Showing papers in "Journal of Parenteral and Enteral Nutrition in 1985"
474 citations
TL;DR: It is concluded that acute protein-energy malnutrition in critically ill children is associated with increased physiologic instability and increased quantity of care.
Abstract: The association of nutritional depletions with physiologic instability and quantity of care was examined in 60 critically ill children. Nutritional status was evaluated by anthropometric techniques. Physiologic stability was measured by the Physiologic Stability Index and quantity of care was measured by the Therapeutic Intervention Scoring System. Acute protein-energy malnutrition was significantly associated with increased physiologic instability and increased quantity of care (p less than 0.01). This association was present for the total group, children less than 24 months of age, and for these two groups with nonsurvivors excluded. Mortality was also significantly associated with acute protein-energy malnutrition (p less than 0.001). Physiologic instability and increased quantity of care were not associated with chronic protein-energy malnutrition, fat store depletion, or somatic protein store depletion. We conclude that acute protein-energy malnutrition in critically ill children is associated with increased physiologic instability and increased quantity of care.
188 citations
TL;DR: Treating hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.
Abstract: Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.
149 citations
TL;DR: Parenteral nutrition formulas where LCT has been partially replaced with MCT may better support host bactericidal capacity than similar regimens comprised of LCT as the sole lipid source.
Abstract: Use of intravenous lipid emulsions in trauma and sepsis still remains controversial. In order to examine the impact lipid emulsions have on host defense against bacterial infection during total parenteral nutrition (TPN), 56 male Sprague-Dawley rats underwent jugular cannulation and were randomly divided into three groups, each receiving one of three TPN regimens. All regimens delivered approximately 250 kcal/kg X body weight/day, of which 12.5 g were as amino acids. Group 1 received 100% of the nonprotein calories as glucose (AA + G). Group 2 was given 50% of the nonprotein calories as a longchain triglyceride emulsion (100% LCT). Group 3 received 50% of nonprotein calories as a mixed lipid system, composed of medium- and long-chain triglycerides (75% MCT/25% LCT). After 24 hr on intravenous nutrition, all animals received bilateral septic femur fractures and were continued on TPN for 3 days. On the last day, the level of bacteremia and the in vivo response to an intravenous challenge of 59Fe-labeled Escherichia coli were examined. Three days following the septic injury, animals given MCT as part of their lipid calories were not bacteremic, whereas the other groups had greater than 10(2) cfu/ml of blood. Animals receiving TPN with MCT sequestered a greater percentage of exogenously administered bacteria in the liver and sequestered less in the lung compared to animals given 100% LCT (p less than 0.05). From these data, we conclude that parenteral nutrition formulas where LCT has been partially replaced with MCT may better support host bactericidal capacity than similar regimens comprised of LCT as the sole lipid source.
148 citations
TL;DR: Delaying tubing changes does not increase catheter sepsis or hub contamination rates and, together with adequate hub protection, has proved to be a valuable factor in controlling an outbreak of catheter Sepsis due to the coagulase negative staphylococci.
Abstract: In previous studies the contamination of the catheter hub was found to be a common portal of entry for bacteria causing catheter-related sepsis. Since hub manipulations during tubing changes may increase the risk of contamination, a prospective trial was conducted to find out the effects of the frequency of tubing replacements on hub colonization and catheter sepsis rates. The results were compared with those obtained during an outbreak of coagulase negative staphylococci septicemia. Fifty-two patients were randomly allocated into two groups. Group A (n = 20) had the line changes every 2 days while group B (n = 32) had it replaced every 4 days. When the catheter was removed, the catheter tip and the hub were cultured by a quantitative method. Sterile, colonized, or infected hubs were equally distributed in both groups (A: 80, 15, and 5% vs B: 84, 6, and 10%). There were three episodes of catheter sepsis, one in group A and one in group B due to hub infection, and one in group B due to hematogenous seeding of the catheter tip. There were significant (p less than 0.001) differences between the trial and the historic series in respect to rates of hub colonization infection (19 vs 50%) and catheter sepsis (5.7 vs 40%). Delaying tubing changes does not increase catheter sepsis or hub contamination rates and, together with adequate hub protection, has proved to be a valuable factor in controlling an outbreak of catheter sepsis due to the coagulase negative staphylococci.
