Ca y est. L’essai dirigé par les canadiens sur la supplémentation en glutamine et en antioxydants en réanimation est parue dans le NEJM.
Les résultats sont simples : les antioxydants « classiques » n’aident pas le patient et la supplémentation en glutamine semble desservir le patient.
Le papier est limpide. Ca fait longtemps que le groupe canadien dirigé par Daren Heyland planche sur le sujet et ça se sent : la méthodologie est solide. Je regrette comme l’a déjà fait l’ami Jean-Marie Vailloud dans plusieurs de ces articles le renvoi trop facile vers des suppléments.
Les points forts
- étude multicentrique, américains et européens dans le même panier
- 1223 patients de réanimation, ça commence à faire une cohorte importante pour un travail en réanimation
- vrais patients de réanimation, défaillants, en choc (correspond à des critères d’entrée en réa comme on les connait en France)
- une méthodologie solide
- produits et soutiens financiers fournis par le laboratoire mais l’étude « négative » est publiée (=gage d’indépendance ?)
- protocole clair, applicable dans la vraie vie
Les points faibles
- plus de 6 ans pour inclure !
- population très hétérogène, globalement c’est plutôt de la réanimation médicale (la contre-indication à la nutrition entérale est un critère d’exclusion, de même pour les patients neuro-traumatisés ou les brûlés)
- il y a 15% de patients éligibles qui n’ont pas été randomisés. Je ne comprends jamais vraiment ce phénomène… on pense au protocole mais finalement on ne peut pas le faire… quid.
Je ne suis pas surpris que les antioxydants ne fournissent pas d’amélioration sensible aux patients de réanimation. Tenter de manipuler le stress oxydant chez ces patients c’est un peu comme éteindre un feu de forêt avec un verre d’eau.
Pour la glutamine, plusieurs auteurs avait trouvé des arguments pour son utilité en réanimation, notamment pour les patients qui sont en nutrition parentérale exclusive. Ici la supplémentation en glutamine est vraiment appuyée : 0,5 g/kg d’alanyl-glutamine (aka DIPEPTIVEN) en IV et 30 g en plus en entéral. Ce qui fait pifométriquement 60 g de glutamine par jour ! Les auteurs ne donnent pas d’explication physiopathologique pour un effet néfaste de la glutamine dans leur étude mais de prime abord j’ai envie de penser que les apports azotés deviennent trop importants. Mais dans les suppléments, on peut lire que les patients recevant la glutamine ont 20 g d’azote par jour en moyenne ce qui parait être dans les clous. Bref, il n’y a aujourd’hui pas d’explication physiopathologique.
Greet Van den Berghe explique dans son éditorial que les hypothèses de départ sur la glutamine sont peut être fausses. Lorsque l’on trouve une mesure biologique en dehors de la norme chez un sujet gravement malade, il peut s’agit d’un état adaptatif et pas d’un chiffre à normaliser. Ensuite son édito se tourne vers la nécessité d’avoir des essais riches de plusieurs centaines de patients de réanimation si on veut avancer. Ce besoin du nombre pose à mon sens le très grand problème de l’hétérogénéité des pratiques et des populations sous l’étiquette « Critical Care », comment trouver des liens entre des patients si différents ? et puis comment concilier une médecine personnalisée avec des cohortes toujours plus grande ? voilà un vrai défi pour la Réanimation
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2 réponses sur « Glutamine et antioxydants en réanimation »
Hello
J’ai bossé en long en large et en travers le sujet de la nutrition en réa (c’est même mon sujet de mémoire). Ce que j’ai retenu c’est que les pratiques sont très hétérogènes en effet, les définitions floues et qu’il y a peu de consensus (à part les guidelines ESPEN). On touche à un sujet assez passionnel ou alors carrément d’inintérêt total de la part des médecins (tout ou rien) et la moindre critique ou modifications d’habitudes engendre parfois des réactions…surprenantes.
Bref, la nutrition c’est de la cuisine…
Je serai ravi d’en discuter avec toi, ton point de vue m’intéresse beaucoup.
yo
oui tu résumes parfaitement la situation avec pour être clair une vraie différence des deux côtés de l’atlantique entre ASPEN et ESPEN.
J’ai des idées d’études pour 10 ans devant moi (notamment en périopératoire ou nutrition et douleur) mais les commissions genre CPPRB me gonflent +++ Quand tu veux pour taper la discut ici même ou autrement (twitter, mail, etc)