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Heutlinger O, Acharya N, Tedesco A, Ramesh A, Smith B, Nguyen NT, Wischmeyer PE. Nutritional Optimization of the Surgical Patient: A Narrative Review. Adv Nutr 2025; 16:100351. [PMID: 39617150 PMCID: PMC11784791 DOI: 10.1016/j.advnut.2024.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/13/2024] [Accepted: 11/14/2024] [Indexed: 12/18/2024] Open
Abstract
An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.
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Affiliation(s)
- Olivia Heutlinger
- School of Medicine, University of California-Irvine, Irvine, California, United States.
| | - Nischal Acharya
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Amanda Tedesco
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Ashish Ramesh
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Brian Smith
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Ninh T Nguyen
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, United States; Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States
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Yue HY, Wang Y, Zeng J, Jiang H, Li W. Enteral glutamine supplements for patients with severe burns: A systematic review and meta-analysis. Chin J Traumatol 2024; 27:359-367. [PMID: 37460347 PMCID: PMC11624305 DOI: 10.1016/j.cjtee.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/23/2023] [Accepted: 06/15/2023] [Indexed: 11/24/2024] Open
Abstract
PURPOSE Our previous study in 2009 concluded that glutamine may shorten the length of hospital stay (LOS) in patients with severe burns. Recent large-scale studies have suggested a decline in the effectiveness of glutamine in treating patients with severe burns over the last decade. Therefore, we conducted this systematic review and meta-analysis to update the status of glutamine uses in patients with severe burns. METHODS We retrieved related literature prior to December 2022 from the PubMed, Web of Science, Cochrane Library, Embase, SinoMed, Wanfang, and CNKI databases. Terms such as glutamine, enteral and burn were linked for searching. Adults patients with severe burns were included and non-randomized controlled trials were excluded. Data from studies that compared enteral glutamine for severe burns with a control group were extracted. The primary outcomes of mortality and infectious morbidities were pooled and analyzed. The modified Jadad scale and Cochrane collaboration's tool were used to assess the risk of bias in RCTs, and the Review Manager 5.4 was used to pool and analyze the data. RESULTS Six randomized controlled trials involving 1398 patients were included in the analysis. There were no significant differences in overall mortality (risk ratio (RR) = 0.37; 95% confidence interval (CI): 0.06 - 2.37; p = 0.300) or infectious morbidities (RR = 0.73; 95% CI: 0.41 - 1.31; p = 0.290). The incidence of multiple organ dysfunction syndrome was similar between the 2 groups (RR = 0.27; 95% CI: 0.03 - 2.24; p = 0.220). The LOS (mean difference (MD) = -8.97; 95% CI: -15.22 to -2.71; p = 0.005) and LOS/total burn surface area (MD = -0.27; 95% CI: -0.54 to 0.00; p = 0.050) decreased in the enteral glutamine group. The incidence of wound infection was significantly reduced (RR = 0.42; 95% CI: 0.16 - 1.06; p = 0.070). CONCLUSION Compared to the control group, enteral glutamine administration may not improve the mortality, although it may be associated with a shorter LOS, a lower LOS/total burn surface area ratio, and may reduce the risk of wound infection in patients with severe burns.
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Affiliation(s)
- Han-Yang Yue
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yu Wang
- Department of Clinical Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China; Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China; Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China; Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Wei Li
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China; Department of Burns, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Funk Debleds P, Chambrier C, Slim K. Postoperative nutrition in the setting of enhanced recovery programmes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106866. [PMID: 36914532 DOI: 10.1016/j.ejso.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023]
Abstract
Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.
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Affiliation(s)
- Pamela Funk Debleds
- Department of Supportive Care, Centre de Lutte Contre le Cancer Léon Bérard, Lyon, France
| | - Cécile Chambrier
- Intensive Clinical Nutrition Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite, France
| | - Karem Slim
- Department of Digestive Surgery, University Hospital, CHU, Clermont-Ferrand, France; Francophone Group for Enhanced Recovery After Surgery, France.
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Muranaka H, Akinsola R, Billet S, Pandol SJ, Hendifar AE, Bhowmick NA, Gong J. Glutamine Supplementation as an Anticancer Strategy: A Potential Therapeutic Alternative to the Convention. Cancers (Basel) 2024; 16:1057. [PMID: 38473414 PMCID: PMC10930819 DOI: 10.3390/cancers16051057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Glutamine, a multifaceted nonessential/conditionally essential amino acid integral to cellular metabolism and immune function, holds pivotal importance in the landscape of cancer therapy. This review delves into the intricate dynamics surrounding both glutamine antagonism strategies and glutamine supplementation within the context of cancer treatment, emphasizing the critical role of glutamine metabolism in cancer progression and therapy. Glutamine antagonism, aiming to disrupt tumor growth by targeting critical metabolic pathways, is challenged by the adaptive nature of cancer cells and the complex metabolic microenvironment, potentially compromising its therapeutic efficacy. In contrast, glutamine supplementation supports immune function, improves gut integrity, alleviates treatment-related toxicities, and improves patient well-being. Moreover, recent studies highlighted its contributions to epigenetic regulation within cancer cells and its potential to bolster anti-cancer immune functions. However, glutamine implementation necessitates careful consideration of potential interactions with ongoing treatment regimens and the delicate equilibrium between supporting normal cellular function and promoting tumorigenesis. By critically assessing the implications of both glutamine antagonism strategies and glutamine supplementation, this review aims to offer comprehensive insights into potential therapeutic strategies targeting glutamine metabolism for effective cancer management.
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Affiliation(s)
- Hayato Muranaka
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Rasaq Akinsola
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Sandrine Billet
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Stephen J. Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew E. Hendifar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Neil A. Bhowmick
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Research, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Jun Gong
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (R.A.); (S.B.); (S.J.P.); (A.E.H.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Valla FV, Uberti T, Henry C, Slim K. Perioperative nutritional assessment and support in visceral surgery. J Visc Surg 2023; 160:356-367. [PMID: 37587003 DOI: 10.1016/j.jviscsurg.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.
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Affiliation(s)
- Frederic V Valla
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France.
| | - Thomas Uberti
- Anesthesiology and Critical Care Department, Hôpital E.-Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France
| | - Caroline Henry
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France
| | - Karem Slim
- Digestive Surgery Department and Ambulatory Surgery Unit, 63003 Clermont-Ferrand, France
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Wang Q, Yang Z, Guo L, Li Z, Liu Y, Feng S, Wang Y. Chemical composition, pharmacology and pharmacokinetic studies of GuHong injection in the treatment of ischemic stroke. Front Pharmacol 2023; 14:1261326. [PMID: 37745083 PMCID: PMC10512552 DOI: 10.3389/fphar.2023.1261326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
GuHong injection is composed of safflower and N-acetyl-L-glutamine. It is widely used in clinical for cerebrovascular diseases, such as ischemic stroke and related diseases. The objective of this review is to comprehensively summarize the most recent information related to GuHong in the treatment of stroke, including chemical composition, clinical studies, potential pharmacological mechanisms and pharmacokinetics. Additionally, it examines possible scientific gaps in current study and aims to provide a reliable reference for future GuHong studies. The systematic review reveals that the chemical composition of safflower in GuHong is more than 300 chemical components in five categories. GuHong injection is primarily used in clinical applications for acute ischemic stroke and related diseases. Pharmacological investigations have indicated that GuHong acts in the early and recovery stages of ischemic stroke by anti-inflammatory, anti-oxidative stress, anti-coagulation, neuroprotective and anti-apoptotic mechanisms simultaneously. Pharmacokinetic studies found that the main exposed substances in rat plasma after GuHong administration are hydroxysafflor yellow A and N-acetyl-L-glutamine, and N-acetyl-L-glutamine could exert its pharmacological effect across the blood-brain barrier. As a combination of Chinese herb and chemical drug, GuHong injection has great value in drug research and clinical treatment, especially for ischemic stroke disease. This article represents a comprehensive and systematic review of existing studies on GuHong injection, including chemical composition, pharmacological mechanism, and pharmacokinetics, which provides reference significance for the clinical treatment of ischemic stroke with GuHong, as well as provides guidance for further study.
