Arginine Immunonutrition in Critically Ill Patients: A Clinical Dilemma

Joyce K. Stechmiller, PhD, ARNP; Beverly Childress, MSN; Tricia Porter, BSN

Disclosures

Am J Crit Care. 2004;13(1) 

In This Article

Implications for Nursing Practice and Research

Immunonutritional formulas supplemented with arginine ( Table ) are widely used in acute and critical care units to enhance immune function in metabolically stressed patients. These formulas are expensive, and on the basis of the clinical evidence, significant improvements are restricted to surgical patients.

We think that immunonutrition with arginine can be safely used in surgical patients. Patients with critical illness, however, have a heightened immune response and systemic inflammation. Patients with SIRS, sepsis, and organ failure have had adverse effects when given immunonutritional formulas containing high concentrations of arginine, a substance that may increase systemic inflammation and compromise clinical outcomes. Because arginine is potentially toxic, critically ill patients should be given immunonutritional formulas containing arginine only in situations in which extreme caution is taken and under controlled study conditions. Indications of the toxic effects of arginine may include immunosuppression, hemodynamic instability, organ dysfunction, and cytotoxicity. Because arginine intensifies the inflammatory response, the likelihood of toxic effects is highest in patients who have sepsis, SIRS, organ failure, or severe infections. Furthermore, differentiating sepsis from the toxic effects of arginine may be difficult, because the signs and symptoms are similar. Toxic effects due to arginine can also occur in patients with renal or hepatic dysfunction. The effects of immunonutrition with arginine in other subgroups of critically ill patients are less clear, and further research is necessary to determine the safety and efficacy of such immunonutrition.

Further studies are needed that incorporate prospective, randomized, controlled clinical trials designed to carefully investigate the effect of treatment with immunonutrition and arginine in subsets of patients (eg, patients with trauma, sepsis, or SIRS). In addition, clinical trials should include study groups stratified according to severity of illness, and control groups should receive isoenergetic and/or isonitrogenous treatments. Statistical analyses should include intent to treat subjects, and interactions between compliance or tolerance to the study interventions should be dealt with because of the threat of bias. Furthermore, studies should include comparable groups of patients to increase the generalizability of the results.[1]

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