Enteral Support and N-3 Fatty Acids in Critically Ill Elderly Patients

  • Karina V. Barros
  • Ana Paula Cassulino
  • Vera Lúcia Flor Silveira
Reference work entry

Abstract

Ageing is characterized by a series of physiological and psychological changes that are related, in turn, with alterations in the nutritional status. The human immune system progressively deteriorates with age, leading to a greater incidence or the reactivation of infectious diseases, as well as to the development of autoimmune disorders and cancer.

The critically ill elderly are more likely to suffer an exacerbated inflammatory response increasing the susceptibility of infection, sepsis, septic shock and multiple organ failure development, which are related to a longer hospitalization period and elevated risk of mortality.

The relationship between inflammatory response and polyunsaturated fatty acids (PUFA)–enriched diets has been investigated in last years. Several studies have shown that PUFA can modify immunological and inflammatory reactions and can be used as a complementary therapy in chronic diseases. Enteral formulas supplied with specific pharmaconutrients can help offset tissue damage and moderate the inflammation.

In this sense, n-3 PUFA intake can alter the fatty acid composition in membranes of cells involved in immune inflammatory responses and leading to better outcomes. Several clinical studies have shown that the administration of n-3 PUFA can blunt the inflammatory response in critically ill patients.

Although n-3 PUFA as pharmaconutrition appears to exert beneficial effects with no side effects, enteral supplementation of this fatty acid has presented conflicting data in the literature. These discordant data are most likely due to different routes of administration (enteral or parenteral), dose, duration of administration, timing of onset in relation to stage of the inflammatory response and differences in the nutrient combinations used. Further researches are necessary before any definitive recommendations can be made about enteral n-3 PUFA supplementation in critically ill patients, mainly in special populations, such as the elderly.

This chapter will focus on the literature review about the critically ill elderly, inflammation, fatty acids and n-3 PUFA supplementation in enteral nutrition.

Keywords

Cholesterol Permeability Arthritis Glycerol Phytoplankton 

List of Abbreviations

AA

Arachidonic acid

ALA

α-linolenic acid

APC

Antigen presenting cells

ASPEN

American society of parenteral and enteral nutrition

CVD

Cardiovascular disease

D5D

Delta-5-desaturases enzyme

D6D

Delta-6-desaturases enzyme

DHA

Docosapentaenoic acid

EFSA

European Food and Safety Authority (EFSA)

EPA

Eicosapentaenoic acid

ESPEN

European society of parenteral and enteral nutrition

FA

Fatty acids

FDA

Food and Drug Administration

GLA

Gamma linolenic acid

ICAM

Intercellular adhesion molecule

ICU

Intensive care unit

IL

Interleukin

LA

Linoleic acid

NHF

National heart foundation

NHMRC

National Healthy of Medical Research Council (NHMRC)