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Affiliation(s)
- Qiuyue Wang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhihua Yang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Liuli Guo
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhenzhen Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangxi Liu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shaoling Feng
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yanxia Wang
- Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
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Schönenberger KA, Reber E, Dürig C, Baumgartner A, Efthymiou A, Huwiler VV, Laimer M, Bally L, Stanga Z. Management of Hyperglycemia in Hospitalized Patients Receiving Parenteral Nutrition. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:829412. [PMID: 36992742 PMCID: PMC10012056 DOI: 10.3389/fcdhc.2022.829412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Almost half of inpatients on parenteral nutrition experience hyperglycemia, which increases the risk of complications and mortality. The blood glucose target for hospitalized patients on parenteral nutrition is 7.8 to 10.0 mmol/L (140 to 180 mg/dL). For patients with diabetes, the same parenteral nutrition formulae as for patients without diabetes can be used, as long as blood glucose levels can be adequately controlled using insulin. Insulin can be delivered via the subcutaneous or intravenous route or, alternatively, added to parenteral nutrition admixtures. Combining parenteral with enteral and oral nutrition can improve glycemic control in patients with sufficient endogenous insulin stores. Intravenous insulin infusion is the preferred route of insulin delivery in critical care as doses can be rapidly adjusted to altered requirements. For stable patients, insulin can be added directly to the parenteral nutrition bag. If parenteral nutrition is infused continuously over 24 hours, the subcutaneous injection of a long-acting insulin combined with correctional bolus insulin may be adequate. The aim of this review is to give an overview of the management of parenteral nutrition-associated hyperglycemia in inpatients with diabetes.
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Affiliation(s)
- Katja A. Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- *Correspondence: Katja A. Schönenberger,
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Dürig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annic Baumgartner
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andriana Efthymiou
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentina V. Huwiler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Markus Laimer
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Dmitriev AV, Machulina IA, Shestopalov AE. [Glutamine as a component of nutritional and metabolic therapy for surgical patients in ICU]. Khirurgiia (Mosk) 2021:98-106. [PMID: 34363451 DOI: 10.17116/hirurgia202108198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Glutamine is the most abundant amino acid in the human body that is involved in various metabolic processes. The development of hypermetabolic and hypercatabolic syndrome that accompanies critical conditions of ICU patients is associated with a decrease in the concentration of glutamine, especially in the blood plasma and muscles. This process may last for quite a long time and lead to a number of complications up to a fatal outcome. This review was aimed to analyze clinical studies conducted over the past 20 years that demonstrate the effect of intravenous infusion of glutamine dipeptide as part of balanced parenteral nutrition on the perioperative period: the severity of inflammatory response; the state of the intestinal mucosa; the incidence and severity of complications; mortality; the duration of stay in the ICU and hospital in general, etc. The analysis was performed using systematic reviews and meta-analyses based on randomized double-blind, placebo-controlled trials in different countries selected in the main databases (PubMed, EMBASE, Web of Science, The Cochrane Library, etc.). Most of the reports state that the inclusion of glutamine dipeptide in nutritional and metabolic therapy (NMT) in surgical patients reduces the frequency and severity of infectious complications and mortality, reduces the length of stay in ICU and in hospital in general, improves the biochemical parameters that reflect the condition of patients, and reduces the treatment costs. Thus, the conducted systematic reviews and meta-analyses confirm that the use of the parenteral form of glutamine dipeptide (Dipeptiven 20%) as part of balanced standard parenteral nutrition (PN) is a clinically and pharmacoeconomically justified strategy of NMT in surgical ICU patients.
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Affiliation(s)
- A V Dmitriev
- Northwest Society for Parenteral and Enteral Nutrition, Saint Petersbur, Northwest Society for Parenteral and Enteral Nutrition, Saint Petersburg
| | - I A Machulina
- SBHI City Clinical Hospital No. 70 named after E.O. Mukhin of the Moscow City Health Department, Mosco, SBHI City Clinical Hospital No. 70 named after E.O. Mukhin of the Moscow City Health Department, Moscow
| | - A E Shestopalov
- FSBE FPE Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Mosco, FSBE FPE Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow.,FSBI N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of Russia, Mosco, FSBI N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of Russia, Moscow
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Gholamalizadeh M, Tabrizi R, Rezaei S, Badeli M, Shadnoush M, Jarrahi AM, Doaei S. Effect of glutamine supplementation on inflammatory markers in critically ill patients supported with enteral or parenteral feeding. JPEN J Parenter Enteral Nutr 2021; 46:61-68. [PMID: 34213769 DOI: 10.1002/jpen.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Glutamine plays an important role in acute catabolic conditions in critically ill patients. This meta-analysis aimed to investigate the effect of glutamine supplementation on inflammatory markers in critically ill patients supported with enteral feeding (EN) or parenteral feeding (PN). METHODS PubMed, Web of Science, Scopus, and Embase were explored to identify the studies investigating the effect of glutamine on serum inflammatory markers in intensive care unit patients. All randomized clinical trials that assessed the effect of glutamine supplementation on "inflammatory markers" in EN or PN were included in the study. Because a small number of studies were included, SE was adjusted for overall effect size by using the Knapp-Hartung method. RESULTS In this study, 2728 eligible studies were initially included, and 10 eligible case-control studies were finally enrolled for further investigations. There was a statistical reduction between preintervention and postintervention CRP levels (standardized mean difference [SMD] = -0.38 mg/L; 95% CI, -0.72 to -0.03). No significant association was found between L-glutamine supplementation in the EN/PN and interleukin 6 (IL-6) (SMD = -0.58 pg/ml; 95% CI, -2.15 to 0.99) and tumor necrosis factor alpha (TNF-α) (SMD = 2.69 pg/ml; 95% CI, -9.66 to 15.03) compared with the control group. CONCLUSIONS This study identified that glutamine supplementation might have an important effect on CRP in acute conditions and no significant effect on IL-6 and TNF-α in acute conditions.
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Affiliation(s)
- Maryam Gholamalizadeh
- Student Research Committee, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Shahla Rezaei
- Department of Clinical Nutrition, Student Research Committee, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.,Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mostafa Badeli
- Department of Nutrition, Urmia University of Medical Science, Urmia, Iran
| | - Mahdi Shadnoush
- Department of Clinical Nutrition, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Saeid Doaei
- Reproductive Health Research Center, Department of Obstetrics & Gynecology, Al-zahra hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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10
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale RG, Waitzberg D, Bischoff SC, Singer P. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. [PMID: 34242915 DOI: 10.1016/j.clnu.2021.03.031] [Citation(s) in RCA: 329] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Marco Braga
- University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Franco Carli
- Department of Anesthesia of McGill University, School of Nutrition, Montreal General Hospital, Montreal, Canada
| | | | - Martin Hübner
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Lausanne, Lausanne, Switzerland
| | - Stanislaw Klek
- General Surgical Oncology Clinic, National Cancer Institute, Krakow, Poland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | | | - Dan Waitzberg
- University of Sao Paulo Medical School, Ganep, Human Nutrition, Sao Paulo, Brazil
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
| | - Pierre Singer
- Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel
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11
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Alcázar Espín MN, Macaya Redín L, Moreno Clarí E, Sánchez Álvarez C. Recommendations for specialized nutritional-metabolic management of the critical patient: Digestive tract surgery. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:65-68. [PMID: 32532414 DOI: 10.1016/j.medin.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/05/2019] [Accepted: 12/20/2019] [Indexed: 10/24/2022]
Affiliation(s)
| | - L Macaya Redín
- Complejo Hospitalario de Navarra, Pamplona, Navarra, España
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12
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Effects of parenteral glutamine in critically ill surgical patients: a systematic review and meta-analysis. NUTR HOSP 2020; 34:616-621. [PMID: 32338020 DOI: 10.20960/nh.02949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: glutamine (GLN), the most abundant non-essential amino acid in the plasma, tends to be rapidly depleted in cells in situations of metabolic stress. Some studies have demonstrated the benefits of GLN supplementation on mortality, infection, and length of hospital stay. The objective of this review was to analyze whether parenteral supplementation with GLN has any relevant effect in critically ill surgical patients. Methods: based on a systematic database search, randomized clinical trials (RCTs) published since 1985 were included if they had evaluated the effect of parenteral GLN supplementation in critical surgical patients. The statistical analysis was performed using the RevMan 5.3 software. Results: seven RCTs were eligible for the meta-analysis. Parenteral glutamine supplementation was associated with a non-significant 24 % reduction in mortality (RR = 0.76; 95 % CI: 0.50-1.15). Infections were significantly reduced (RR = 0.60; 95 % CI: 0.45-0.80), and length of hospital stay was 4.09 days shorter (95 % CI: -6.71 to -1.46). Conclusion: parenteral GLN usage in critical surgical patients seems to decrease infection and length of hospital stay, but we could not demonstrate a significant reduction in mortality.
