1. Greg Gaines PA-S A RANDOMIZED TRIAL OF GLUTAMINE AND ANTIOXIDANTS IN CRITICALLY ILL PATIENTS

2. OUTLINE Glutamine Depletion Methods Results Conclusion

3. GLUTAMINE DEPLETION In critically ill patients there is rapid depletion of plasma glutamine levels Associated with increased mortality Hypothesized that critically ill patients with organ dysfunction would be most likely to have low plasma glutamine levels

4. TRIAL OBJECTIVE Evaluate the effect of glutamine and antioxidant supplementation Hypothesis: Supplementation will reduce 28 day mortality P<0.044 would indicate statistical significance

5. METHODS Blinded 2-by-2 study Patient Population 1218 critically ill adults Multiorgan failure Mechanical ventilation Location of the trial 40 different ICUs United States, Canada, Europe April 2005 - December 2011

6. METHODS Patients were given Glutamine (303) Antioxidants (308) Both (310) Placebo (302) Administration Within 24 of admission Intravenously and enterally For a maximum of 28, until discharge, or death

7. RESULTS 70.9% of enteral study supplements 89.1% of IV study supplements 28-day mortality: 29.8% (95% CI, 27.2-32.5) Glutamine had increased mortality trend (32.4% vs. 27.2%) Antioxidants had no difference Glutamine and Antioxidants together had no significant difference 6 month mortality Significantly increase with patients who received glutamine Discharge median time from the ICU was significantly increased Antioxidant had no results

8. CONCLUSION Glutamine Nonsignificant 28-day mortality increase Significant increase in in-hospital and 6-month mortality No other effect Unknown how it may cause harm Antioxidant No benefit or harm Study population, dose or administration

9. REASONS FOR GLUTAMINE DISCREPANCY This is a larger, more methodical trial than those done in the past These patients received the highest dose of glutamine Both intravenous and enteral supplementation Targeted critically ill patients, the majority or whom were in shock Supplementation was initiated within 24 hours of admission Most received enteral nutrition Substudy of patients did not consistently find a deficiency of glutamine in 66 patients.

10. MY ASSESSMENT OF THE STUDY Too many variables Remove the antioxidants from the study Consider finding what percentage of those, if any in the study actually had glutamine deficiency. Consider a study with subjects that have been determined to have glutamine deficiency.

11. WORKS CITED Hayland MD, Daren,, et al. "A Randomized Trial of Glutamine." New England Journal of Medicine. 368.16 (2013): 1489-1497. Print..