IMMUNONUTRITION WITH GLUTAMINE IN ICU PATIENTS
Â Objective: Endogenous production of glutamine may be reduced during critical illness. The shortage of glutamine is reflected as a decrease in plasma concentration, which is a prognostic factor for outcome in sepsis. Therefore, we have studied the effect of enteral or parenteral glutamine therapy on biochemical parameters and the hospital stay of critically ill patients.
Methods: A total of 66 critically ill patients aged 18-70 years, admitted to central and medical intensive care unit of a tertiary care hospital were randomly divided into three equal groups; 22 in each group: Group 1 (control group) received no glutamine, Group 2 received oral glutamine 0.5 g/kg/d for 5 days, and Group 3 received parenteral glutamine 0.5 g/kg/d by intravenous infusion for 5 days. All patients received glutamine-free tube feed throughout the study period. Total leukocyte count (TLC), total lymphocyte count, total protein and serum albumin, serum lactate, and sequential organ failure assessment (SOFA) score were recorded on each day for 7 days and were compared.
Results: Decrease in the TLC and increase in lymphocyte count was most evident in Group 3 compared to Groups 2 and 1 which was statistically significant. Decrease in serum lactate and increase in serum protein and albumin was maximum in Group 3 compared to Groups 1 and 2 which was statistically significant. The mean duration of hospital stay of Group 3 was the least followed by Groups 2 and 1 which was statistically not significant. There was an improvement in SOFA score in all the three groups.
Conclusion: Parenteral glutamine in a dose of 0.5 g/kg/d was more potent than oral glutamine in improving the biochemical parameters. The duration of hospital stay was similar in all the groups after treatment.
2. Oudemans-van Straaten HM, Bosman RJ, Treskes M, van der Spoel HJ, Zandstra DF. Plasma glutamine depletion and patient outcome in acute ICU admissions. Intensive Care Med 2001;27(1):84-90.
3. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, Champoux J, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: A prospective, controlled, randomized clinical trial. Crit Care Med 2003;31(10):2444-9.
4. Dechelotte P, Hasselmann M, Cynober L, Allaouchiche B, CoÃ«ffier M, Hecketsweiler B, et al. L-alanyi L-glutamine dipeptide supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in crtitically ill patient: The French controlled, randomized, double blind, multicentre study. Crit Care Med 2006;34(3):598-604.
5. Novak F, Heyland DK, Avenell A, Drover JW, Su X. Glutamine supplementation in serious illness: A systematic review of the evidence. Crit Care Med 2002;30(9):2022-9.
6. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. SCCM and A.S.P.E.N. J Parenter Enteral Nutr 2016;40(2):159-211.
7. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003;27(5):355-73.
8. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: Intensive care. Clin Nutr 2006;25(2):210-23.
9. Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013;368(16):1489-97.
10. Andrews PJ, Avenell A, Noble DW, Campbell MK, Croal BL, Simpson WG, et al. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. Br Med J 2011;342:d1542.
11. Hall JC, Dobb G, Hall J, de Sousa R, Brennan L, McCauley R. A prospective randomized trial of enternal glutamine in critical illness. Intensive Care Med 2003;29(10):1710-6.
12. Zhou YP, Jiang ZM, Sun YH, Wang XR, Ma EL, Wilmore D. The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: A randomized, double-blind, controlled clinical trial. JPEN J Parenter Enteral Nutr 2003;27(4):241-5.
13. Goeters C, Wenn A, Mertes N, Wempe C, Van Ake H, Stehle P, et al. Parenteral L-alanyl-L-glutamine improves 6 months out come in critically ill patients. Crit Care Med 2002;30(9):2032-7.
14. Wischmeyer PE, Lynch J, Liedel J, Wolfson R, Riehm J, Gottlieb L, 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(11):2075-80.
15. Heyland DK, Dhaliwal R, Day A, Drover J, Cote H, Wischmeyer P, et al. Optimizing the dose of glutamine dipeptides and antioxidants in critically ill patients: A phase I dose-finding study. J Parenter Enteral Nutr 2007;31(2):109-18.
16. Luo M, Bazargan N, Griffith DP, EstÃvariz CF, Leader LM, Easley KA, et al. Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: A pilot study. Clin Nutr 2008;27(2):297-306.
