The Clinical Role of Intravenous Glutamine in Trauma Patients Receiving Enteral Nutrition (GLINT)

Effect of Intravenous GLutamine Supplementation IN Trauma Patients Receiving Enteral Nutrition Study Protocol (GLINT Study): A Prospective, Blinded, Randomized, Placebo-controlled Clinical Trial

The purpose of this trial is to investigate if pharmacologically safe dose intravenous glutamine dipeptide supplementation to multiple trauma patients receiving enteral nutrition is associated with improved clinical outcomes in terms of decreased organ dysfunction, infectious complications, and other secondary outcomes

Trauma Patients are characterized by alteration in the immune response, increased exposure to infectious complications, sepsis, and consequently organ failure and death. Glutamine supplementation to parenteral nutrition is one of the nutritional interventions that have been proven to be associated with improved survival rate, decreased infectious morbidity, costs, intensive care unit, and hospital length of stay. However, glutamine supplementation in patients receiving enteral nutrition and its best route are still controversial. A number of trials investigated the beneficial effects of intravenous alanyl-glutamine supplementation in critically ill patients receiving enteral nutrition. However, these trials were: pilot trials, investigated surrogate outcomes, or supplementation was for a short period of time. Therefore, a well designed trial is needed to investigate the effect of intravenous alanyl-glutamine supplementation in critically ill patients with multiple trauma receiving enteral nutrition on major clinical outcomes. Our hypothesis is that trauma patients receiving standard enteral nutrition supplemented with intravenous alanyl-glutamine will demonstrate improved clinical outcomes compared to patients receiving standard enteral nutrition without supplementation.

Intravenous alanyl-glutamine (0.5 g/kg body weight; i.e. 0.35 g L-glutamine / kg body weight; continuous infusion (20-24 hr/day) via central venous access for a maximum duration of 3 weeks.

0.5 g/kg bod weight /day, continuous infusion (20-24 hr/day) via central venous access for a maximum duration of 3 weeks

The change in daily total SOFA score plotted each day over 10 days, where we will compare the regression slope between the two arms of the study.

The change in daily total Sequential Organ failure Assessment Score (SOFA) on the last day of treatment as a measure of severity of organ dysfunction.

Length of stay in hospital (if delayed discharge due to placement problems, will record from the date the patient is regarded as fit for discharge by medical staff).

Fat free mass and fat percentage as a measure of body composition by Bioelectric Impedance analysis (BIA).

Inclusion Criteria: Age 18-58 years Patients admitted with a diagnosis of multiple trauma requiring enteral feeding for > 48 hours Expected length of stay in ICU > 48 hours Has a functional access for enteral tube feeding and a central access for administration of test solution Negative Beta HCG (pregnancy test) in females (18-60 years) Exclusion Criteria: Age < 18 years Significant hepatic failure (Patients with Childs C Cirrhosis) Severe renal failure (estimated glomerular filtration rate [eGFR] < 50 ml/min) Patients with severe metabolic acidosis (pH <7.35) Not expected to be in the ICU > 48 hours (due to imminent death) Unable to tolerate enteral nutrition within 72 hours Enrolment in other ICU intervention study if contraindicated Patients in whom parenteral nutrition is required from the outset Absolute contraindication to enteral nutrition

Al Balushi RM, Paratz JD, Cohen J, Banks M, Dulhunty J, Roberts JA, Lipman J. Effect of intravenous GLutamine supplementation IN Trauma patients receiving enteral nutrition study protocol (GLINT Study): a prospective, blinded, randomised, placebo-controlled clinical trial. BMJ Open. 2011 Nov 14;1(2):e000334. doi: 10.1136/bmjopen-2011-000334. Print 2011.