Specialized nutrition support in critically ill patients

Current Opinion in Critical Care

Volumn 9, Issue 4, 2003, Pages 249-259

  Griffiths, Richard D ^a,b  

^a UNIVERSITY OF LIVERPOOL   (United Kingdom)

^b UNIVERSITY OF LIVERPOOL   (United Kingdom)

Author keywords

Glutamine; Immunonutrition; Nutrition; Outcome

Indexed keywords

CYTOKINE; GLUTAMINE; HLA DR ANTIGEN; INTERLEUKIN 6; OMEGA 3 FATTY ACID; TUMOR NECROSIS FACTOR ALPHA;

ABDOMINAL SURGERY; ADULT RESPIRATORY DISTRESS SYNDROME; CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; CONTROLLED STUDY; CRITICAL ILLNESS; ENTERIC FEEDING; HOSPITAL INFECTION; HUMAN; IMMUNE SYSTEM; IMMUNOMODULATION; IMMUNONUTRITION; INFLAMMATION; INTENSIVE CARE UNIT; LENGTH OF STAY; MAJOR CLINICAL STUDY; META ANALYSIS; METABOLIC REGULATION; MORTALITY; MULTICENTER STUDY; NUTRITION; NUTRITIONAL SUPPORT; PARENTERAL NUTRITION; PROTEIN METABOLISM; RANDOMIZED CONTROLLED TRIAL; REVIEW; RISK BENEFIT ANALYSIS; SEPSIS; SURGICAL PATIENT;

CRITICAL CARE; GLUTAMINE; HUMANS; IMMUNE SYSTEM; INTENSIVE CARE; NUTRITIONAL REQUIREMENTS; NUTRITIONAL SUPPORT;

EID: 0041766670     PISSN: 10705295     EISSN: None     Source Type: Journal    
DOI: 10.1097/00075198-200308000-00001     Document Type: Review

References (60)

