Nutritional pharmacology in surgery and critical care: 'you must unlearn what you have learned'.

PURPOSE OF REVIEW: This review highlights the rapidly evolving field of 'pharmaconutrition' by discussing the mechanistic and clinical data for calorie delivery and nutrients shown to improve outcome in surgical and ICU care. RECENT FINDINGS: International survey data reveals patients in acute care settings receive approximately 50% of calories/protein they are prescribed. This is, in part, due to the archaic practice of patients remaining nil per os postoperatively until return of bowel sounds. We also know certain nutrients serve as pharmacologic agents and improve clinically relevant outcomes. Thus, larger therapeutic doses of specific nutrients may be required to replace acute deficiencies brought on by specific injury states. Specifically, arginine can reduce postsurgical infection 40% as shown in over 30 trials of more than 3200 patients. Glutamine and fish oil have been shown to reduce mortality in general critical care and acute respiratory distress syndrome patients, respectively. SUMMARY: We believe the future of surgical and ICU nutrition will involve administering specific pharmaconutrients as separate components, much like drugs are given. The current use of clinical pharmacology, molecular biology, and clinical research principles in the study of pharmaconutrients should yield answers on how to administer the right nutrients, in the right doses, at the right time in sick patients.

Duke Scholars

Author Paul Edmund Wischmeyer Anesthesiology, Critical Care Medicine