Glutamine Supplemented Parenteral Nutrition to Prevent Ventilator-Associated Pneumonia in the Intensive Care Unit

Yıl 2012, , 414 - 418, 01.04.2012

Meltem Türkay Aydoğmuş Yakup Tomak Murat Tekin İsmail Katı Ürfettin Hüseyinoğlu

https://doi.org/10.5152/balkanmedj.2012.043

Öz

Objective: Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). Material and Methods: With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. Results: No statistically significant difference was found among groups in terms of development of VAP (p=0.622). Conclusion: Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP. Turkish Başlık: Yoğun Bakım Ünitesinde Ventilatör İlişkili Pnömoniyi Önlemede Glutamin Destekli Total Parenteral Beslenme Anahtar Kelimeler: Beslenme Desteği, Glutamin, Ventilatör-ilişkili Pnömoni Amaç: Ventilatör ilişkili pnömoni (VAP), mortalite ve morbiditeyi artıran, hastanede kalış süresini uzatan ve hastane giderlerini artıran bir nazokomial pnömoni formudur. Glutamin intestinal mukozal yapıyı korur, immün fonksiyonları artırır ve total parenteral beslenme (TPN) uygulanan hastalarda zararlı değişiklikleri azaltır. Biz yoğun bakım ünitesinde (YBÜ) mekanik ventilatör desteği alan hastalarda VAP gelişiminin glutamin destekli TPN ile önlenebileceği hipotezini kurduk. Materyal ve Metodlar: Çalışmamızda etik kurul onayı ve bilgilendirilmiş onam alındıktan sonra YBÜ'nde mekanik ventilatör desteği alan 60 hasta takip edildi. Hastalar 3 gruba ayrıldı. İlk grup enteral beslenme (n=20) alırken, ikinci gruba TPN (n=20), üçüncü gruba ise glutamin destekli TPN (n=20) başlandı. C-reaktif protein (CRP), sedimentasyon hızı, vücut ısısı, pürülan sekresyon gelişip gelişmediği, sekresyon miktarında artış olup olmadığı, sekresyonların karakterinde değişiklik ve derin trakeal aspirasyon ihtiyacında artış olup olmadığı günlük muayeneler ve radyografi ile takip edildi. Bulgular: Gruplar arasında VAP gelişim açısından istatistiksel olarak anlamlı fark bulunmadı (p=0.622). Sonuç: Glutamin destekli TPN alan grupta daha az oranda VAP gelişmesine rağmen, gruplar arasındaki fark istatistiksel olarak anlamlı değildi. Glutamin destekli TPN, VAP gelişimini önlemede glutaminsiz TPN ve enteral beslenmeden üstün değildir.

Anahtar Kelimeler

Nutritional support, glutamine, ventilator-associated pneumonia

Glutamine Supplemented Parenteral Nutrition to Prevent Ventilator-Associated Pneumonia in the Intensive Care Unit