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13
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Yue C, Tian W, Wang W, Huang Q, Zhao R, Zhao Y, Li Q, Li J. The Impact of Perioperative Glutamine-supplemented Parenteral Nutrition on Outcomes of Patients Undergoing Abdominal Surgery: A Meta-analysis of Randomized Clinical Trials. Am Surg 2020. [DOI: 10.1177/000313481307900527] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The objective of this study was to evaluate the impact of perioperative glutamine-supplemented parenteral nutrition (GLN-PN) on clinical outcomes in patients undergoing abdominal surgery. MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register were searched to retrieve the eligible studies. Eligible studies were randomized controlled trials (RCTs) that compared the effect of GLN-PN and standard PN on clinical outcomes in patients undergoing abdominal surgery. Clinical outcomes of interest were postoperative mortality, length of hospital stay, morbidity of infectious complication, and cumulative nitrogen balance. Statistical analysis was conducted by RevMan 5.0 software from the Cochrane Collaboration. Sixteen RCTs with 773 patients were included in this meta-analysis. The results showed a significant decrease in the infectious complication rates of patients undergoing abdominal surgery receiving GLN-PN (risk ratio [RR], 0.48; 95% confidence interval [CI], 0.32 to 0.72; P = 0.0004). The overall effect indicated glutamine significantly reduced the length of hospital stay in the form of alanyl-glutamine (weighted mean difference [WMD], -3.17; 95% CI, -5.51 to -0.82; P = 0.008) and in the form of glycyl-glutamine (WMD, -3.40; 95% CI, -5.82 to -0.97; P = 0.006). A positive effect in improving postoperative cumulative nitrogen balance was observed between groups (WMD, 7.40; 95% CI, 3.16 to 11.63; P = 0.0006), but no mortality (RR, 1.52; 95% CI, 0.21 to 11.9; P = 0.68). Perioperative GLN-PN is effective and safe to shorten the length of hospital stay, reduce the morbidity of postoperative infectious complications, and improve nitrogen balance in patients undergoing abdominal surgery.
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Affiliation(s)
- Chao Yue
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiliang Tian
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wei Wang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Risheng Zhao
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yunzhao Zhao
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qiurong Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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14
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Plasma Glutamine Levels in Relation to Intensive Care Unit Patient Outcome. Nutrients 2020; 12:nu12020402. [PMID: 32028696 PMCID: PMC7071267 DOI: 10.3390/nu12020402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 02/06/2023] Open
Abstract
Low and high plasma glutamine levels are associated with increased mortality. This study aimed to measure glutamine levels in critically ill patients admitted to the intensive care unit (ICU) , correlate the glutamine values with clinical outcomes, and identify proxy indicators of abnormal glutamine levels. Patients were enrolled from three ICUs in South Africa, provided they met the inclusion criteria. Clinical and biochemical data were collected. Plasma glutamine was categorized as low (<420 µmol/L), normal (420-700 µmol/L), or high (>700 µmol/L). Three hundred and thirty patients (median age 46.8 years, 56.4% male) were enrolled (median APACHE II score) 18.0 and SOFA) score 7.0). On admission, 58.5% had low (median 299.5 µmol/L) and 14.2% high (median 898.9 µmol/L) plasma glutamine levels. Patients with a diagnosis of polytrauma and sepsis on ICU admission presented with the lowest, and those with liver failure had the highest glutamine levels. Admission low plasma glutamine was associated with higher APACHE II scores (p = 0.003), SOFA scores (p = 0.003), C-reactive protein (CRP) values (p < 0.001), serum urea (p = 0.008), and serum creatinine (p = 0.023) and lower serum albumin (p < 0.001). Low plasma glutamine was also associated with requiring mechanical ventilation and receiving nutritional support. However, it was not significantly associated with length of stay or mortality. ROC curve analysis revealed a CRP threshold value of 87.9 mg/L to be indicative of low plasma glutamine levels (area under the curve (AUC) 0.7, p < 0.001). Fifty-nine percent of ICU patients had low plasma glutamine on admission, with significant differences found between diagnostic groupings. Markers of infection and disease severity were significant indicators of low plasma glutamine.
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15
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Cruzat V, Macedo Rogero M, Noel Keane K, Curi R, Newsholme P. Glutamine: Metabolism and Immune Function, Supplementation and Clinical Translation. Nutrients 2018; 10:nu10111564. [PMID: 30360490 PMCID: PMC6266414 DOI: 10.3390/nu10111564] [Citation(s) in RCA: 642] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 02/07/2023] Open
Abstract
Glutamine is the most abundant and versatile amino acid in the body. In health and disease, the rate of glutamine consumption by immune cells is similar or greater than glucose. For instance, in vitro and in vivo studies have determined that glutamine is an essential nutrient for lymphocyte proliferation and cytokine production, macrophage phagocytic plus secretory activities, and neutrophil bacterial killing. Glutamine release to the circulation and availability is mainly controlled by key metabolic organs, such as the gut, liver, and skeletal muscles. During catabolic/hypercatabolic situations glutamine can become essential for metabolic function, but its availability may be compromised due to the impairment of homeostasis in the inter-tissue metabolism of amino acids. For this reason, glutamine is currently part of clinical nutrition supplementation protocols and/or recommended for immune suppressed individuals. However, in a wide range of catabolic/hypercatabolic situations (e.g., ill/critically ill, post-trauma, sepsis, exhausted athletes), it is currently difficult to determine whether glutamine supplementation (oral/enteral or parenteral) should be recommended based on the amino acid plasma/bloodstream concentration (also known as glutaminemia). Although the beneficial immune-based effects of glutamine supplementation are already established, many questions and evidence for positive in vivo outcomes still remain to be presented. Therefore, this paper provides an integrated review of how glutamine metabolism in key organs is important to cells of the immune system. We also discuss glutamine metabolism and action, and important issues related to the effects of glutamine supplementation in catabolic situations.
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Affiliation(s)
- Vinicius Cruzat
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia.
- Faculty of Health, Torrens University, Melbourne 3065, Australia.
| | - Marcelo Macedo Rogero
- Department of Nutrition, Faculty of Public Health, University of São Paulo, Avenida Doutor Arnaldo 715, São Paulo 01246-904, Brazil.
| | - Kevin Noel Keane
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia.
| | - Rui Curi
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, São Paulo 01506-000, Brazil.
| | - Philip Newsholme
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia.
