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Intravenous Glutamine Supplementation in Critically Ill Patients Receiving Enteral
Feeding
Reporter: 黃孜立Instructor: 賴聖如 營養師
1
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Abstract
• Glutamine and Dipeptiven• Metabolism under stress• Paper
– Metabolic Effects Of Enteral Versus Parenteral Alanyl-glutamine Dipeptide Administration In Critically Ill Patients Receiving Enteral Feeding: A Pilot Study
– The Effect Of Intravenous Alanyl-glutamine Supplementation On Plasma Glutathione Levels In Intensive Care Unit Trauma Patients Receiving Enteral Nutrition: The Results Of A Randomized Controlled Trial
– Effect Of Intravenous Glutamine Supplementation IN Trauma Patients Receiving Enteral Nutrition Study Protocol (GLINT Study): A Prospective, Blinded, Randomised, Placebo Controlled Clinical Trial
• Conclusion
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What is Glutamine (GLN) ?3
Endogenous
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Glutamine
Plasma Glutamine concentrations↑, improve:1.Antioxidant capacity2.Nitrogen balance ↑3.Immune function ↑4.Intestinal permeability ↑5.The incidence of hospital-acquired infection ↓
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Hypermetabolic response5
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Metabolism under stress6
Stress hypermetabolismREE ↑↑Respiratory quotient 0.8-0.9Proteolysis ↑↑Hepatic protein synthesis
↑↑
Ureagenesis ↑↑Gluconeogenesis ↑↑Urinary nitrogen loss ↑↑
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Glutamine Therapy
Glutamine Therapy
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Dipeptiven 雙胜胺8
Concentrated GLN solution containing the dipeptide alanyl-glutamine (Ala-Gln)
100 ml contains: 20 g N(2)-L-alanyl-L-glutamine
=>13.46 g L-glutamine, 8.20 g L-alanine(= 3.87 g N)-Water for injection-Theoretical osmolarity: 921 mosmol/ lIndication
In patients in catabolic and/ or hypermetabolic states
Prescribing information Dosage per day:0.4 g Ala-Gln / kg BW
(= 2.0 ml Dipeptiven®/ kg BW)Administration: For central venous infusion, as part of a PN regime
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Aim of the three papers9
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Metabolic Effects Of Enteral Versus Parenteral Alanyl-glutamine Dipeptide Administration In Critically Ill Patients Receiving Enteral Feeding: A Pilot Study
Menghua Luo, Niloofar Bazargan, Daniel P. Griffith, Concepción Fernández-Estívariz, Lorraine M. Leader, Kirk A. Easley, Nicole M. Daignault, Li Hao, Jon B. Meddings, John R. Galloway, Jeffrey B. Blumberg, Dean P. Jones, and Thomas R. ZieglerClinical Nutrition 27(2009),297–306
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Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: a pilot study
Objective To find the metabolic effects of intravenous (IV) alanyl-Gln dipeptide (AG) supplementation and enteral (EN) AG supplementation in adult critically ill patients requiring tube feeding
Design double-blind, pilot clinical trial
Setting surgical Intensive Care Unit (SICU)
Patients Critically ill patients (N=44) in the ICU with indication for PNExcluded:active uncontrolled infection, hepatic dysfunction, renal dysfunction, active GI bleeding or gastric outletobstruction, history of small intestinal or gastric resection
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Double-blindrandonmization
Control:IV Gln-free amino acid (0.5g/kg/d) (n=15)
IV AG: IV Gln (0.5g/kg/d) (n=14)
EN AG: IV placebo + EN Gln (0.5g/kg/d) (n=15)
11 33 66 99Study day
3-day N blance
Iso-N, iso-caloric tube feedsLab dataLab data Lab dataLab data
MethodMethod
Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: a pilot study
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MethodMethod
Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: a pilot study
Lab data:•Day1, 9:1.plasma Gln2.antioxidant indices3.lymphocyte subsets4.serum IGF-1 and IGF binding protein-35.intestinal permeability
•Days 6 to 8: Nitrogen balance study
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Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: a pilot study
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ConclusionConclusion
criteria Result (compared to control group)
antioxidant capacity X No significant differences
oxidative stress markers X No significant differences
α-tocopherol EN AG group↑
T-lymphocyte subset number X No significant differences
gut barrier function X No significant differences
whole-body protein metabolism
X No significant differences
Plasama glutamine ↑ IV AG group: Significant increase
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Plasama glutamine→ IV AG group: Significant increasePlasama glutamine→ IV AG group: Significant increase
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EN AG group : ↑
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IV AG group : ↑
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The Effect Of Intravenous Alanyl-glutamine Supplementation On Plasma Glutathione Levels InIntensive Care Unit Trauma Patients Receiving Enteral Nutrition: The Results Of A Randomized Controlled Trial
Ahmet Eroglu, MDInternational Anesthesia Research Society 109(2009),502-505
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The Effect of Intravenous Alanyl-Glutamine Supplementation on Plasma Glutathione Levels in Intensive Care Unit Trauma Patients Receiving Enteral Nutrition: The Results of a Randomized Controlled Trial
Design randomized, controlled study (double blind manner)
Setting Intensive Care Unit (ICU)
Patients 40 adult patients with severe trauma according to the Injury Severity Score(ISS) >20
Interventions 1. Group G received 0.5 g /kg/d of IV alanyl-glutamine dipeptide supplementation
2. Group C received a control solution without alanyl-glutamine
for 7 days
Parameter Blood samples: total glutathione, C reactive protein (CRP), prealbumin, and glucose before the initiation of supplementation and on the 3rd, 7th, and 10th days of feeding.
