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Human nutrition is a broad, interdisciplinary cultural and scientific field, involving a wide range of chemical, molecular, genetic, biochemical, physiological, psychological, cognitive-behavioral, statistical-epidemiological, clinical, technological, educational, economic, political and social aspects. The high levels of over- and under-nutrition represent an important risk factor for mortality and burden of disease worldwide. It is the opinion of Federation of the Italian Nutrition Societies (FeSIN) that these two sides of the same coin, with their socio-cultural background, are related to a low ‘nutritional culture’ secondary, at least in part, to an insufficient academic training for healthcare professionals. Therefore FeSIN created a study group, composed of delegates of all the federated societies and representing the different healthcare professionals involved in human nutrition, with the aim of identifying and defining the domains of human nutrition in the attempt to more clearly define the cultural identity of human nutrition in an academically- and professionally-oriented perspective and to report the conclusions in position paper. Three main domains of human nutrition, namely Basic Nutrition, Applied Nutrition and Clinical Nutrition, were identified. FeSIN has examined the areas of knowledge pertinent to human nutrition. Thirty-two items were identified, attributed to one or more of the three domains and ranked considering their diverse importance for academic training in the different domains of human nutrition. Finally, the study group proposed the attribution of the different areas of knowledge to the degree courses where training in human nutrition is deemed necessary (e.g. schools of medicine, biology, nursing, etc). It is conceivable that, based on the implementation of knowledge-competences-skills trajectories in the different areas and domains of human nutrition, a better, pro-active, cost-effective integration of the professionals involved in this field will eventually occur.

La nutrizione artificiale in terapia intensiva riveste un ruolo chiave poichè, oltre a fornire il supporto metabolico-nutrizionale adeguato, ha dimostrato di essere in grado di influenzare positivamente la prognosi del paziente. La letteratura internazionale riguardo alla nutrizione artificiale nel paziente critico è in forte evoluzione e per questo sono necessari confronti frequenti tra specialisti al fine di mettere a punto indirizzi di buona pratica clinica orientati all' applicazione delle più forti evidenze della EBM el settore. La discussione di casi clinici reali condotta tra medici intensivisti è un dimostrato strumento di confronto positivo a forte valenza formativa e di aggiornamento e con poitivo impatto sul miglioramento delle condotte e delle performance.

Pneumonia, sepsis, respiratory failure and multiple organ system failure are among the most common causes of death in critically ill patients (1). Particularly pneumonia and respiratory failure are frequently associated to protein calorie malnutrition (2-4), which can modify respiratory muscle function, ventilatory drive and lung defence mechanisms (5, 6). Both drive and muscle derangement can be corrected by nutritional support (1, 7, 8); however, the improvement of nutritional status does not always result in a better prognosis (9, 10). Nevertheless, many clinicians suggest the administration of a nutritional therapy to all patients at risk for metabolic complications due to starving (1, 6, 11, 12). The planning of nutritional support for patients under mechanical ventilation and/or suffering from respiratory failure should carefully consider the diet induced thermogenesis (DIT), gas exchanges, the effect on lung tissue of single substrates and protein sparing effect of nutrition.

To investigate the kinetics of body nitrogen (N) excretion during 24 h glucose infusion (relating glycemia with insulin supply) and during subsequent 24 h saline infusion in injured patients during a full blown stress reaction. To define the lag time between the start of the withdrawal of glucose and insulin infusion, and the modification in the N loss from the body, and the time span to reach the maximum effect and its size. The knowledge of these variables is mandatory to plan short term studies in critically ill patients, while assuring the stability of the metabolic condition during the study period, and also to assess the possible weaning of the effect on protein breakdown during prolonged glucose and insulin infusion.24-36 h after injury, patients were fasted (100 g glucose) for 24 h (basal day). Thereafter, a 24 h glucose infusion in amount corresponding to measured fasting energy production rate (EPR), clamping glycemia at normal level with insulin supply followed by 24 h saline infusion, was performed. Total N, urea and 3-methyl-histidine (3-MH) in urine were measures on 4 h samples starting from 20th h of the basal day.Multipurpose ICU in University Hospital.6 consecutive patients who underwent accidental and/or surgical injury, immediately admitted for respiratory assistance (FIO20.04). Excluded patients were those with abnormal nutritional status, cardiovascular compromise and organ failures.Patients showed a 33% increase in measured versus predicted fasting EPR and a consistent increase in N and 3-MH urinary loss. An infusion of glucose at 5.95 +/- 0.53 mg/kg x min (97.20 +/- 0.03% of the fasting measured EPR) with 1.22 +/- 0.18 mU/kg x min insulin infusion reduced N and 3-MH loss after a time lag of 12 h. The peak decrease in body N (-36%) and 3-MH loss (-38%) was reached during the first 12 h of glucose withdrawal period. Thereafter, during the following 12 h, the effect completely vanished confirming that it is therapy-dependent and that the metabolic environment of the patients did not change during the three days study period.24 h glucose withdrawal reduces N and 3-MH loss injured patients, the drug-like effect is maintained during the first 12 h of withdrawal and thereafter disappears. The study suggests that at least a 24 h study period is necessary when planning studies exploring energy-protein metabolism relationship in injured patients, and, again 24 h before changing protocol in a crossover study.

