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Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
Cerrahi
Travma
Şok
Omega-3 yağ
asitleri
Arjinin
Glutamin
Dolaşım yetmezliği
Doku hipoksisi
İnflamatuarcevap
IL-6, TNF-α
Hücresel immüniteninciddi baskılanması
Makrofaj
Enfeksiyon
Sepsis MODS
Ölüm
Lenfosit
Antiinflamatuarcevap
IL-10, TGF-β,
Angele MK, 2005
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
Elderly/diabetics/ obese
Immunosupression in patients who die of sepsis
Cytokins
Inhibitory mediators
Suppressor cells
BW, BMI
Albumin, transthyretin, white blood cells counts, C-reactive protein Nutritional Risk Index (NRI)
Prognostic Inflammatory and Nutritional Index (PINI)
Modified Glasgow Prognostic Score (mGPS)
Neutrophil-to-lymphocyte ratio (NLR)
CD4 & CD8 lymphocytes counts
platelet-to-lymphocyte ratio (PLR)
Prognostic Index(PI)
Prognostic Nutritional Index (PNI) are prognostic factors of outcome, but are not always correlated to immunonutrition effect.
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
1223 patients 40 ICUs
MOF, MV
Glutamine + antioxidants
Glutamine 0.35 g /kg/İBW/d iv (0.50 g/kg/day dipeptid
alanyl-glutamine [Dipeptiven, Fresenius Kabi]
42.5 g alanyl-glutamin + glycine-glutamin dipeptid (30
g/gün glutamin, enteral
500 μg of selenium iv (Selenase, Biosyn)
Enteral: 300 μg selenium, 20 mg Zinc, 10 mg beta
carotene, 500 mg vitamin E, 1500 mg vitamin C.
iv+ enteral within 24 hours
28 day mortality
32.4% / 27.2%; adjusted odds ratio, 1.28, 95% CI
1.00-1.64)
Hospital mortality
37.2% / 31%; P=0.02
6 month mortality
43.7% / 37.2%; P=0.02
65 gr glutamine %60 (910 kcal 45gr protein)
Eaa /arg deficiencyhyperamonemia
Low pro Low S homosistine
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
Citrulline substition
Better gastrointestinal tolerance
Better absorption
No hepatic elimination, does not
increase urea
NO does not increase
Cellular transport is not inhibited
5 g/kg mortality in rats
0.09-0.2 g/kg/d (PE-EN)
ICU >12 g/L arg (>%4 REE)
(Bistrian 2006)
>3 days, optimum 3-10 gün
(Bistrian 2006)
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma
Future
No differene with
PE Glutamine
Selenium 500/d
≥ 5 d PE decrease
infection without
a change in
mortality
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids Burns
Trauma
Future
N3 suplement increases 60
day mortality
(%26.6 X %16.3)
Study is unique due to
Infüsion X bolus
High n6Xn9 X carbohydrates
Lung protectice strategy
Fluid restriction
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns Trauma
Future
Why pharmaconutrition/ immunonutrition
New mechanisms
Interrelation of nutrients
Immunometer
Update for critically ill patients
Glutamine
Arginine
Antioxidants
Omega-3 fatty acids
Burns
Trauma Future
0.5g/kg/BW/d dipeptid form iv
5 day inefficient
6. day GLN still low
Worse prognosis if GLN 6. day levels are low