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16
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Cruzat V, Macedo Rogero M, Noel Keane K, Curi R, Newsholme P. Glutamine: Metabolism and Immune Function, Supplementation and Clinical Translation. Nutrients 2018. [PMID: 30360490 DOI: 10.20944/preprints201809.0459.v1] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Glutamine is the most abundant and versatile amino acid in the body. In health and disease, the rate of glutamine consumption by immune cells is similar or greater than glucose. For instance, in vitro and in vivo studies have determined that glutamine is an essential nutrient for lymphocyte proliferation and cytokine production, macrophage phagocytic plus secretory activities, and neutrophil bacterial killing. Glutamine release to the circulation and availability is mainly controlled by key metabolic organs, such as the gut, liver, and skeletal muscles. During catabolic/hypercatabolic situations glutamine can become essential for metabolic function, but its availability may be compromised due to the impairment of homeostasis in the inter-tissue metabolism of amino acids. For this reason, glutamine is currently part of clinical nutrition supplementation protocols and/or recommended for immune suppressed individuals. However, in a wide range of catabolic/hypercatabolic situations (e.g., ill/critically ill, post-trauma, sepsis, exhausted athletes), it is currently difficult to determine whether glutamine supplementation (oral/enteral or parenteral) should be recommended based on the amino acid plasma/bloodstream concentration (also known as glutaminemia). Although the beneficial immune-based effects of glutamine supplementation are already established, many questions and evidence for positive in vivo outcomes still remain to be presented. Therefore, this paper provides an integrated review of how glutamine metabolism in key organs is important to cells of the immune system. We also discuss glutamine metabolism and action, and important issues related to the effects of glutamine supplementation in catabolic situations.
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Affiliation(s)
- Vinicius Cruzat
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia. .,Faculty of Health, Torrens University, Melbourne 3065, Australia.
| | - Marcelo Macedo Rogero
- Department of Nutrition, Faculty of Public Health, University of São Paulo, Avenida Doutor Arnaldo 715, São Paulo 01246-904, Brazil.
| | - Kevin Noel Keane
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia.
| | - Rui Curi
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, São Paulo 01506-000, Brazil.
| | - Philip Newsholme
- School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Biosciences, Curtin University, Perth 6102, Australia.
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17
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Vychytil A, Herzog R, Probst P, Ribitsch W, Lhotta K, Machold-Fabrizii V, Wiesholzer M, Kaufmann M, Salmhofer H, Windpessl M, Rosenkranz AR, Oberbauer R, König F, Kratochwill K, Aufricht C. A randomized controlled trial of alanyl-glutamine supplementation in peritoneal dialysis fluid to assess impact on biomarkers of peritoneal health. Kidney Int 2018; 94:1227-1237. [PMID: 30360960 DOI: 10.1016/j.kint.2018.08.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 07/25/2018] [Accepted: 08/09/2018] [Indexed: 01/26/2023]
Abstract
In early clinical testing, acute addition of alanyl-glutamine (AlaGln) to glucose-based peritoneal dialysis (PD) fluids restored peritoneal cellular stress responses and leukocyte function. This study was designed to test the effect of extended treatment with AlaGln-supplemented PD fluid on biomarkers of peritoneal health. In a double-blinded, randomized crossover design, stable PD patients were treated with AlaGln (8 mM) or placebo added to PD fluid for eight weeks. As primary outcome measures, dialysate cancer-antigen 125 (CA-125) appearance rate and ex vivo stimulated interleukin-6 (IL-6) release were assessed in peritoneal equilibration tests. In 8 Austrian centers, 54 patients were screened, 50 randomized, and 41 included in the full analysis set. AlaGln supplementation significantly increased CA-125 appearance rate and ex vivo stimulated IL-6 release. AlaGln supplementation also reduced peritoneal protein loss, increased ex vivo stimulated tumor necrosis factor (TNF)-α release, and reduced systemic IL-8 levels. No adverse safety signals were observed. All 4 peritonitis episodes occurred during standard PD fluid treatment. A novel AlaGln-supplemented PD fluid improves biomarkers of peritoneal membrane integrity, immune competence, and systemic inflammation compared to unsupplemented PD fluid with neutral pH and low-glucose degradation. A phase 3 trial is needed to determine the impact of AlaGln supplementation on hard clinical outcomes.
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Affiliation(s)
- Andreas Vychytil
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
| | - Rebecca Herzog
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, Vienna, Austria
| | - Paul Probst
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Werner Ribitsch
- Department of Internal Medicine, Clinical Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Karl Lhotta
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Austria
| | | | - Martin Wiesholzer
- Department of Internal Medicine I, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, St. Poelten, Austria
| | - Michaela Kaufmann
- Department of Medicine III, Nephrology, Transplantation, Rheumatology, Geriatrics, Ordensklinikum Linz, Krankenhaus der Elisabethinen Linz, Linz, Austria
| | - Hermann Salmhofer
- Department of Medicine I, Paracelsus Medical University, Salzburg, Austria
| | - Martin Windpessl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Alexander R Rosenkranz
- Department of Internal Medicine, Clinical Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Rainer Oberbauer
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Franz König
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Klaus Kratochwill
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christoph Aufricht
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
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18
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 1039] [Impact Index Per Article: 129.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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19
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McRae MP. Therapeutic benefits of glutamine: An umbrella review of meta-analyses. Biomed Rep 2017; 6:576-584. [PMID: 28529738 DOI: 10.3892/br.2017.885] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/09/2017] [Indexed: 02/07/2023] Open
Abstract
Glutamine may be an essential amino acid in patients with catabolic disease, as it has been demonstrated that circulating glutamine levels drop during critical illness and following major surgery; this may result in an increase in secondary infection risk, recovery time and mortality rates. However, there is much discrepancy in the literature with regards to randomized controlled studies, and therefore, the present study is an umbrella review of published meta-analyses, conducted to examine the effectiveness of glutamine's role as a therapeutic agent. A search using PubMed, Cochrane Library and CINAHL from January 1st, 1980 to December 31st, 2016 was conducted using the following strategy: 'Glutamine AND (meta-analysis OR systematic review)' and publications were retrieved, which provided quantitative statistical analysis of pooled treatment effects on the relative risks of infectious complications, mortality and length of stay in hospital. A total of 22 meta-analyses were entered into the current umbrella review. As displayed in Tables I, II and III, these analyses are split into three groups, based on different parameters. Of the 19 meta-analyses investigating the effects of infectious complications, 15 identified statistically significant reductions in complications, with relative risks ranging between 0.42 and 0.93. In addition, 12 of the 18 meta-analyses analyzing the length of hospital stays presented statistically significant reductions in the length of stay, with reductions ranging between 0.19 to 4.73 days. Only 4 of the 15 meta-analyses studying mortality effects identified statistically significant reductions in mortality with relative risks ranging between 0.64 and 1.28. Statistically significant heterogeneity was observed in 16 of 22 meta-analyses, and publication bias was observed in five of 11 meta-analyses. Glutamine supplementation for critically ill or surgical patients through parenteral or enteral routes appears to reduce the rate of hospital acquired infectious complications and shortening of the length of stay in hospital. Furthermore, glutamine supplementation appeared to reduce the rate of in-patient mortality, but the majority of meta-analyses did not reach statistical significance. However, researchers must appreciate the positive results with caution in light of the fact that there exists statistically significant heterogeneity for the majority of meta-analyses, and statistically significant publication bias in almost half.