PC

Plasma phosphatidylcholine

PUFA

Polyunsaturated fatty acids

ROS

Reactive oxygen species

SNP

Single nucleotide polymorphism

TNF

Tumor necrose factor

References

  1. Barros KV, Cassulino AP, Schalch L, et al. Supplemental intravenous n-3 fatty acids and n-3 fatty acid status and outcome in critically ill elderly patients in the ICU receiving enteral nutrition. Clin Nutr. 2012;32(4):599–605.CrossRefPubMedGoogle Scholar
  2. Barros KV, Cassulino AP, Schalch L, et al. Pharmaconutrition: Acute fatty acid modulation of circulating cytokines in elderly patients in the ICU. JPEN J Parenter Enteral Nutr. 2014; 38(4):467–74CrossRefPubMedGoogle Scholar
  3. Bokor S, Dumont J, Spinneker A, HELENA Study Group, et al. Single nucleotide polymorphisms in the FADS gene cluster are associated with delta-5 and delta-6 desaturase activities estimated by serum fatty acid ratios. J Lipid Res. 2010;51(8):2325–33.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Bottoni A, Bottoni A, Cassulino AP, et al. Impact of nutrition support teams on hospitals’ nutritional support in the largest South American city and its metropolitan area. Nutrition. 2008;24(3):224–32.CrossRefPubMedGoogle Scholar
  5. Burr GO, Burr MM. A new deficiency disease produced by the rigid exclusion of fat from the diet. Nutr Rev. 1973;31:248–9.PubMedGoogle Scholar
  6. Calder PC. Immunomodulation by omega-3 fatty acids. Prostaglandins Leukot Essent Fatty Acids. 2007;77:327–35.CrossRefPubMedGoogle Scholar
  7. Calder PC. The 2008 ESPEN Sir David Cuthbertson lecture: fatty acids and inflammation: from the membrane to the nucleus and from the laboratory bench to the clinic. Clin Nutr. 2010;29:5–12.CrossRefPubMedGoogle Scholar
  8. Calder PC. Fatty acids and inflammation: the cutting edge between food and pharma. Eur J Pharmacol. 2011;668:S50–8.CrossRefPubMedGoogle Scholar
  9. Calder PC. Long-chain fatty acids and inflammation. Proc Nutr Soc. 2012;71:284–9.CrossRefPubMedGoogle Scholar
  10. Calder PC, Jensen GL, Koletzko BV, et al. Lipid emulsion in parenteral nutrition of intensive care patients: current thinking and future directions. Intensive Care Med. 2009;36:735–49.CrossRefGoogle Scholar
  11. Carvalho-Silva DR, Santos FR, Rocha J, Pena SD. The phytogeography of Brazilian Y-chromosome lineages. Am J Hum Genet. 2001;68:281–9.CrossRefPubMedGoogle Scholar
  12. Cederholm T, Persson M, Anderson P, et al. Polymorphisms in cytokine genes influence long-term survival differently in elderly male and female patients. J Intern Med. 2007;262:215–23.CrossRefPubMedGoogle Scholar
  13. Chan LY, Moran JL, Clarke C, et al. Mortality and cost outcomes of elderly trauma patients admitted to intensive care and the general wards of an Australian tertiary referral hospital. Anaesth Intensive Care. 2009;37:773–83.PubMedGoogle Scholar
  14. Chernoff R. Physiologic aging and nutritional status. Nutr Clin Pract. 1990;5:8–13.CrossRefPubMedGoogle Scholar
  15. Cormier H, Rudkowska I, Paradis AM, et al. Association between polymorphisms in the fatty acid desaturase gene cluster and the plasma triacylglycerol response to an n-3 PUFA supplementation. Nutrients. 2012;4(8):1026–41.CrossRefPubMedPubMedCentralGoogle Scholar
  16. EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA) (2010) Scientific Opinion on Dietary Reference Values for fats, including saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids, and cholesterol. EFSA Journal 2010; 8(3):1461 [107 pp.]. http://www.efsa.europa.eu/en/efsajournal/pub/1461.htm
  17. Fülöp T, Larbi A, Hirokawa K, et al. Immunosupportive therapies in aging. Clin Interv Aging. 2007;2(1):33–54.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Gadek JE, DeMichele SJ, Karistad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linoleic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral nutrition in ARDS Study Group. Crit Care Med. 1999;27:1409–20.CrossRefPubMedGoogle Scholar