141 citations
TL;DR: Persistent abnormalities of liver chemistries in nine patients and progressive liver disease while receiving home parenteral nutrition in three patients are quite worrisome and suggest that home p Arenteral Nutrition-associated steatohepatitis with or without cholestasis may progress to chronic liver disease.
Abstract: Sixty patients with gut failure were treated with home parenteral nutrition for 2000 patient months. Fifty-one of these 60 patients had either no abnormalities or mild and transient elevations of their liver chemistries and did not have liver biopsies. Nine (15%) of 60 patients had abnormalities of liver tests that persisted from 8 to 95 months (median, 18 months) which prompted one or more liver biopsies per patient. Three patients had prolonged jaundice, one died of hepatic encephalopathy, and another with protracted intrahepatic cholestasis died following a biliary tract exploration. A third patient remains ill with signs and symptoms of chronic liver disease. Steatohepatitis was found in eight of the nine patients and was characterized by centrilobular and midzonal microvesicular and macrovesicular fatty changes with fat cysts, focal necrosis, and mixed inflammatory infiltrates. Centrilobular fibrosis was present in three patients and evidence of nodular regeneration in one. In the three patients demonstrating cholestasis, bile pigment was identified both in hepatocytes and canaliculi. Ceroid pigment in Kupffer cells was a consistent finding and much more severe than expected from the mildness of the hepatitis. Persistent abnormalities of liver chemistries in nine patients and progressive liver disease while receiving home parenteral nutrition in three patients are quite worrisome and suggest that home parenteral nutrition-associated steatohepatitis with or without cholestasis may progress to chronic liver disease.
138 citations
TL;DR: Total parenteral nutrition with complete bowel rest appears to be an effective therapeutic modality in the primary management of complicated Crohn's disease.
Abstract: The role of parenteral nutrition with complete bowel rest in the management of active Crohn's disease was evaluated retrospectively in 100 patients who were otherwise refractory to conventional medical management. Ninety patients received complete nutrient replacement and 10 received protein-sparing therapy. In 77 patients, a clinical remission was achieved. Analysis of subgroups revealed that the remission rate was equivalent in patients with subacute bowel obstruction (76%), inflammatory mass (82%), and otherwise uncomplicated severe active disease (89%). However, those patients with fistulae responded less well (63%). The location of the intestinal involvement with the disease did not influence the remission rate (73% in those with small bowel disease only and 78% in those with combined small and large bowel disease). All six patients with only large bowel involvement achieved a remission. In 81% of those patients with a remission, no corticosteroids were given, or the dose prior to TPN was maintained. The serum albumin improved significantly (p less than 0.001) from 3.2 +/- 0.1 to 3.6 +/- 0.1 g/dl with total parenteral nutrition, but there was no significant effect on the hematocrit (p greater than 0.5). The percentage of patients still in remission after 3 months and 1 yr of follow-up was 75 to 79 and 58 to 61%, respectively, in the three nonfistulous groups, and 46 and 36%, respectively, in those with fistulous disease. Thus total parenteral nutrition with complete bowel rest appears to be an effective therapeutic modality in the primary management of complicated Crohn's disease.
119 citations
TL;DR: It is suggested that patients with acute alcoholic hepatitis require additional nutritional therapy to maintain and improve their nutrition parameters, especially those related to marasmus; and that Hepatic Aid is well tolerated for this purpose.
