【持续性肾脏替代治疗crrt英文精品课件】glutamine therapy

GlutamineTherapy Whatdoestheevidenceshow DarenK HeylandProfessorofMedicineQueen sUniversity Kingston ONCanada TheFirstEverRecordedClinicalTrial Nebuchadnezzar kingofBabylon carriedawaychildrenofIsrael intohiscourt 5Andthekingappointedthemadailyprovisionoftheking smeat andofthewinewhichhedrank 8Danielwouldnotdefilehimselfwiththeportionoftheking smeat norwiththewine10PrinceoftheeunuchssaiduntoDaniel Ifeartheking whohathappointedyourmeatandyourdrink forwhyshouldheseeyourfacesworselikingthanthechildrenwhichareofyoursort thenshallyemakemeendangermyheadtotheking BookofDaniel1 1 15 11ThensaidDanieltoMelzar whomtheprinceoftheeunuchshadsetoverDaniel 12Provethyservants Ibeseechthee tendays andletthemgiveuspulsetoeat andwatertodrink 13Thenletourcountenancesbelookeduponbeforethee andthecountenanceofthechildrenthateatoftheportionoftheking smeat andasthouseest dealwiththyservants 14Soheconsentedtotheminthismatter 15Andattheendoftendaystheircountenancesappearedfairerandfatterinfleshthanallthechildrenwhichdideattheportionoftheking smeat TheFirstEverRecordedClinicalTrial BookofDaniel1 1 15 16 fromallthechildrenofIsraelintheKing sCourt ThusMelzartookawaytheportionoftheirmeat andthewinethattheyshoulddrink andgavethempulse TranslatingResearchFindingsintoPractice BookofDaniel1 1 16 198RCT sReviewedinCriticalCareNutritionGuidelines 198RCT sReviewedinCriticalCareNutritionGuidelines 198RCT sReviewedinCriticalCareNutritionGuidelines ProlongedICUstay dischargedweakanddebilitated Diesonday43inhospitalfrommassivePE AdequacyofEN CaseScenario AdequacyofEN Whysuchpooradoption SuboptimalPatientCare InformationOverload Impracticalforindividualclinicianstoassimilatemassiveamountsofinformationtomakeunaidedjudgmentsaboutcomplexdecisions ClinicalPracticeGuidelines systematicallydevelopedstatementstoassistpractitionerandpatientdecisionsaboutappropriatehealthcareforspecificclinicalcircumstances U S InstituteofMedicineappliestotheaveragepatientimproveprocessofcareandpatientoutcomes DevelopmentofCPGs ValidityHomogeneitySafetyFeasibilityCost Evidence IntegrationofValues PracticeGuidelines UpdatedJanuary2009Summarizes 200trialsstudying15080patients34topics17recommendations Guidelines Topics ENvsPNEarlyvsdelayedENDoseofENCompositionofENArginine fishoilsGlutamineCHO fat Pro fibrepHStrategiestooptimizeENFeedingprotocolsMotilityagentsSmallbowelfeedingBodyposition ENotherENincombinationwithPNPNvs standardcareCompositionofPNBCAATypeoflipidsZincGlutamineStrategiestooptimizePNandminimizerisksUseoflipids hypocaloricModeoflipiddeliveryIntensiveinsulintherapyAntioxidantscombinedselenium Nutrientsvs Nutrition Impactsmortality arginineglutamineantioxidantsomega 3fattyacids ImpactsmorbidityENvsPNEarlyENsmallbowelfeeding OverallEffectofGlutaminesupplementation EffectofGlutamine ASystematicReviewoftheLiterature InfectiousComplications UpdatedJan2009 EffectofGlutamine ASystematicReviewoftheLiterature HospitalLengthofStay UpdatedJan2009 EffectofGlutamine ASystematicReviewoftheLiterature UpdatedJan2009 Mortality EnteralvsParenteralGlutaminesupplementation WhyParenteralGlutamine PropredictabledailydosecanbeaddedtoallpatientsregardlessgutintolerancehigestlevelofglutamineisobservedwithparenteralinfusioncomparedtoenteralinfusiongreatertreatmenteffectisobservedwithparenteralcomparedtoenteralglutaminesupplmentationGriffithsRD IntensiveCareMed2001Powell TuckJ Gut1999Lian AnWorldJGastroenterol2003NovakF CritCareMed2002MelisBrLNutrition2005 94 19 ConunstableaminoacidsolutionssolvedwithsyntheticglutaminecontainingdipeptidescostsGrimmH KrausA Langenbeck sArchSurg2001GoetersC WennA MertesNetal CritCareMed2002 WhyEnteralGlutamine Proenteralfeedingispreferredrouteofnutritionincriticallyillglutamineaccountsfor35 