Metabolic and immune effects of dietary arginine, glutamine and omega-3 fatty acids supplementation in immunocompromised patients.

To evaluate the nutritional, metabolic and immune effects of dietary arginine, glutamine and omega-3 fatty acids (fish oil) supplementation in immunocompromised patients, we performed a prospective study on the effect of immune formula administered to 11 severe trauma patients (average ISS = 24), 10 burn patients (average % TBSA = 48) and 5 cancer patients. Daily calorie and protein administration were based on the patient's severity (Stress factor with the range of 35-50 kcal/kg/day and 1.5-2.5 g/kg/day, respectively) Starting with half concentration liquid immune formula through nasogastric tube by continuous drip at 30 ml/h and increasing to maximum level within 4 days. The additional energy and protein requirement will be given either by parenteral or oral nutritional support. Various nutritional, metabolic, immunologic and clinical parameters were observed on day 0 (baseline), day 3, 7, and 14. Analysis was performed by paired student-t test. Initial mean serum albumin and transferrin showed mild (trauma) to moderate (burn and cancer) degree of malnutrition. Significant improvement of nutritional parameters was seen at day 7 and 14 in trauma and burn patients. Significant increase of total lymphocyte count (day 7, P < 0.01), CD4 + count (day 7, p < 0.01), CD8 + count (day 7, p < 0.0005 & day 14, p < 0.05), complement C3 (day 7, p < 0.005 day 14, p < 0.01), IgG (day 7, and 14, p < 0.0005), IgA (day 7, p < 0.0005 & day 14, p < 0.05), in all patients. C-reactive protein decreased significantly on day 7 (p < 0.0005) and day 14 (p < 0.005). 3 cases of burn wound infection, one case of UTI and one case of sepsis were observed. Two cases of hyperglycemia in burn, 3 cases of hyperbilirubinemia in trauma, 10 cases of elevated LFT (5 trauma/5 burn), and one case of hyponatremia in cancer patients were observed. Two cases of nausea, 4 cases of vomiting, 5 cases of diarrhea (< 3 times/day), 2 cases of abdominal cramp, 1 case of distension were observed. The feeding of IMMUNE FORMULA was well tolerated and significant improvement was observed in nutritional and immunologic parameters as in other immunoenhancing diets. Further clinical trials of prospective double-blind randomized design are necessary to address the so that the necessity of using immunonutrition in critically ill patients will be clarified.

Early nutritional support in severe traumatic patients.

Multiple trauma is associated with altered metabolism, wasting of the lean body mass and compromised wound healing. Nutritional support is one way to improve the condition of these critically ill patients. We performed a prospective randomized study on the effect of early nutritional support in severely injured patients admitted to the Division of Traumatic Surgery, Siriraj Hospital between June 1992 and January 1994. Thirty-eight severe traumatic patients with ISS between 20-40 were randomly divided into control and study group. The 17 patients in the control group were treated in the conventional method with administration of hypo caloric intravenous regimen and supplement with oral diet as soon as the bowel function was returned. The 21 patients of the study group were fed either by enteral or parenteral feeding or both with an appropriate caloric and protein requirement as soon as hemodynamic status was stabilized. We found the study group had a lower mortality rate, a lower complication rate, a shorter period of ICU stay, and an earlier weaning from the ventilator than the control group. The study group also lost less weight than the control group. Nitrogen balance in the study group was significantly lower than the control group.

A supplemental special burn diet for extensively burned patients.

Sixteen severely burned patients, divided into four groups according to the extent of their burns, were studied while being fed a special diet used as a supplemental nutritional support. The first group of two patients comprised those with burns covering less than 20 percent of the body surface area (BSA). The second group of six patients comprised those with burns covering 21-40 percent BSA. The third group of six patients had burns covering 41-60 percent BSA, and the fourth group of two patients had burns more than 60 percent BSA. The special diet for burn patients was given as a supplemental diet between meals or with meals to fulfil each patient’s demand for calories and protein. Enteral feeding was started as soon as the gastrointestinal function could be tolerated. We found that the special diet for burn patients raised the positive nitrogen balance in all group and kept weight loss to a minimum. For those burned extensively, particularly those with burns exceeding 40 percent BSA, some from of parenteral nutrition was needed as a secondary supplemental diet. Serum albumin gradually rose to the normal levels tended to be slightly elevated. Unfortunately, we have not been able to follow the changes in body chemistry after the patients were discharged from the hospital.

Knowledge, attitude and practice in food values, exercise and daily behaviour in obese children at out-patient clinic of Siriraj Hospital.

An analysis of questionaires taken from 20 cases of childhood obesity in the out-patient clinic of Siriraj Hospital showed these patients lacked in knowledge about food value, exercise, daily behaviour which are contributing factors. Their attitudes towards dietary control, exercise and active asctivity were also negative. In term of practice. these patients were fond of various kinds of foods, inactive in physical exercise and household routine work. We can use this preliminary report as a guideline for treating these patients, by changing or improving their knowledge, attitude and practices in food values. Exercise and daily behaviour.