Abstract: Patients with moderate to severe alcoholic hepatitis and features of protein-calorie malnutrition were studied with respect to changes in their nutritional status during 30 days of hospitalization. Thirty-four patients served as controls, were given a 2500 kcal hospital diet and allowed to eat ad libitum. Twenty-three patients were given, in addition to the hospital diet, a nutrition supplement high in calories, protein, and branched-chain amino acids (Hepatic Aid). Because of anorexia, the controls consumed lesser amounts of both calories and protein while those given the nutritional therapy exceeded their estimated energy requirements (116.1 %) and consumed a mean of 98.3 g of protein per day. This was well tolerated despite the fact that portal systemic encephalopathy was present in 72% of the patients. Mortality associated with the liver disease was comparable in both groups, 16.7% in the treated us 20.6% in the controls. In those patients that survived the 30 days of hospitalization, clinical and bio...
117 citations
TL;DR: Prealbumin effectively demonstrated an anabolic response in the study sample and could possibly be used as an early indicator of visceral protein anabolism in patients receiving metabolic/nutritional support.
Abstract: The response of prealbumin was compared to that of albumin and transferrin in 16 patients following 7 days of metabolic/nutritional support. Baseline values were compared to day 7 results to assess the degree of change. Prealbumin demonstrated a significant increase in the mean serum concentration (13.0 vs 19.6 mg/100 ml) in the presence of a positive nitrogen balance. Transferrin exhibited a similar significant response (168.8 vs 223.7 mg/100 ml). Albumin, body weight, and serum iron concentration did not change significantly during the 7-day period. Prealbumin effectively demonstrated an anabolic response in the study sample and could possibly be used as an early indicator of visceral protein anabolism in patients receiving metabolic/nutritional support.
93 citations
TL;DR: Grip strength was the most sensitive single parameter, but forearm muscle circumference and percentage ideal body weight were the most specific indices.
Abstract: This study evaluates hand grip strength as an indicator of nutritional status and a predictor of postoperative complications. Hand grip strength and other parameters of nutritional status, namely, midarm muscle circumference, forearm muscle circumference, triceps skinfold, percentage ideal body weight, serum albumin, and percent usual weight were determined preoperatively in 205 patients. Complications occurred in 28 patients (14%). Patients with at least one abnormal nutritional parameter had a higher incidence of postoperative complications. Their length of total and postoperative hospitalization was greater by 6.2 and 4.6 days, respectively (p less than 0.01). Grip strength was the most sensitive single parameter, but forearm muscle circumference and percentage ideal body weight were the most specific indices. Hand grip strength is a simple measure of nutritional status and an accurate prognostic indicator that requires further clinical evaluation.
86 citations
TL;DR: Current parenteral formulation may not provide appropriate fuels for the gastrointestinal tract in patients with gastrointestinal disorders, because circulating levels of beta-hydroxybutyrate and glutamines are often low, and glutamine is absent from standard amino acid solutions.
Abstract: Total parenteral nutrition has been extensively used to feed patients with a variety of gastrointestinal diseases, but little attention has focused on the nutritional requirements of the gut. To investigate intestinal consumption of intravenously administered nutrients, uptake of three principal fuels determined from in vitro studies was quantitated in seven awake, unrestrained dogs. Portal blood flow was measured by a dye dilution technique and, simultaneously, substrate samples were obtained from chronic indwelling arterial and portal venous catheters. Studies were performed during a postabsorptive basal period and during separate infusions of glutamine (0.10 mmol/kg X min), glucose (0.10 mmol/kg X min), and beta-hydroxybutyrate, (0.40 mmol/kg X min). During the basal period there was a significant arterial-portal vein gradient for glucose (144 +/- 26 mumol/liter) and glutamine (49 +/- 11 mumol/liter). These substances were taken up by the gut at rates of 4.11 +/- 1.23 and 1.43 +/- 0.19 mumol/kg X min, respectively. No significant uptake of beta-hydroxybutyrate was determined in the basal studies (0.27 +/- 0.10 mumol/kg X min). During substrate infusion, gut glucose uptake was unchanged (2.68 +/- 1.67 mumol/kg X min, NS), but consumption of glutamine (4.60 +/- 0.66 mumol/kg X min, p less than 0.001) and beta-hydroxybutyrate (4.33 +/- 0.71 mumol/kg X min, p less than 0.001) increased significantly. During parenteral feedings in patients with gastrointestinal disorders, circulating levels of beta-hydroxybutyrate and glutamine are often low, and glutamine is absent from standard amino acid solutions. Current parenteral formulation may not provide appropriate fuels for the gastrointestinal tract.
