Showing papers in "Journal of Parenteral and Enteral Nutrition in 1982"

Detection of Dangerous Malnutrition

Abstract: The assessment of malnutrition by simple methods was studied in 120 patients undergoing elective major abdominal surgery to determine which index was of the most value in predicting postoperative complications. Weight for height and weight loss were of little significant value; serum albumin less than 35 g/l was more significant (p less than 0.05) but predicted only a quarter of those patients who developed serious complications. Measurements of muscle stores by anthropometry (arm and forearm muscle circumference) predicted nearly half the patients (p less than 0.01). By far the most useful index was hand-grip dynamometry, which predicted 90% of those who developed complications (p less than 0.001). The incidence of serious complications was 6 times greater in those patients with a low grip strength. Hand-grip dynamometry appears to be a useful screening test of patients at risk, and a valuable additional test for nutritional assessment.

Arm Length Measurement as an Alternative to Height in Nutritional Assessment of the Elderly

Abstract: The use of long bone measurements as an alternative to height in nutritional assessment of the elderly was investigated in 100 young and 63 aged individuals. Highly significant correlations between height and total arm length, humerus length, forearm length, and proximal phalanx length were found. Compared to young subjects, values for the elderly were shifted significantly, demonstrating a reduction in height not paralleled by decreases in arm length measurements. In subsequent studies, lean body mass was evaluated by creatinine excretion in groups of young and elderly male and female volunteers. In both males and females, when creatinine excretion was related to height, ideal body weight, or total arm length, significantly lower values were found in the elderly as compared to the young. In all groups highly significant correlations between the use of arm length and the other two methods of expressing creatinine excretion were found. This validates the use of arm length measurement as an alternative to height for nutritional assessment. Since arm length is less affected than height by the aging process and more easily obtained in the bedfast patient, it should provide a more accurate reflection of stature when performing nutritional assessments of the elderly. These preliminary data emphasize the need for appropriate standards for subjects of different ages when evaluating lean body mass.

Utility of skin testing in nutritional assessment: a critical review.

Abstract: To evaluate the claim that delayed cutaneous hypersensitivity skin testing is useful in nutritional assessment of hospitalized patients, we reviewed the English language literature of the last 12 years. Although several hundred publications discussed delayed cutaneous hypersensitivity testing and nutritional status, only 15 provided new, objective data correlating these variables in hospitalized adults. Of these, only three provided age-matched control groups to control for antigen variability, lack of prior exposure, and other technical problems. The majority of reports took no account of diseases (cancer, immune disease, infection) or therapies (radiation, drugs, surgery) known to affect skin test response. In the reports specifying different degrees of malnutrition, the most important group, those with less than obvious malnutrition, were not abnormal by skin testing. Ten reports described serial skin testing during nutritional intervention. Non reported serially tested controls without nutritional intervention, important since serial testing alone can augment skin test response. Nonnutritional intercurrent therapy which might affect skin tests was seldom mentioned. In the few reports specifying that nutritional repletion was even achieved, repleted patients were not separated from unrepleted in subsequent analyses. No report examined skin testing for its predictive accuracy, cost/benefit ratio, or influence on outcome. Because of these problems in experimental design, the frequent lack of appropriate controls, and the low specificity of abnormal delayed cutaneous hypersensitivity responses, we conclude that the utility of skin testing in nutritional assessment remains unproved.

A comparison of essential and general amino acid infusions in the nutritional support of patients with compromised renal function.

Abstract: A comparative study of an essential amino acid (EAA) solution versus a general amino acid (GAA) solution in combination with a high density caloric solution (350 gram dextrose per 750 milliliter total volume) in patients with impaired renal function and receiving total parenteral nutrition was conducted. Forty-five patients were randomly assigned to receive either EAA [17 grams per liter (24)] or GAA [20 grams per liter (21)]. BUN values for days 1 to 10 of the study for each group declined at the same rate, 3.7 milligrams per deciliter per day for the GAA group and 2.8 milligrams per deciliter per day for the EAA group (p > 0.05, analysis of variance). BUN values at the start of the study were 78 ± 6.5, mean ± standard error of mean milligram per deciliter for the GAA group and 75 ± 7.5, mean ± standard error of mean, mg/dl for the EAA` group which were not different (p > 0.05, analysis of variance). Serum creatinine values of 5.9 ± 0.9, mean ± standard error of mean, milligram per deciliter for the GAA ...

