Background: Since the hepatosplanchnic region plays a central role
in development of multiple-organ failure and infections in critically ill
trauma patients, this study focuses on the influence of glutamine, peptide,
and synbiotics on intestinal permeability and clinical outcome.
Methods: One hundred thirteen multiple injured patients were
prospectively randomized into 4 groups: group A, glutamine; B, fermentable
fiber; C, peptide diet; and D, standard enteral formula with fibers combined
with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula
containing live lactobacilli and specific bioactive fibers. Intestinal
permeability was evaluated by measuring lactulose-mannitol excretion ratio on
days 2, 4, and 7. Results: No differences in days of mechanical
ventilation, intensive care unit stay, or multiple-organ failure scores were
found between the patient groups. A total of 51 infections, including 38
pneumonia, were observed, with only 5 infections and 4 pneumonias in group D,
which was significantly less than combined infections (p = .003) and
pneumonias (p = .03) in groups A, B, and C. Intestinal permeability
decreased only in group D, from 0.148 (0.056–0.240) on day 4 to 0.061
(0.040–0.099) on day 7; (p < .05). In group A, the
lactulose-mannitol excretion ratio increased significantly (p <
.02) from 0.050 (0.013–0.116) on day 2 to 0.159 (0.088–0.311) on
day 7. The total gastric retention volume in 7 days was 1150 (785–2395)
mL in group D, which was significantly more than the 410 (382–1062) mL
in group A (p < .02), and 620 (337–1190) mL in group C
(p < .03). Conclusions: Patients supplemented with
synbiotics did better than the others, with lower intestinal permeability and
fewer infections.
The study focuses on the influence of specific immunonutrients on intestinal permeability and clinical outcome. Patients who received the immunomodulatory treatment supplemented with Synbiotic exhibited less infections and lower intestinal permeability compared with the other 3 treatment groups.
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References
1.
Biffl WL, Moore EE, Moore FA, Barnett CC Jr. Interleukin-6 delays
neutrophil apoptosis via a mechanism involving platelet-activating factor.J Trauma.1996;40:575–
579.
2.
Sautner T, Fugger R, Gotzinger P, et al. Tumour necrosis
factor-alpha and interleukin-6: early indicators of bacterial infection after
human orthotopic liver transplantation. Eur J Surg.1995
;161:97–
101.
3.
Deitch EA. Role of the gut lymphatic system in multiple organ
failure. Curr Opin Crit Care.2001
;7:92–
98.
4.
Dayal SD, Hasko G, Lu Q, et al. Trauma/hemorrhagic shock mesenteric
lymph upregulates adhesion molecule expression and IL-6 production in human
umbilical vein endothelial cells. Shock.2002
;17:491–
495.
5.
Galban C, Montejo JC, Mesejo A, et al. An immune-enhancing enteral
diet reduces mortality rate and episodes of bacteremia in septic intensive
care unit patients. Crit Care Med.2000
;28:643–
648.
6.
Bower RH, Cerra FB, Bershadsky B, et al. Early enteral
administration of a formula (Impact) supplemented with arginine, nucleotides,
and fish oil in intensive care unit patients: results of a multicenter,
prospective, randomized, clinical trial. Crit Care Med.1995
;23:436–
449.
7.
Bertolini G, Iapichino G, Radrizzani D, et al. Early enteral
immunonutrition in patients with severe sepsis: results of an interim analysis
of a randomized multicentre clinical trial. Intensive Care Med.2003
;29:834–
840.
8.
Heyland DK, Novak F, Drover JW, Jain M, Su X, Suchner U. Should
immunonutrition become routine in critically ill patients? A systematic review
of the evidence. JAMA.2001
;286:944–
953.
9.
Oudemans-van Straaten HM, Bosman RJ, Treskes M, van der Spoel HJ,
Zandstra DF. Plasma glutamine depletion and patient outcome in acute ICU
admissions. Intensive Care Med.2001
;27:84–
90.
10.
