General information:
Over the past decade, there have been significant advances in our understanding of the role of nutrition in general, and key nutrients specifically, in the treatment of critically ill patients. Over 40 years ago, when artificial nutrition was developed, it was conceived of as supportive care, as administering metabolic support while the patient recovers from their underlying illness.  Nutrition support teams were developed, malnourished and catabolic patients were identified, measurements and calculations were done, and artificial nutrition was provided to minimize the loss of protein, calories, and micronutrients associated with inflammatory conditions. During this era, very few large-scale trials informed practice patterns. It seemed that as long as the nutrition interventions ‘restored' deficient substrates or reduced the loss of expended substrates, it was provided to broad, heterogeneous groups of patients, with little regard for its effect on clinically important outcomes.  Debates over energy requirements or protein loss dominated the discussion.  Over the last decade, with the application of meta-analytic techniques, and larger randomized clinical trials, stronger signals of therapeutic effect have appeared. Our nutritional strategies appeared to be making an impact on patient outcomes as recently summarized in the form of clinical practice guidelines (i). What was most illuminating from this review process was that the largest treatment effects on clinically important outcomes were from studies of specific nutrients, such as glutamine, antioxidants, fish oils, and arginine.  Thus, the concept of pharmaconutrition emerged.  Distinct from the historical concepts, this new treatment paradigm embraced the fact that nutrients (and some nutritional strategies) have profound effects on underlying inflammatory, immunological, metabolic, and other pathophysiological processes of critically ill patients. The focus was on understanding the influence of these nutrients on the underlying disease process and subsequent clinical outcomes, and less about nitrogen balance or energy requirements.  We have moved from supporting patients while they recover from their underlying illness to modulating that disease response and improving the chances of survival.

Listen to the Podcast of Dr. Daren Heyland on Pharmaconutrition here, presented by the Society of Critical Care Medicine (SSCM)

Recently published reviews:

• Jones, N. E. Heyland, D. K. Pharmaconutrition: a new emerging paradigm. Current Opinion in Gastroenterology. 2008: 24: 215-222. Pubmed Abstract
• Wischmeyer, P. E. Glutamine: role in critical illness and ongoing clinical trials. Current Opinion in Gastroenterology. 2008: 24: 190-197. Pubmed Abstract
• Heyland DK, Jones N, Cvijanovich NZ, Wong H. Zinc supplementation in critically ill patients: a key pharmaconutrient?  JPEN 2008 32(5):509 19. Pubmed Abstract

See the Presentations section for information on Pharmaconutrition.

See the CPGs for randomized controlled trials in pharmaconutrition.