Thromboembolic complications with silicone elastomer subclavian catheters.

Abstract: Central venous thrombosis is a well-recognized complication of plastic catheters used during parenteral nutrition and occurs in up to 33% of cases if examined venographically. Silicone elastomer catheters, in addition to their favorable handling properties, are less thrombogenic than plastic varieties and are now increasingly used for parenteral nutrition. However, their use does not prevent the possibility of catheter-related thrombosis as this study demonstrates. In a consecutive series of 118 silicone elastomer subclavian catheters, 83% of which were used for parenteral nutrition, two instances of clinically apparent catheter-related thrombosis occurred and one of these was complicated by major pulmonary embolism. Catheter malplacement, catheter infection, and coagulation abnormalities were absent. Both catheters were used for parenteral nutrition and were in place for 20 and 28 days, respectively. Twenty-eight consecutive silastic catheters used for parenteral nutrition were studied, prior to removal, by simultaneous bilateral ascending phlebography. One clinically inapparent nonocclusive, catheter-related thrombus was detected which detached during catheter removal. This study suggests an incidence of symptomatic and asymptomatic silastic catheter-related thrombosis to be around 4%. Silicone catheters therefore may reduce but cannot abolish catheter-related thrombosis. Furthermore, when present, catheter-related thrombosis may be a source of major pulmonary thromboembolism.

Malnutrition in Critically III Infants and Children

Abstract: The prevalences of acute and chronic protein-energy malnutrition (PEM) and deficiencies in stores of fat and somatic protein have not been previously examined in pediatric intensive care unit. One hundred eight nutritional assessments were performed using anthropometric techniques on infants and children in a multidisciplinary intensive care unit. Overall, the prevalence of acute PEM was 19% and chronic PEM was 18%. The prevalence of fat store depletion was 14% and somatic protein store depletion was 21%. In general, children less than 2 years had poorer nutritional status compared to children greater than 2 years. There was not a statistically significant difference between medical and surgical patients. It is concluded that PEM and deficiencies in the macronutrient stores of fat and somatic protein are common in critically ill infants and children.

Reduced Metabolic Complications in Total Parenteral Nutrition: Pilot Study Using Fat to Replace One-third of Glucose Calories

Abstract: The limitations of glucose-based TPN solutions are high glucose concentration, high osmolality, lack of fat, and essential fatty acids, which result in glucose intolerance and hepatotoxic effects. We replaced one-third of the calories in a standard amino acid-glucose solution with Liposyn 10% for 14 days in 23 critically ill men who needed total parenteral nutrition. Serial measurements included weight, albumin, glucose, triglyceride concentrations, and liver function tests. Serum osmolality was calculated, and found to remain constant. Body weight and serum albumin were maintained. Minor changes occurred in hepatic enzymes which were physiologically insignificant. Glycosuria occurred in 15%. Adverse side effects of hypoglycemia, hyperosmolar coma, and hypertriglyceridemia were avoided. Our results show that the addition of fat reduced glucose and hepatic related metabolic complications.

Continuous elemental enteral alimentation in the treatment of children and adolescents with Crohn's disease.

Abstract: Ten pediatric patients, aged 8.5-19 years, with active symptomatic Crohn's disease, received a three-week period of continuous elemental enteral alimentation with no other form of treatment. All patients in this study were selected according to the following criteria, which were applied consecutively : (1) newly diagnosed patients with no previous treatment for Crohn's disease, (2) disease activity index over 200, and (3) no complication requiring surgery.All patients experienced a clinical remission and improved their immunologic and nutritional status during the elemental enteral alimentation. The mean disease activity index for the whole group was 307.0 ± 23.6 (range: 203 to 413) before and 69.2 ± 11.4 (range: 15 to 114) after the feeding period. Significant increases in body weight, triceps skinfold, mid-arm circumference, serum transferrin and mean percentage of T lymphocytes were also observed. Following cessation of enteral alimentation, a small declining dose of prednisone was used during a one-ye...