TL;DR: It is concluded that protein-calorie malnutrition is common in the group of patients likely to require liver transplant, although individual nutritional assessment parameters may lack sensitivity and specificity in determining nutritional status.
Abstract: Thirteen patients with severe liver disease had nutritional assessment in the weeks prior to orthotopic liver transplantation. Parameters measured included height and weight, upper arm anthropometry, delayed cutaneous hypersensitivity, total lymphocyte count, serum levels of albumin and transferrin, and plasma amino acids. Weight, when expressed as a percentage of ideal body weight, was greater than 85%, considered the normal lower limit, in all but two patients. However, mean triceps skinfold and arm muscle circumference were 49 ± 25 and 78 ± 9% standard, respectively. Mean serum albumin was 2.7 ± 0.6 g/dl and although mean serum transferrin level was 184 ± 86, eight patients had levels less than normal. Seven patients were anergic to Multitest CMI (58%) and 12 patients had depressed total lymphocyte count. All these later measurements in the aggregate support a diagnosis of protein-calorie malnutrition. High preoperative levels of amino acids, especially aspartate, phenylalanine, tyrosine, and methionin...
TL;DR: The addition of Intralipid to the TPN regimen did not alter immune function in these patients who showed depressed cell-mediated immunity before TPN compared with the standard glucose TPN program.
Abstract: The effect of a continuous infusion of a soybean oil emulsion on immune functon was evaluated in 40 malnourished patients who were randomized to receive preoperatively either a 25% glucose-5% amino acid solution (group G) or a 15% glucose-3.3% Intralipid-5% amino acid solution (group G-F). Average length of total parenteral nutrition (TPN) was 10.3 ± 0.9 days for group G and 9.0 ± 0.8 days for group G-F. Initial nutritional status and response to TPN were similar for both groups. Immune function was assessed before TPN and after nutritional repletion prior to surgery for each patient. The levels of immunoglobulins, C3, C4, circulating B lymphocytes and T lymphocytes, suppressor T lymphocytes, natural killer cell activity, and monocytes were normal before TPN and after nutritional therapy. However, the total number of T cells and helper T cells were low before TPN and remained so after TPN. In addition, lymphocyte function measured by the lymphocyte blastogenic response to phytohemagglutinin and pokeweed m...
TL;DR: Soy fiber's physiologic effect on laxation was not changed by heat processing, and although stool weights were larger on higher fiber intakes, transit rates were similar on all the fiber-containing diets.
Abstract: The importance of the level of dietary fiber intake on bowel function was measured in 16 healthy young males consuming self-selected and liquid enteral diets. Subjects consumed liquid Ensure as their sole nutrient source plus 0 (diet a), 30 (diet c), and 60 (diet d) g/day soy fiber, a fiber source high in hemicellulose that was added to the Ensure. Further, to examine whether heat processing affects the physiologic action of fiber, subjects consumed Enrich, an enteral formula similar to Ensure, which contains 30 g of the same soy fiber (diet b). The four diets were consumed in randomized order each for 10 days. Daily wet stool weight averaged 144.6 g on the self-selected diet and decreased significantly to 67.3 g when Ensure was consumed alone. Average stool weights on diets (b), (c), and (d) were 114.6, 100.2, and 150.3 g/day, respectively. Average fecal dry weights for the four diets were 19.1, 28.7, 25.0, and 30.3 g/day for (a-d), respectively. Gastrointestinal transit time, as measured with radiopaque...
TL;DR: Three patients maintained on total parenteral nutrition, who did not receive vitamins and experienced the acute onset of life-threatening metabolic acidosis with pH values as low as 6.70 were probably examples of acute beriberi, a well-documented syndrome.
