The cellular approach to nutrition has developed from increasing knowledge of the pathophysiology of hypotension, hypoperfusion, ischemia, and shock. Gram-negative and Gram-positive septicemia are the predominant causes of these processes in the critically ill patient. The challenge is to increase our understanding of the effects of nutritional manipulation on the cellular processes involved. Although the issues of protein sparing and energy requirement remain paramount to successful nutritional support, a new sphere of influence has materialized: nutritional modulation of the immune system. Immunomodulation, by effecting a shift in the prevailing balance of cell-cell communication, cytokine production, and prostaglandin milieu, can produce salutary changes in the circulation and cell-mediated immune response.
In our laboratory, considerable work has been completed with animal models of trauma, transplantation, and Gram-negative sepsis to reproduce the cascade of responses leading to multiple organ failure. Our data suggest an exciting new avenue is open whereby the hypermetabolic or septic process can be reduced in the early course of multiple organ failure.
Two key concepts are gaining currency in our evaluation of the septic process: first, that the cellular immune system crosses a threshold, as yet poorly defined, between helping and hindering our ability to survive major injury; and second, that damage to the endothelium is the hallmark of progressive deterioration to organ failure. These two concepts are complementary, and we shall seek to identify steps in the process that can be primarily prevented by a cellular nutritional approach.
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