Single lung transplantation (SLT) is now successfully used in patients with severe emphysema. Mechanical imbalance between the native emphysematous and the healthy transplanted lung can be easily managed, unless severe graft failure occurs, leading to acute respiratory failure. Emergency retransplantation has been used in this setting, since the conventional approach to adult respiratory distress syndrome (ARDS) (mechanical ventilation and positive end-expiratory pressure [PEEP]) fails, due to the mechanical discrepancy between the two lungs. We describe two cases of severe graft failure following SLT in emphysema patients that were successfully treated with prolonged independent respiratory treatment. Mechanical ventilation and PEEP were applied to the failing transplanted lung while the native emphysematous lung was maintained on spontaneous breathing to avoid hyperexpansion and barotrauma. The independent lung respiratory treatment lasted 35 and 25 days, respectively: to our knowledge, these are among the longest-lasting independent respiratory treatments reported. The management was simplified by the early use of a double-lumen tracheostomy cannula as an alternative to orotracheal double lumen tube.

The aim of this study was to verify the capability of the Italian Group for the Evaluation of Intervention in Intensive Care Medicine (Gruppo Italiano Valutazione Interventi in Terapia Intensiva, GiViTI) Intensive Care Units (ICUs) in providing high level care (HLC) and to develop a flexible organiziational model, allowing for different levels of care in each ICU.Once the number of active beds, personnel and technology of each ICU were determined, we computed whether the available bed number and all available resources could provide HLC according to international standards. For ICUs lacking staff or equipment for safe HLC in all declared beds, we calculated the best combination between HLC and observation/monitoring beds with less need for nurses and technology (low level of care, LLC) in order to optimise the utilization of each bed. We also investigated the work organisation of physicians and nurses in these units.There are 2 070 available beds in the 293 GiViTI ICUs. To provide HLC according to international criteria, the beds would decrease to 80.9%, because 144 ICUs do not have nurses or equipment to provide HLC in each bed. In order to maximize the suitable use of available resources, these ICUs would have to reduce the HLC bed number using the regained nurse workload for LLC. Because of this, the total number of HLC beds would further decrease to 65.9% of all declared beds. During Sundays and holidays, the bed/doctor and the bed/nurse ratios increase in most ICUs.To maximize the staff and equipment resources available, the bed numbers of a general ICU providing HLC must vary, even daily, according to the level of care provided. This level is not always high for all patients present. Applying this organizing model to each ICU, we could have enough flexibility to face the different demands for assistance if the ICU is built as a large open space to achieve the best clinical model and use of resources.

Nutrition in critically ill patients should be considered as therapy: assessing the energy expenditure and the termogenic effect of food, and knowing the differences among composition and amount of given substrates, it is possible restore, maintain, or at least limit the derangement of energy equilibrium. Energy metabolism comprehends assumption, storage and oxidation of nutrients: all these factors could be discriminant in critical clinical conditions, particularly cardiac and respiratory failure. Then, this review would lead the decision making process beginning from biochemistry and bioenergetics, until the metabolic strategy practically usable at the bedside of patients during the whole critical phase of their pathology.

