TOP Nutrition Newsletter

Vol: 8 No: 3 March 2005

Immunonutrition.
PURPOSE OF REVIEW: To outline recent findings on the efficacy of immunonutrients in patients undergoing inflammatory stress due to surgery, infection and cancer. RECENT FINDINGS: Enteral nutrition is more efficacious and poses lower risks than parenteral nutrition. It reduces infection rates and shortens ICU and hospital length of stay of critically ill patients. Beneficial effects of immunonutrition are most apparent in malnourished patients. Perioperative enteral nutrition is more effective than postoperative nutrition. In Crohn disease similar remission rates are achieved with enteral nutrition as with steroids. Glutamine, omega-3 fatty acids and antioxidants exert beneficial influences in diverse patient populations. L-arginine is an important immunonutrient having both beneficial and adverse effects. The former effect occurs in necrotizing enterocolitis; the latter influence is seen in septic patients. The gut plays a major role in whole body amino acid metabolism, particularly arginine homeostasis. Arginase and nitric oxide synthetase compete for arginine within immune cells and play a pivotal role in clinical outcome during infection. In cancer a range of antioxidants are able to ameliorate immunosuppression. Intravenous lipids may be deleterious due to the pro-inflammatory effects of omega6 fatty acids. Omega-3 fatty acids are anti-inflammatory and combined with medium chain triglyceride (MCT) and olive oil may provide a more efficacious form of intravenous lipid. SUMMARY: Immunonutrition is effective in improving outcome in a wide range of patients when applied enterally, particularly in malnourished individuals. Parenteral immunonutrition carries a higher risk but can be efficacious in selected patient groups for whom enteral nutrition is problematic. Curr Opin Gastroenterol. 2005 Mar;21(2):216-22.

Reducing costs and patient morbidity in the enterally fed intensive care unit

patient.
BACKGROUND: Critically ill patients are at high risk for nosocomial infections and resultant organ dysfunction and death. These patients typically have protracted intensive care unit (ICU) courses and consume increasingly limited resources. Enteral nutrition with specific immune-modulating components has been previously shown to improve outcomes in select populations of patients, but results have been mixed in critically ill patients. Impact 1.5 (Novartis Nutrition, Minneapolis, MN) is a commercially available enteral formula containing ingredients known to improve several parameters of immune function. We hypothesized that administration of Impact 1.5 tube feedings would reduce the incidence of nosocomial infection and ICU resources in critically ill patients admitted to the ICU for severe trauma, burns, or sepsis insults. METHODS: The Impact 1.5 group (n = 17) was compared with a historical cohort of ICU patients (n = 21) of similar illness severity that received a standard high-energy enteral formula. The incidence of nosocomial infections and mortality, and the consumption of multiple ICU resources were examined. A cost analysis based on these results was then performed to determine the cost effectiveness of this proprietary immunonutrition enteral formula. RESULTS: A pronounced reduction in nosocomial pneumonia (12% vs 52%, p < .01) was identified, with consequent trends toward a reduction in duration of mechanical ventilation and ICU length of stay. Urinary tract infections that may have less influence on ICU resources were increased in the Impact 1.5 group. No difference in mortality was identified, despite the inclusion of patients with severe sepsis in the study group. According to the average number of ICU days required for each study cohort, the Impact 1.5 group led to a cost savings of at least $193,350.00. CONCLUSIONS: ICU patients with significant illness severity experienced a decrease in the incidence of an important nosocomial infection that is commonly associated with increased use of ICU resources and length of stay. This decrease in patient morbidity led to substantial cost savings despite the small size of our study trial. JPEN 2005 Jan-Feb;29(1 Suppl):S62-9.

Preoperative immunonutrition: costbenefit analysis.

BACKGROUND: To evaluate whether preoperative immunonutrition might lead to a savings in patient care. Data on resources consumed to treat postoperative complications are scanty, but morbidity costs continue to be a major burden for any health care system. A recent randomized clinical trial carried out in well-nourished patients with gastrointestinal cancer showed that a 5-day preoperative oral immunonutrition reduced postoperative morbidity compared with conventional treatment (no supplementation). METHODS: The abovementioned trial was the basis for the economic evaluation. In-hospital related costs of routine surgical care and costs of nutrition were calculated. Estimates of complication costs were based on both resources used for treatment and additional length of hospital stay. Cost comparison and cost-effectiveness analysis were then carried out. RESULTS: Total cost of nutrition was 3407 euro in the conventional group and 14,729 euro in the preoperative group. In patients without complication, the cost of inhospital routine care was similar in both groups. The mean cost of complication was 6178 euro in the conventional group and 4639 euro in the preoperative group (p = .05). Total cost of patients with complications was 535,236 euro in the conventional group and 334,148 euro in the preoperative group. Total costs consumed 93% of the diagnosis-related-group (DRG) reimbursement rate in the conventional group and 78% in the preoperative group. Cost-effectiveness was 6245 euro for the conventional group and 2985 euro for the preoperative group. CONCLUSIONS: The costs of postoperative morbidity consumed a large amount of the DRG reimbursement rate. Preoperative immunonutrition was cost-effective in our series. JPEN 2005 Jan-Feb;29(1 Suppl):S57-61

T lymphocyte numbers in human gut associated lymphoid tissue are reduced without enteral nutrition.
BACKGROUND: Clinically, in the absence of enteral nutrition, the morbidity of infectious complication is high. Although experiments using mice have shown alterations in gut-associated lymphoid tissue (GALT) to be an important mechanism underlying impaired host defense,

there are no clinical studies on the effects of nutritional routes on GALT. METHODS: A total of 27 colon cancer cases who underwent right colectomy or hemicolectomy were reviewed. Six patients did not receive enteral nutrition for 4 to 28 days before surgery because of bowel obstruction (parenteral nutrition [PNI group). Twenty-one patients were enterally fed before surgery (enteral nutrition [EN] group). The terminal ileum from resected specimens was examined microscopically. T-cell numbers in intraepithelial spaces (IE) and the lamina propria (LP) were determined immunohistochemically in blinded fashion. RESULTS: There were no significant differences in baseline characteristics between the 2 groups. T-cell number in the LP was significantly lower in the PN group than in the EN group, with no difference in IE cell numbers. CONCLUSIONS: Lack of enteral delivery of nutrients reduces GALT cell number in patients with colon cancer, as is the case in mice. JPEN 2005 Jan-Feb;29(1):56

Association between dietary arginine and C-reactive protein.

CONCLUSIONS: The results of this study show a relation between arginine intake and CRP level that persisted after controlling for factors associated with CRP. Individuals may be able to lower their risk for cardiovascular disease by consuming more arginine-rich foods such as nuts and fish. Nutrition. 2005 Feb;21(2):125-30.

Glycemic and lipid control in hospitalized type 2 diabetic patients: evaluation of 2 enteral nutrition formulas (low carbohydrate-high monounsaturated fat vs high carbohydrate).
An enteral formula with lower carbohydrate and higher monounsaturated fat (Glucerna) has a neutral effect on glycemic control and lipid metabolism in type 2 diabetic patients compared with a high-carbohydrate and a lowerfat formula (Precitene Diabet). JPEN 2005 Jan-Feb;29(1):21
http://www.thai-otsuka.co.th/pxnews/index.html Opinions and suggestions are welcomed Dr. Shwe Win, shwewin@thai-otsuka.co.th

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