Alternate modalities for nutrition by Bharesh Dedhia

Bharesh Dedhia
Glutamine has been the focus of much study because it may be important in the maintenance of gut and immunological integrity during critical illness. It is the most abundant free amino acid in the circulation and is a primary fuel for rapidly dividing cells such as enterocytes and immunocytes .It is also involved in the inter-organ transport of nitrogen. Evidence from animal studies has indicated that glutamine may be an essential amino acid during critical illness and that parenteral and enteral glutamine-supplemented nutrition may prevent bacterial translocation. The data in humans are less compelling .Glutamine is rather insoluble and thus is difficult to administer. Some success has been achieved infusing it as the L-amino acid, glutamine-dipeptides or alanyl-glutamate. Initial reports indicate that in some catabolic patients glutamine-containing nutrition may improve gut structure and function, exert an anabolic effect and reduce morbidity, hospital costs, infection rates and duration of hospital stay. More studies are needed to ascertain whether glutamine administration improves outcome .Access for enteral nutrition is a problematic issue due to the problems of securing a reliable route. Placement of the tip of the tube into the jejunum is considered ideal so as to avoid the often present gastric ileus and possibly prevent aspiration. There has been some disagreement as to whether it is mandatory to place the tube into the jejunum. The ideal route is a jejunostomy catheter placed during laparotomy, because feeding may begin within hours of surgery. Complication rates are comparatively low (1.5%) and most commonly involve catheter occlusion or dislodgment. Very rarely bowel necrosis or intra-abdominal leaks may occur .Alternatively, a nasoenteric tube can be passed during surgery and manually manipulated into the jejunum. In patients without surgical placement, nasoenteric tubes may be placed. It is often difficult to pass such tubes from the stomach into the jejunum. Right lateral decubitus positioning and prokinetic drugs may be tried, but often placement must be performed under radiological or endoscopic guidance.
Bharesh Dedhia