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Objective IV alanyl-glutamine dipeptide supplementation↔plasma glutathione
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ConclusionConclusion
IV alanyl-glutamine supplementation for 7 days → total plasma glutathione levels ↑IV alanyl-glutamine supplementation for 7 days → total plasma glutathione levels ↑
•No differences in : CRP, prealbumin, glucose
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Effect Of Intravenous Glutamine Supplementation IN Trauma Patients Receiving Enteral Nutrition Study Protocol (GLINT Study): A Prospective, Blinded, Randomised, Placebo Controlled Clinical Trial
Ruqaiya M Al Balushi,1 Jennifer D Paratz,1,2 Jeremy Cohen,1,2 Merrilyn Banks,3 Joel Dulhunty,1,2 Jason A Roberts,1,2 Jeffrey LipmanAl Balushi RM, Paratz JD, Cohen J, et al. BMJ Open 1(2011),1-7
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Effect Of Intravenous Glutamine Supplementation IN Trauma Patients Receiving Enteral Nutrition Study Protocol (GLINT Study): A Prospective, Blinded, Randomised, Placebo Controlled Clinical Trial
• Objective
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IV alanyl-glutamine supplementation in multiple
trauma patients receiving enteral nutrition
preservation of lean body mass
infectious complications
infectious complications
organ failure
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23Design Prospective, Blinded, Randomised, Placebo
Controlled Clinical Trial
Setting Intensive Care Unit (ICU)
Patients 88 critically ill patients with a diagnosis of multiple trauma requiring mechanical ventilation, patients requiring enteral feeding for >48 h, expected length of stay in the ICU >48 h
Interventions 1. 0.5 g/kg/day IV alanyl-glutamine2. IV placebo continuous infusion (24 h/day) & the same
standard enteral nutrition protocol until discharge from the intensive care unit, death
or a maximum duration of 3 weeks.
parameter 1. Total sequential organ failure assessment score on the last day of treatment
2. infectious complications during the ICU stay3. 60-day mortality4. length of stay in the intensive care unit 5. fat-free mass and fat percentage
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Strengths limitations
Longer study period
1. Mortality2. The long-term
outcomes 3. Trauma patients
with severe renal failure or hepatic impairment
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Comparison251 2 3
Objective IV EN ↔ 1. 血糖2. 抗氧化力3. 免疫能力4. 腸道保護5. 住院天數、死亡率、併發症
IV ↔1. 抗氧化力 (plasma
glutathione)2. 血糖3. 住院天數、死亡率、併發症
IV ↔1.保留 LBM 能力2.住院天數、死亡率、併發症3.ICU 常規檢測數值
Design double-blind,RCT
Setting ICU
Patients 44 40 88
Nutrition Regime
1. EN AG 2. IV AG 0.5 g /kg/d3. control
1. IV :0.5 g /kg/d2. control
1. IV :0.5 g/kg/day2. Control
管灌多元配方for 9 days for 7 days 最多 3 weeks
Conclusion IV:Plasama glutamine↑EN:α-tocopherol ↑
IV:7.10day total plasma glutathione levels ↑
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Conclusion26
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THANK YOU FOR YOUR ATTENTION
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