Seda Banu AkıncıHacettepe University HospitalDepartment of Anesthesiology

Critical Care Medicine

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

Cerrahi

Travma

Şok

Omega-3 yağ

asitleri

Arjinin

Glutamin

Dolaşım yetmezliği

Doku hipoksisi

İnflamatuarcevap

IL-6, TNF-α

Hücresel immüniteninciddi baskılanması

Makrofaj

Enfeksiyon

Sepsis MODS

Ölüm

Lenfosit

Antiinflamatuarcevap

IL-10, TGF-β,

Angele MK, 2005

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

Elderly/diabetics/ obese

Immunosupression in patients who die of sepsis

Cytokins

Inhibitory mediators

Suppressor cells

Sepsis

MODS

Wischmeyer, 2010

BW, BMI

Albumin, transthyretin, white blood cells counts, C-reactive protein Nutritional Risk Index (NRI)

Prognostic Inflammatory and Nutritional Index (PINI)

Modified Glasgow Prognostic Score (mGPS)

Neutrophil-to-lymphocyte ratio (NLR)

CD4 & CD8 lymphocytes counts

platelet-to-lymphocyte ratio (PLR)

Prognostic Index(PI)

Prognostic Nutritional Index (PNI) are prognostic factors of outcome, but are not always correlated to immunonutrition effect.

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

1223 patients 40 ICUs

MOF, MV

Glutamine + antioxidants

Glutamine 0.35 g /kg/İBW/d iv (0.50 g/kg/day dipeptid

alanyl-glutamine [Dipeptiven, Fresenius Kabi]

42.5 g alanyl-glutamin + glycine-glutamin dipeptid (30

g/gün glutamin, enteral

500 μg of selenium iv (Selenase, Biosyn)

Enteral: 300 μg selenium, 20 mg Zinc, 10 mg beta

carotene, 500 mg vitamin E, 1500 mg vitamin C.

iv+ enteral within 24 hours

28 day mortality

32.4% / 27.2%; adjusted odds ratio, 1.28, 95% CI

1.00-1.64)

Hospital mortality

37.2% / 31%; P=0.02

6 month mortality

43.7% / 37.2%; P=0.02

301 patients 14 ICUs

Within 48 hrs- 28 days (GLN+3+antioxidants)

65 gr glutamine %60 (910 kcal 45gr protein)

Eaa /arg deficiencyhyperamonemia

Low pro Low S homosistine

Is it adaptive?

Too early?

Harmfull when excessive?

Caution in renal

insufficiency

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

Citrulline substition

Better gastrointestinal tolerance

Better absorption

No hepatic elimination, does not

increase urea

NO does not increase

Cellular transport is not inhibited

5 g/kg mortality in rats

0.09-0.2 g/kg/d (PE-EN)

ICU >12 g/L arg (>%4 REE)

(Bistrian 2006)

>3 days, optimum 3-10 gün

(Bistrian 2006)

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma

Future

Dose?

No differene with

PE Glutamine

Selenium 500/d

≥ 5 d PE decrease

infection without

a change in

mortality

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids Burns

Trauma

Future

No difference in mortality

OMEGA study

Study was terminated early

N3 suplement increases 60

day mortality

(%26.6 X %16.3)

Study is unique due to

Infüsion X bolus

High n6Xn9 X carbohydrates

Lung protectice strategy

Fluid restriction

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns Trauma

Future

4 RKÇ, 155 hasta

Glutamine decreases LOS in burns

Why pharmaconutrition/ immunonutrition

New mechanisms

Interrelation of nutrients

Immunometer

Update for critically ill patients

Glutamine

Arginine

Antioxidants

Omega-3 fatty acids

Burns

Trauma Future

0.5g/kg/BW/d dipeptid form iv

5 day inefficient

6. day GLN still low

Worse prognosis if GLN 6. day levels are low

No neurologic deterioration

Pharmaconutrition (drug, dose, route, duration)

According to serum levels

Adjustment for organ insufficiency

Other aa, calori, protein ratios

Management(calori, nitrogen, other parameters)

Immunometer