Showing papers by "Claude Pichard published in 1998"
TL;DR: Practical guidelines are provided on the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas based on presently available evidence.
Abstract: Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.
227 citations
TL;DR: A prediction equation, validated against dual-energy X-ray absorptiometry and based on subjects with similar clinical characteristics, is more applicable to the patients with respiratory insufficiency than a formula developed for healthy subjects.
Abstract: Malnutrition in patients with severe respiratory insufficiency can lead to severe complications, justifying the use of objective nutritional assessment techniques, such as bioelectrical impedance analysis (BIA), which is an easy, noninvasive method of measuring body composition. The purpose of this study was to develop, and validate against dual-energy X-ray absorptiometry (DXA), a BIA formula to predict fat-free mass (FFM) specific for patients with chronic severe respiratory insufficiency. Seventy-five ambulatory patients (15 females and 60 males) with severe chronic respiratory insufficiency (obstructive and restrictive) aged 63.6+/-19.2 yrs (mean+/-SD), in a stable pulmonary and cardiac condition for > or = 2 months, were measured simultaneously with BIA and DXA. Patients younger than 45 yrs of age and with a body mass index > or = 32 kg x m(-2) were excluded. The best-fitting multiple regression equation to predict FFM = -6.06 +/- (height x 0.283) +/- (weight x 0.207) - (resistance x 0.024) +/- (sex (males=1, females=0) x 4.036), gave a correlation coefficient of r=0.952, slope+/-SEM 0.902+/-0.034, standard error of the estimate 1.670, and p<0.0001. The mean difference for FFM was 0.2+/-2.3 kg (mean+/-SD) and percentage fat mass was -0.7+/-3.8%. These results suggest that the bioelectrical impedance analysis formula specific to patients with severe respiratory insufficiency give a better correlation and smaller mean differences than 12 different bioelectrical impedance analysis formulae described in the medical literature. A prediction equation, validated against dual-energy X-ray absorptiometry and based on subjects with similar clinical characteristics, is more applicable to the patients with respiratory insufficiency than a formula developed for healthy subjects.
94 citations
TL;DR: Enrichment of an oral nutritive supplement with arginine and omega-3 fatty acids did not improve immunological parameters, however, body weight increased in both groups.
Abstract: OBJECTIVE: To evaluate the effects of an oral nutritional supplement enriched with two potentially immunostimulant compounds (arginine and omega-3 fatty acids) on the changes in food intake, body composition, immune parameters and viraemia in HIV-infected outpatients. DESIGN: Six-month prospective randomized double-blind controlled study. SETTING: University hospital outpatient nutrition clinic. PATIENTS: Sixty-four HIV-infected outpatients with CD4 lymphocyte count > or = 10O x 10(6)/l. INTERVENTION: All patients received a daily oral nutritional supplement (606 kcal supplemented with vitamins, trace elements and minerals). In addition, half of the patients were randomized to receive 7.4 g arginine plus 1.7 g omega-3 fatty acids. MAIN OUTCOME MEASURES: Disease progression measured by AIDS-defining events, CD4 and CD8 lymphocyte counts, viraemia, tumour necrosis factor soluble receptors, nutritional status determined by anthropometric, bioelectrical impedance and dietetic assessment. RESULTS: Fifty-five patients completed the protocol. Compliance with and tolerance of oral nutritional supplement during the 6-month period was excellent. In both groups of patients the following were found: total energy intake was transiently increased and then returned to baseline level; nitrogen/energy intake ratio was increased throughout the study; gain of body weight and fat mass were approximately 2 and 1kg, respectively, over 6 months, and were similar in both groups. In addition, CD4 and CD8 lymphocyte counts, viraemia, tumour necrosis factor soluble receptors remained statistically unchanged and were similar in both groups. CONCLUSIONS: Enrichment of an oral nutritive supplement with arginine and omega-3 fatty acids did not improve immunological parameters. However, body weight increased in both groups.
70 citations
TL;DR: Total body potassium, total body water and in-vivo neutron activation analysis are research methods that elucidate the abnormal consequences of chronic pathologies on hydration status and body cell mass.