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Affiliation(s)
- Marc P McRae
- Department of Basic Science, National University of Health Sciences, Lombard, IL 60148, USA
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20
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Hoffer LJ. Human Protein and Amino Acid Requirements. JPEN J Parenter Enteral Nutr 2016; 40:460-74. [PMID: 26796095 DOI: 10.1177/0148607115624084] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/12/2015] [Indexed: 12/24/2022]
Abstract
Human protein and amino acid nutrition encompasses a wide, complex, frequently misunderstood, and often contentious area of clinical research and practice. This tutorial explains the basic biochemical and physiologic principles that underlie our current understanding of protein and amino acid nutrition. The following topics are discussed: (1) the identity, measurement, and essentiality of nutritional proteins; (2) the definition and determination of minimum requirements; (3) nutrition adaptation; (4) obligatory nitrogen excretion and the minimum protein requirement; (5) minimum versus optimum protein intakes; (6) metabolic responses to surfeit and deficient protein intakes; (7) body composition and protein requirements; (8) labile protein; (9) N balance; (10) the principles of protein and amino acid turnover, including an analysis of the controversial indicator amino acid oxidation technique; (11) general guidelines for evaluating protein turnover articles; (12) amino acid turnover versus clearance; (13) the protein content of hydrated amino acid solutions; (14) protein requirements in special situations, including protein-catabolic critical illness; (15) amino acid supplements and additives, including monosodium glutamate and glutamine; and (16) a perspective on the future of protein and amino acid nutrition research. In addition to providing practical information, this tutorial aims to demonstrate the importance of rigorous physiologic reasoning, stimulate intellectual curiosity, and encourage fresh ideas in this dynamic area of human nutrition. In general, references are provided only for topics that are not well covered in modern textbooks.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
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21
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Akbarzadeh M, Eftekhari MH, Shafa M, Alipour S, Hassanzadeh J. Effects of a New Metabolic Conditioning Supplement on Perioperative Metabolic Stress and Clinical Outcomes: A Randomized, Placebo-Controlled Trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e26207. [PMID: 26889394 PMCID: PMC4752820 DOI: 10.5812/ircmj.26207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 12/31/2014] [Accepted: 01/18/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Insulin resistance is a measure of metabolic stress in the perioperative period. Before now, no clinical trial has determined the summative effects of glutamine, L-carnitine, and antioxidants as metabolic conditioning supplements in the perioperative period. OBJECTIVES The purpose of this study was to determine the effects of a new conditioning supplement on perioperative metabolic stress and clinical outcomes in non-diabetic patients. PATIENTS AND METHODS In this randomized controlled trial, 89 non-diabetic patients scheduled for coronary artery bypass grafting, with ejection fractions above 30%, were selected. Using the balanced block randomization method, the patients were allocated to one of four study arms: 1) SP (supplement/placebo): supplement seven days before and placebo 30 days after the surgery; 2) PS: placebo before and supplement after the surgery; 3) SS: supplement before and after the surgery; and 4) PP: placebo before and after the surgery. The supplement was composed of glutamine, L-carnitine, vitamin C, vitamin E, and selenium, which was manufactured for the first time by this research team. Five blood samples were drawn: seven days preoperatively, at the entrance to the operating room, while leaving the operating room, seven days postoperatively, and 30 days postoperatively. Levels of glucose, insulin, and HbA1c were measured in blood samples. Insulin resistance and sensitivity were calculated using a formula. Surgical complications were assessed 30 days postoperatively. Data analysis was done using one-way ANOVA, the Chi-square test, and a general linear model repeated-measures analysis with Bonferroni adjustment. RESULTS Blood glucose levels were increased postoperatively in the four groups (< 0.001), but a significantly higher increase occurred in the PP group compared to the SP (0.027), PS (0.026), and SS (0.004) groups. The superficial wound infection rate was significantly different between the four groups (0.021): 26.08% in PP, 9.09% in SP, 4.54% in PS, and 0% in SS. CONCLUSIONS Our new metabolic conditioning supplement, whether given pre- or postoperatively, led to better perioperative glycemic control and decreased postsurgical wound infections in non-diabetic patients.
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Affiliation(s)
- Marzieh Akbarzadeh
- Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Mohammad Hassan Eftekhari
- Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Author: Mohammad Hassan Eftekhari, Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-7137267056, Fax: +98-7137257288, E-mail:
| | - Masih Shafa
- Department of Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Shohreh Alipour
- Department of Pharmaceutics, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Jafar Hassanzadeh
- Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, IR Iran
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22
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Infektionsschutz und spezielle Hygienemaßnahmen in klinischen Disziplinen. KRANKENHAUS- UND PRAXISHYGIENE 2016. [PMCID: PMC7152143 DOI: 10.1016/b978-3-437-22312-9.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Watford M. Glutamine and glutamate: Nonessential or essential amino acids? ACTA ACUST UNITED AC 2015; 1:119-122. [PMID: 29767158 PMCID: PMC5945979 DOI: 10.1016/j.aninu.2015.08.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/17/2015] [Indexed: 12/15/2022]
Abstract
Glutamine and glutamate are not considered essential amino acids but they play important roles in maintaining growth and health in both neonates and adults. Although glutamine and glutamate are highly abundant in most feedstuffs there is increasing evidence that they may be limiting during pregnancy, lactation and neonatal growth, particularly when relatively low protein diets are fed. Supplementation of diets with glutamine, glutamate or both at 0.5 to 1.0% to both suckling and recently weaned piglets improves intestinal and immune function and results in better growth. In addition such supplementation to the sow prevents some of the loss of lean body mass during lactation, and increases milk glutamine content. However, a number of important questions related to physiological condition, species under study and the form and amount of the supplements need to be addressed before the full benefits of glutamine and glutamate supplementation in domestic animal production can be realized.
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Affiliation(s)
- Malcolm Watford
- Department of Nutritional Sciences, Rutgers, The State University, New Brunswick 08901, USA
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24
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Yong L, Lu QP, Liu SH, Fan H. Efficacy of Glutamine-Enriched Nutrition Support for Patients With Severe Acute Pancreatitis: A Meta-Analysis. JPEN J Parenter Enteral Nutr 2015; 40:83-94. [PMID: 25655622 DOI: 10.1177/0148607115570391] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/12/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma glutamine (Gln) level has been negatively correlated with the severity of severe acute pancreatitis (SAP). Although Gln is widely used today, the results of individual randomized controlled trials of Gln-enriched nutrition support for patients with SAP are conflicting. METHODS PubMed, EMBASE, HighWire, Cochrane Central Register of Controlled Trials, Wanfang, China Journals Full-Text Database, and the Chinese Biomedical Literature Database were searched. Literature published before June 2014 was searched. Randomized controlled trials investigating the comparison of conventional and Gln-enriched nutrition support were included; a random effect model using Rev Man 5.2 software was chosen to complete this meta-analysis. The count data were analyzed using the risk ratio (RR) and 95% confidence interval (CI), and the measurement data were analyzed using the standard mean difference or weighted mean difference and 95% CI. Heterogeneity analyses were conducted by I(2) test; publication bias analyses were conducted by Begg test. RESULTS Ten studies were eventually chosen for analysis, including 218 patients who received conventional methods (control group) and 215 patients who received Gln-enriched nutrition support (experimental group). Compared with the control group, Gln is helpful in elevating the albumin level, decreasing C-reaction protein (standard mean difference = 1.01, -1.89; 95% CI: 0.50 to 1.51, -3.23 to -0.56; P < .05), decreasing the incidence of infectious complication and mortality (RR = 0.62, 0.36; 95% CI: 0.46 to 0.83, 0.16 to 0.83; P < .05), and shortening the hospital stay length (weighted mean difference [WMD] = -3.89; 95% CI: -4.98 to -2.81; P < .05) without increasing expenses (WMD = -0.16; 95% CI: -1.34 to 1.02; P > .05). Intravenous infusion manifested more advantages by decreasing the incidence of infectious complications and mortality. CONCLUSIONS Gln-enriched nutrition support is superior to conventional methods for SAP, and intravenous infusion may be a better choice for drug administration.