Manhart N, Vierlinger K, Spittler A, Bergmeister H, Sautner T, Roth
E. Oral feeding with glutamine prevents lymphocyte and glutathione depletion
of Peyer's patches in endotoxemic mice. Ann Surg.2001
;234:92–
97.
11.
Wischmeyer PE, Kahana M, Wolfson R, Ren H, Musch MM, Chang EB.
Glutamine reduces cytokine release, organ damage, and mortality in a rat model
of endotoxemia. Shock.2001
;16:398–
402.
12.
Novak F, Heyland DK, Avenell A, Drover JW, Su X. Glutamine
supplementation in serious illness: a systematic review of the evidence.Crit Care Med.2002;30:2022–
2029.
13.
de Felippe Junior J, da Roche e Silva Junior M, Maciel FM, Soares
Ade M, Mendes NF. Infection prevention in patients with severe multiple trauma
with the immunomodulator beta 1–3 polyglucose (glucan). Surg
Gynecol Obstet.1993;177:383–
388.
14.
Rayes N, Hansen S, Seehofer D, et al. Early enteral supply of fiber
and Lactobacilli versus conventional nutrition: a controlled trial in patients
with major abdominal surgery. Nutrition.2002
;18:609–
615.
15.
Rayes N, Seehofer D, Hansen S, et al. Early enteral supply of
lactobacillus and fiber versus selective bowel decontamination: a controlled
trial in liver transplant recipients. Transplantation.2002
;74:123–
127.
16.
Olah A, Belagyi T, Issekutz A, Gamal ME, Bengmark S. Randomized
clinical trial of specific lactobacillus and fibre supplement to early enteral
nutrition in patients with acute pancreatitis. Br J Surg.2002
;89:1103–
1107.
17.
Bengmark S. Bio-ecological control of perioperative and ITU
morbidity. Langenbecks Arch Surg.2004
;389:145–
154.
18.
Kompan L, Kremzar B, Gadzijev E, Prosek M. Effects of early enteral
nutrition on intestinal permeability and the development of multiple organ
failure after multiple injury. Intensive Care Med.1999
;25:157–
161.
19.
Knight DJW, Ala'Aldeen D, Bengmark S, Girling KJ. The effect of
synbiotics on gastrointestinal flora in the critically ill. Br J
Anaesth. 2004;92:307–
308.
20.
Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity
score: a method for describing patients with multiple injuries and evaluating
emergency care. J Trauma.1974
;14:187–
196.
21.
Kruszewska D, Lan J, Lorca G, Yanagisawa N, Marklinder I, LjunghÅ
. Selection of lactic acid bacteria as probiotic strains by in vitro
tests. Microecol Ther.2002
;29:37–
51.
22.
Ljungh Å, Lan JG, Yamagisawa N. Isolation, selection and
characteristics of Lactobacillus paracasei ssp paracasei isolate F19.Microbiol Ecol Health Disease.2002;suppl 3: 4–6.
23.
Seneff M, Knaus WA. APACHE: a prognostic scoring system.Probl Crit Care.1989;3:563–
578.
24.
Goris RJ, te Boekhorst TP, Nuytinck JK, Gimbrere JSF. Multiple
organ failure. Generalised autodestructive inflammation? Arch
Surg.1985;120:1109–
1115.
25.
Vovk I, Simonovska B, Kompan L, Prošek M. TLC determination
of mannitol and lactulose on amino HPTLC plates. JPC J Planar
Chromatogr Mod TLC.2003;16:372–
374.
26.
Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC
definitions for nosocomial infections. Am J Infect Control.1988
;16:128–
140.
27.
Rello J, Paiva JA, Baraibar J, et al. International conference for
the development of consensus on the diagnosis and treatment of
ventilator-associated pneumonia. Chest.2001
;120:955–
970.
28.
Wanner GA, Keel M, Steckholzer U, Beier W, Stocker R, Ertel W.