Abstract: Total parenteral nutrition is one of the most important recent advances in medicine. The delivery of total parenteral nutrition, however, can be associated with a broad spectrum of complications ranging from mechanical (catheter related) to metabolic. We have recently seen a previously unreported complication of total parenteral nutrition - three patients maintained on total parenteral nutrition, who did not receive vitamins and experienced the acute onset of life-threatening metabolic acidosis with pH values as low as 6.70. All responded promptly and completely to the administration of intravenous thiamine, and thus were probably examples of acute beriberi. Acute beriberi is a well-documented syndrome which usually occurs in nutritionally compromised individuals outside the hospital setting who lack thiamine in their diet. Without thiamine, glucose cannot enter the Krebs cycle in order to be completely oxidized for energy production and therefore, accumulates as lactic acid. This lactic acidosis is refra...
TL;DR: Improved protein tolerance in both groups was not further increased by a highly enriched BCAA formula compared to one with a moderate BCAA content from a natural dietary protein source, and both conventional casein-based supplements and enrichedBCAA formulas are well tolerated.
Abstract: An orally administered branched-chain amino acid (BCAA) rich supplement (T), Travasorb-Hepatic was compared to a casein based supplement (E), Ensure, in a randomized double-blind cross-over study in eight malnourished, stable cirrhotics unable to achieve a daily dietary protein intake of 1.0 g/kg. Doses of antiportal systemic encephalopathy drugs remained constant and a baseline 1000 kcal, 40 g dietary protein intake was encouraged. To this diet, supplemental protein was added in daily 20-g increments to a maximum of 60 g supplemental protein. Mental status, asterixis, and number connection tests were assessed daily and an antiportal systemic encephalopathy index calculated. There was no significant difference in the mean intake of dietary protein (T, 33.7 +/- 4.0 g; E, 26.7 +/- 10.8 g), supplemental protein (T, 43.1 +/- 8.3 g; E, 47.9 +/- 7.1 g), or N2 balance (T, 4.2 +/- 3.7 g; E, 3.4 +/- 4.4) between treatment trials. The antiportal systemic encephalopathy index improved on E, with no significant change in the BCAA:aromatic acid molar ratio. This ratio improved on T (1.02 +/- 2.0 to 2.7 +/- 1.1), but was not accompanied by improvement in the antiportal systemic encephalopathy index. The improved protein tolerance in both groups was not further increased by a highly enriched BCAA formula compared to one with a moderate BCAA content from a natural dietary protein source. Thus, both conventional casein-based supplements and enriched BCAA formulas are well tolerated and can be safely and effectively used as an integral part of diet therapy.
TL;DR: This study demonstrates that nutritional supplementation results in significant improvement in selected nutritional parameters and indicates that the hematopoietic and immunological status of these patients was unchanged.
Abstract: A nutritional assessment of 33 elderly subjects participating in a "meals on wheels" program revealed a high prevalence of nutritional deficiencies. Twelve of these subjects, who were considered to be at high risk for protein calorie malnutrition, received 240 ml of a polymeric dietary supplement three times daily for 16 wk. This resulted in a significant (50%) increase in total caloric and protein intake which was maintained for the entire 16 wk of study. In seven of the 12 subjects a weight gain of greater than 2 kg was found. Modest but significant elevations in serum albumin and highly significant elevations of the total iron binding capacity, serum and red cell folate, leukocyte ascorbate, and serum vitamin B12 provided strong evidence for improved nutritional status. In contrast no improvement in the hemoglobin, total lymphocyte count, T cell number, T suppressor cells, T helper, or B cells was noted. In no anergic subjects was skin test conversion found. In addition no increase in serum trace metals or vitamin B6 levels were noted. Thus this study demonstrates that nutritional supplementation results in significant improvement in selected nutritional parameters. The fact that the hematopoietic and immunological status of these patients was unchanged suggest that the abnormalities may be age rather than nutritionally related or that a critical nutritional deficiency was not corrected.