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Affiliation(s)
- Li Yong
- Department of General Surgery, Wuhan Clinical College of Southern Medical University (Wuhan General Hospital of Guangzhou Military Command),Wuhan, Hubei Province, China
| | - Qi-Ping Lu
- Department of General Surgery, Wuhan Clinical College of Southern Medical University (Wuhan General Hospital of Guangzhou Military Command),Wuhan, Hubei Province, China.
| | - Sheng-Hui Liu
- Department of General Surgery, Wuhan Clinical College of Southern Medical University (Wuhan General Hospital of Guangzhou Military Command),Wuhan, Hubei Province, China
| | - Hu Fan
- Department of General Surgery, Wuhan Clinical College of Southern Medical University (Wuhan General Hospital of Guangzhou Military Command),Wuhan, Hubei Province, China
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Sandini M, Nespoli L, Oldani M, Bernasconi DP, Gianotti L. Effect of glutamine dipeptide supplementation on primary outcomes for elective major surgery: systematic review and meta-analysis. Nutrients 2015; 7:481-499. [PMID: 25584966 PMCID: PMC4303850 DOI: 10.3390/nu7010481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/04/2015] [Indexed: 12/15/2022] Open
Abstract
To evaluate if glutamine (GLN) supplementation may affect primary outcomes in patients undergoing major elective abdominal operations, we performed a systematic literature review of randomized clinical trials (RCTs) published from 1983 to 2013 and comparing intravenous glutamine dipeptide supplementation to no supplementation in elective surgical abdominal procedures. A meta-analysis for each outcome (overall and infectious morbidity and length of stay) of interest was carried out. The effect size was estimated by the risk ratio (RR) or by the weighted mean difference (WMD). Nineteen RCTs were identified with a total of 1243 patients (640 receiving GLN and 603 controls). In general, the studies were underpowered and of medium or low quality. GLN supplementation did not affect overall morbidity (RR = 0.84, 95% CI 0.51 to 1.36; p = 0.473) and infectious morbidity (RR = 0.64; 95% CI = 0.38 to 1.07; p = 0.087). Patients treated with glutamine had a significant reduction in length of hospital stay (WMD = -2.67; 95% CI = -3.83 to -1.50; p < 0.0001). In conclusion, GLN supplementation appears to reduce hospital stay without affecting the rate of complications. The positive effect of GLN on time of hospitalization is difficult to interpret due to the lack of significant effects on surgery-related morbidity.
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Affiliation(s)
- Marta Sandini
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital (4° piano A), via Pergolesi 33, 20900 Monza, Italy.
| | - Luca Nespoli
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital (4° piano A), via Pergolesi 33, 20900 Monza, Italy.
| | - Massimo Oldani
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital (4° piano A), via Pergolesi 33, 20900 Monza, Italy.
| | - Davide Paolo Bernasconi
- Department of Health Sciences, Center of Biostatistics for Clinical Epidemiology, Milano-Bicocca University, 20900 Monza, Italy.
| | - Luca Gianotti
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital (4° piano A), via Pergolesi 33, 20900 Monza, Italy.
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Pradelli L, Povero M, Muscaritoli M, Eandi M. Updated cost-effectiveness analysis of supplemental glutamine for parenteral nutrition of intensive-care patients. Eur J Clin Nutr 2014; 69:546-51. [PMID: 25469466 PMCID: PMC4424803 DOI: 10.1038/ejcn.2014.255] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 10/10/2014] [Accepted: 10/18/2014] [Indexed: 01/21/2023]
Abstract
Background/Objectives: Intravenous (i.v.) glutamine supplementation of parenteral nutrition (PN) can improve clinical outcomes, reduce mortality and infection rates and shorten the length of hospital and/or intensive care unit (ICU) stays compared with standard PN. This study is a pharmacoeconomic analysis to determine whether i.v. glutamine supplementation of PN remains both a highly favourable and cost-effective option for Italian ICU patients. Subjects/Methods: A previously published discrete event simulation model was updated by incorporating the most up-to-date and clinically relevant efficacy data (a clinically realistic subgroup analysis from a published meta-analysis), recent cost data from the Italian health-care system and the latest epidemiology data from a large Italian ICU database (covering 230 Italian ICUs and more than 77 000 patients). Sensitivity analyses were performed to test the robustness of the results. Results: Parenteral glutamine supplementation can significantly improve ICU efficiency in Italy, as the additional cost of supplemented treatment is more than completely offset by cost savings in hospital care. Supplementation was more cost-effective (cost-effectiveness ratio (CER)=€35 165 per patient discharged alive) than standard, non-supplemented PN (CER=€40 156 per patient discharged alive), and it resulted in mean cost savings of €4991 per patient discharged alive or €1047 per patient admitted to the hospital. Sensitivity analyses confirmed the robustness of these results. Conclusions: Alanyl-glutamine supplementation of PN is a clinically and economically attractive strategy for ICU patients in Italy and may be applicable to selected ICU patient populations in other countries.
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Affiliation(s)
- L Pradelli
- AdRes Health Economics and Outcomes Research, Turin, Italy
| | - M Povero
- AdRes Health Economics and Outcomes Research, Turin, Italy
| | - M Muscaritoli
- Department of Internal Medicine, Università La Sapienza, Rome, Italy
| | - M Eandi
- Department of Pharmacology, Università degli Studi di Torino, Torino, Italy
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Abstract
BACKGROUND Glutamine is a non-essential amino acid which is abundant in the healthy human body. There are studies reporting that plasma glutamine levels are reduced in patients with critical illness or following major surgery, suggesting that glutamine may be a conditionally essential amino acid in situations of extreme stress. In the past decade, several clinical trials examining the effects of glutamine supplementation in patients with critical illness or receiving surgery have been done, and the systematic review of this clinical evidence has suggested that glutamine supplementation may reduce infection and mortality rates in patients with critical illness. However, two recent large-scale randomized clinical trials did not find any beneficial effects of glutamine supplementation in patients with critical illness. OBJECTIVES The objective of this review was to:1. assess the effects of glutamine supplementation in critically ill adults and in adults after major surgery on infection rate, mortality and other clinically relevant outcomes;2. investigate potential heterogeneity across different patient groups and different routes for providing nutrition. SEARCH METHODS We searched the Cochrane Anaesthesia Review Group (CARG) Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 5); MEDLINE (1950 to May 2013); EMBASE (1980 to May 2013) and Web of Science (1945 to May 2013). SELECTION CRITERIA We included controlled clinical trials with random or quasi-random allocation that examined glutamine supplementation versus no supplementation or placebo in adults with a critical illness or undergoing elective major surgery. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two authors independently extracted the relevant information from each included study using a standardized data extraction form. For infectious complications and mortality and morbidity outcomes we used risk ratio (RR) as the summary measure with the 95% confidence interval (CI). We calculated, where appropriate, the number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH). We presented continuous data as the difference between means (MD) with the 95% CI. MAIN RESULTS Our search identified 1999 titles, of which 53 trials (57 articles) fulfilled our inclusion criteria. The 53 included studies enrolled a total of 4671 participants with critical illness or undergoing elective major surgery. We analysed seven domains of potential risk of bias. In 10 studies the risk of bias was evaluated as low in all of the domains. Thirty-three trials (2303 patients) provided data on nosocomial infectious complications; pooling of these data suggested that glutamine supplementation reduced the infectious complications rate in adults with critical illness or undergoing elective major surgery (RR 0.79, 95% CI 0.71 to 0.87, P ＜ 0.00001, I² = 8%, moderate quality evidence). Thirty-six studies reported short-term (hospital or less than one month) mortality. The combined rate of mortality from these studies was not statistically different between the groups receiving glutamine supplement and those receiving no supplement (RR 0.89, 95% CI 0.78 to 1.02, P = 0.10, I² = 22%, low quality evidence). Eleven studies reported long-term (more than six months) mortality; meta-analysis of these studies (2277 participants) yielded a RR of 1.00 (95% CI 0.89 to 1.12, P = 0.94, I² = 30%, moderate quality evidence). Subgroup analysis of infectious complications and mortality outcomes did not find any statistically significant differences between the predefined groups. Hospital length of stay was reported in 36 studies. We found that the length of hospital stay was shorter in the intervention group than in the control group (MD -3.46 days, 95% CI -4.61 to -2.32, P < 0.0001, I² = 63%, low quality evidence). Slightly prolonged intensive care unit (ICU) stay was found in the glutamine supplemented group from 22 studies (2285 participants) (MD 0.18 days, 95% CI 0.07 to 0.29, P = 0.002, I² = 11%, moderate quality evidence). Days on mechanical ventilation (14 studies, 1297 participants) was found to be slightly shorter in the intervention group than in the control group (MD - 0.69 days, 95% CI -1.37 to -0.02, P = 0.04, I² = 18%, moderate quality evidence). There was no clear evidence of a difference between the groups for side effects and quality of life, however results were imprecise for serious adverse events and few studies reported on quality of life. Sensitivity analysis including only low risk of bias studies found that glutamine supplementation had beneficial effects in reducing the length of hospital stay (MD -2.9 days, 95% CI -5.3 to -0.5, P = 0.02, I² = 58%, eight studies) while there was no statistically significant difference between the groups for all of the other outcomes. AUTHORS' CONCLUSIONS This review found moderate evidence that glutamine supplementation reduced the infection rate and days on mechanical ventilation, and low quality evidence that glutamine supplementation reduced length of hospital stay in critically ill or surgical patients. It seems to have little or no effect on the risk of mortality and length of ICU stay, however. The effects on the risk of serious side effects were imprecise. The strength of evidence in this review was impaired by a high risk of overall bias, suspected publication bias, and moderate to substantial heterogeneity within the included studies.