Throughout the world, the cost of critical care medicine is increasing more than the overall health care cost. Thus, a higher attention to improve the efficiency of the use of ICU resources is indispensable. The objective of this study was the development of a simple and reliable tool for the evaluation of the appropriateness of ICU utilization.A repeated cross-sectional data collection was performed twice a week, during a 61-day study period.Twenty-three Italian general ICUs.All patients present in the 23 ICUs on the 17 index days.On each index day, patients were checked for receiving ventilation/CPAP, pulmonary arterial pressure monitoring, intracranial pressure monitoring, vaso-active drug infusion and hemodialysis-ultrafiltration. Simultaneously, each ICU bed was assessed for its technical and personnel facilities in order to estimate the deliverable level of care.A total of 1250 patients were studied, for a total number of 7533 patient-days. The overall occupancy rate per ICU was 83.8% (-range: 54.4% to 96.1%). The high-level occupancy rate (rate of patients requiring high level of care and actually occupying high-facility beds) was 69.4% (range: 25.0% to 149.0%), while the corresponding low-level occupancy rate was 101.1% (range: 31.3% to 329.4%).Our model clearly showed up a certain degree of inappropriateness in the use of ICU resources. Most of the ICUs (69.6%) used a very large proportion of their high-facility beds for patients who did not need high-level care. Being very simple, our method could represent a useful tool for continuous evaluation of the appropriateness of resource utilization in the ICU.

We evaluated muscle-visceral interorgan flux of substrates in 8 critically ill patients in the flow phase after injury.This study was conducted on critically ill patients admitted in ICU.8 patients were studied immediately after injury.We measured leg flux for oxygen, amino acids, glucose, lactate pyruvate, keton bodies, free fatty acids (FFA), free and total carnitine, and whole body oxygen consumption, nitrogen (N) balance and 3-methyl hystidine (3MEH) excretion during fasting and the second day of metabolic treatment (10.7 +/- 0.06 g x N x m-2 e 1035.5 +/- 3.9 kcal x m-2 x die). During fast the leg shows a net release of N, pyruvate, FFA and free carnitine while glucose, lactate and keton bodies fluxes are not different from zero. The energy balance of the leg is markedly negative (substrate for 79 kcal x m-2 burned for leg energy requirement and 347 kcal x m-2 released as a such). Assuming the body muscle tissue 4.5 times the leg tissue and knowing whole body energy balance, we were able to assess that the non muscular (visceral) part of the body resulted in a consistently positive energy balance. The metabolic treatment is able to match the energy expenditure and the substrate efflux of the leg (and the whole body muscle tissue). In fact the efflux of amino acids and FFA is reduced pyruvate blunted while glucose is remarkably taken up (the uptake of the whole muscle tissue accounted for 72% of the daily load). At the same time, the treatment blunts leg free carnitine and reduces body 3MEH output. Moreover, the caloric balance of the non muscular part of the body remains positive even if the qualiquantitative uptake of substrates is different from fasting.Substrates for energy requirements of visceral tissue came from muscular tissue. The metabolic treatment is able to modulate this process.

This report describes a computer based program of patient clinical data collection: the ARCHIDIA system. The project relies on descriptive analysis of clinical events according to well defined methodological criteria. This allows the formulation of a concise diagnosis which is, at the same time, exhaustive of all essential information. Two are the basis principles of this methodology: To define, as accurately as possible, the logical steps necessary to elaborate the diagnosis, that is construed by a sequence of codes. To define all the conditions that must be followed so to use any code in a controlled and independent way. These criteria were derived from literature. The major claim of the system is likely to be the introduction of a "common language" between different ICUs. Uniformed diagnostic and clinical criteria are the main source of large data collection for descriptive, analytic and prospective studies. After a one year pilot study performed by 4 ICUs, ARCHIDIA was used, in 1991, by 20 centers from the area of Milan, Pavia, Como, Varese (70% of total) and 4148 patient data were collected. A descriptive analysis will be reported in the following paper.

To describe a population of patients admitted in ICU in an homogeneous urban area by means of a computed system.Observational study.20 general intensive care units of general and university hospitals.Patients admitted in ICU from 1-1-1991 to 31-12-1991. 3 centers collected patients only for 6 months, starting on 1-6-1991.For each patient demographic data, hospitalization data, outcome, diagnosis and diagnostic procedures used during hospitalization according to defined criteria previously described, were collected. Data have been collected on PC using dedicated software.All centers concluded data collection, none abandoned the study. General characteristics of 4148 valuable patients were reported. Age was 52.9 years, SAPS 12.4 and mortality 21.7%. The patients spent 8.7 days in ICU and, when transferred to a general ward, the following hospitalization was 21.5 days.Data collection demonstrated the project feasibility. It realizes a continue up to date system inside each unit and allows the use of a "common language" and homogeneous methodology between centers.

