Plasma glutamine concentration among critically ill children

Eksteen, Joanna ; Wilson, Joanna (2019-03)

Thesis (MNutr)--Stellenbosch University, 2019.

Thesis

ENGLISH SUMMARY : Background: Glutamine is considered conditionally essential during critical illness and supplementation of the nutrient has become commonplace among adult ICU populations. However, recent concern over the safety of this practice has highlighted the need for focused research on plasma glutamine levels in specific patient groups. There is limited evidence for glutamine supplementation in children, with even les s data available on plasma concentrations within this group. The aim of this study was to describe plasma glutamine concentration among critically ill children on admission to and on day two of Paediatric Intensive Care Unit (PICU) stay, and to identify associations between plasma glutamine and markers of clinical condition, nutritional status and intake, and clinical outcome. Methods: This descriptive cross-sectional study investigated the plasma glutamine concentrations of patients admitted to a tertiary PICU in the Western Cape, South Africa, over a period of one month. Plasma glutamine was analysed using blood samples collected on admission, and on day two of PICU stay. Markers of clinical condition on admission (diagnostic profile, severity of disease, presence of infectious disease, and routine biochemistry) were collected. Age-appropriate anthropometry was conducted, and the nutritional status of participants was assessed using World Health Organization Z scores. Nutritional intake was recorded and analysed for the first two days of PICU stay. Results: Seventy six participants were included in this study, many of whom (47%) were post-operative cardiac patients. Plasma glutamine concentrations were normal for most participants on admission (median 556.5 umol/l, IQR 459- 664.5 umol/l) and on day two of PICU stay (median 529.0 umol/l, IQR 356.0-716.0 umol/l). No obvious change in plasma levels occurred during this period. Significant differences in plasma glutamine were found between medical and elective surgery (p = 0.007) and trauma (p = 0.013) patients with trauma observed to have the lowest concentrations on admission (mean 450.3 ± 166.7 umol/l). Differences were also observed between cardiology and gastroenterology (p = 0.018), and between sepsis and pulmonology (p = 0.031), burns (p = 0.035), gastroenterology (p = 0.006), and ‘other’ (p = 0.049) diagnoses. Participants with sepsis had the highest plasma glutamine on admission (mean 736.3 ± 142.5 umol/l). Participants with higher plasma glutamine on admission tended to have longer hospital stays (p = 0.067), and a higher mortality risk (p = 0.052). Although no link was made with mortality, those who died had higher plasma glutamine on day two of PICU stay (p = 0.057). Conclusion: This study found normal plasma glutamine concentrations among critically ill children over the first two days of PICU stay. Significant differences were found in plasma glutamine between diagnostic groups, with sepsis and trauma identified as areas for future study. A tendency was demonstrated toward poorer outcome and increased mortality risk among those with high plasma glutamine. Additional exploratory research is required to better understand plasma glutamine in different paediatric subgroups.

AFRIKAANSE OPSOMMING : Agtergrond: Glutamien word beskou as kondisioneel noodsaaklik tydens kritiese siektes en aanvullings van die nutriënt word gereeld in intensiewe sorg eenhede gebruik. Onlangse kommer oor die veiligheid van dié praktyk beklemtoon die behoedfte vir meer gefokusde navorsing oor plasma glutamienvlakke in spesifieke pasiënt populasies. Daar is ‘n gebrek aan navorsing oor die rol van glutamien aanvullings in kinders, en data oor plasma konsentrasies in die groep is selfs meer beperk. Die doel van die studie was om plasma glutamien konsentrasies in kinders in die pediatriese intensiewe sorg eenheid (PICU) te beskryf, beide met hospitaal toelating en op dag twee van verblyf; en om assosiasies tussen plasma glutamien en merkers van kliniese toestand, voedingstatus, inname en ook kliniese uitkomste te identifiseer. Metodes: Hierdie dwarssnit beskrywende studie het die plasma glutamien konsentrasies ondersoek in pasiënte opgeneem tot ‘n tersiêre PICU in die Wes-Kaap, Suid Afrika, oor ‘n tydperk van een maand. Bloedmonsters is geneem met toelating en op die tweede dag van PICU verblyf en is geanaliseer vir plasma glutamine konsentrasie. Merkers van kliniese toestande met toelating (diagnostiese profiel, erns van siekte, teenwoordigheid van infeksie, en roetine biochemie) is ingesamel. Ouderdoms-toepaslike antropometrie is geneem en voedingstatus is bepaal met die Wêreldgesondheidsorganisasie Z-tellings. Voedingsinname is gedokumenteer en geanaliseer vir die eerste twee dae van PICU verblyf. Resultate: Die studie het ses-en-sewentig deelnemers ingesluit, die meerderheid (47%) was post-kardiale chirurgie pasiënte. Plasma glutamien konsentrasies was normaal vir meeste van die deelnemers met toelating [mediaan 556.5 umol/l, interkwartielvariasiewydte (IQR) 459- 664.5 umol/l] en op dag twee PICU verblyf (mediaan 529.0 umol/l, IQR 356.0-716.0 umol/l). Geen ooglopende veranderinge in plasma vlakke het tydens die periode plaasgevind nie. Beduidende verskille in plasma glutamien is gevind tussen mediese en elektiewe chirurgie (p = 0.007) en ook trauma (p = 0.013) pasiënte, met die laagste konsentrasies met toelating in trauma pasiënte (gemiddeld 450.3 ± 166.7 umol/l). Verskille in glutamien konsentrasie is ook waargeneem tussen kardiologie en gastroënterologie (p = 0.018), tussen sepsis en pulmonologie (p = 0.031), brandwonde (p = 0.035), gastroënterologie (p = 0.006), en ‘ander’ (p = 0.049) diagnoses. Deelnemers met sepsis het die hoogste glutamien met toelating gehad (gemiddeld 736.3 ± 142.5 umol/l). Deelnemers met hoër plasma glutamien met toelating was meer geneig om langer in die hospitaal te bly (p = 0.067), en het ‘n hoër sterfterisiko gehad (p = 0.052). Alhoewel daar geen verband met mortaliteit was nie, het dié wat oorlede is hoër plasma glutamien vlakke getoon op dag twee van PICU verblyf (p = 0.057). Gevolgtrekking: Die studie het normale plasma glutamien konsentrasies in kritiese siek kinders tydens die eerste twee dae van PICU verblyf gevind. Beduidende verskille is gevind in plasma glutamien tussen diagnostiese groepe, met sepsis en trauma geïdentifiseer as fokus areas vir toekomstige navorsing. ‘n Neiging na swakker uitkomste en hoër sterfterisiko in diegene met hoër plasma glutamien is gedemonstreer. Addisionele verkennende navorsing word benodig vir ‘n beter begrip van plasma glutamien in verskillende pediatriese subgroepe.

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