Weight Loss in Patients Receiving Radical Radiation Therapy for Head and Neck Cancer: A Prospective Study

Abstract: Thirty-one patients receiving radiation therapy for localized cancer of the head and neck areas were systematically assessed before, during, and after treatment. The pathogenesis of weight loss and its association with treatment morbidity and other determinants were sought. The serial data collected consisted of a food frequency questionnaire based on Canada's Food Guide, anthropometric measurements, 10 Linear Analogue Self Assessment questions on morbidity, and biochemical and hematological indices. Twenty of 31 patients (68%) lost over 5% of their presenting weight within one month after completing treatment. The mean weight loss was 10% and the range of weight loss in this group was 5.4 to 18.9%. Pretreatment dietary habits, serum albumin, absolute lymphocyte count, serum creatinine, creatinine height index, and anthropometric measurements did not predict for weight loss. However, weight loss can be predicted on the basis of field size and site irradiated. Treatment-related morbidity involving dysguesia, xerostomia, dysphagia of solids, and mouth pain was greater and of longer duration in patients with weight loss. The sequence of development of these symptoms during treatment and their duration provide a rational basis for the timing and methods of nutritional intervention in this patient population.

Central venous alimentation: a prospective study of the frequency of metabolic abnormalities among medical and surgical patients.

Abstract: Many studies have described the frequency of septic and technical complications of central venous alimentation (CVA), but metabolic complications of CVA have received scant attention. Among 100 consecutive medical and surgical patients receiving CVA under routine hospital conditions, at least one severe biochemical defect (above the 99th percentile ranking) was observed in 63 cases (63%). Uncontrolled hyperglycemia (defined as blood glucose greater than 300 milligrams per deciliter after more than 48 hours of CVA) was present in 47 individuals. Hypophosphatemia (serum phosphorus less than 2.0 milligrams per deciliter) occurred in 30 and was life-threatening (less than 1.0 milligrams per deciliter) in 6. Although liver function tests (LFT) remained stable or improved in 26% of the 34 evaluable subjects, 74% showed deterioration in one or more tests, and 35% showed deterioration in two or more tests. Deterioration was defined as an abnormal result that was 50% or more above baseline in patients having weekly LFT and CVA for a minimum of 10 days. The study involved 1378 patient-days of CVA, a mean of 14 days per patient with a range of 2 to 70 days, and an average of 2.2 catheter insertions per patient. Technical complications occurred in 3% and septic complications occurred in 4% of 220 catheter insertions. There was no significant difference in the type or frequencies of metabolic, septic, and technical complications occurring between medical and surgical patients. The findings suggest that many reports concerning septic and technical complications of CVA have promoted awareness of the problem and served to minimize these risks. However, this study demonstrates that serious metabolic complications of CVA occur at an unexpectedly high rate and that greater attention should be directed at their prevention.

Evaluation of Opsite Catheter Dressings for Parenteral Nutrition: A Prospective, Randomized Study

Abstract: A prospective, randomized study compared the use of Opsite and standard gauze/tape dressings in 261 patients receiving parenteral nutrition. Eighty-four patients had a source of external drainage and were evaluated as a separate group. Catheter-related sepsis was assessed by blood culture, catheter tip culture, clinical sepsis, and clinical defervescence of fever after catheter removal. Although no statistically significant difference between Opsite and standard dressings could be identified, Opsite-treated patients consistently had increased parameters of catheter-related sepsis in all comparisons. As used here, Opsite is probably not a suitable catheter dressing system for parenteral nutrition.

Experience with double lumen right atrial catheters.

Abstract: A double lumen right atrial catheter was placed in 57 allogeneic marrow transplant recipients, and its use was compared to a concurrent series of 63 patients receiving the large-bore single lumen catheter. Ten double lumen catheter recipients developed septicemia, while neutropenic with granulocyte counts less than 100 per cubic centimeter, and three had their catheters removed for persistent septicemia. Seventeen single lumen catheter recipients developed septicemia while granulocytopenic, and one had the catheter removed for persistent septicemia. Hyperalimentation was more effectively delivered with the double lumen catheter which provides a route for infusion of hyperalimentation solutions at a constant rate during infusions of blood products, antibiotics, and other fluids.

Serum-sulfated lithocholate as an indicator of cholestasis during parenteral nutrition in infants and children.