  19. Glaser C, Lattka E, Rzehak P, et al. Genetic variation in polyunsaturated fatty acid metabolism and its potential relevance for human development and health. Matern Child Nutr. 2011;7 Suppl 2:27–40.CrossRefPubMedGoogle Scholar
  20. Graf C. Functional decline in hospitalized older adults. Am Nurs J. 2006;106(1):58–67.CrossRefGoogle Scholar
  21. Grau-Carmona T, Morán-García V, García-de-Lorenzo A, et al. Effect of an enteral diet enriched with eicosapentaenoic acid, gamma-linolenic acid and anti-oxidants on the outcome of mechanically ventilated, critically ill, septic patients. Clin Nutr. 2011;30(5):578–84.CrossRefPubMedGoogle Scholar
  22. Hegazi RA, Wischmeyer PE. Clinical review: optimizing enteral nutrition for critically ill patients-a simple data-driven formula. Crit Care. 2011;15(6):234.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Heller AR, Rossler S, Litz RJ, et al. Omega-3 fatty acids improve the diagnosis-related clinical outcome. Crit Care Med. 2006;34:972–9.CrossRefPubMedGoogle Scholar
  24. Hensen AE, Haggard ME, Boelsche NA, et al. Essential fatty acids in infant nutrition. J Nutr. 1958;66:565–76.Google Scholar
  25. Heyland DK, Schroter-Noppe D, Drover JW, et al. Nutrition support in the critical care setting: current practice in Canadian ICUs-opportunities for improvement? J Parenter Enteral Nutr. 2003;27(1):74–83.CrossRefGoogle Scholar
  26. Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med. 2011;39(12):2619–26.CrossRefPubMedGoogle Scholar
  27. Holman RT. The slow discovery of the importance of n-3 essential fatty acids in human health. J Nutr. 1998;128:427S–33.PubMedGoogle Scholar
  28. Innis SM. Essential fatty acids in growth and development. Prog Lipid Res. 1991;30:39–108.CrossRefPubMedGoogle Scholar
  29. Jeejeebhoy KN. Enteral nutrition versus parenteral nutrition–the risks and benefits. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):260–5.CrossRefPubMedGoogle Scholar
  30. Kinsella JE. Lipids, membrane receptors, and enzymes: effects of dietary fatty acids. J Parenter Enteral Nutr. 1990;14(5 Suppl):200S–17.CrossRefGoogle Scholar
  31. Kreymann KG, Berger MM, Deutz NEP, et al. ESPEN guidelines on enteral nutrition. Intensive care. Clin Nutr. 2006;25:210–23.CrossRefPubMedGoogle Scholar
  32. Makinodan T, Kay MM. Age influence on the immune system. Adv Immunol. 1980;29:287–330.CrossRefPubMedGoogle Scholar
  33. Marik PE. Management of the critically ill geriatric patients. Crit Care Med. 2006;34(9S):S176–82.CrossRefPubMedGoogle Scholar
  34. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Board of Directors and the American College of Critical Care Medicine. J Parenter Enteral Nutr. 2009;33:277–316.CrossRefGoogle Scholar
  35. Mira JP, Cariou A, Grall F, et al. Association of TNF2, a TNF-α promoter polymorphism, with septic shock susceptibility and mortality: a multicenter study. JAMA. 1999;282(6):561–68.CrossRefPubMedGoogle Scholar
  36. Nakada T, Hirasawa H, Oda S, et al. Influence of toll-like receptor 4, CD14, tumor necrosis factor, and interleukine-10 gene polymorphisms on clinical outcome in Japanese critically ill patients. J Surg Res. 2005;129:322–8.CrossRefPubMedGoogle Scholar
  37. National Heart Foundation of Australia. Position statement on Fish, fish oils, n-3 polyunsaturated fatty acids and cardiovascular health, 2008. http://www.heartfoundation.org.au/SiteCollectionDocuments/Fish-position-statement.pdf
  38. Paoloni-Giacobino A, Grimble R, Pichard C. Genomic interactions with disease and nutrition. Clin Nutr. 2003;22(6):507–14.CrossRefPubMedGoogle Scholar
  39. Peuhkuri K, Vapaatalo H, Korpela R. Even low-grade inflammation impacts on small intestinal function. World J Gastroenterol. 2010;16(9):1057–62.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Pontes-Arruda A, Demichele S, Seth A, Singer P. The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome data. J Parenter Enteral Nutr. 2008;32(6):596–605.CrossRefGoogle Scholar
