Download Clinical Nutrition Week 2001: A Summary of Recommendations

CLINICAL NUTRITION WEEK 2011: A SUMMARY
OF RECOMMENDATIONS FOR GLUTAMINE AND
ANTIOXIDANT SUPPLEMENTATION
Cecilia Freeman RD, LD, CNSC
Learning Objectives
• Review the metabolic, immunological, and antiinflammatory functions of glutamine and antioxidants
• Review the clinical benefits of supplementing with
glutamine and antioxidants
• Become familiar with supplementation guidelines
Glutamine
• The human body normally
produces in sufficient amounts
• Metabolic functions
• Immunologic functions
Metabolic Functions of Glutamine
• Primary fuel for mucosal cells and immune cells
• Precursor for the synthesis of substrates
• Transports nitrogen between tissues for anabolic
processes
• Important for maintaining cell hydration
Immunologic Functions of Glutamine
• Energy source for leucocytes, lymphocytes, monocytes,
and macrophages
• Provides amino acids for synthesis of DNA and RNA
• Promotes cytokine production by lymphocytes and
macrophages, reduces release of pro-inflammatory
cytokines
Glutamine in Trauma
• Patients having a higher plasma glutamine level have higher chance of survival
compared to patients with lower glutamine levels
• Oudemans-van Straaten et al, Intensive Care Med 2001
• Trauma patients experience a rapid decrease in concentrations of glutamine in
muscle
• Stehele et al, Klin. Em. 35, 1991
• Hammarqvist et al, Amino Acids 1994
• Low plasma glutamine correlates with higher APACHE II score and increased
mortality
• Oudemans-van Straaten et al, Intensive Care Med 2001
Enteral Glutamine Pros
• Glutamine accounts for 35% of total
metabolic requirements of enterocytes
• Preserves gut barrier function by
enhancing immune function
• Decreases free radical availability by
increasing glutathione
Enteral Glutamine Cons
• Difficult to deliver total daily dose because of
intolerance problems or treatment/procedures
• Reduction in the number of glutamine transport
proteins on the surface of the gut during sepsis
• Decreased absorptive function due to rapid
turnover of enterocytes
Dosing
Burn/Trauma Patients


5-10 grams 4-5 x per
day (0.40.5gm/kg/day)
Parenteral glutamine
probably better
Medical/Surgical Intensive Care


0.35-0.5gm/kg/day
Greatest benefit ≥
0.5g/kg/day IV
General Recommendations
• Parenteral glutamine should be provided for
all patients receiving parenteral nutrition
• Enteral glutamine supplementation
recommended for trauma and burn patients
• For patients receiving enteral nutrition,
parenteral glutamine might be supplemented
Summary


0.3-0.5g/kg/day, starting within first
24 hours, for at least 7 days
Improves clinical outcomes such as
decreased episodes of pneumonia,
bacteremia, and sepsis in trauma
patients
Houdijk et al, Lancet 1998
Importance of Antioxidants
• Prevent lipid perioxidation
• Co-factor for glutathione
perioxidase
• Supports catalase and superoxide
dismutase
Antioxidants
• Antioxidant levels are low in critically ill
and injured patients upon arriving to the
ICU and remain low
• Supplementation with ascorbic acid, αtocopherol, and selenium may prove
beneficial in patients with intense
inflammation and tissue damage
following trauma/surgery
Background

All SIRS patients had below normal selenium


Selenium replacement may attenuate the progression to
MOF, speed recovery


Bulgar E et al, Arch Surg 2001
Ascorbic acid and α-tocopherol may reduce incidence
of infections complications


Forceville X et Al, Crit Care Med 1998
Schorah C et al, Am J Clin Nutri 1996
Antioxidant supplementation may prevent MOF


Bulgar E et al, Arch Surg 2001
Bichard C et al, CCM 1990
Supplementation in Critically Ill Surgery Patients
• More vent free days in the
antioxidant group
• Decrease ICU-LOS, overall LOS in
antioxidant group
• 28 day mortality decreased in
antioxidant group
• Nathans A et al, Ann Surg 2002
Supplementation to facilitate ventilator weaning
• Median mechanical ventilation time 15d
placebo vs. 6 day in antioxidant group; p
<0.05
• Concluded antioxidants are a safe,
inexpensive and effective way to reduce
days of mechanical ventilation
• Concluded no additional benefit from Nacetylcysteine supplementation in patients receiving
vitamin C + E
• Howe et al, SCCM 2005
Selenium in sepsis
• Prospective randomized, placebocontrolled, multicenter trial in
Germany
• 249 patients with severe SIRS, sepsis,
or septic shock + APACHE III score
>70
• 1000 mcg of sodium-selenite (bolus),
then 14 days of 1000 mcg
intravenously OR placebo
Selenium in sepsis
• Intention to treat analysis performed
• 28 day mortality: 57% placebo, 42%
selenium group (p=0.05)
• Subgroup analysis: mortality rate significantly reduced in septic
shock + DIC (p=0.01), APACHE III>102 (p=0.04), and ≥ 3
organ dysfunctions (p=0.03)
• Angstwrum MA et al, Crit Care Med 2007
2008 Premier Research Paper

Impact of High-Dose Antioxidants on
Outcomes in Acutely Injured Patients
28%
relative risk reduction in mortality
Reduction in ICU and Hospital LOS

JPEN July/August 2008
Summary



Antioxidant levels are low in critically ill
and injured patients upon ICU admission
and remain low
Supplementation is effective in raising
levels
Supplementation reduced infectious
complications and inflammatory
response
Take Home Information




Supplementation with these substances is proven to
improve patient outcomes
As clinicians we should include glutamine and
antioxidant supplementation recommendations
along with our nutrition support (TF/TPN)
recommendations for appropriate patients
Should we consider implementing protocols for
glutamine and antioxidants in our facilities?
Would a combination of supplementation with
glutamine and antioxidants together be beneficial?
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Question