Abstract: Serum-sulfated lithocholate concentrations were followed in 55 patients receiving parenteral nutrition. Elevation of serum lithocholate occurred in 18 (10/34 under 6 months of age, 8/21 older than 6 months). Serum sulfated lithocholate concentrations were a more sensitive indicator of cholestasis than either direct bilirubin or aminotransferases. The serum lithocholate concentrations in parenteral nutrition-associated liver disease were similar to those seen in patients with known cholestasis.

Bacterial Safety of Reconstituted Continuous Drip Tube Feeding

Abstract: Chemically defined diets require reconstitution and transfer to a delivery system. When reconstituted High Vivonex was noted in our Medical Center to be bacteriologically contaminated, we instituted a series of control procedures. We then reevaluated bacterial growth in reconstituted High Nitrogen Vivonex and diluted Isocal under ward conditions. The mixtures were prepared with sterile water versus tap water, using a hand washed blender versus a machine washed blender. We also investigated the bacteriological effect of blast freezing reconstituted High Nitrogen Vivonex. All preparations of the nonfrozen High Nitrogen Vivonex showed occasional low level contamination, although quantitative cultures did not show logarithmic growth over eight hours of observation. No growth occurred in the blast frozen High Nitrogen Vivonex or in the Isocal. We conclude that reconstituted High Nitrogen Vivonex and diluted Isocal may be prepared and hung safely for eight hours, and that blast freezing of High Nitrogen Vivonex is bacteriologically safe. As a result of our initial findings of bacteriologic contamination, we believe a program for bacterial monitoring of the tube feeding is desirable.

Management of Lymphatic Fistulas by Total Parenteral Nutrition

Abstract: Lymphatic fistula is a rare surgical complication, which mainly occurs after cervical or retroperitoneal lymph node dissection and which frequently requires a surgical repair. A small series of nine postoperative lymphatic fistulas treated conservatively with total parenteral nutrition (TPN) is reported. All the patients were malnourished at the beginning of the TPN, and all exhibited an objective improvement of their nutritional status after completion of the treatment. Due to the interruption of the enteral alimentation or to the nutritional repletion, spontaneous closure of the fistula was achieved in eight of nine patients treated with TPN longer than 1 week. The authors conclude that whenever the immediate surgical repair is not recommended, or it is not successful, a 2- to 3-week course of TPN may be used with the chance of spontaneous healing. In any case, patients conservatively treated by TPN can undergo a delayed operation with minimal risk because of the improved nutritional status.

Selenium Status of Seven Chronic Intravenous Hyperalimentation Patients

Abstract: Selenium status was determined on seven patients receiving long-term intravenous hyperalimentation (IVH) and they were followed monthly for 4 to 17 months. Analysis of the IVH solutions for selenium revealed no detectable amounts. The selenium indices measures were (1) erythrocyte selenium levels, (2) erythrocyte glutathione peroxidase activities (GSH-Px), and (3) plasma selenium levels. In general, the IVH population had significantly lower values (p less than 0.001) for these selenium indices than a healthy population (n = 275). The plasma selenium levels decreased to below the normal range within one to two months after initiation of IVH. The below normal ranges varied by patient: three patients by three months, one patient by nine months, and three patients had low and normal values throughout the study. No consistent correlation of individual patient's erythrocyte GSH-Px activities and erythrocyte selenium levels existed, but a positive correlation (r = 0.51, p less than 0.01) occurred between plasma selenium levels and erythrocyte GSH-Px activities. Thus, erythrocyte GSH-Px activities decrease parallel to decreases in plasma selenium levels but not with changes in erythrocyte selenium levels. These data suggest that some of these IVH patients may be at risk for selenium deficiency and that selenium supplementation of IVH solutions may be required. Furthermore, these data suggest that the measurement of erythrocyte GSH-Px activity or selenium levels in some IVH patients may not be related to available body selenium.

Prealbumin: a parameter of visceral protein levels during albumin infusion.

Abstract: Prealbumin estimations were obtained to determine nutritional states in a group of patients supported with total parenteral nutrition and exogenous albumin infusions. Patients who were in positive nitrogen balance demonstrated an increase in prealbumin levels (11.0 ± 1.6 milligram percent versus 20.3 ± 3.3 milligram percent), whereas patients who were in negative nitrogen balance demonstrated a decrease in prealbumin levels (13.1 ± 5.3 milligram percent versus 9.8 ± 2.2 milligram percent).Prealbumin can be utilized as a test to reflect visceral protein states in patients receiving exogenous albumin infusions.