TL;DR: Data indicate that once enteral formulas are tolerated high nitrogen regimens are required to achieve positive nitrogen balance in acute severe head injury patients.
Abstract: In an attempt to improve early enteral nitrogen replacement, nitrogen status was compared in two groups of head injured patients receiving enteral regimens of 38 to 51 kcal/kg/day with different protein concentrations. Eleven control patients received 1.5 g protein/kg/day and 10 study patients received 2.2 g protein/kg/day. Daily nitrogen excretion, corrected nitrogen balance, blood urea nitrogen changes, and enteral formula tolerance were compared between groups over a 10-day period. Those receiving 2.2 g protein/kg/day had significantly higher daily and cumulative nitrogen balances despite their higher nitrogen excretion levels. Over 10 days, the study group retained 9.2 g nitrogen. By comparison, the control group sustained a cumulative loss of 31.2 g nitrogen over 10 days, despite a mean intake of 109 g protein/day. In both groups, full strength, full rate feedings were not possible until day 10 postinjury. These data indicate that once enteral formulas are tolerated high nitrogen regimens are required to achieve positive nitrogen balance in acute severe head injury patients.
TL;DR: Arginine-rich solution suppressed tumor growth at an early stage and prevented metastases to the liver and kidney and enhanced the phagocytic activity of alveolar macrophages.
Abstract: To investigate the effect of arginine-enriched solution on tumor growth and metastasis, rats were infused with solutions containing 5.5 and 0.66% arginine for 8 days. Infusions were started at the same time of subcutaneous transplant of Yoshida sarcoma. Arginine-rich solution suppressed tumor growth at an early stage and prevented metastases. to the liver and kidney. In addition, arginine supplements enhanced the phagocytic activity of alveolar macrophages. It also resulted in maintenance of a positive nitrogen balance and prevented the increases in the levels of several amino acids observed in the control group. The suppressive effect of arginine-enriched solution on tumor growth may be due to its activation of the immunologic system, in which the phagocytic activity of macrophages probably participates. (Journal of Parenteral and Enteral Nutrition9:428-434, 1985)
TL;DR: In this paper, a nucleotide and nucleoside mixture was added to the total parenteral nutrition solution in rats after 70% hepatectomy to restore nitrogen balance in the first 3 days.
Abstract: After partial hepatectomy rats were used as a model of patients with liver tumor after extensive hepatectomy. Supplementation of a nucleotide and nucleoside mixture to the total parenteral nutrition solution in rats after 70% hepatectomy resulted in earlier restoration of the nitrogen balance in the first 3 days than the solution without this supplementation. This supplementation had no unfavorable effects on the compositions of the blood and urine, and particularly the metabolites of nucleic acids such as uric acid, β-alanine, and β-aminoisobutyric acid. A suitable ratio of nucleotides plus nucleoside to amino acids was tentatively concluded to be 1:2 g N with a calorie supply of 400 kcal. (Journal of Parenteral and Enteral Nutrition 9:339-342, 1985)
TL;DR: It is concluded that febrile illness is an important determinant of abnormal serum albumin concentrations in pediatric oncology inpatients and may more often reflect the acute metabolic response to fever and infection than depletion of body mass.
Abstract: Nutritional status was evaluated on 210 occasions in 90 pediatric oncology inpatients during a 7-month period; 39 had solid tumors and 51 leukemia. Ages ranged from 3 months to 20 yr. Nutritional parameters were defined as normal, "at risk," or "probably malnourished." Fifty-seven and 29% of assessments revealed at least one parameter "at risk" or "probably malnourished," respectively. Prognosis was negatively related to the number of abnormal nutritional parameters. Serum albumin was most frequently abnormal. However, on most occasions, hypoalbuminemia was associated with weight/height, arm muscle area, and triceps skinfold measurements in the normal range. In order to further identify determinants of serum albumin, we analyzed dietary, chemotherapy, and temperature data in 10 prospectively studied leukemia patients, half of whom received parenteral nutrition. In these patients there was little relationship of serum albumin to chemotherapy or dietary intake. In all of these patients, especially those receiving total parenteral nutrition, low serum albumin was highly associated with fever (p less than 0.0005). We concluded that febrile illness is an important determinant of abnormal serum albumin concentrations. In pediatric cancer patients, abnormal serum albumin may more often reflect the acute metabolic response to fever and infection than depletion of body mass.