Relationship between procalcitonin plasma levels and severity of injury,
sepsis, organ failure, and mortality in injured patients. Crit Care
Med.2000;28:950–
957.
29.
Marik PE, Zaloga GP. Early enteral nutrition in acutely ill
patients: a systematic review. Crit Care Med.2001
;29:2264–
2270.
30.
Montejo JC, Zarazaga A, Lopez-Martinez J, et al. Immunonutrition in
the intensive care unit. A systematic review and consensus statement.Clin Nutr.2003;22:221–
233.
31.
McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual
volumes as a marker for risk of aspiration in critically ill patients.Crit Care Med.2005;33:324–
330.
32.
Bouin M, Savoye G, Hervé S, Hellot MF, Denis P,
Ducrotté P. Does the supplementation of the formula with fibre increase
the risk of gastro-oesophageal reflux during enteral nutrition? A human study.Clin Nutr.2001;20:307–
312.
33.
Faries PL, Simon RJ, Martella AT, Lee MJ, Machiedo GW. Intestinal
permeability correlates with severity of injury in trauma patients. J
Trauma.1998;44:1031–
1035.
34.
Khan J, Iiboshi Y, Cui L, et al. Alanyl-glutamine-supplemented
parenteral nutrition increases luminal mucus gel and decreases permeability in
the rat small intestine. JPEN J Parenter Enteral Nutr.1999
;23:24–
31.
35.
Kozar RA, Schultz SG, Bick RJ, Poindexter BJ, DeSoignie R, Moore
FA. Enteral glutamine but not alanine maintains small bowel barrier function
after ischemia/reperfusion injury in rats. Shock.2004
;21:433–
437.
36.
Conejero R, Bonet A, Grau T, et al. Effect of a glutamine-enriched
enteral diet on intestinal permeability and infectious morbidity at 28 days in
critically ill patients with systemic inflammatory response syndrome: a
randomized, single-blind, prospective, multicenter study.Nutrition.2002;18:716–
721.
37.
Velasco N, Hernandez G, Wainstein C, et al. Influence of polymeric
enteral nutrition supplemented with different doses of glutamine on gut
permeability in critically ill patients. Nutrition.2001
;17:907–
911.
38.
Peng X, Yan H, You Z, Wang P, Wang S. Effects of enteral
supplementation with glutamine granules on intestinal mucosal barrier function
in severe burned patients. Burns.2004
;30:135–
139.
39.
Hulsewe KW, van Acker BA, Hameeteman W, et al. Does
glutamine-enriched parenteral nutrition really affect intestinal morphology
and gut permeability? Clin Nutr.2004
;23:1217–
1225.
40.
Schulman AS, Willcutts KF, Claridge JA, et al. Does the addition of
glutamine to enteral feeds affect patient mortality? Crit Care
Med.2005;33:2501–
2506.
41.
Bengmark S. Bioecological control of inflammation and infection in
transplantation. Transplant Rev.2004
;18:38–
45.
42.
Bengmark S. Synbiotics to strengthen gut barrier function and
reduce morbidity in critically ill patients. Clin Nutr.2004
;23:441–
445.
43.
Jain PK, McNaught CE, Anderson AD, MacFie J, Mitchell CJ. Influence
of synbiotic containing Lactobacillus acidophilus La5, Bifidobacterium lactis
Bb 12, Streptococcus thermophilus, Lactobacillus bulgaricus and oligofructose
on gut barrier function and sepsis in critically ill patients: a randomised
controlled trial. Clin Nutr.2004
;23:467–
475.
44.
Woodcock NP, McNaught CE, Morgan DR, Gregg KL, MacFie J. An
investigation into the effect of a probiotic on gut immune function in
surgical patients. Clin Nutr.2004
;23:1069–
1073.
45.
Heimburger DC, Geels WJ, Thiesse KT, Bartolucci AA. Randomized
trial of tolerance and efficacy of a small-peptide enteral feeding formula
versus a whole-protein formula. Nutrition.1995
;11:360–
364.