1. Stephan F, Yang K, Tankovic J, et al.: Impairment of polymorphonuclear neutrophil function preceded nosocomial infections in critically ill patients. Crit Care Med 2002, 30:315-322. That circulating neutrophils of ICU patients have an impaired ability to kill invading microorganisms presumably contributes to their acquiring new infections. Some nutrition therapies have been shown to restore neutrophil function.
2. Tschaikowsky K, Hedwig-Geissing M, Schiele A, et al.: Coincidence of pro- and anti-inflammatory responses in the early phase of severe sepsis: longitudinal study of mononuclear histocompatibility leukocyte antigen-DR expression, procalcitonin, C-reactive protein, and changes in T-cell subsets in septic and postoperative patients. Crit Care Med 2002, 30:1015-1023. This elegant work demonstrates the time scale and interrelationships of the changes in immune status in the critically ill.
3. Boelens PG, Houdijk AP, Fonk JC, et al.: Glutamine-enriched enteral nutrition increases HLA-DR expression on monocytes of trauma patients. J Nutr 2002, 132:2580-2586. This is a good clinical example of how glutamine restores immune function in the stressed. By restoring HLA-DR expression on monocytes, the all-important interface with the T cell is enhanced and the innate and acquired immune responses can work in concert.
4. Kudsk KA: Effect of route and type of nutrition on intestine-derived inflammatory responses. Am J Surg 2003, 185:16-21. This article provides a good summary of the work demonstrating the relationship between the lack of enteral nutrition and the promotion of systemic inflammation.
5. Marik PE, Zaloga GP: Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 2001, 29:2264-2270. The important message is not lost in this zealous metaanalysis, but remember that it applies to trauma and surgical patients (many elective), and there is still heterogeneity in the results and no evidence in nonsurgical patients.
6. Ibrahim EH, Mehringer L, Prentice D, et al.: Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. JPEN J Parenter Enteral Nutr 2002, 26:174-181. This paper purports to challenge the dogma of [7•] but perhaps demonstrates how poorly delivered enteral nutrition is in intensive care.
7. Mentec H, Dupont H, Bocchetti M, et al.: Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001, 29:1955-1961. This study reminds us that upper digestive intolerance with feeding is associated with more ventilator-associated pneumonia and is more frequent in the patient who is sedated and on catecholamines (ie, enteral nutrition carries risks).
8. Booth CM, Heyland DK, Parterson WG: Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence. Crit Care Med 2002, 30:1429-1435. Essentially, there is no evidence.
9. Montejo JC, Grau T, Acosta J, et al.: for the Nutritional and Metabolic working group of the Spanish Society of Intensive Care Medicine and Coronary Care Units. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med 2002, 30:796-800. Perhaps this should remind us that if there is gastrointestinal intolerance, a jejunal tube is not necessarily going to solve the problem.
10. Marvin RG, McKinley BA, McQuiggan M, et al.: Nonccclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests not reliable clinical signs for early detection. Am J Surg 2000, 179:7-12. This article is a must read about a not-to-be-forgotten serious and possibly fatal complication of small bowel enteral nutrition with an incidence in major trauma patients of three per 1000, diagnosed after approximately a week in patients fed into the duodenum or jejunum. Unfortunately, it could not be predicted.
11. Neumann DA, Delegge MH: Gastric versus small-bowel tube feeding in intensive care unit: a prospective comparison of efficacy. Crit Care Med 2002, 30:1436-1438. This article suggests, contrary to popular belief, that gastric feeding (30 patients) was able to be advanced to goals sooner than jejunal feeding (30 patients) with no increase in aspiration or adverse events.
12. Zauner C, Schuster BI, Schneeweiss B: Similar metabolic responses to standardized total parenteral nutrition of septic and nonseptic critically ill patients. Am J Clin Nutr 2001, 74:265-270.
13. Spapen H, Diltoer M, Van Malderen C, et al.: Soluble fiber reduces the incidence of diarrhoea in septic patients receiving total enteral nutrition: a prospective, double blind, randomized, and controlled trial. Clin Nutr 2001, 20:301-305. Despite the failure of other fibers, this product appears to reduce a problem that will put a smile on the face of any intensive care nurse!
14. Rayes N, Hansen S, Seehofer D, et al.: Early enteral supply of fiber and lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery. Nutrition 2002, 18:609-615. Restoring a less invasive gastro-intestinal bacterial flora holds much promise; however, I think that this trial is a disappointment for those interested in this approach.
15. Suchner U, Katz DP, Furst P, et al.: Effect of intravenous fat emulsions on lung function in patients with acute respiratory distress syndrome or sepsis. Crit Care Med 2001, 29:1569-1574. This study reminds those who were ever foolish enough to infuse lipids at unphysiologic rates that they can disturb metabolism. However, infusing at the standard recommended safe rates shows no effect.
