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JPEN readers have consistently indicated a desire to learn to be more skilled in critical appraisal of the literature. The eJOURNAL is an opportunity for the JPEN reader to review current, recently published, key articles in clinical nutrition and to examine critical review comments from other clinical nutrition practitioners from around the world. In addition, we want this to be an open forum for you to share your opinions on whether this article would lead to you changing your practice: we would love to know why or why not. We very much wish to learn from you what are your motivations to change your practice, what leads to practice change, and what are the unique obstacles you face in your own practice to implementing new data to your patient care.
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November-December 2008 JPEN (Vol 32,6)
Early enteral supplementation with key pharmaconutrients improves Sequential Organ Failure Assessment score in critically ill patients with sepsis: Outcome of a randomized, controlled, double-blind trial
Beale RJ, Sherry T, Lei K, Campbell-Stephen L, McCook J, Smith J, Venetz W, Alteheld B, Stehle P, Schneider H
Objective: To assess the safety and efficacy of an early enteral pharmaconutrition supplement containing glutamine dipeptides, antioxidative vitamins and trace elements, and butyrate in critically ill, septic patients. Design: A prospective, randomized, controlled, double-blind clinical trial. Setting: Adult intensive care unit in a university hospital. Patients: Fifty-five critically ill, septic patients requiring enteral feeding. Interventions: Patients received either an enteral supplement (500 mL of Intestamin, Fresenius Kabi) containing conditionally essential nutrients or a control solution via the nasogastric route for up to 10 days. Inclusion occurred within 24 hrs of intensive care unit admission. Additionally, patients received enteral feeding with an immunonutrition formula (experimental group) or standard formula (control group) initiated within 48 hrs after enrollment. Measurements and Main Results: Organ dysfunction was assessed by daily total Sequential Organ Failure Assessment (SOFA) score over the 10-day study period in both patient groups. Patients receiving the experimental supplement showed a significantly faster decline in the regression slopes of delta daily total SOFA score over time compared with control. The difference between the regression coefficients of the 2 slopes was significant irrespective of the level of analysis: intent to treat –0.32 vs –0.14, P < .0001; per protocol –0.34 vs –0.14, P < .0001; and completers (patients receiving 80% of the calculated caloric target over a period of 6 days) –0.26 vs –0.16, P = .0005. Vitamin C, as a marker of supplement absorption, increased from 10.6 (1.9-159.4) µmol/L (normal range 20-50 µmol/L) on day 1 to 58.7 (5.4-189.9) µmol/L by day 3 (P = .002) in the intervention group but remained below the normal range in the control group 17.0 (2.8-78.5) on day 1 and 14.3 (2.4-179.6) on day 3. Serum levels of glycine, serine, arginine, ornithine, vitamin E, and ß-carotene all increased significantly with treatment in the supplementation group. Conclusions: In medical patients with sepsis, early enteral pharmaconutrition with glutamine dipeptides, vitamin C and E, ß-carotene, selenium, zinc, and butyrate in combination with an immunonutrition formula results in significantly faster recovery of organ function compared with control. (Crit Care Med. 2008; 36:131–144)
Editorial comments by Dr. Daren Heyland can be found on pages 673-674 in the printed JPEN journal or online at http://jpen.sagepub.com/cgi/reprint/32/6/673.
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