17. Ferreira FL, Bota DP, Bross A, MÃ©lot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286(14):1754-8.
18. Beale RJ, Sherry T, Lei K, Campbell-Stephen L, McCook J, Smith J, et al. Early enteral supplementation with key pharmaconutrients improves Sequential Organ Failure Assessment score in critically ill patients with sepsis: Outcome of a randomized, controlled, double-blind trial. Crit Care Med 2008;36(1):131-44.
19. Fuentes-Orozco C, Anaya-Prado R, GonzÃ¡lez-Ojeda A, Arenas-MÃ¡rquez H, Cabrera-Pivaral C, Cervantes-Guevara G, et al. L-alanyl-L-glutamine-supplemented parenteral nutrition improves infectious morbidity in secondary peritonitis. Clin Nutr 2004;23(1):13-21.
20. Ockenga J, Borchert K, Rifai K, Mans MP, Bischoff CC. Effect of glutamine-enriched total parenteral nutrition in patients with acute pancreatitis. Clin Nutr 2002;21(5):409-16.
21. Kumar S, Kumar R, Sharma SB, Jain BK. Effect of oral glutamine administration on oxidative stress, morbidity and mortality in critically ill surgical patients. Indian J Gastroenterol 2007;26(2):70-3.
22. Schulman AS, Willcutts KF, Claridge JA, Evans HL, Radigan AE, Oâ€™Donnell KB, et al. Does the addition of glutamine to enteral feeds affect patient mortality? Crit Care Med 2005;33(11):2501-6.
23. Griffiths RD, Jones C, Palmer TE. Six-month outcome of critically ill patients given glutamine-supplemented parenteral nutrition. Nutrition 1997;13(4):295-302.
24. Griffiths RD, Allen KD, Andrews FJ, Jones C. Infection, multiple organ failure, and survival in the intensive care unit: Influence of glutamine-supplemented parenteral nutrition on acquired infection. Nutrition 2002;18(7-8):546-52.
25. Xian-Li H, Qing-Ji M, Jian-Guo L, Yan-Kui C, Xi-Lin D. Effect of total parenteral nutrition (TPN)with and without glutamine dipeptide supplementation on out come in severe acute pancreatitis (SAP). Clin Nutr Suppl 2004;1(1):43-7.
26. van Zanten AR, Dhaliwal R, Garrel D, Heyland DK. Enteral glutamine supplementation in critically ill patients: A systematic review and meta-analysis. Crit Care 2015;19:294.
27. Oldani M, Sandini M, Nespoli L, Coppola S, Bernasconi DP, Gianotti L. Glutamine supplementation in intensive care patients: A meta-analysis of randomized clinical trials. Medicine (Baltimore) 2015;94(31):e1319.
28. Bollhalder L, Pfeil AM, Tomonaga Y, Schwenkglenks M. A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation. Clin Nutr 2013;32(2):213-23.
29. Chen QH, Yang Y, He HL, Xie JF, Cai SX, Liu AR, et al. The effect of glutamine therapy on outcomes in critically ill patients: A meta-analysis of randomized controlled trials. Crit Care 2014;18(1):R8.
30. Tao KM, Li XQ, Yang LQ, Yu WF, Lu ZJ, Sun YM, et al. Glutamine supplementation for critically ill adults. Cochrane Database Syst Rev 2014;9:CD010050.
31. Kang K, Shu XL, Zhang YS, Liu XL, Zhao J. Effect of glutamine enriched nutrition support on surgical patients with gastrointestinal tumor: A meta-analysis of randomized controlled trials. Chin Med J (Engl) 2015;128(2):245-51.
32. El-Din AA, Korraa A, Labib H, Salah DD. Studying the effect of parenterally administered L-alanyl L-glutamine dipeptide in diabetes and new onset diabetes in liver transplantation. Egypt J Anaesth 2016;32(3):415-20.
33. John MR, Aanandhi MV. Enteral/oral glutamine supplementation in patients following surgery and accidental injury. Asian J Pharm Clin Res 2017;10(3):477-9.
34. Oktavia SY, Arifin H, Yosmar R. Parenteral nutrition in neonates and compatibility issues: A review article. Asian J Pharm Clin Res 2017;10(2):54-64.
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