16. Braga M, Gianotti L, Gentilini O, et al.: Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Crit Care Med 2001, 29:242-248. In 257 patients this sounds great, but there was no difference in the rate of infections and complications, the length of stay (the big costs), or mortality, and approximately 6% failed enteral nutrition feeding.
17. Pacelli F, Bossalo M, Papa V, et al.: Enteral vs parenteral nutrition after major abdominal surgery: an even match. Arch Surg 2001, 136:933-936. This is another recent large study showing that modern practice of total parenteral nutrition is risk neutral compared with enteral nutrition with no difference in the rate of complications.
18. Braunschweig CL, Levy P, Sheean PM, et al.: Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001, 74:534-542. This is a detailed and thorough metaanalysis.
19. Woodcock NP, Zeigler D, Palmer D, et al.: Enteral versus parenteral nutrition: a pragmatic study. Nutrition 2001, 17:1-12. This is a fascinating, true-to-life study from an expert nutrition team that asks the risk-benefit question of those patients whom we are unsure by which route to feed. The results may well be surprising to readers.
20. Galban C, Montejo JC, Mesejo A, et al.: An immune-enhancing diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 2000, 28:643-648.
21. Bower RH, Cerra FB, Bershadsky B, et al.: Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 1995, 23:436-449.
22. Atkinson S, Sieffert E, Bihari D: A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Crit Care Med 1998, 26:1164-1172.
23. Heyland DK, Novak F, Drover JW, et al.: Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001, 286:944-953. The most recent of the detailed metaanalyses of immunonutrition highlights the risks and benefits. This article contains results of an unpublished study that showed the detrimental effects in the critically ill using a feed still currently commercially available in the United States.
24. Braga M, Gianotti L, Nespoli L, et al.: Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 2002, 137:174-180. Immune nutrition works for surgical stress, even when simply given preoperatively.
25. Calder PC: Dietary modification of inflammation with lipids. Proc Nutr Soc 2002, 61:345-358.
26. Suchner U, Heyland DK, Peter K: Immune-modulatory actions of arginine in the critically ill. Br J Nutr 2002, 87(suppl 1):S121-S132.
27. Caparros T, Lopez J, Grau T: Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. JPEN J Parenter Enteral Nutr 2001, 25:299-309. This is a large nutrition study that showed surprisingly little benefit.
28. Van Bokhorst-devan der Schueren MAE, Quak JJ, von Blomberg-van der Flier BME, et al.: Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients. Am J Clin Nutr 2001, 73:323-332. Arginine supplementation alone appears to have little benefit.
29. De Luis DA, Izaola O, Cuellar L, et al.: Effect of c-reactive protein and interleukins blood levels in postsurgery arginine-enhanced enteral nutrition in head and neck cancer patients. Eur J Clin Nutr 2003, 57:96-99.
30. Yu Y-M, Ryan CM, Castillo L, et al.: Arginine and ornithine kinetics in severely burned patients: increased rate of arginine disposal. Am J Physiol 2001, 280:E509-E517.
31. Senkal M, Mumme A, Eickhoff U, et al.: Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients. Crit Care Med 1997, 25:1489-1496.
32. Mendez C, Jurkovich GJ, Garcia I, et al.: Effects of an immune enhancing diet in critically injured patients. J Trauma 1997, 42:933-940.
33. Gadek JE, DeMichele SJ, Karlstad MD, et al., and the Enteral Nutrition in ARDS Study Group: Effect of enteral feeding with eicosapentaenoic acid, γ-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Crit Care Med 1999, 27:1409-1420.
34. Preiser J-C, Van Gossum A, Berré J, et al.: Enteral feeding with a solution enriched with antioxidants vitamins A, C, and E enhances the resistance to oxidative stress. Crit Care Med 2000, 28:3828-3832.
35. Pacht ER, DeMichele SJ, Nelson JL, et al.: Enteral nutrition with eicosapentaenoic acid, γ-linolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome. Crit Care Med 2003, 31:491-500.
36. Griffiths RD: The evidence for glutamine use in the critically-ill. Proc Nutr Soc 2001, 60:1-8.
37. Kelly D, Wischmeyer PE: Role of L-glutamine in critical illness: new insights. Curr Opin Clin Nutr Metab Care 2003, 6:217-222.
38. Wernerman J, Hammarqvist F: Glutamine: a necessary nutrient for the intensive care patient. Int J Colorectal Dis 1999, 14:137-142.
39. Griffiths RD: Glutamine: establishing clinical indications. Curr Opin Clin Nutr Metab Care 1999, 2:177-182.
40. Conejero R, Bonet A, Grau T, et al.: Effect of a glutamine-enriched enteral diet on intestinal permeability and infectious morbidity at 28 days in critically ill patients with systemic inflammatory response syndrome: a randomized, single-blind, prospective, multicenter study. Nutrition 2002, 18:716-721. A glutamine-enhanced enteral feed and some other nutrient differences consistent with other immunonutrient studies show reduced infection but no effect on mortality rate.