In sixteen severely catabolic patients, two different nutritional treatments with the same nitrogen input (0.30 gN.kg-1.die-1) but with a different caloric support: 30 kcal.kg-1.die-1 foe group A and 15 kcal.kg-1.die-1 for group B were infused. Body nitrogen balance (BN), muscle nitrogen balance (BNm) and, calculated as a difference of the two, visceral nitrogen balance were measured in every patient on basal day and on the second day of total parenteral nutrition. Both nutritional treatment reduced the catabolic state in the same amount: this was confirmed by a less negative body BN and by the reduced excretion of 3-MEH and amino acidic catabolic markers. Otherwise in the other compartments the treatments showed different effects: the metabolic support was more reduced by treatment A than it was by B, supplying to visceral compartment a lower nitrogen amount: the nitrogen dismission from muscle compartment, available for visceral tissues, is greater with treatment B than with treatment A. In conclusion, even if both treatments show the same effect on body nitrogen balance, they penalize either one of the examined compartment or the other. To avoid this problem, the study and the use of tissue-specific nutrients are desiderable. Tissue-specific solutions may warrant the balance among body compartment without any further increase of the nitrogen rate.

In view of the influence of different calorie substrates on protein metabolism, we need to consider the interactions between substrate disposal and hormonal control of body metabolism that constitute the so called “anabolic drive” [1]. Moreover, we know that amino acids have a dominant role in regulating protein synthesis. The role of amino acids exceeds that of calories and is in part independent from their property to induce the production of insulin and other hormones involved in protein metabolism [1–6].

A plasmatic concentration for each aminoacid, between 1 and 1.5 times the normal value in fasting healthy subjects, is considered as an optimal target during total parenteral nutrition (TPN) in malnourished patients. We have analyzed the correlation between the aminoacid input and the aminoacid plasmatic concentration during TPN at different aminoacid composition. By exponential regression curves we then calculated the input required to keep each aminoacid plasma concentration in the optimal range.

The aim of this study was to evaluate the kinetics of arterial plasma amino acid profile during the first 48 h of clinical TPN in order to assess the time necessary to reach the steady-state condition during infusion. Each patient was treated with one of three different amino acid solutions yielding, in the same nitrogen intake, different intakes of individual amino acids. We found four different kinetics for the administered amino acids: an increase of plasma levels immediately after the start of the TPN with no variations during the steady period; the same trend with the steady-state obtained after 6-24 h of TPN infusion; no influence at all; a decrease of fasting plasma levels with the steady-state attained variably during the study period. Each given amino acid showed a different trend partly depending on the supply, suggesting that the steady-state was reached sooner for most amino acids, when the supply was larger. With lower intakes, plasma levels were unaffected or decreased. We conclude that in critically ill patients at least 24 h are needed to obtain stable arterial plasma amino acid concentration during TPN with adequate intakes of amino acid. Knowledge offers the possibility for a quick and accurate assessment of the adequacy of a given preparation (tailored for critically ill patients), it reduces the time span of the study and, as a consequence, the influence of varied metabolic conditions.

Despite consistent improvement in its treatment, amatoxin poisoning still extolls an elevated overall mortality, ranging between 10 and 15%, which approaches 100% when severe (grade 3-4 encephalopathy) hepatic failure supervened. Therefore, the proper treatment of intoxication by amatoxin containing mushrooms, and particularly of its complications, remains a challenge in emergency medicine. Klein and coworkers reviewed the role of liver transplantation in amatoxin poisoning as a useful therapeutic tool for patients with severe impairment of liver function. Their indication for intervention is the presence of any of the following signs: grade 2 encephalopathy or higher; prothrombin time twice than normal, despite fresh frozen plasma infusion; hypoglycemia requiring hypertonic glucose infusion; hyperbilirubinemia (greater than 25 mg/dl). During the past autumn two patients with fulminant hepatic failure due to amatoxin poisoning were referred to our institutions as candidates for liver transplantation, since both satisfied Klein's criteria. However, due to shortage of organ donors it was impossible to transplant them over the following days. Despite they did not receive liver transplantation, both patients wakened from coma, their liver function improved, and they recovered from terminal amatoxin poisoning. After one year, both patients are long-term survivors, in good health and without any sequelae either in brain or liver function.