TL;DR: The combination of gamma-glutamyl transpeptidase and alkaline phosphatase is recommended as the most cost effective way of detecting parenteral nutrition-associated cholestasis.
Abstract: We carried out a study to determine which of the liver function tests was the most sensitive and/or specific in detecting parenteral nutrition associated cholestasis. The tests utilized were alkaline phosphatase, γ-glutamyl transpeptidase, cholyglycine, sulfolithocholylglycine, and bilirubin. Fifty-nine patients with no prior evidence of liver dysfunction were studied. We found γ-glutamyl transpeptidase to be the most sensitive (89.5%) and also the least specific (61.9% specificity). Specificity of γ-glutamyl transpeptidase was improved when it was combined with alkaline phosphatase. We recommend the combination of these two enzymes as the most cost effective way of detecting parenteral nutrition-associated cholestasis. (Journal of Parenteral and Enteral Nutrition9:307-308, 1985)
TL;DR: The concept that anerobic intestinal bacteria may be involved in the pathogenesis of liver changes commonly observed during total parenteral nutrition (TPN) is supported.
Abstract: Abnormal serum liver enzymes are common in adults receiving total parenteral nutrition (TPN). The mechanism(s) responsible for these changes is unclear. One hypothesis is that there is overgrowth of intestinal anaerobic bacteria with subsequent toxic effects on the liver from endotoxins and/or bile acids. A retrospective survey of patients receiving TPN was undertaken. The patients were divided into two matched groups. One group had received metronidazole, a drug that suppresses anaerobic bacteria, while the other group had not. The administration of metronidazole during TPN was associated with prevention of the expected rise of serum alkaline phosphatase, gamma glutamyl transpeptidase, and aspartate amino-transferase. This study supports the concept that anerobic intestinal bacteria may be involved in the pathogenesis of liver changes commonly observed during TPN.
TL;DR: In an attempt to prevent this decline and to characterize its influence on the efflux of amino acid (AA) from skeletal muscle, varying quantities of AA were administered as saline or AA solutions with or without GLN enrichment to 22 postoperative dogs.
Abstract: Skeletal muscle glutamine (GLN) concentration falls following injury and infection. In an attempt to prevent this decline and to characterize its influence on the efflux of amino acid (AA) from skeletal muscle, we administered varying quantities of AA (0, 2, and 4 g/kg·day) as saline or AA solutions with or without GLN enrichment to 22 postoperative dogs. Plasma and muscle AA were determined before and 24 hr after standard laparotomy. Hindquarter AA efflux was measured at 6 and 24 hr. Skeletal muscle nitrogen declined in saline controls (69.8 ± 8.5 us 52.8 ± 8.4 mmol/liter; p < 0.01), largely due to the fall in intracellular GLN (21.48 ± 3.21 us 15.86 ± 3.80; p < 0.05). Similar alterations were seen in the animals receiving 2 g/kg. However, both intracellular nitrogen and GLN were maintained in animals receiving 4 g/kg, whether the AA solutions contained GLN or not (skeletal muscle nitrogen before 64.3 ± 8.6 mmol/l vs 65.4 ± 7.0 after, GLN 19.2 ± 3.4 vs 19.9 ± 3.0). Hindquarter AA efflux was reduced in th...
TL;DR: The best metabolic and nutritional results were obtained with diets containing 20 to 30% of calories as protein and providing a caloric intake that paralleled the measured energy expenditure.
