dr.chris a johannes_micronutrients in critical ill-1
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MICRONUTRIENTS IN CRITICAL
ILL
Chris A Johannes
Central Army HospitalJAKARTA, INDONESIA
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Introduction
Micronutrient:
- Vitamins.
Cofactors in the different
metabolic steps of enzyms, CH,
Prot. Lipid Metabolism.
- Trace element : metals andmetalloids pressent in the body at fairly
constant concentrations.
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Introduction
Micronutrients, involved in :
- Prevention of nutritional deficiencies.
- Immune-humoral .
- Cellular defence.
- Regulation of gen expression during the
acute phase response.- Antioxidant defense.
- Prevention of chronic diseases.
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Introduction
There is growing evidence that
micronutrient deficiencies occur in the
critically ill . ( Sepsis, major burns andconditions with ischemia reperfusion.
Micronutrient in critically ill patients will
be those that are directly or indirectlyinvolve in metabolic support as well as in
antioxidant and immune defense.
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Systemic responses of the Critically Ill
Critically Ill patients:
- Dependent on Artificial, technical and
metabolic support.
- Hypermetabolic.
- Increased nutritional requirements.- Increased of Vitamins and Trace
element losses .
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Systemic responses of the critically Ill
e.g :
- Septic patients : high vitamin A
urinary excretion.
- Burns patients : Lose major amounts
of copper, zinc.
- Trauma patients : Lose zinc and selenium.
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Systemic responses of the critically Ill
Critically Ill patients:
- Exhibit intense inflammatory and acute
phase response, which cause := Major changes to endocrine and immune
systems, and metabolic regulations with
resistance to nutrition.
= Increased of production of cytokines and
other mediators, increased of free radical
production ( ROS and NO ).
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Antioxidation and Immunity: Role of
Micronutrient Free radicals are atoms or molecules
containing one or more unpaired
electrons: they are unstable and strive torestore parity. ( ROS ) production occurs
under normal aerobic metabolism.
NO normal product of endothelialmetabolism
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Antioxidation and Immunity: Role of
Micronutrients ROS :
- Mainly produced by leukocytes and by
respiratory mitochondrial chain.
- Required for cell signaling.
- Bacterial defense.
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Antioxidation and Immunity: Role of
Micronutrients Antioxidant are substances which inhibit
or delay oxidation of a substrate while
present in minute amounts.
Endogenous Antioxidant defenses :
- enzymatic ( superoxide, dismutase,
glutathione peroxidases/ GSHPx,
catalase )
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Antioxidation and Immunity: Role of
Micronutrients- nonenzymatic ( uric acid, gluthatione,
bilirubin, thiols, albumin and
nutrtional factors including vitamins
and trace elements )
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Antioxidation and Immunity: Role of
Micronutrients The enzymes act in cascades and depend on
trace element for structure and activity.
Nutritional antioxidants act through differentmechanism :
1. Directly neutralize free radicals.
2. Reduce the peroxide concentrations
and repair oxidized membranes.3. Quench iron to decrease ROS production.
4. Via lipid metabolism, short chain FFA andCholesteryl ester neutralize ROS.
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Antioxidation and Immunity: Role of
Micronutrients Oxidative stress:
- Increased ROS and NO production,
respectively by products of lipid
peroxidation.
- Determination of low antioxidantdefense.
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Antioxidation and Immunity: Role of
Micronutrients- Imunnity compromised.
Immune defense is closely linked to
antioxidant defense:
= Membrane fluidity and intergrity
=> Vit. E.
= Genomic change => selenium.
= cell replication => zinc
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Antioxidation and Immunity: Role of
Micronutrients Leukocytes membranes are constituted by
saturated and unsaturated FA mayb
oxidized, and can be destroyed by ROS. Selenium essential for immune defense.
Vitamin B Group. Contributes indirectly to
antioxidant defense through theintermediary metabolism.
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Antioxidation and Immunity: Role of
Micronutrients Thiamine ( Vi.B1 ), co enzyme of
carbohydrate decarboxylation reaction.
Thiamine deficiency is very frequent in
Critically ill patients.
Riboflavine ( vit.B2 ), coenzyme in
mitochondrial respiratory chain.
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Supplementation in the Critically Ill
Antioxidant supplementation in criticall
ill:
1. Vitamins C.
2. Vitamins E.
3. Cooper.
4. Selenium.
5. Zinc.
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Supplementation in the Critically Ill
Angstwum et al ( 1999 ):
In 42 Critically ill pts with Sepsis,
selenium supplementation for 9 days was
associated with a significant reduction in
ARF.( 3/21 pts vs 9/21 pts, p = 0,035 )
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Supplementation in the Critically Ill
Berger et al ( 2002 ) :
In 10 burns pts, interleukin 6 levels were
lower in the supplemented pts after 24 h
of trace element supllementation
including 350 ug/day selenium.
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Micronutrient: Basic Nutritional and
Antioxidant RequrementsMicronut. Rdi for Oral iv dose
===========================================
iv use 45% - burn: 2,5 -
Copper 0,51,5mg 5 mg
liver dis.
5 mg
Selenium 3060 ug 70% - burns: 350
sepsis: 300
- 900
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Conclusions
Vitamins and Trace elements are
particularly important in the critically ill pts,
mainly thyamine, tocopherol, ascorbic acid,copper, selenium and zinc.
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