Immunonutrition In ICU: Does It Improve Patient ... - RM Solutions

Immunonutrition in ICU:
Does it improve patient outcomes
Arwa Ruwaid Al Akkad, M.Sc
Head, Dietary Therapy Department
King Fahad Specialist Hospital-Dammam

Immunity in ICU pt’s
The widespread recognition that critical
illness is characterized as a state of
immunosuppression and inflammation
has lead to the development of nutritional
support products or interventions designed
to enhance the host immune response
and/or suppress inflammation.
Curr Opin Gastroenterol 2008;24,215-222.

Immunity in ICU pt’s
Proceedings of the Nutrition Society 2001; 60, 389-397

Immunonutrition
Modulation of the activities of the immune
system by nutrients or specific food items
fed in amounts above these normally
encountered in the diet.
Nutr Rev 2003;61(6Pt.1),214–8.

Immunonutrients
• Arginine
• Glutamine
• Nucleotides (RNA)
• ω -3 Fatty Acids (EPA/DHA)
• Branched Chain Amino Acids (BCAA)

Immunonutrients
Proceedings of the Nutrition Society 2001; 60, 389.397

Route of Administration
PO vs
EN vs
PN

Immunonutrients
Immune-Enhancing
Diets (IED’s)
Immuno-Modulating
Diets (IMD’s)
Improved
Clinical
Outcomes

IED’s/IMD’s Outcomes
• Meta-analysis of clinical trials have shown
improvement such as reduced risk of
infection, fewer days on a ventilator, and
reduced length of intensive care unit and
hospital stay.
Proc Nutr Soc 2000;59(4):553–63.

IED’s/IMD’s Outcomes
Pak J Physiol 2010;6(1),50-3

IED’s/IMD’s Outcomes
• Does IED’s /IMD’s improve outcomes in
critically ill patients
• Difficult question to answer!!

Deutschman C.S. & Neligan P.J,Evidence Based Practice of Critical Care
2010.
Meta-analysis
In analyzing clinical trials, we should pay
attention to four key areas:
(1)Type of immunonutrition.
(2)Timing of initiation of feeds.
(3)Dose of formula and if patients reached
their goals in terms of kilocalories and
protein.
(4)Patient population studied.

Enteral formulas
• Impact
• Immune-Aid
• Oxepa
• Perative
• Stressen
• Crucial
• Combination of of one or more
immunonutrients added to standard
enteral formula.

Enteral formulas
Intensive Care Med 2008;34,1980–1990

Timing
Early EN
Improved Outcome

Population in ICU
Surgery
Sepsis
ARDS
Trauma
Burn

IED’s & Trauma
Deutschman C.S. & Neligan P.J,Evidence Based Practice of Critical Care 2010.

IED’s & Surgery
Deutschman C.S. & Neligan P.J,Evidence Based Practice of Critical Care
2010.

IED’s & Surgery

IED’s & Surgery

IED’s & Burns
• Only few studies.
• Burn ICU patients supplemented with
Glutamine improved wound healing,
reduced LOS. severely burned patients.
Burns 2005;31,342-346.
• Decreased infection rate.
Crit Care Med 2003;31,2444-2449.

IED’s & other ICU pt’s

Meta-analysis

IMD’s & Mortality
• All meta-analysis concluded that IMD’s
generate no overall effect on mortality in
ICU patients.
Crit Care Med 1999;27,2799-2805.
JAMA. 2001;286:944-953.
Ann Surg. 1999;229:467-477.
Clin Nutr. 2003;22:221-233.

IMD’s & Mortality
Intensive Care Med 2008; 34,1980–1990

Arginine & Sepsis
Arginine supplementation, however, has
been linked to a potentially increased
mortality rate in hemodynamically unstable
septic patients, as compared with standard
enteral formula.
Crit Care Med 1995;23,436–49.
Intensive Care Med 2003;29:834–40.

Arginine & Sepsis
High
Arginine
High
NO
↑ vasodilation
HD instability
JAMA 2001;286,944–53.
J Nutr 2007;137(6 Suppl 2),1687S–92S

Arginine & Sepsis
• Other studies have disputed those findings
and, instead, showed a reduced mortality
rate in moderately septic patients.
Crit Care Med 2000;28,643–8.
• The current recommendations are that
IMD’s containing arginine are safe to use in
patients with mild to moderate sepsis, but
that caution should be employed in patients
with more severe sepsis.
JPEN 2009;33,277–316.

Recommendations
JPEN J 2001, 25:S1–S63.

Conclusion
• Move towards complex formula that help in
regulating the immune system in ICU pt’s.
• Consider the use of the appropriate IED’s/IMD’s
for each population of ICU patient.
• IED’s/IMD’s are effective in surgical patients preand
post operatively, leading in lowering infection
rate & LOS and promote wound healing.
• IED’s/IMD’s provide benefit effect in decreasing
infectious and LOS, especially in trauma pt’s,

Conclusion
• Arginine still it remains unclear whether it is
harmful in septic pt’s.
• Arginine appear to have a limited role in trauma
patients.
• Fish oil (ω-3 fatty acid) without added arginine
reduces mortality, infections and LOS in patients
with sepsis, SIRS and ARDS.
• The role of a high ω-3 fatty acid in trauma patients
has yet to be determined.
• Glutamine supplementation may be beneficial in
burn patients.

Conclusion
• Additional RCTs are required to support and
extend these findings.

Thank You