MICRONUTRIENTS IN CRITICAL

ILL
Chris A Johannes

Central Army Hospital

JAKARTA, INDONESIA

Introduction
Micronutrient:
- Vitamins.
Cofactors in the different
metabolic steps of enzyms, CH,
Prot. Lipid Metabolism.
- Trace element : metals and
metalloids pressent in the body at fairly
constant concentrations.

Introduction
Micronutrients, involved in :
- Prevention of nutritional deficiencies.
- Immune-humoral .
- Cellular defence.
- Regulation of gen expression during the
acute phase response.
- Antioxidant defense.
- Prevention of chronic diseases.

Introduction
There is growing evidence that
micronutrient deficiencies occur in the
critically ill . ( Sepsis, major burns and
conditions with ischemia reperfusion.
Micronutrient in critically ill patients will
be those that are directly or indirectly
involve in metabolic support as well as in
antioxidant and immune defense.

Systemic responses of the Critically Ill

Critically Ill patients:
- Dependent on Artificial, technical and
metabolic support.
- Hypermetabolic.
- Increased nutritional requirements.
- Increased of Vitamins and Trace
element losses .

Systemic responses of the critically Ill

e.g :
- Septic patients : high vitamin A
urinary excretion.
- Burns patients : Lose major amounts
of copper, zinc.
- Trauma patients : Lose zinc and selenium.

Systemic responses of the critically Ill

Critically Ill patients:
- Exhibit intense inflammatory and acute
phase response, which cause :
= Major changes to endocrine and immune
systems, and metabolic regulations with
resistance to nutrition.
= Increased of production of cytokines and
other mediators, increased of free radical
production ( ROS and NO ).

Antioxidation and Immunity: Role of

Micronutrient
Free radicals are atoms or molecules
containing one or more unpaired
electrons: they are unstable and strive to
restore parity. ( ROS ) production occurs
under normal aerobic metabolism.
NO normal product of endothelial
metabolism

Antioxidation and Immunity: Role of

Micronutrients
ROS :
- Mainly produced by leukocytes and by
respiratory mitochondrial chain.
- Required for cell signaling.
- Bacterial defense.

Antioxidation and Immunity: Role of

Micronutrients
Antioxidant are substances which inhibit
or delay oxidation of a substrate while
present in minute amounts.
Endogenous Antioxidant defenses :
- enzymatic ( superoxide, dismutase,
glutathione peroxidases/ GSHPx,
catalase )

Antioxidation and Immunity: Role of

Micronutrients
- nonenzymatic ( uric acid, gluthatione,
bilirubin, thiols, albumin and
nutrtional factors including vitamins
and trace elements )

Antioxidation and Immunity: Role of

Micronutrients
The enzymes act in cascades and depend on
trace element for structure and activity.
Nutritional antioxidants act through different
mechanism :
1. Directly neutralize free radicals.
2. Reduce the peroxide concentrations
and repair oxidized membranes.
3. Quench iron to decrease ROS production.
4. Via lipid metabolism, short chain FFA and
Cholesteryl ester neutralize ROS.

Antioxidation and Immunity: Role of

Micronutrients
Oxidative stress:
- Increased ROS and NO production,
respectively by products of lipid
peroxidation.
- Determination of low antioxidant
defense.

Antioxidation and Immunity: Role of

Micronutrients
- Imunnity compromised.
Immune defense is closely linked to
antioxidant defense:
= Membrane fluidity and intergrity
=> Vit. E.
= Genomic change => selenium.
= cell replication => zinc

Antioxidation and Immunity: Role of

Micronutrients
Leukocytes membranes are constituted by
saturated and unsaturated FA mayb
oxidized, and can be destroyed by ROS.
Selenium essential for immune defense.
Vitamin B Group. Contributes indirectly to
antioxidant defense through the
intermediary metabolism.

Antioxidation and Immunity: Role of

Micronutrients
Thiamine ( Vi.B1 ), co enzyme of
carbohydrate decarboxylation reaction.
Thiamine deficiency is very frequent in
Critically ill patients.
Riboflavine ( vit.B2 ), coenzyme in
mitochondrial respiratory chain.

Supplementation in the Critically Ill

Antioxidant supplementation in criticall
ill:
1. Vitamins C.
2. Vitamins E.
3. Cooper.
4. Selenium.
5. Zinc.

Supplementation in the Critically Ill

Angstwum et al ( 1999 ):
In 42 Critically ill pts with Sepsis,
selenium supplementation for 9 days was
associated with a significant reduction in
ARF.( 3/21 pts vs 9/21 pts, p = 0,035 )

Supplementation in the Critically Ill

Berger et al ( 2002 ) :
In 10 burns pts, interleukin 6 levels were
lower in the supplemented pts after 24 h
of trace element supllementation
including 350 ug/day selenium.

Supplementation in the Critically Ill

Tanaka et al ( 2000 ):
Mega doses of vit.C providing during the
first 24 h of resuscitation in pts with
major burns, reduce fluid requirements
by about 30%, by reducing alteration in
capillary permeability.

Micronutrient: Basic Nutritional and

Antioxidant Requrements
Micronut. Rdi for
Oral
iv
dose
===========================================
iv use
45%
burn: 2,5 Copper
0,5 1,5mg
5 mg
liver dis.
5 mg
Selenium 30 60 ug
70%
burns: 350
sepsis: 300
- 900

Micronutrient: Basic Nutritional and

Antioxidant Requirement
Micronut.
Rdi
Oral
iv
dose
===========================================
Zinc
2-4 mg
25%
Burns : 35
Liver Dis:
10 20 mg
Tocopherol 10 mg
100% 10 mg
100 mg- 3 g
Vit.C
100 mg
160% 200mg
1 10g.
Niacin
40 mg
250%
40 mg
Thiamin
3 mg
300 % 6 mg 100 200 mg

Conclusions
Vitamins and Trace elements are
particularly important in the critically ill pts,
mainly thyamine, tocopherol, ascorbic acid,
copper, selenium and zinc.

THANK YOU