Nutrition Support Traineeship
This is my first attempt at an e-journal club. My goal will be to keep it short and sweet, provide you with some interesting new citations, some of the key things we discussed, and encouragement to critically evaluate the articles for yourself.
This month we reviewed two recently published articles that investigated the use of enteral glutamine in critically ill patients. These articles are interesting because they were both double-blind, randomized controlled trials, and gave glutamine in adequate dose (> 0.2gm/Kg), and yet provided “opposite” conclusions. See the abstracts below. Oh yea, Carol has maintained a record of what articles we have reviewed in the past, so I will include that list at the bottom. Sorry, there is just not enough coffee to get me to go back and do a review of all those, but I will try to do so for our future articles.
Garrel, Dominique; Patenaude, Julie; Nedelec, Bernadette; Samson, Louise; Dorais, Judy; Champoux, Julie; D'Elia, Michele; Bernier, Jacques Critical Care Medicine. 31(10):2444-2449, October 2000 Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: A prospective, controlled, randomized clinical trial.
The Critical Care Medicine study was small, with only 22 control and 19 glutamine subjects- too much room for random bias to creep in. The glutamine group had less inhalation injury (36%) than the controls (46%)- this was not significantly different, but since inhalation injury is a strong predictor of outcome in burns, and the “N” was so small, it is possible for it to affect the mortality data. Most of the patients received TPN in addition to the tube feeds (19 control and 18 glutamine)- the authors do not provide any information on the amount of calories that came from tube feeds Vs TPN so you don’t know if there was a difference that favored more infections in one group ! They gave 26 gms of glutamine/day.
We agreed with their final conclusion- more research is needed.
John C. Hall , Geoffrey Dobb, Jane Hall, Ruth de Sousa, Lisa Brennan and Rosalie McCauley A prospective randomized trial of enteral glutamine in critical illness Intensive Care Medicine ; Issue: Volume 29, Number 10 Pages: 1710 – 1716
The Intensive Care Med study was much larger (179 glutamine, 184 control). Most of the patients were trauma (42%) neuro (22%) with most of the rest medicine ICU types- only 2% had burns. Patients received a little less glutamine (19gm/day), and perhaps importantly for less time than in the study above- 10 days (range 6-17 days). (In the Crit Care Med study they received glutamine for nearly 30 days.)
We saw no fatal flaws in this study, and there were no improvements in the glutamine group. This is a much larger study than previous studies. Houdijk (Lancet. 1998 Sep 5;352(9130):772-6.) who reported positive glutamine effects had only 30 patients in each group.
Some (very thin and unlikely) reasons why glutamine did not “work”. One question raised by the authors was that the control groups received glycine- they could not rule out some kind of positive effect of glycine that masked the effect of glutamine. The patients in this study only received an avg. of 1400 calories per day- perhaps you need to receive full calories and protein to see an effect. Perhaps you need to receive glutamine for 30 days for it to “work”. Perhaps the dose was too small. Perhaps glutamine functions backwards in the Southern Hemisphere-just like water swirls down the drain in the opposite direction in Australia .
The only one with much credibility is the dose question. This is one of the better done glutamine studies, and they gave it much as you would do in a real world ICU setting.
Our take home message – the best data cast doubt on the usefulness of glutamine in the normal ICU setting – we won’t be charging anyone for glutamine or glutamine-rich formulas until there is better data that it is useful. JK
PREVIOUS ARTICLES USED FOR TRAINEESHIP JOURNAL CRITIQUES
Ibrahim EH, et al. Early vs late enteral feeding of mechanically ventilated pts: results of a clinical feeding trial. JPEN 2002;26:174-181.
Davies AR , et al. Randomized comparison of nasojejunal and nasogastric feeding in critically patients. Crit Care Med 2002;30:586-590.
Montejo JC, Grau T, Acosta J, et al. Multicenter, prospective, randomized, single blinded study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Crit Care Med 2002;30(4):796-800.
Abou-Assi S, et al. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002;97:2255-2262.
No journal club
Neumann DA, DeLegge MH. Gastric versus small bowel feeding in the intensive care unit: a comparison of efficacy. Crit Care Med 2002;30(7):1436-1438.
Bozzetti F, et al. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 2001;358(3):1487-1492.
Nathens , AB , et al. Randomized, Prospective Trial of Antioxidant Supplementation in Critically Ill Surgical Patients. Ann Surg 2002;236(6):814-822.
Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Bozzetti F, et al. Lancet, 2001;358(3):1487-1492. (poor attendance in March, therefore redone)
Effect of neuromuscular blockade on energy expenditure in patients with severe head injury. McCall, et al. JPEN (Jan-Feb) 2003; 27:27-35.
G Marchesini, G, et al. Nutritional Supplementation With Branched-Chain Amino Acids in Advanced Cirrhosis. A Double -Blind, Randomized Trial. Gastroenterology 2003;124(6):1792-1801.
Bertolini G. Et al. Early enteral Immunonutrition in patients with severe sepsis. Intensive Care Med 2003;29:834-840.
Mentec, Herve MD, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: Frequency, risk factors, and complications. Critical Care Medicine. 29(10):1955-1961, October 2001.
Scheinkestel CD, et al. Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal therapy replacement therapy. Nutrition 2003;19:733-740.
Hall J.C., et al. A prospective randomized trial of enteral glutamine in critical illness. Intensive Care Med 2003;29:1710-1716.
Garrel D., et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: A prospective, controlled, randomized clinical trial. Crit Care Med 2003;31:2444-2449.
Austrums et al. Postoperative enteral stimulation by gut feeding improves outcomes in severe acute pancreatitis. Nutrition 2003;19:487-491.
Finney S, et al. Glucose control and mortality in critically ill patients. JAMA 2003; 290:2041-2047.