Nutrition and Protein Turnover: A Review

Abstract: The proteins of the body are continuously being broken down and resynthesized. This review discusses the physiological significance of this process, how it can be measured in patients, and how it is altered by malnutrition and various disease states.

Changes in body protein, body potassium, and lean body mass during total parenteral nutrition.

Abstract: Lean body mass by anthropometry (AMLBM), total body potassium (TBK), and total body nitrogen (TBN) by prompt gamma analysis, are reported in 38 malnourished patients during total parenteral nutrition. Over long periods (greater than 2 months) TBN increased 32% while AMLBM and TBK rose only by 9.2 and 9.5%, respectively. Changes in AMLBM and in K were significantly correlated, but changes in nitrogen were not correlated with either. From short-term studies, the same conclusions can be obtained; although there are changes in lean body mass and in potassium, there is no correlation with such changes in nitrogen. With repletion, changes in body protein are not necessarily related to changes in AMLBM or to TBK: the latter two reflecting total and intracellular water, respectively, but not protein content.

Selenium and Vitamin E Sufficiency in Premature Infants Requiring Total Parenteral Nutrition

Abstract: A randomized prospective study of LBW infants was undertaken to evaluate the effect of parenteral lipid infusions upon their antioxidant systems. Ten babies received a parenteral nutrition regimen with lipid emulsion, and ten received a regimen without lipid. Although the addition of lipid emulsion to the total parenteral nutrition regimen led to a rise in vitamin E levels, the selenium levels fell in both groups. Neither group showed evidence of deficient antioxidant systems by the peroxide hemolysis test or thiobarbituric acid test. There did not seem to be any adverse effect of the lipid infusion upon the clinical course of the infants except for hyperlipidemia. There was a better weight gain in infants receiving lipid.

Primary Taste Thresholds in Children with Leukemia Undergoing Marrow Transplantation

Abstract: Taste threshold for the four basic tastes were determined to assess taste impairment in 11 children with acute leukemia undergoing marrow transplantation and in 20 normal children. Thresholds were measured on admission, 2 days, and 45 days after transplant using the Up-Down Staircase method. No significant difference was noted between patients at admission and the control group for sweet, bitter, or salt. There was a significant difference between patients and controls for the sour threshold (p = 0.006). Patient threshold values on day 2 and day 45 posttransplant were compared with admission values. No significant differences were seen, except for the salt threshold which was increased at day 2 posttransplant when compared with the admission values.We conclude that only minor changes in taste thresholds were demonstrated in this study. These changes probably do not account for abnormal food tastes reported by patients.

Nutritional Responses of Tumor-bearing Rats to Oral or Intravenous Feeding

Abstract: Two experiments were conducted with male rats weighing 170 to 190 grams. In experiment 1, some nutritional parameters were determined in tumor-bearing (TB) (Walker 256 carcinosarcoma) rats fed a 23.6% casein diet for 4 weeks after the tumor inoculation. Cumulative weight gain and food intake were less in TB rats than in nontumor-bearing (NTB) rats. At 3 and 4 weeks after the tumor inoculation, plasma histidine, alanine, and glycine levels were higher in TB rats than in NTB animals. The arginine level was lower in the plasma of TB rats at 4 weeks after the inoculation. The significance of decrease in plasma arginine with regard to tumor growth is discussed. In experiment 2, the effects of total parenteral nutrition (TPN) on TB rats were evaluated as compared with those of 5% glucose (Glc) solution. Body weights of TPN rats were maintained and their nitrogen (N) balances were positive during a 7-day experimental period. while 5% Glc animals showed severe body weight loss and apparent negative N balance. Aft...

