Does immunonutrition in patients with sepsis do more harm than good?

Heyland, Daren K.; Samis, Andrew J. W.

doi:10.1007/s00134-003-1710-6

Cited by 102 publications

(61 citation statements)

References 9 publications

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“…However, arginine is a precursor for nitric oxide, a potent vasodilator, and arginine supplementation in animal models has shown increased nitric oxide production with subsequent loss of vascular tone and hypotension [54,55]. This finding has also been found in human clinical trials [56][57][58]. These detrimental effects were not seen in stable populations.…”

Section: Argininesupporting

confidence: 54%

“…The same intervention may be beneficial in one patient and harmful in another. We must guard against inappropriate extrapolations, lest we throw the baby out with the bath water [58,94]. At present, the existing evidence does not support the routine supplementation of arginine or fish oils in severely injured, critically ill patients [35••].…”

Section: Discussionmentioning

confidence: 99%

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Immune-Enhancing Diets: What is the Final Answer?

Yeh

Heyland

2016

Curr Trauma Rep

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Supplementation of certain micronutrients to standard nutrition therapy in pharmacological doses can modulate the host immunologic response. The three most extensively studied: arginine, glutamine, and omega-3 fatty acids (Bfish oils^). While animal studies are encouraging, human clinical trials arrive at conflicting conclusions for multiple reasons, mainly related to heterogeneity in patient selection, concentration and combination of agents, dose, route, and timing and administration. Glutamine should not be given to patients with multi-organ (especially renal) failure and arginine should be avoided in septic shock. Enteral glutamine may be beneficial in burn and trauma patients. Larger, higher-quality studies are required before strong recommendations can be made.

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Section: Argininesupporting

confidence: 54%

Section: Discussionmentioning

confidence: 99%

Immune-Enhancing Diets: What is the Final Answer?

Yeh

Heyland

2016

Curr Trauma Rep

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“…Metaanalyses of controlled, randomised clinical studies using IMPACT or similar formulas have identified significant reductions in infections and length of hospital stay but these effects are more evident in surgical rather than critically ill patients (79)(80)(81)(82)(83) , and none of the meta-analyses shows a significant effect on mortality. Despite some clear statements to the contrary in the earlier meta-analyses (79)(80)(81) , concern has been raised that these formulas may actually be detrimental in the seriously ill (84)(85)(86) . This is because some studies of these formulas in critically ill patients reported increased mortality (79)(80)(81) .…”

Section: Enteral Formulas Combining Fish Oil and Argininementioning

confidence: 98%

Rationale and use of n-3 fatty acids in artificial nutrition

Calder

2010

Proc. Nutr. Soc.

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Lipids traditionally used in artificial nutrition are based on n-6 fatty acid-rich vegetable oils like soyabean oil. This may not be optimal because it may present an excessive supply of linoleic acid. One alternative to the use of soyabean oil is its partial replacement by fish oil, which contains n-3 fatty acids. These fatty acids influence inflammatory and immune responses and so may be useful in particular situations where those responses are not optimal. Fish oil-containing lipid emulsions have been used in parenteral nutrition in adult patients post-surgery (mainly gastrointestinal). This has been associated with alterations in patterns of inflammatory mediators and in immune function and, in some studies, a reduction in length of intensive care unit (ICU) and hospital stay. Perioperative administration of fish oil may be superior to post-operative. Parenteral fish oil has been used in critically ill adults. Here the influence on inflammatory processes, immune function and clinical endpoints is not clear, since there are too few studies and those that are available report contradictory findings. Fish oil is included in combination with other nutrients in various enteral formulas. In post-surgical patients and in those with mild sepsis or trauma, there is clinical benefit from a formula including fish oil and arginine. A formula including fish oil, borage oil and antioxidants has demonstrated marked benefits on gas exchange, ventilation requirement, new organ failures, ICU stay and mortality in patients with acute respiratory distress syndrome, acute lung injury or severe sepsis.

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“…The ICU mortality proved to be significantly higher in the enteral feeded group (44.4%) than in the parenteral feeded group (14.3%). These results show that additional arginine should not be used in septic patients (Heyland & Samis, 2003), whereas it may be beneficial in other groups of ICU patients.…”

Section: Discussionmentioning

confidence: 82%

High plasma arginine concentrations in critically ill patients suffering from hepatic failure

et al. 2004

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Objective: In physiological conditions, the liver plays an important role in the regulation of plasma arginine concentrations by taking up large amounts of arginine from the hepatic circulation. When hepatic failure is present, arginine metabolism may be disturbed. Therefore, we hypothesized high arginine plasma concentrations in critically ill patients suffering from hepatic failure. Design: We prospectively collected blood samples from a cross-section of intensive care unit patients. Setting: Surgical intensive care unit of a Dutch university medical center. Subjects: A total of 52 critically ill patients with clinical evidence of dysfunction of more than two organs were recruited. Measurements: Plasma arginine concentrations were determined by HPLC. We identified correlations of arginine concentrations with organ failure scores and laboratory variables by univariate and multiple regression analyses. Results: High plasma arginine concentrations were found in critically ill patients developing organ failure. Patients who were in the highest quartile of plasma arginine concentrations had significantly lower fibrinogen concentrations, higher lactic acid concentrations, and longer prothrombin time. Stepwise multiple regression analysis showed that concentrations of arginine were independently associated with the presence of hepatic failure (P ¼ 0.03) and renal failure (P ¼ 0.048). In addition, lactic acid proved to be an independent determinant of plasma arginine concentration (P ¼ 0.014). Conclusions: Critically ill patients who suffer from hepatic failure have elevated plasma arginine concentrations. Additional arginine in the treatment of these patients can be harmful, and therefore should not be used as a standard nutritional regimen until further evaluation.

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Does immunonutrition in patients with sepsis do more harm than good?

Cited by 102 publications

References 9 publications

Immune-Enhancing Diets: What is the Final Answer?

Immune-Enhancing Diets: What is the Final Answer?

Rationale and use of n-3 fatty acids in artificial nutrition

High plasma arginine concentrations in critically ill patients suffering from hepatic failure

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