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Affiliation(s)
- Kun‐Ming Tao
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Xiao‐Qian Li
- Changhai Hospital, Second Military Medical UniversityDepartment of Traditional Chinese MedicineRoom 2201, School of TCM, No.800 Xiangyin RoadShanghaiShanghaiChina200433
| | - Li‐Qun Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Wei‐Feng Yu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Zhi‐Jie Lu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Yu‐Ming Sun
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Fei‐Xiang Wu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
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Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, Carli F, Demartines N, Griffin SM, Lassen K, Fearon KCF, Ljungqvist O, Lobo DN, Revhaug A. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 2014; 101:1209-29. [PMID: 25047143 DOI: 10.1002/bjs.9582] [Citation(s) in RCA: 479] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/20/2014] [Accepted: 05/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.
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Affiliation(s)
- K Mortensen
- Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | | | | | | | | | | | | | | | | | - K C F Fearon
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, UK
| | - O Ljungqvist
- Department of Surgery, Örebro University Hospital, Örebro and Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - A Revhaug
- Department of Gastrointestinal and Hepatopancreaticobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
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Chambrier C. Nutrition en postopératoire. Quand indiquer la pharmaco-nutrition en postopératoire ? NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lefrant JY, Hurel D, Cano N, Ichai C, Preiser JC, Tamion F. Nutrition artificielle en réanimation. NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lefrant JY, Hurel D, Cano NJ, Ichai C, Preiser JC, Tamion F. [Guidelines for nutrition support in critically ill patient]. ACTA ACUST UNITED AC 2014; 33:202-18. [PMID: 24565944 DOI: 10.1016/j.annfar.2014.01.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J-Y Lefrant
- Services des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hurel
- Service de réanimation médico-chirurgicale, centre hospitalier François-Quesnay, 2, boulevard Sully, 78201 Mantes-la-Jolie cedex, France
| | - N J Cano
- Service de nutrition, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand cedex, France; Unité de nutrition humaine, Clermont université, université d'Auvergne, BP 10448, 63000 Clermont-Ferrand, France; Inra, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - C Ichai
- Service de réanimation médico-chirurgicale, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06006 Nice cedex 1, France
| | - J-C Preiser
- Service des soins intensifs, hôpital universitaire Erasme, 808, route de Lennik, 1070 Bruxelles, Belgique
| | - F Tamion
- Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76081 Rouen cedex, France
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Uranjek J, Vovk I, Kompan L. Effect of the route of glutamine supplementation (enteral versus parenteral) on intestinal permeability on surgical intensive care unit patients: A pilot study. SURGICAL PRACTICE 2013. [DOI: 10.1111/1744-1633.12028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jasna Uranjek
- Department for Anaesthesiology and Intensive Care Medicine; General Hospital Slovenj Gradec; Slovenj Gradec; Slovenia
| | - Irena Vovk
- National Institute of Chemistry; Ljubljana; Slovenia
| | - Lidija Kompan
- Department for Nutritional Support; Institute of Oncology; Ljubljana; Slovenia
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Rolle des Gastrointestinaltrakts im Rahmen kardiochirurgischer Eingriffe. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Pharmaco-nutrients have beneficial effects on protective and immunological mechanisms in patients undergoing surgery, which are important for recovery after injury and in combating infectious agents. The aim of this review article was to outline the potential of the administration of nutritional substrates to surgical patients and the underlying mechanisms that make them particularly important in peri-operative care. Surgery causes a stress response, which has catabolic effects on the body's substrate stores. The amino acid glutamine is a stimulating agent for immune cells. It activates protective mechanisms through its role as a precursor for antioxidants and it improves the barrier function of the gut. Arginine also enhances the function of the immune system, since it is the substrate for T-lymphocytes. Furthermore, n-3 PUFA stabilise surgery-induced hyper-inflammation. Taurine is another substrate that may counteract the negative effects of surgical injury on acid–base balance and osmotic balance. These pharmaco-nutrients rapidly become deficient under the influence of surgical stress. Supplementation of these nutrients in surgical patients may restore their protective and immune-enhancing actions and improve clinical outcome. Moreover, pre-operative fasting is still common practice in the Western world, although fasting has a negative effect on the patient's condition and the recovery after surgery. This may be counteracted by a simple intervention such as administering a carbohydrate-rich supplement just before surgery. In conclusion, there are various nutritional substrates that may be of great value in improving the condition of the surgical patient, which may be beneficial for post-operative recovery.
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Zhong X, Liang CP, Gong S. Intravenous glutamine for severe acute pancreatitis: A meta-analysis. World J Crit Care Med 2013; 2:4-8. [PMID: 24701410 PMCID: PMC3953862 DOI: 10.5492/wjccm.v2.i1.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/29/2013] [Accepted: 03/27/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of intravenous glutamine on the patients with severe acute pancreatitis (SAP).
METHODS: The Cochrane Library, PubMed, EMBASE, and EBM review databases were searched up to June 2012. Randomized controlled trials (RCTs) that compared non-glutamine nutrition with intravenous glutamine supplemented nutrition in patients with SAP were included. A method recommended by the Cochrane Collaboration was used to perform a meta-analysis of those RCTs.
RESULTS: Four RCTs involving a total of 190 participants were included. Analysis of these RCTs revealed the presence of statistical homogeneity among them. Results showed that glutamine dipeptide has a positive effect in reducing the mortality rate (OR = 0.26, 95%CI: 0.09-0.73, P = 0.01), length of hospital stay (weighted mean difference = -4.85, 95%CI: 6.67--3.03, P < 0.001), and the rate of complications (OR = 0.41, 95%CI: 0.22-0.78, P = 0.006). No serious adverse effects were found.
CONCLUSION: Current best evidence demonstrates that glutamine is effective for SAP. Further high quality trials are required and parameters of nutritional condition and hospital cost should be considered in future RCTs with sufficient size and rigorous design.
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Weimann A. [Immunonutrition in intensive care medicine]. Med Klin Intensivmed Notfmed 2013; 108:85-94; quiz 95. [PMID: 23354409 DOI: 10.1007/s00063-012-0211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
Abstract
The review presents the concept of immunonutrition in enteral and parenteral nutrition of the critically ill. The present indications for supplementing immune enhancing and anti-inflammatory substances are summarized and discussed in accordance with the recent literature and guidelines.
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Affiliation(s)
- A Weimann
- Klinik für Allgemein- und Visceralchirurgie, Klinikum St. Georg Leipzig, Delitzscher Strasse 141, Leipzig, Germany.
