Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (82 page)
Certain nutrients can have effects on cellular and tissue function. Some of these nutrients modulate immune and inflammatory responses if given in excess of normal intake or requirements. The use of nutrients (‘nutriceuticals’) in this way has been termed ‘nutritional pharmacology’. Examples and specific effects include:
L
-arginine – stimulates aspects of immune function, improves nitrogen retention after surgery, enhances wound healing;
58,
59
L
-glutamine – stimulates immune function, reduces nitrogen loss postoperatively, may be important in maintaining gut-barrier function;
60
branched-chain amino acids – may control protein synthesis in muscle and stimulate whole-body protein synthesis, especially in severely traumatised patients;
61
essential fatty acids – stimulation or inhibition of immune function, anti-inflammatory effects;
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polyribonucleotides and ribonucleic acid – stimulate immune function;
vitamins, trace elements – stimulation of immune function, antioxidant effects, wound healing;
selenium – stimulation of immune function, prevention of tissue damage, anti-inflammatory effects;
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The clinical benefits of supplementation with key nutrients have, however, been difficult to demonstrate.
Several studies have evaluated the use of combinations of key nutrients in clinical practice in patients with critical illnesses (trauma, surgery for malignant disease, burns), but particularly in upper gastrointestinal cancer. A combination of
L
-arginine,
n
-3 essential fatty acids and ribonucleic acid is commercially available (Impact; Sandoz Nutrition, Minneapolis, MN, USA) and has been used in many trials. The supplemented nutrition has been given in the postoperative period (nasoenteric tube or feeding jejunostomy), starting within 12–48 hours of the critical events and continued for several days.
The first meta-analysis of the studies that have compared supplemented nutritional versus standard nutritional diets (
Figs 17.2
and
17.3
) showed that supplemented nutrition had clinical benefits:
66
Figure 17.2
Effect of immune-enhancing diets on the incidence of major infective complications (wound infections, intra-abdominal abscesses, pneumonia, septicaemia). Expt, patients receiving immune-enhancing diets; Ctrl, patients receiving standard nutrition; n, number of events; N, number of patients in each group on an intention-to-treat basis; OR, odds ratio; CI, confidence interval. (Study sources are given in Heys et al.
60
).
Reproduced from Heys SD, Walker LG, Smith IC et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomised controlled clinical trials. Ann Surg 1999; 229:467–77. With permission from Wolter Kluwers Health.
Figure 17.3
Effect of immune-enhancing diets on the length of hospital stay. WMD, weighted mean difference; CI, confidence interval. (Study sources are given in Heys et al.
66
)
Reproduced from Heys SD, Walker LG, Smith IC et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomised controlled clinical trials. Ann Surg 1999; 229:467–77. With permission from Wolter Kluwers Health.
reduction in infectious complications (wound infections, intra-abdominal abscesses, septicaemia), with an odds ratio of 0.47 (95% CI 0.32–0.70);
reduction in length of hospital stay, with a weighted mean difference of − 2.4 days (95% CI − 4 to − 1).
However, there was no significant difference in mortality. A subsequent meta-analysis of 17 trials has confirmed this benefit.
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Many of these studies had methodological limitations but, nevertheless, the role of immunonutrition in critically ill patients was further investigated by ESPEN
56
(
www.espen.org/Education/documents/ENICU.pdf
). The conclusion drawn from the consensus based on the available evidence was that an immune-modulating nutrition (enriched with arginine, nucleotides and omega-3 fatty acids) was beneficial and recommended for the following:
patients with mild sepsis (APACHE II score < 15);
patients undergoing elective major intra-abdominal surgery for cancer to receive 5–7 days of immune-enhancing nutrition (arginine, omega-3 fatty acids and polyribonucleotides);
patients with acute respiratory distress syndrome (ARDS) should receive enteral nutrition supplemented with omega-3 fatty acids and antioxidants.
In addition, there were situations identified where immunonutrition should not be given due to potentially adverse effects:
patients with severe sepsis;
patients unable to tolerate more than 700 mL/day of immunonutrition.
Immune-modulating nutrition is associated with a reduction in septic complications and a reduced hospital stay. It should be considered in patients with mild sepsis (APACHE II score < 15), patients undergoing elective major intra-abdominal surgery for cancer and in patients with ARDS.
56,
66,
67
Key points
Malnutrition is associated with loss of body weight and impairments in organ function.
The metabolic changes that occur in patients undergoing surgery or in those who have experienced trauma and sepsis can be compounded by inadequate nutritional support.
Nutritional requirements must take into consideration the underlying pathophysiological changes.
An assessment of nutritional status should be made in all patients.
If nutritional support is considered necessary, the route and composition of this support should be considered carefully.
Remember re-feeding syndrome and possible thiamine deficiency.
The role of certain key nutrients and their effects, either individually or in combination, on aspects of organ and immune function should be taken into consideration when planning nutritional interventions.
There is now emerging evidence to indicate that manipulating the composition of nutritional support can affect patient outcome.
Careful monitoring of patients receiving nutritional support and the role of the multidisciplinary team is essential for all patients.
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