Abstract: Enteral nutrition was provided by continuous pump-controlled gastrostomy tube feeding for 14 days in 97 guinea pigs bearing a 30% full thickness burn Seven defined combinations of caloric and protein intake were studied With a caloric intake of 175 kcal/kg/day, equaling the measured energy expenditure, the animals receiving 10% of calories as protein had a significantly greater postburn weight loss (p less than 005) and muscle mass depletion (p less than 005), and a significantly lower muscle nitrogen concentration (p less than 005), serum albumin level (p less than 001) and liver nitrogen content (p less than 001) With the same caloric intake but with more than 20% of calories as protein, the weight loss and the muscle wasting were reduced, but not abolished, and the serum albumin level and liver nitrogen content were normalized Also with the diets containing 200 kcal/kg/day the muscle tissue depletion could not be abolished However, with this caloric intake, the animals given 20% of calories as protein had a lower weight loss and a higher serum albumin level (p less than 001), but also a greater fat infiltration of the liver (p less than 001) At both levels of caloric intake, the nitrogen balance correlated significantly with the level of nitrogen intake but did not correlate with the changes of body weight The incidence of diarrhea was lowest in animals fed 20% protein calories at a caloric intake of 175 kcal/kg/day All things considered, the best metabolic and nutritional results were obtained with diets containing 20 to 30% of calories as protein and providing a caloric intake that paralleled the measured energy expenditure
TL;DR: Weight loss alone can be used as a rapid, inexpensive assessment of nutritional status for predicting postoperative complications, and the difference between specificity of weight loss alone vs INA was statistically significant, p less than 0.05.
Abstract: The prevalence of malnutrition in Veterans Administration Hospitals has been well documented. Several methods have been proposed to assess nutritional status including prognostic nutritional index (PNI) and instant nutritional assessment (INA). A prospective study was done to evaluate the currently used nutritional assessments and determine their efficacy based on sensitivity and specificity in predicting surgical morbidity and mortality. Data on 46 patients were evaluated for the multiparameter index of PNI, total lymphocyte count and serum albumin for INA, and weight loss alone. In this analysis, intermediate and high risk PNI were combined as positive predictor of complications. Any abnormal value in INA was considered positive as was weight loss of greater than 6% of usual body weight. Sensitivity and specificity of each assessment method were determined by 2 x 2 contingency table, and significance of observed differences between methods was determined by X2 analysis. There were no complications or de...
TL;DR: In 26 patients during total parenteral nutrition D, L-acetyl-carnitine was administered and was associated, in septic patients only, with a significant decrease in the respiratory quotient, suggesting enhanced oxidation of low respiratory quotients substrates (fatty acids and/or branched-chain amino acids).
Abstract: Carnitine is an indispensable factor for the beta-oxidation of medium- and long-chain fatty acids, and it plays a possible role in the oxidation of branched-chain amino acids. Plasma and urinary levels of free carnitine and short-chain acyl-carnitines were studied in 67 surgical patients, after non-septic surgical procedures or during sepsis. The septic state was associated with increased urinary excretion of free carnitine (p less than 0.001), as well as with lower plasma levels of short-chain acyl-carnitines (p less than 0.001); the latter feature correlated with the level of hypermetabolism, as evaluated by the metabolic rate and by the arterial-mixed venous O2 difference. In 26 patients during total parenteral nutrition D, L-acetyl-carnitine was administered (100 mg/kg/24 hrs, in continuous iv infusion) and was associated, in septic patients only, with a significant decrease in the respiratory quotient, suggesting enhanced oxidation of low respiratory quotient substrates (fatty acids and/or branched-chain amino acids). Carnitine supplementation during total parenteral nutrition might be of theoretical benefit in some clinical conditions, such as sepsis, in which the following conditions coexist enhanced utilization of substrates whose oxidation is partially or totally carnitine dependent; prolonged absence of exogenous intake of carnitine (as in long-term total parenteral nutrition); eventual impairment of carnitine synthesis due to hepatic dysfunction; increased, massive urinary loss of carnitine.