Safety of Intravenous Hyperalimentation in Children with Malignancies: A Cooperative Group Trial

Abstract: A prospective randomized cooperative trial of intravenous hyperalimentation (IVH) was executed in children with malignancies in two segments: those patients who are newly diagnosed and who would undergo abdominal irradiation, and patients with tumors that were metastatic to or from bone. The combined experience was pooled to evaluate the safety of IVH in these children with cancer. Patients who were not malnourished were randomized to receive IVH or regular diets. Malnutrition was defined by a weight for height below the 80th percentile of the median for age and sex and/or serum albumin below 3.0 grams per 100 milliliter. Patients falling below such standards were given IVH as nonrandomized entries in the study. Twenty-three were randomized to IVH, 25 randomized to control, and 18 entered on IVH without randomization, for a total patient entry of 66. No incidence of pneumothorax or local infections at the catheter insertion site were seen. Among the patients randomized to IVH, no local infections were fou...

Rapidly Declining Serum Albumin Values in Newly Hospitalized Patients: Prevalence, Severity, and Contributory Factors

Abstract: We had noted that a number of hospitalized patients showed abnormally low serum albumin levels within a few days of admission, although the albumin had been normal at admission. Since this rapid decline in albumin could not be accounted for on the basis of starvation, we hypothesized that the changes were due to the increase in intravascular fluid volume which normally occurs with assumption of the recumbent position. Since albumin is often a nutritional screening parameter in hospitalized patients, it is important to ascertain the incidence of such profound changes in albumin as well as to identify possible causes for this change. A survey of 34 concurrent hospital admissions showed that 28 out of 34 (82%) patients had a decline in serum albumin within 5 days of hospitalization. These 28 patients had a decrease of 0.5 +/- 0.09 g/dl. Twenty-five additional patients were studied in order to elucidate causative factors. Twenty out of the 25 showed a decrease in serum albumin within 5 days of admission (mean decrease 0.5 +/- 0.05 g/dl). Hemoglobins in these patients decreased by a mean of 1.1 +/- 0.34 g/dl (p less than 0.01), but BUN and uric acid levels did not change significantly. The one factor common to all patients with declining albumin values was change in posture. All patients were ambulatory at the time of the initial albumin determination but were on bedrest for at least 6 1/2 hours before the second determination. The findings indicate that most hospitalized patients have significant changes in serum albumin levels which occur with change in posture. If the albumin level is to be used as a nutritional indicator, the patient's position at the time of phlebotomy is essential for accurate interpretation of results.

Hyperammonemia During Total Parenteral Nutrition in Children

Abstract: Serial blood ammonia (NH3) determinations in 19 low birth weight (LBW) infants, 14 term neonates and 12 children receiving total parenteral nutrition (TPN) have shown that 73% of patients had one or more elevated NH3 values (greater than 150 micrograms/dl). The mean blood NH3 was 220 +/- 13 micrograms/dl in LBW infants, 180 +/- 9 micrograms/dl in 10 infants, and 140 +/- 7 micrograms/dl in children. All of these values are significantly higher than normal (p less than 0.001). There was no difference in incidence or mean blood ammonia concentration between patients receiving casein hydrolysate and those receiving a crystalline amino acid solution. Only four patients were symptomatic and several infants remained fully alert despite blood NH3 concentration in excess of 400 micrograms/dl. One infant who had sustained hyperammonemia was given another amino acid source (Travasol) containing 1.2 mmol/dl of arginine; blood NH3 promptly fell to the normal range. However, six of seven additional infants had hyperammonemia while receiving Travasol (mean = 184 micrograms/dl). Hyperammonemia is common during TPN in children, often is not recognized clinically, and occurs with equal frequency in infants and older children. The high levels observed in LBW infants may be due to hepatic immaturity. Blood NH3 concentration should be monitored frequently during TPN. Persistent hyperammonemia should be treated by decreasing protein content of the infusate. The role of supplemental arginine is unclear.

Malnutrition and hospital prognosis in the alcoholic patient.

Abstract: The nutritional status of 65 alcoholic patients admitted to the Medical Service of a Veterans Administration Hospital was evaluated and compared to that 87 nonalcoholic patients admitted during the same period of time. There was no statistical difference in the prevalence of malnutrition in the alcoholic population (36.9%) when compared to the nonalcoholic population (43.7%). The death rate and incidence of infection were similar in both populations as was the prevalence of anemia, depressed total lymphocyte count, and skin test anergy. Malnutrition, however, correlated with an increased death rate and incidence of infection, regardless of whether the patient was an alcoholic or not.