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Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:817-30. [DOI: 10.1016/j.clnu.2012.08.011] [Citation(s) in RCA: 357] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/19/2012] [Indexed: 02/06/2023]
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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 2012. [PMID: 23196117 DOI: 10.1016/j.clnu.2012.11.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Glutamine supplementation has been associated with reduced mortality, infections and hospital length of stay in critically ill patients and patients undergoing major surgery. We carried out a meta-analysis to examine randomized clinical trial (RCT)-based evidence of these effects. METHODS Based on a systematic database search, RCTs published since 1990 were included if they evaluated the effect of parenteral glutamine supplementation against a background of parenteral nutrition. Enteral (tube) feeding in a proportion of patients was allowable. Information on RCT methodology, quality and outcomes was extracted. Random effects meta-analysis followed the DerSimonian-Laird approach. RESULTS Forty RCTs were eligible for meta-analysis. Parenteral glutamine supplementation was associated with a non-significant 11% reduction in short-term mortality (RR = 0.89; 95% CI, 0.77-1.04). Infections were significantly reduced (RR = 0.83; 95% CI, 0.72-0.95) and length of stay was 2.35 days shorter (95% CI, -3.68 to -1.02) in the glutamine arms. Meta-analysis results were strongly influenced by one recent trial. An element of publication bias could not be excluded. CONCLUSION Parenteral glutamine supplementation in severely ill patients may reduce infections, length of stay and mortality, but substantial uncertainty remains. Unlike previous meta-analyses, we could not demonstrate a significant reduction in mortality.
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Affiliation(s)
- Lea Bollhalder
- Institute of Social and Preventive Medicine, Medical Economics Unit, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland.
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Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2012; 37:240-58. [DOI: 10.1007/s00268-012-1771-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Stachowicz-Stencel T, Synakiewicz A. Glutamine as a supplemental treatment in pediatric and adult oncology patients. Expert Opin Investig Drugs 2012; 21:1861-71. [DOI: 10.1517/13543784.2012.717929] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Awad S, Lobo DN. Metabolic conditioning to attenuate the adverse effects of perioperative fasting and improve patient outcomes. Curr Opin Clin Nutr Metab Care 2012; 15:194-200. [PMID: 22157348 DOI: 10.1097/mco.0b013e32834f0078] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To review recent articles, published between October 2009 and September 2011, that examined the adverse metabolic consequences of perioperative fasting and interventions that may be utilized to minimize these effects. RECENT FINDINGS Fasting induces metabolic stress and insulin resistance consequent upon effects on cellular mitochondria, gene and protein expression. Development of perioperative insulin resistance leads to increased postoperative morbidity and mortality. Preoperative carbohydrate loading attenuates insulin resistance via effects on cellular gene and protein expression, but its effects on clinical outcomes remain unclear. Perioperative arginine-supplemented diets were shown to be associated with significant reductions in infectious complications and length of hospital stay in patients undergoing elective surgery. Perioperative metabolic conditioning using glutamine and L-carnitine may be used to modulate insulin sensitivity but further studies need to determine whether these interventions result in clinical benefit. Finally, energy and protein provision to critically ill patients remains inadequate and is hampered by a number of factors including reliance on inaccurate means of estimating energy expenditure and enteral feed tolerance, conflicting data on the effects of energy deficit on clinical outcomes, and poor methodological quality of studies of perioperative nutritional interventions. SUMMARY Numerous perioperative interventions are available, which if utilized should help attenuate the adverse effects of perioperative fasting and lead to improved patient outcomes.
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Affiliation(s)
- Sherif Awad
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK.
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Ueno PM, Oriá RB, Maier EA, Guedes M, de Azevedo OG, Wu D, Willson T, Hogan SP, Lima AAM, Guerrant RL, Polk DB, Denson LA, Moore SR. Alanyl-glutamine promotes intestinal epithelial cell homeostasis in vitro and in a murine model of weanling undernutrition. Am J Physiol Gastrointest Liver Physiol 2011; 301:G612-22. [PMID: 21799183 PMCID: PMC3191556 DOI: 10.1152/ajpgi.00531.2010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alanyl-glutamine (Ala-Gln) has recently been shown to enhance catch-up growth and gut integrity in undernourished children from Northeast Brazil. We hypothesized that the intestinal epithelial effects of Ala-Gln in malnourished weanling mice and mouse small intestinal epithelial (MSIE) cells would include modulation of barrier function, proliferation, and apoptosis. Dams of 10-day-old suckling C57BL/6 pups were randomized to a standard diet or an isocaloric Northeast Brazil "regional basic diet," moderately deficient in protein, fat, and minerals. Upon weaning to their dam's diet on day of life 21, pups were randomized to Ala-Gln solution or water. At 6 wk of age, mice were killed, and jejunal tissue was collected for morphology, immunohistochemistry, and Ussing chamber analysis of transmucosal resistance and permeability. Proliferation of MSIE cells in the presence or absence of Ala-Gln was measured by MTS and bromodeoxyuridine assays. MSIE apoptosis was assessed by annexin and 7-amino-actinomycin D staining. Pups of regional basic diet-fed dams exhibited failure to thrive. Jejunal specimens from undernourished weanlings showed decreased villous height and crypt depth, decreased transmucosal resistance, increased permeability to FITC-dextran, increased claudin-3 expression, and decreased epithelial proliferation and increased epithelial apoptosis (as measured by bromodeoxyuridine and cleaved caspase-3 staining, respectively). Undernourished weanlings supplemented with Ala-Gln showed improvements in weight velocity, villous height, crypt depth, transmucosal resistance, and epithelial proliferation/apoptosis compared with unsupplemented controls. Similarly, Ala-Gln increased proliferation and reduced apoptosis in MSIE cells. In summary, Ala-Gln promotes intestinal epithelial homeostasis in a mouse model of malnutrition-associated enteropathy, mimicking key features of the human disease.
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Affiliation(s)
- Priscilla M. Ueno
- 1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | | | - Elizabeth A. Maier
- 1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Marjorie Guedes
- 3Institute of Biomedicine, Federal University of Ceará, Ceará, Brazil;
| | | | - David Wu
- 4Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Tara Willson
- 1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Simon P. Hogan
- 4Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Aldo A. M. Lima
- 3Institute of Biomedicine, Federal University of Ceará, Ceará, Brazil;
| | - Richard L. Guerrant
- 5Center for Global Health, University of Virginia, Charlottesville, Virginia; and
| | - D. Brent Polk
- 6Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Lee A. Denson
- 1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Sean R. Moore
- 1Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
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Abstract
PURPOSE OF REVIEW This article reviews the recent research on perioperative nutrition in digestive tract surgery in the light of modern perioperative care principles, that is, enhanced recovery after surgery (ERAS). Four major directions of research emerge: detecting malnutrition, perioperative hyperglycemia/insulin resistance, enteral/parenteral nutrition and immunonutrition. RECENT FINDINGS For preoperative nutritional screening/assessment, current data cannot single out superiority for SGA questionnaire, nutritional risk score, Reilly's nutritional risk score or nutritional risk index in the ability to predict nutrition-related complications. The use of ERAS elements to reduce surgical stress and preclude postoperative insulin resistance has recently been clearly linked to reductions in adverse outcomes. There are specific situations in which enteral nutrition is contraindicated and criterias for preoperative and postoperative parenteral nutrition in undernourished patients are defined in guidelines recently available. Several controlled randomized studies and systematic reviews indicate that immune nutrition formulas reduce both morbidity and length of stay after major abdominal surgery. SUMMARY To reduce surgical stress, insulin resistance, unnecessary protein losses and postoperative complications, the use of an ERAS protocol is important. Current data shows that the use of perioperative immunonutrition diets for major abdominal surgery is beneficial. Further research on nutritional assessment tools to predict who is at risk for postoperative complications is needed.
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Sacks GS. Effect of glutamine-supplemented parenteral nutrition on mortality in critically ill patients. Nutr Clin Pract 2011; 26:44-7. [PMID: 21266696 DOI: 10.1177/0884533610392923] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Glutamine is recognized as a critical amino acid involved in immunity, intestinal health, and nitrogen transport between organs. Prior to the pivotal study by Griffiths and colleagues in 1997, no clinical trials had demonstrated a positive effect from glutamine supplementation on improving long-term survival in critically ill intensive care unit patients receiving parenteral nutrition. Subsequent investigations have confirmed these findings, but further data are needed to determine the optimal dose and timing of glutamine as well as the form of glutamine (ie, free vs dipeptide) that produces the most significant improvement in outcome parameters.
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Vanek VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M. A.S.P.E.N. Position Paper. Nutr Clin Pract 2011; 26:479-94. [DOI: 10.1177/0884533611410975] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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