Öz

Kaynakça

• Bonten MJ. Controversies on diagnosis and prevention of ventilator-associated pneumonia. Diagn Microbiol Infect Dis 1999;34:199-204. [CrossRef]
• Rello J, Paiva JA, Baraibar J, Barcenilla F, Bodi M, Castander D, et al. International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-associated Pneu- monia. Chest 2001;120:955-70. [CrossRef]
• Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:2184-93. [CrossRef]
• Robert PR, Zolaga GP. Enteral Nutrition, In: Textbook of Critical Care Ed. W.C. Schomaker, 4 th Ed., W.B. Saunders; 2000.pp.875-97.
• Furst P, Albers S, Stehle P. Glutamine-containing dipeptides in parenteral nutrition. JPEN 1990;14:118-24. [CrossRef]
• Wischmeyer PE, Lynch J, Liedel J, Wolfson R, Riehm J, Gottlieb L, et al. Glutamine administration reduces gram-negative bac- teremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control. Crit Care Med 2000;29:2075-80. [CrossRef]
• Jiang ZM, Jiang H. [The clinical efficacy of glutamine dipeptides on postoperative patients: an updated systematic review of ran- domized controlled trials from Europe and Asia (1997-2005)]. Zhonghua Yi Xue Zhi 2006;86:1610-4.
• Torres A, Aznar R, Gatell JM, Jiménez P, González J, Ferrer A, et al. Incidence, risk, and prognosis factors of nosocomial pneu- monia in mechanically ventilated patients. Am Rev Respir Dis 1990;142:523-8. [CrossRef]
• Chevret S, Hemmer M, Carlet J, Langer M. Incidence and risk fac- tors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. European Co- operative Group on Nosocomial Pneumonia. Intensive Care Med 1993;19:256-64. [CrossRef]
• Rello J, Ausina V, Ricart M, Castella J, Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator- associated pneumonia. Chest 1993;104:1230-5. [CrossRef]
• Joshi N, Localio AR, Hamory BH. A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med 1992;93:135-42. [CrossRef]
• Kollef MH. Ventilator-associated pneumonia. A multivariate anal- ysis. JAMA 1993;270:1965-70. [CrossRef]
• Antonelli M, Moro ML, Capelli O, De Blasi RA, D’Errico RR, Conti G, et al. Risk factors for early onset pneumonia in trauma pa- tients. Chest 1994;105:224-8. [CrossRef]
• Cunnion KM, Weber DJ, Broadhead WE, Hanson LC, Pieper CF, Rutala WA, et al. Risk factors for nosocomial pneumonia: com- paring adult critical-care populations. Am J Respir Crit Care Med 1996;153:158-62.
• American Thoracic Society; Infectious Diseases Society of Amer- ica. Guidelines for the management of adults with hospital-ac- quired, ventilator-associated, and healthcare-associated pneu- monia. Am J Respir Crit Care Med 2005;171:388-416. [CrossRef]
• Michaud S, Suzuki S, Harbart S. Effect of design-related bias in studies of diagnostic tests for ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;166:1320-5. [CrossRef]
• Fabregas N, Ewig S, Torres A. Clinical diagnosis of ventilator-associ- ated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax 1999;54:867-73. [CrossRef]
• Magnotti LJ, Deitch JA. Burns, Bacterial Translokation, Gut Barrier Function, and Failuire. Burn Care Rehabil 2005;26:383-91. [CrossRef]
• Altunkan AA, Koçak Z, Cinel I, A. Şükrü Taner AŞ, Oral U. Effects of Different Enteral Diets on Immune System: Rat Malnutrition Model. Türk Anest Rean Cem Mecmuası 2000;28:68-72.
• Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma: Reduced septic morbidity. J Trauma 1989;29:916-22. [CrossRef]
• Heyland DK, Cook DJ, Schoenfeld PS, Frietag A, Varon J, Wood G, et al. The effect of acidified enteral feeds on gastric coloniza- tion in critically ill patients: results of a multicenter randomized trial. Crit Care Med 1999;27:2399-406. [CrossRef]
• Chastre J, Fagon JY. Ventilator-associated Pneumonia. Am J Respir Crit Care Med 2002;165:867-903.
• Li J, Kudsk KA, Gocinski B, Dent D, Glezer J, Langkamp-Hengen B, et al. Effects of parenteral and enteral nutrition on gut-associ- ated lymphoid tissue. J Trauma 1995;39:44-51. [CrossRef]
• O’Dwyer ST, Smith RJ, Hwang TL, Wilmore DW. Maintenance of small bowel mucosa with glutamine-enriched parenteral nutri- tion. JPEN 1989;13:579-85. [CrossRef]
• Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterol- ogy 2003;124:1111-34. [CrossRef]
• Scolapio JS, McGreevy K, Tennyson GS, Burnett OL. Effect of glutamine in short-bowel syndrome. Clin Nutr 2001;20:319-23. [CrossRef]
• Boelens PG, Houdijk AP, Fonk JC, Nijveldt RJ, Ferwerda CC, Von Blomberg-Van Der Flier BM, et al. Glutamine-enriched enteral nutrition increases HLA-DR expression on monocytes of trauma patients. J Nutr 2002;132:2580-6.
• Griffiths RD, Allen KD, Andrews FJ, Jones C. Infection, multiple organ failure, and survival in the intensive care unit: influence of glutamine-supplemented parenteral nutrition on acquired infec- tion. Nutrition 2002;18:546-52. [CrossRef]
• Yeh CH, Lee HL, Liu YY, Chiang KC, Hwang TL, Jan YY, et al. The role of parenteral glutamine supplement for surgical patient peri- operatively: result of a single center, prospective and controlled study. Langenbecks Arch Surg 2008;393:849-55. [CrossRef]
• Wernermen J. Clinical use of glutamine suplementation. J Nutr 2008;138:2040-4.
• Grau T, Bonet A, Minambres E, Pineiro L, Irles JA, Robles A, et al. The effect of L-alanyl-L-glutamine dipeptide supple- mented total parenteral nutrition on infectious morbidity and insülin sensitivity in critically ill patients. Crit Care Med 2011;39: 1263-8. [CrossRef]
• Bongers T, Griffiths RD, McArdle A. Exogenous glutamine: the clinical evidence. Crit Care Med 2007;35:545-52. [CrossRef]
• National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-85. [CrossRef]
• Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator- associated pneumonia in a tertiary care hospital in India: incidens and risk factors. J Infect Dev Ctries 2009;3:771-7. [CrossRef]