In a 3 year period (1975-77) 50 patients have been admitted to the I.C.U. of Polyclinic Hospital of Milan for poisoning from mushrooms of Amanita genus. In 47 cases the diagnosis was confirmed "a posteriori" by serum or urinary detection of amtoxins and/or by clinical evidence of typical liver injury. Besides the symptomatologic support, the therapeutic treatment included combined removal procedures, such as peritoneal dialysis, plasmapheresis, forced diuresis. The detection by radioimmunoassay of amatoxins [6] in the serum and in the urine of these patients proves that this therapeutic treatment can be effective within about 36 hours from ingestion time. The intensive medical care and the removal approach yielded as the whole favourable results in our patients (overall mortality was 6 patients, i.e. 12,7%). It should moreover be emphasized that of the 35 patients, who had been treated with early removal techniques, 12 with ascertained amanita poisoning, had neither clinical nor biochemical evidence of hepatic damage; 14 had a moderate liver damage; 9 experienced a severe liver failure and hepatic coma occurred in 4 of the latter. These poor results can be ascribed to the severity of the poisoning as well as to a peculiar kinetic of amatoxins in each subject.

In a 3 year period (1975-77) 50 patients have been admitted to the I.C.U. of Polyclinic Hospital of Milan for poisoning from mushrooms of Amanita genus. In 47 cases the diagnosis was confirmed "a posteriori" by serum or urinary detection of amtoxins and/or by clinical evidence of typical liver injury. Besides the symptomatologic support, the therapeutic treatment included combined removal procedures, such as peritoneal dialysis, plasmapheresis, forced diuresis. The detection by radioimmunoassay of amatoxins [6] in the serum and in the urine of these patients proves that this therapeutic treatment can be effective within about 36 hours from ingestion time. The intensive medical care and the removal approach yielded as the whole favourable results in our patients (overall mortality was 6 patients, i.e. 12,7%). It should moreover be emphasized that of the 35 patients, who had been treated with early removal techniques, 12 with ascertained amanita poisoning, had neither clinical nor biochemical evidence of hepatic damage; 14 had a moderate liver damage; 9 experienced a severe liver failure and hepatic coma occurred in 4 of the latter. These poor results can be ascribed to the severity of the poisoning as well as to a peculiar kinetic of amatoxins in each subject.

Humoral immunity (immunoglobulins and C3) as well as nutritional conditions (serum albumin, transferrin) have been investigated in 23 patients in the acute phase after surgery and/or trauma. Immunoglobulin deficiency, well correlated with the severity of trauma, was observed in the most critically ill patients in the very early phase, followed by a rapid rise to near to normal values and typical immunologic response. There is no evidence that this depression of humoral immunity may enhance the risk of infectious complications in the postoperative period. Very different immunological patterns were observed in surgical patients with chronic sepsis.

Septic and severely traumatized patients show an increased nitrogen output that, in absence of supply, results in a conspicuous nitrogen loss from the body. This is evident from the muscle wastage and weakness commonly observed in these patients [1–4].

Injured patients treated with fructose 1,6-diphosphate (1 millimole of phosphate per kilogram per day) together with parenteral nutrition had a better nitrogen balance than patients treated with isocaloric nutrition and an inorganic source of phosphate. Excretion of 3-methylhystidine was similar while tyrosine and alanine output from the extremities was lower in the group of patients given fructose 1,6-diphosphate. The data indicates that the protein sparing action of fructose 1,6-diphosphate is exerted through an increased protein synthesis.

Nitrogen metabolism was studied in ten injured/septic patients by means of a two compartment model, differentiating muscle from non muscle (central) tissue. During fasting muscle tissue loses a consistent amount of aminoacids which is retained in part by central tissue, giving rise to a positive nitrogen balance, whilst three methyl histidine and body nitrogen output are elevated. Total parenteral nutrition (glucose 15 kcal kg-1 day-1, nitrogen 0.30 g kg-1 die-1) improved body nitrogen balance and three methyl histidine excretion, but did not affect significantly either muscle or central nitrogen balance. Increasing caloric support to 30 kcal kg-1 day-1 did not showed any further effect on body nitrogen balance and three methyl histidine, while it improved significantly vs basal muscle nitrogen balance, but did not affect central nitrogen balance.

