Critically ill patients have considerable oxidative stress. Glutamine and antioxidant supplementation may offer therapeutic benefit, although current data are conflicting.

Introduction: To develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU). Methods: A prospective, observational study of patients expected to stay > 24 hours. We collected data for key variables considered for inclusion in the score which included: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) < 20, estimated % oral intake in the week prior, weight loss in the last 3 months and serum interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) levels. Approximate quintiles of each variable were assigned points based on the strength of their association with 28 day mortality. Results: A total of 597 patients were enrolled in this study. Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated percentage oral intake and weight loss. As the score increased, so did mortality rate and duration of mechanical ventilation. Logistic regression demonstrated that nutritional adequacy modifies the association between the score and 28 day mortality (p = 0.01). Conclusions: This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.

Research from JAMA — Should Immunonutrition Become Routine in Critically Ill Patients? — A Systematic Review of the Evidence — ContextSeveral nutrients have been shown to influence immunologic and inflammatory responses in humans. Whether these effects translate into an improvement in clinical outcomes in critically ill patients remains unclear.ObjectiveTo examine the relationship between enteral nutrition supplemented with immune-enhancing nutrients and infectious complications and mortality rates in critically ill patients.Data SourcesThe databases of MEDLINE, EMBASE, Biosis, and CINAHL were searched for articles published from 1990 to 2000. Additional data sources included the Cochrane Controlled Trials Register from 1990 to 2000, personal files, abstract proceedings, and relevant reference lists of articles identified by database review.Study SelectionA total of 326 titles, abstracts, and articles were reviewed. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of enteral nutrition supplemented with some combination of arginine, glutamine, nucleotides, and omega-3 fatty acids on infectious complication and mortality rates compared with standard enteral nutrition, and included clinically important outcomes, such as mortality.Data ExtractionMethodological quality of individual studies was scored and necessary data were abstracted in duplicate and independently.Data SynthesisTwenty-two randomized trials with a total of 2419 patients compared the use of immunonutrition with standard enteral nutrition in surgical and critically ill patients. With respect to mortality, immunonutrition was associated with a pooled risk ratio (RR) of 1.10 (95% confidence interval [CI], 0.93-1.31). Immunonutrition was associated with lower infectious complications (RR, 0.66; 95% CI, 0.54-0.80). Since there was significant heterogeneity across studies, we examined several a priori subgroup analyses. We found that studies using commercial formulas with high arginine content were associated with a significant reduction in infectious complications and a trend toward a lower mortality rate compared with other immune-enhancing diets. Studies of surgical patients were associated with a significant reduction in infectious complication rates compared with studies of critically ill patients. In studies of critically ill patients, studies with a high-quality score were associated with increased mortality and a significant reduction in infectious complication rates compared with studies with a low-quality score.ConclusionImmunonutrition may decrease infectious complication rates but it is not associated with an overall mortality advantage. However, the treatment effect varies depending on the intervention, the patient population, and the methodological quality of the study.

To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, we conducted a prospective, matched cohort study. Patients expected to be ventilated for > 48 h were prospectively followed for the development of VAP. To determine the excess ICU stay and mortality attributable to VAP, we matched patients with VAP to patients who did not develop clinically suspected pneumonia. We also conducted sensitivity analyses to examine the effect of different populations, onset of pneumonia, diagnostic criteria, causative organisms, and adequacy of empiric treatment on the outcome of VAP. One hundred and seventy-seven patients developed VAP. As compared with matched patients who did not develop VAP, patients with VAP stayed in the ICU for 4.3 d (95% confidence interval [CI]: 1.5 to 7.0 d) longer and had a trend toward an increase in risk of death (absolute risk increase: 5.8%; 95% CI: − 2.4 to 14.0 d; relative risk (RR) increase: 32.3%; 95% CI: − 20.6 to 85.1%). The attributable ICU length of stay was longer for medical than for surgical patients (6.5 versus 0.7 d, p < 0.004), and for patients infected with “high risk” organisms as compared with “low risk” organisms (9.1 d versus 2.9 d). The attributable mortality was higher for medical patients than for surgical patients (RR increase of 65% versus − 27.3%, p = 0.04). Results were similar for three different VAP diagnostic criteria. We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients. The attributable risk of VAP appears to vary with patient population and infecting organism.