Abstract: Body wasting is a common feature of severe chronic diseases Determination of body compartments is essential in the evaluation of patients with wasting diseases in order to optimize their nutritional support The main methods described together with their advantages and disadvantages are anthropometric measurements, bioelectrical impedance analysis, dual-energy X-ray absorptiometry, total body water, total body potassium and in-vivo neutron activation analysis The combination of dual-energy X-ray absorptiometry to measure bone and fat mass and bioelectrical impedance analysis to determine total body water and fat-free mass permits evaluation of body composition and periodic follow-up of body compartments in various pathologies Total body potassium, total body water and in-vivo neutron activation analysis are research methods that elucidate the abnormal consequences of chronic pathologies on hydration status and body cell mass
40 citations
TL;DR: Parenteral ternary mixture containing LCT or LCT/MCT are clinically well tolerated in AIDS patients over 6 days, and with 2 g/kg/d of lipids, LCT seems to induce significant abnormalities in lymphocyte function, but such abnormalities are not observed with LCT /MCT.
Abstract: Background Total parenteral nutrition (TPN) may offer significant clinical benefit in malnourished patients with acquired immunodeficiency syndrome (AIDS). However, the immunologic effect of parenteral lipids remains unknown in these severely immunodepressed patients. Methods We undertook a prospective randomized double-blind multicenter study comparing the effects of two i.v. lipid emulsions used during TPN: long-chain triglycerides (LCT) or balanced emulsion of long-and medium-chain triglycerides (LCT/MCT). Thirty-three AIDS patients requiring TPN for wasting and reduced oral intake were allocated randomly to receive a ternary TPN mixture consisting of 1.5 g/kg/d proteins, 18 kcal/kg/d lipids, and 12 Kcal/kg/d carbohydrates for 6 days. The following tests were performed at days 0 and 7: immunoglobulins, complement fractions, lymphocyte subpopulations count, and lymphocyte proliferation with mitogens. Results Patients were all severely malnourished (weight loss: -14.0 +/- 1.3 kg). No clinical or biological differences were observed between the groups at baseline. At day 7, both groups reported a significant increase in weight. Patients in the LCT group exhibited a significant decrease in phytohemagglutinin A response (p = .04) compared with baseline. Patients in the LCT/MCT group exhibited a lower level of IgM (p = .03) and significant increase in C3 fraction (p = .03) compared with baseline. They also showed a tendency to have a higher CD4/CD8 lymphocyte ratio (p = .07), whereas other immunological parameters remained unchanged Conclusions Parenteral ternary mixture containing LCT or LCT/MCT are clinically well tolerated in AIDS patients over 6 days. With 2 g/kg/d of lipids, LCT seems to induce significant abnormalities in lymphocyte function. Such abnormalities are not observed with LCT/MCT.
27 citations
TL;DR: Choosing the optimal strategy for TPN administration is essential both in terms of clinical effectiveness and economic efficiency, because TPN is a relatively expensive nutrition therapy.
8 citations
5 citations
Journal Article•
TL;DR: In the group of patients with severe airflow obstruction on domiciliary oxygen, 25% were malnourished and this was in spite of netly increased calorie consumption which is superior to their theoretical need, suggesting that the solution of increasing supplements to their dietary requirements would be a difficult to realise.
Abstract: AIM OF THE STUDY The aim of the study was to document the nutritional status and the calorie demands of patients suffering from severe chronic airflow obstruction (BPCO) who were on continuous domiciliary oxygen therapy (OCD) and to correlate this information with the clinical picture, the severity of the respiratory disease and the daily distance walked, this to be measured in a prospective manner. PATIENTS AND METHODS Fifty clinically stable patients with chronic airflow obstruction on continuous oxygen therapy for 33 months (range 4-106) in whom the following measures were made at home: pulmonary function, maximal static inspiratory and expiratory pressure (PIMAX and PEMAX), strength of hand, grip, the mean distance walked daily (wearing a pedometer for one week), body mass index (IMC), and the body composition by electrical bio-impedence and calorie requirements. RESULTS Thirty four per cent of patients presented with an excessive body mass (IMC > 27 kg/m2), 42 per cent had normal nutrition (IMC 20-27 kg/m2) and 24 per cent were malnourished (IMC < 20 kg/m2). Malnourished patients had, in a statistically significant manner, airflow obstruction of greater severity and a lower oxygen saturation and a PEMAX as well as a lower daily distance compared to over weight subjects. However, their net calorie requirements were markedly higher (39 +/- 5 Kcal/kg/j) compared to patients having normal weight (29 +/- 11 kcal/kg/j) or excess weight (25 +/- 8 kcal/kg/j). From the clinical standpoint no malnourished patient fulfilled the clinical criteria of chronic bronchitis. By contrast 61 per cent of subjects with normal nutrition and 94 per cent of subjects with excessive weight were chronic bronchitics. CONCLUSION In the group of patients with severe airflow obstruction on domiciliary oxygen, 25 per cent were malnourished and this was in spite of netly increased calorie consumption which is superior to their theoretical need. This suggests that the solution of increasing supplements to their dietary requirements would be a difficult to realise. These subjects presented also with a more marked ventilatory handicap and a clinical picture characterised by the absence of the classical signs of chronic bronchitis.