Echocardiography is a non invasive technique particularly useful to assess both hemodynamics and left ventricular performances; different methods have been proposed to evaluate echocardiographically the cardiac output. The aim of this work is to suggest a new method (planimetry of the area enclosed by echoes from the mitral valve) stating its advantages and limits and to test three already known methods (cubes method, method of Lalani and Lee, method of Rasmussen and coll.) comparing them to thermodilution. In 24 patients admitted in our Coronary Care Unit for acute myocardial infarction 30 measurements have been performed simultaneously with echocardiography and thermodilution. Statistical analysis (correlation coefficient with the method of the square minimums and Student's 't') of the results has shown that the cubes method is unprecise (P = NS) and unbiased (d = 0.97 +/- 15.46); Lalani-Lee method is unprecise (P = NS) and biased (d = 9.64 +/- 21.36) by a systematic underestimate error concealed by the poor precision; Rasmussen and coll. method is precise (P0.01) but biased (d = --3.03 +/- 5.5), the systematic mistake being entirely due to the group of patients with abnormal hemodynamics. Our method is precise (P0.01) and unbiased (d = --0.04 +/- 9.62) in patients both with normal and abnormal hemodynamics. Therefore this method offers the following advantages: 1) it is unbiased, even in the presence of abnormal left ventricular performance; 2) it is sufficiently precise, having a correlation coefficient with thermodilution of r = 0.80; 3) it measures directly the amount of flow due to the atrial systole; 4) the measurement is rapid and hardly biased by the reader.

PROTEINE E PEPTIDI ENTERALI E MISCELE AMINOACIDICHE PARENTERALI M. Zanello La fonte proteica e della miscela aminoacidica in nutrizione artificiale risulta centrale per l’ efficacia nutrizionale e questo dipende strettamente sia da quantità che qualità apportata. La composizione aminoacidica proteica ottimale non è nota e la fonte proteica (animale e vegetale) viene ponderata in relazione a proteine di riferimento di provata efficacia in alimentazione naturale (valore biologico, etc.). La composizione della fonte di azoto deve rispettare la presenza di aminoacidi essenziali, non essenziali, semiessenziali ed essenziali-sotto condizione la cui quantià si ritiene essere lievemente dissimile nelle età della vita e, talora spiccatamente, diversa in situazioni cliniche peculiari (formulazioni ad uso generale e ad uso specifico). In nutrizione enterale, l’ apporto azotato è rappresentato nelle varie formulazioni da proteine (in prevalenza della caseina, ma non solo), poli-oligopeptidi (talora) la cui efficacia nutrizionale è una variabile ulteriore rispetto agli effetti da essi indotti su digestione, assorbimento e modulazione morfo-funzionale intestinale: le formule presenti perseguono più o meno spiccatamente questi obiettivi e, tutte, mantengono finalità (protidosintetica, biometabolica) indotte della specifica coorte aminoacidica rappresentata. L’ apporto diretto nel circolo venoso è limitato, per evidenti motivi fisiologici e patologici (allergeni), a miscele cristalline di aminoacidi di sintesi la cui composizione ha subito negli anni modificazioni in relazione a nuove conoscenze sull’ efficacia metabolica e nutrizionale di diversificate quantità (EAA, EAA/NEAA, BCAA) o specifica tipologia (alanina, taurina, istidina, tirosina, glutamina, citrullina, etc.) dei singoli apporti utili in particolari situazioni. Per indurre effetti farmaconutriceutici alcuni aminoacidi, stabilizzati in dipeptidi per l’ apporto endovenoso, trovano impiego in supplementazione e fortificazione.

Ten patients who underwent elective abdominal surgery were given a daily load of one liter of a 10% aminoacid solution randomly containing cationic aminoacid as clorure or acetate salt during the first four post-operative days. None of the patients developed acidosis but the mean daily urinary excretion of titratable acidity and ammonium ions was significantly higher in clorure treated patients. An aminoacid solution containing aminoacid as acetate acts as a sparing solution for tubular buffer activity, and therefore should be preferred for patients with tubular impairment.

Nutrition support in critically ill patients is not merely simple nutrition, but rather metabolic support. In the last few years, the pharmacological properties of nutrients have been specifically addressed in a new field called pharmaconutrition. This review will offer a deeper insight into this field, focusing on the properties of arginine, glutamine, antioxidants, and omega-3 fatty acids as well as the level of blood glycemia which should be maintained in critically ill patients.