Early enteral farmaconutrition improve nutritional status and reduce systemic inflammation in severe subarachnoid hemorrhage

Introduction Critically ill patients are at high risk to develop acute protein-energy malnutrition due to stress catabolic reaction and adaptative inflammatory and immunological responses. In severe aneurismatic subarachnoid hemorrhage (SAH) there are evidences that supports the role of inflammation and malnutrition on worse outcome, as important players of local (vasospasm) and general (extra-cerebral organ dysfunction) effects. Objective and methods The objective of this study was to compare the effects of early enteral farmaconutrition vs. standard formula on blood visceral protein and on plasmatic markers and clinical expression of systemic inflammatory response (SIRS) in critically ill patients suffering from severe SAH. Thirty-two consecutive patients (age 61.6±11.6; well nourished: BMI 25.4±4) with critical catabolism (0.150±0.05 g/kg/day nitrogen loss) and severe aneurysmatic SAH (HH grade: 4-5; GCS: <9; SAPS II: 48±9) were enrolled and randomized to receive early (target reached 44±20 hours post admission) enteral nutrition with two isocaloric isoprotein regimens for 7 days. The nutrition support consisted in 27±3 kcal/kg/day and 1.43±0.4 g/kg/day of protein. The farmaconutrition treated group (FnG, 19 pts.) received a whey protein-based formula supplemented with n-3 PUFAs (α-linolenic ac., DHA, EPA) and low n-6 PUFAs (Peptamen AF, Nestlé, CH); the control group (CG, 13 pts.) received a standard formula (Nutrison Energy, Nutricia, NL plus Isosource Protein, Nestlé, CH). Pre (T0) and post-treatment (T8) were monitored the blood levels of Prealbumin (PRE), Transferrin (TSF), C-reactive Protein (PCR), Procalcitonine (PCT), Aptoglobine (APT), and IL-6. Clinical presence of systemic inflammation and related organ failure were defined according standard criteria (SIRS, SOFA score). At day T3 and T8 was also measured the nitrogen balance (NB). Results were expressed as a mean±SD and comparison using Student’s t-test. Results Both groups at T0 showed similar and comparable (t-test: n.s.), occurrence of clinical SIRS (CG: 73% vs. FnG: 71% pts), and SOFA severity score (CG: 6.4±2.4 vs. FnG: 6.9±1.4). IL-6, and PCR blood levels result raised at supernormal values (three, ten times). At T0, PCT, and APT result slightly over normal, whereas PRE and TSF showed reduced and under normal levels. FnG respect to CG presented at the end of the nutritional protocol more free SIRS days over the treatment period (3,3 vs. 1 day, p<0.01), decrease in SOFA Score (-2 vs. -1,1, p< 0,01), reduced IL-6 plasma levels (33.2±6,5 vs. 58.5±7.3 pg/mL, p<0.05) and PCR (8.1±5.5 vs. 11.2±4.3 mg/dL, p< 0.05). The same FnG showed more marked increase in PRE (39.7±18 vs. 24.2±11 mg/dL) and APT plasma levels (466.9±157 vs. 325.2±186 mg/dL). The enteral tolerance in FnG resulted higher as in CG (energy administered respect to prescribed over the protocol: 96% vs. 84%). Conclusions: In neurocritical patients short term enteral nutrition enriched with n-3 may protect the visceral protein synthesis and reduce the systemic inflammatory response.