  41. Rangel-Huerta OD, Aguilera CM, Mesa MD, Angel GA. Omega-3 long-chain polyunsaturated fatty acids supplementation on inflammatory biomarkers: a systematic review of randomized clinical trials. Br J Nutr. 2012;107:S159–70.CrossRefPubMedGoogle Scholar
  42. Rankin JA. Biological mediators of acute inflammation. AACN Clin Issues. 2004;15(1):3–17.CrossRefPubMedGoogle Scholar
  43. Rice TW, Wheeler AP, Thompson BT, NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators, et al. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA. 2011;306(14):1574–581.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Rymkiewicz PD, Heng YX, Vasudev A, Larbi A. The immune system in the aging human. Immunol Res. 2012;53(1–3):235–50.CrossRefPubMedGoogle Scholar
  45. Rzehak P, Heinrich J, Klopp N, et al. Evidence for an association between genetic variants of the fatty acid desaturase 1 fatty acid desaturase 2 (FADS1 FADS2) gene cluster and the fatty acid composition of erythrocyte membranes. Br J Nutr. 2009;101(1):20–6.CrossRefPubMedGoogle Scholar
  46. Sala-Vila A, Miles EA, Calder PC. Fatty acid composition abnormalities in atopic disease: evidence explored and role in the disease process examined. Clin Exp Allergy. 2008;38(9):1432–50.CrossRefPubMedGoogle Scholar
  47. Semplicini A, Valle R. Fish oils and their possible role in the treatment of cardiovascular diseases. Pharmacol Ther. 1994;61(3):385–97.CrossRefPubMedGoogle Scholar
  48. Serhan CN. Novel chemical mediators in the resolution of inflammation: resolvins and protectins. Anesthesiol Clin. 2006;24:341–64.CrossRefPubMedGoogle Scholar
  49. Shimaoka M, Park EJ. The compensatory anti-inflammatory response syndrome (CARS) in critically ill patients. Clin Chest Med. 2008;29:617–27.CrossRefGoogle Scholar
  50. Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21:495–505.CrossRefPubMedGoogle Scholar
  51. Simopoulos AP. The importance of the Omega-6/Omega-3 fatty acid ratio in cardiovascular disease and other chronic diseases. Exp Biol Med. 2008;233:674–88.CrossRefGoogle Scholar
  52. Singer P, Cohen J. Nutrition is metabolism. J Parenter Enteral Nutr. 2010;34(5):471–2.CrossRefGoogle Scholar
  53. Singer P, Theilla M, Fisher H, et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med. 2006;34:1861.CrossRefGoogle Scholar
  54. Stapleton RD, Martin JM, Mayer K. Fish oil critical illness: mechanisms and clinical applications. Crit Care Clin. 2010;26:501–14.CrossRefPubMedPubMedCentralGoogle Scholar
  55. Theilla M, Singer P, Cohen J, Dekeyser F. A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with acute lung injury: a randomized, prospective, controlled study. Clin Nutr. 2007;26(6):752–7.CrossRefPubMedGoogle Scholar
  56. Villani AM, Crotty M, Cleland LG. Fish oil administration in older adults: is there potential for adverse events? A systematic review of the literature. BMC Geriatr. 2013;13(1):41.CrossRefPubMedPubMedCentralGoogle Scholar
  57. Visentainer JEL, Lieber SR, Persoli LBL, et al. Serum cytokine levels and acute graft-versus-host disease after HLA-identical hematopoietic stem cell transplantation. Exp Hematol. 2003;31:1044–50.CrossRefPubMedGoogle Scholar
  58. Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007;35:1928–36.CrossRefPubMedGoogle Scholar
  59. Weiss G, Meyer F, Mathies B, et al. Immunomodulation by preoperative administration of n-3 fatty acids. Br J Nutr. 2002;87:S89–94.CrossRefPubMedGoogle Scholar
  60. Wick G, Jansen-Dürr P, Berger P, et al. Diseases of aging. Vaccine. 2000;18:1567–83.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Karina V. Barros
    • 1
  • Ana Paula Cassulino
    • 1
  • Vera Lúcia Flor Silveira
    • 2
  1. 1.Departamento de FisiologiaUniversidade Federal de São Paulo-Campus São PauloSão PauloBrazil
  2. 2.Departamento de Ciências BiológicasUniversidade Federal de São Paulo-Campus DiademaEldorado, DiademaBrazil

Personalised recommendations