142.27 4.59 t � − 1.32 df �32 P � 0.19 − 350.50 − 225 Journal of Nutrition and Metabolism 5 Table 3: Continued. One hour before the One week after the intervention Group intervention Paired t-test Maximum Maximum Glucose level Mean SD Mean SD Minimum Minimum 85.50 95.50 Day 3 163.42 54.74 145.95 4.52 t � − 1.05 df �32 P � 0.29 − 318 − 227.25 79.50 95.50 Day 4 167.80 54.85 141.8 43.30 t � − 1.57 df �32 P � 0.12 − 298.50 − 239.25 81.50 96.25 Day 5 162.20 58.67 144.77 44.35 t �0.97 df �32 P � 0.33 − 302.50 − 247.25 84.75 108 Day 6 159 53.17 144.39 39.46 t �0.90 df �32 P � 0.37 − 300.50 − 230 102.2 104 Day 7 163.85 51.76 141.64 39.87 t �1.40 df �32 P � 0.17 − 307.25 − 241.25 F �1.15 F �1.91 ANOVA test of repeated data P � 0.33 P � 0.086 range of blood glucose level varied more than that in the tracheal intubation,” Journal of Research in Medical Sciences: ,e Official Journal of Isfahan University of Medical Sciences, intervention group. Studies have shown that the speed and vol. 18, no. 9, p. 733, 2013. volume of the patients’ feeding have a direct impact on the [2] O. Aghadavoudi, S. Abbasi, P. 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