oftotalmetabolicrequirementsoftheenterocytestrophiceffectonthesmallbowelandcolonicmucosepreservinggutbarrierfunctionbyaugmentingimmuneresponsereducedbacterialtranslocationbenefficialeffectonradicalscavengerproduction glutathione preservingintestinalbloodflowArndtH KullmannF ReubFetal JPEN1999HoudijkAPJ RijnsburgerER JansenJetal Lancet1998ConejeroR BonetA GrauTetal Nutrition2002 CondifficulttopredictandachievedailydosebecauseofgutintoleranceproblemsdifficulttoachievehighenoughplasmaandtissuelevelsofglutaminereductioninaffinityornumberoftransportproteinsforglutamineonthesurficeofthegutduringsepsisreducedflowintheintestinalmicrocirculationimpairsexportofabsorbedsubstrateacrossbasolateralmembranedecreaseofabsobtionfunctionduetorapidturnoverofenterocytesGriffiths ProceedingsofthenutritionSociety2001 HallJetal IntensiveCareMed2003 EnteralvParenteralGlutamineSupplementation animalmodelenteralglutaminesupplementationreducedtheseverityofthemethotrexsate inducedenterocolitis maintainedbarrierfunctionofthegutwithreducedbacterialtranslocationandresultedinadecreasedmortalityparenteralglutaminesupplementhadnobenifitinthesamemodelFoxAD KripkeSA DePaulaJetal Effectofglutaminesupplementedenteraldietonmethotrexateinducedenterocolitis JPEN1988 ResultsofSubgroupAnalysis PN EN Luo ClinicalNutrition 2008 27 297 306 Metaboliceffectsofenteralversusparenteralalanyl glutaminedipeptideadministrationincriticallyillpatientsreceivingenteralfeeding Apilotstudy RCT double blindIVala glut 0 5 vsENala GLN 0 32gm kg day vsplacebo32criticallyillpatientsrec ingEN Nodifferencein Antioxidantcapacity vitC Glutathione Oxidativestress malondialdehyde TlymphocytesIntestinalpermeabilityNitrogenbalance ConcealedrandomizationDouble blind72Trauma ISS 20 Reportedon60successfulfeedpatients non ITT GlnaddedtoENvsisonitrogenouscontrol 12days ResultsLesspneumonia bacteremia andsepsis majorityinfirstweek PlasmaglutaminelevelselevatedinGlngroupinfirstweekLowerlevelsofp55andp75solubleTNFreceptorsNodifferenceinmechventilation LOS mortality HoudijkLancet1998 352 772 EffectofGlutamineinCriticallyIll IndividualStudies EffectofEnteralGlutamineinBurns 3RCTsofenteralglutamineBurnspatientsIncreasedplasmaglutamineImprovedpermeabilityDecreasedendotoxinlevelsReducedGNBinfectionsReducedhospitalLOSReducedmortality GarrellCCM2003 31 2444 ZhouJPEN200327 241 PengBurns2004 30 135 EffectofENGlutamineonHospitalLOS WhataboutGlutamineinHeadInjury 31 Bergetal ClinNutr2008 inpress BrainGlutamineLevels BrainGlutamateLevels SafetyofGlutamineinHeadInjury YangChineseJournalofTraumatology2007 10 145 EfficacyofGlutamineinHeadInjury 46patientwithsevereTBIrandomizedtoIVala glnvsstandardcare doseAllpatientsfedPNonday3withENtofollow P 0 05 WhataboutGlutamineinPancreatitis EfficacyofGlutamineinPancreatitis 4RCTsofIVGlutaminesupplementedPN relevancewhenENstandardofcare WhataboutGlutamineinShock JPEN2008 32 28 20severelytraumatizedpatientsRCTEnteralglut0 5gm kg dayvscontrolAllpatientsrec dImpactStartedwithin24hrsandcontinuedfor10days CanadianCriticalCareNutritionClinicalPracticeGuidelines Ifusingparentalnutrition westronglyrecommendsupplementingwithparenteralglutamine EnteralGlutamineshouldbeconsideredforBurnsandTraumaPatients Thereareinsufficientdatatosupporttheroutineuseofenteralglutamineinothercriticallyillpatients BenefitofParenteralGlutamineinPatientsonEN JPEN2003 27 forcurrentversion WhataboutdoseofGlutamine RCT368heterogeneouscriticallyillpatientsDouble blindEnteralnutritionsupplementedglutamine 20grams LControl Glycine20g LWellmatchedgroupsGlutaminegrouprec daverage19g dayofglutamine HallIntensiveCareMed2003 29 1710 InadequateDoseandWrongPatientPopulation Nodifferencesnoted NormalHealthyrange TjaderICM2004 OptimalDose REDOXSDosingStudy HighdoseappearssafeHighdoseassociatedwithnoworseningofSOFAScoresgreaterresolut