41. Hall JC, Dobb G, Hall J, et al.: A clinical trial evaluating enteral glutamine in critically ill patients [abstract]. Am J Clin Nutr 2002, 75S:415S.
42. Kozar RA, Schultz SG, Hassoun HT, et al.: The type of sodium-coupled solute modulates small bowel mucosal injury, transport function, and ATP after ischaemia/reperfusion injury in rats. Gastroenterology 2002, 123:810-816.
43. Griffiths RD, Jones C, Palmer TEA: Six month outcome of critically ill patients given glutamine-supplemented parenteral nutrition. Nutrition 1997, 13:295-302.
44. Griffiths RD, Allen KD, Andrews FJ, et al.: Infection, multiple organ failure, and survival in the intensive care unit: influence of glutamine-supplemented parenteral nutrition on acquired infection. Nutrition 2002, 18:546-552. An analysis of new original data from the study in [43] shows overall only a modest reduction in later infection but improved handling of Candida infection. It also shows that the improved survival with glutamine is predominantly explained by a reduced death rate from multiple organ failure while in intensive care. The concept of a deficiency is emphasized in that it is the patients dependent on standard total parenteral nutrition for a long time (weeks) who have the increased mortality rate.
45. Dechelotte P, Bleichner G, Hasselmann M, et al.: Improved clinical outcome in ICU patients receiving alanyl-glutamine (Depeptiven) supplemented total parenteral nutrition (TPN). A French double-blind multicenter study [abstract]. Clin Nutr 2002, 21:1.
46. Goeters C, Wenn A, Mertes N, et al.: Parenteral L-alanyl-L-glutamine improves 6-month outcome in critically ill patients. Crit Care Med 2002, 30:2032-2037. This study confirms the study by Griffiths et al. [43] that survival differences become apparent in those fed for a week or more.
47. Novak F, Heyland DK, Avenell A, et al.: Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med 2002, 30:2022-2029. This is a metaanalysis that mixes many types of studies and both enteral and parenteral delivery of glutamine and, for this reason, may only be hypothesis generating in some of its conclusions. Importantly, there is no evidence for any harmful effect unlike in other metaanalyses. It confirms the clinical outcome advantage of parenteral glutamine.
48. Babu R, Eaton S, Drake DP, et al.: Glutamine and glutathione counteract the inhibitory effects of mediators of sepsis in neonatal hepatocytes. J Pediatr Surg 2001, 36:282-286.
49. Manhart N, Vierlinger K, Akomeah R, et al.: Influence of enteral diets supplemented with key nutrients on lymphocyte subpopulations in Peyer's patches of endotoxin-boostered mice. Clin Nutr 2000, 19:265-269.
50. Flaring UB, Rooyackers OE, Wernerman J, et al.: Glutamine attenuates posttraumatic glutathione depletion in human muscle. Clin Sci 2003, 104:275-282.
51. Vesall RF, Klaude M, Rooyackers OE, et al.: Longitudinal pattern of glutamine/glutamate balance across the leg in long-stay intensive care patients. Clin Nutr 2002, 6:505-514.
52. Gore DC, Wolfe RR: Glutamine supplementation fails to affect muscle protein kinetics in critically ill patients. JPEN J Parenter Enteral Nutr 2002, 26:342-350.
53. Wischmeyer PE, Kahana M, Wolfson R, et al.: Glutamine induces heat shock protein and protects against endotoxin shock in the rat. J Appl Physiol 2001, 90:2403-2410.
54. Oehler R, Pusch E, Dungel P, et al.: Glutamine depletion impairs cellular stress response in human leucocytes. Br J Nutr 2002, 87(suppl 1):S17-S21.
55. Wischmeyer PE, Riehm JR, Singleton KD, et al.: Glutamine attenuates tumour necrosis factor-α release and enhances heat shock protein 72 in human peripheral blood mononuclear cells. Nutrition 2002, 19:1-6.
56. Boelens PG, Houdijk APJ, de Thouars HN, et al.: Plasma taurine concentrations increase after enteral glutamine supplementation in trauma patients and stressed rats. Am J Clin Nutr 2003, 77:250-256.
57. Wischmeyer PE, Lynch J, Liedel J, et al.: Glutamine administration reduces gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control. Crit Care Med 2001, 29:2075-2080. This study addressed the problems of delivery of enteral glutamine by administering it parenterally.
58. Spapen HD, Nguyen DN, ver Elst K, et al.: N-acetylcysteine and cardiac dysfunction in human septic shock. Clin Intensive Care 2002, 13:27-32. This article should remind intensive care physicians that not all treatments being used for sepsis are safe.
59. Van Den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patient. N Engl J Med 2001, 345:1359-1367. This is a must-read paper that is already changing intensive care insulin practice but should also change current nutrition practice. Not only was late mortality from multiple organ failure reduced, the investigators were also able to show reduced infections and reduced development of critical illness polyneuropathy (which has been considered similar to diabetic neuropathy). Further large confirmatory studies are awaited, but soon it may prove impossible to find a control hyperglycemic group if one listens to the buzz at meetings.
60. Van den Berghe G, Wouters PJ, Bouillon R, et al.: Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycaemic control. Crit Care Med 2003, 31:359-366.