3 citations
Journal Article•
TL;DR: Documenter l'etat nutritionnel et les apports caloriques de patients souffrant de BPCO severe, sous oxygenotherapie continue a domicile (OCD), and correler ces informations avec le tableau clinique, l'importance de l'atteinte respiratoire et the distance parcourue quotidiennement, ceci de maniere prospective.
Abstract: But de l'etude. Documenter l'etat nutritionnel et les apports caloriques de patients souffrant de BPCO severe, sous oxygenotherapie continue a domicile (OCD), et correler ces informations avec le tableau clinique, l'importance de l'atteinte respiratoire et la distance parcourue quotidiennement, ceci de maniere prospective. Patients et methodes. Cinquante patients BPCO cliniquement stables, sous OCD depuis 33 mois (extremes 4-106) chez lesquels on mesure a domicile : les fonctions pulmonaires, les pressions statiques maximales inspiratoires et expiratoires (PIMAX et PEMAX), la force manuelle de serrement, la distance moyenne parcourue quotidiennement (podometre porte pendant une semaine), l'indice de masse corporelle (IMC), la composition corporelle par bioimpedance electrique et les apports caloriques. Resultats. Trente-quatre pour cent des patients presentaient un exces ponderal (IMC >27 kg/m 2 ); 42% avaient un etat de nutrition normal (IMC: 20-27 kg/m 2 ); 24 % etaient denutris (IMC <20 kg/m 2 ). Les patients denutris ont, de maniere statistiquement significative, une obstruction bronchique plus severe, une saturation en oxygene et une PEMAX plus basses, ainsi qu'une distance de deplacement quotidienne inferieure aux sujets avec exces ponderal. Ils ont toutefois des apports caloriques nettement plus eleves (39±5 kcal/kg/j) que les patients ayant un poids normal (29±11 kcal/kg/j) ou un exces ponderal (25±8 kcal/kg/j). Sur le plan clinique, aucun des patients denutris ne remplit les criteres cliniques de bronchiteux chronique, par opposition a 61% des sujets ayant un etat de nutrition normal et a 94% des sujets presentant un exces ponderal. Conclusions. Dans ce collectif de BPCO severe, sous OCD, 25 % des patients souffraient de denutrition, et ce malgre des apports caloriques nettement superieurs a leurs besoins theoriques. Ceci suggere qu'une augmentation supplementaire de leurs apports alimentaires semble une solution difficilement realisable. Ces sujets presentaient aussi un handicap ventilatoire plus important et un tableau clinique caracterise par l'absence des signes classiques de bronchite chronique.
2 citations
1 citations
TL;DR: Dans ces conditions, le support nutritionnel vise a limiter le catabolisme proteique, mais son effet anticatabolique est insuffisant et l'adjonction systematique de substances anabolisantes semble necessaire.
Abstract: Resume Le stress observe en soins intensifs entraine un catabolisme azote et une fonte musculaire, qui varient en fonction du niveau de stress initial, puis de celui genere par les traitements medico-chirurgicaux et les complications secondaires Les progres therapeutiques en medecine de soins intensifs permettent la survie prolongee de patients presentant un catabolisme considerable entrainant un affaiblissement immunitaire, une capacite de cicatrisation diminuee, et des dysfonctions musculaires respiratoires et peripheriques correlees a une dependance du respirateur et a des durees prolongees de reeducation physique La denutrition par catabolisme aigu influence donc le pronostic et la cinetique de guerison Dans ces conditions, le support nutritionnel vise a limiter le catabolisme proteique, mais son effet anticatabolique est insuffisant et l'adjonction systematique de substances anabolisantes semble necessaire L'hormone de croissance, l'insuline, l' insuline-like growth factor-1 , la testosterone et ses derives peuvent limiter le catabolisme de stress En revanche, leurs effets therapeutiques globaux sont insuffisamment explores tant au niveau de la physiopathologie que des rapports benefice-cout et benefice-risque pour recommander leur usage en routine clinique