İmmun nutri̇syonda son duru mkısaing

1. Seda Banu Akıncı
Hacettepe University Hospital
Department of Anesthesiology
Critical Care Medicine

2.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

6.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

9. Cerrahi
Travma
Şok
Omega-3 yağ
asitleri
Arjinin
Glutamin
Dolaşım
yetmezliği
Doku
hipoksisi
İnflamatuar
cevap
IL-6, TNF-α
Hücresel
immünitenin
ciddi
baskılanması
Makrofaj
Enfeksiyon
Sepsis MODS
Ölüm
Lenfosit
Antiinflamatuar
cevap
IL-10, TGF-β,
Angele MK, 2005

11.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

12. Elderly/diabetics/ obese
Immunosupression in patients who die of sepsis
Cytokins 
 Inhibitory mediators
 Suppressor cells

13. Sepsis
MODS
Wischmeyer, 2010

14.  BW, BMI
 Albumin, transthyretin, white blood cells counts, C-
reactive protein
 Nutritional Risk Index (NRI)
 Prognostic Inflammatory and Nutritional Index (PINI)
 Modified Glasgow Prognostic Score (mGPS)
 Neutrophil-to-lymphocyte ratio (NLR)
 CD4 & CD8 lymphocytes counts
 platelet-to-lymphocyte ratio (PLR)
 Prognostic Index(PI)
 Prognostic Nutritional Index (PNI) are prognostic factors
of outcome, but are not always correlated to

15.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

16.  1223 patients 40 ICUs
 MOF, MV
 Glutamine + antioxidants
 Glutamine 0.35 g /kg/İBW/d iv (0.50 g/kg/day dipeptid
alanyl-glutamine [Dipeptiven, Fresenius Kabi]
 42.5 g alanyl-glutamin + glycine-glutamin dipeptid (30
g/gün glutamin, enteral
 500 μg of selenium iv (Selenase, Biosyn)
 Enteral: 300 μg selenium, 20 mg Zinc, 10 mg beta
carotene, 500 mg vitamin E, 1500 mg vitamin C.
 iv+ enteral within 24 hours

18.  28 day mortality
 32.4% / 27.2%; adjusted odds ratio, 1.28, 95% CI
1.00-1.64)
 Hospital mortality
 37.2% / 31%; P=0.02
 6 month mortality
 43.7% / 37.2%; P=0.02

20.  301 patients 14 ICUs
 Within 48 hrs- 28 days (GLN+3+antioxidants)

22.  65 gr glutamine %60 (910 kcal 45gr protein)
 Eaa /arg deficiencyhyperamonemia
 Low pro Low S homosistine

27.  Is it adaptive?
 Too early?
 Harmfull when excessive?

28.  Caution in renal
insufficiency

30.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

31.  Citrulline substition
Better gastrointestinal tolerance
Better absorption
No hepatic elimination, does not
increase urea
NO does not increase
Cellular transport is not inhibited

32.  5 g/kg mortality in rats
 0.09-0.2 g/kg/d (PE-EN)
 ICU >12 g/L arg (>%4 REE)
(Bistrian 2006)
 >3 days, optimum 3-10 gün
(Bistrian 2006)

34.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

35. Dose?

36.  No differene with
PE Glutamine
 Selenium 500/d
≥ 5 d PE decrease
infection without
a change in
mortality

42.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

45.  No difference in mortality

46.  OMEGA study

47.  Study was terminated early

48.  N3 suplement increases 60
day mortality
(%26.6 X %16.3)
 Study is unique due to
 Infüsion X bolus
 High n6Xn9 X carbohydrates
 Lung protectice strategy
 Fluid restriction

49.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
 Trauma
 Future

50.  4 RKÇ, 155 hasta

52.  Glutamine decreases LOS in burns

58.  Why pharmaconutrition/ immunonutrition
 New mechanisms
 Interrelation of nutrients
 Immunometer
 Update for critically ill patients
 Glutamine
 Arginine
 Antioxidants
 Omega-3 fatty acids
 Burns
Trauma
 Future

59.  0.5g/kg/BW/d dipeptid form iv
 5 day inefficient
 6. day GLN still low
 Worse prognosis if GLN 6. day levels are low

63. No neurologic deterioration

66.  Pharmaconutrition (drug, dose, route, duration)
 According to serum levels
 Adjustment for organ insufficiency
 Other aa, calori, protein ratios
 Management(calori, nitrogen, other parameters)
 Immunometer