Showing papers in "Journal of Parenteral and Enteral Nutrition in 1993"

Total Parenteral Nutrition With Glutamine in Bone Marrow Transplantation and Other Clinical Applications (A Randomized, Double-Blind Study)

Abstract: In a paper by Ziegler et al (Ann Intern Med 116:821-828, 1992), total parenteral nutrition supplemented with L-glutamine (TPN/GLN) was reported beneficial in patients receiving bone marrow transplantation (EMT) for hematologic malignancies By using a similar protocol, we studied 29 patients with both hematologic malignancies and solid tumors, and with both allogeneic and autologous BMTS In a double-blind, randomized approach, patients were given isocaloric, isonitrogenous TPN after BMT until they consumed 50% of their required diet orally Total body water and extracellular water were measured before and after TPN in 10 patients Total body water increased in patients receiving standard TPN and decreased significantly in patients receiving TPN/GLN Length of hospital stay after BMT was significantly (58 days) less in patients receiving TPN/GLN Incidence of positive bacterial cultures, clinical infections, and mortality did not differ significantly between the two groups When the groups were subdivide

Controlled trial on nutrition supplementation in outpatients with symptomatic alcoholic cirrhosis

Abstract: A controlled trial on nutrition supplementation in ambulatory patients with decompensated alcoholic liver disease was carried out during 1 year. Fifty-one patients were studied; 26 were assigned to an experimental group receiving a daily supplement of 1000 kcal and 34 g of proteins given as a casein-based enteral nutrition product and 25 to a control group receiving one placebo capsule. Patients were examined in a special clinic once a month or more if required. Sixty-eight percent of patients admitted to alcohol ingestion or had alcohol in urine samples on at least one occasion. Dietary recalls showed a significantly higher protein and caloric intake in case patients subjects (p < .0001). Nine patients died during the study, three case patients and six control patients (p = NS). The frequency of hospitalizations was significantly less in the experimental group. This difference was attributed to a reduction in severe infections. Mid-arm circumference, serum albumin concentration, and hand grip strength improved earlier in case patients, although both groups had a significant improvement in these parameters. Bilirubin and aspartate aminotransferase decreased and prothrombin time increased significantly in both groups during the study period, without differences between groups. It is concluded that nutrition support decreases nutrition-associated complications in patients with alcoholic liver disease.

Comparison of Weighted vs Unweighted Enteral Feeding Tubes for Efficacy of Transpyloric Intubation

Abstract: Routine transpyloric placement of feeding tubes reduces aspiration in intensive care unit patients. Spontaneous passage eliminates the need for radiologic or endoscopic intervention. It is unclear whether the addition of a weight to the end of the tube or the use of the prokinetic agent metoclopramide in the conventional dose (10 mg) improves spontaneous transpyloric placement. In a randomized, prospective trial, 39 intensive care unit patients (age > 2 years) had a total of 50 nasoenteral tubes placed after intravenous metoclopramide (20 mg in adults, 0.2 mg/kg in children). The tubes were 8 French in diameter with either a weighted end or an unweighted bullet tip. Tip position was confirmed radiographically within 4 hours after blinded placement and at 1 and 2 days if spontaneous passage had not occurred. At 4 hours, 36% of the weighted tubes and 84% of the unweighted tubes (p < .002) had passed through the pylorus. At 1 day, 48% of the weighted tubes and 86% of the unweighted tubes (p < .007) had achieved transpyloric position. At 2 days, 56% and 92% of the weighted and unweighted tubes, respectively, had passed through the pylorus (p < .009, chi 2). The occurrence of transpyloric passage and the rapidity at which it occurred was significantly greater for the unweighted tube during all time periods. A poststudy trial was conducted to evaluate the effect of the normal dose of metoclopramide (10 mg in adults and 0.1 mg/kg in children) and the transpyloric passage of the unweighted feeding tube. Twenty-five patients received 10 mg of metoclopramide before the insertion of the unweighted tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutritional Outcome and Pneumonia in Critical Care Patients Randomized to Gastric versus Jejunal Tube Feedings M. A. MONTECALVO, K. A. STEGER, H. W. FARBER, ET AL Critical Care Medicine 20:1377-1387, 1992

Abstract: A prospective study was carried out over a 10-month period to compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in intensive care unit (ICU) patients randomized to either gastric tube feeding or feeding by an endoscopically placed jejunal tube. Sixty-nine patients were considered eligible for the study. Thirty-eight patients were enrolled from medical and surgical ICUs at two hospitals and were equally divided into two groups. The groups were similar in age, sex, race, underlying disease, type of surgical procedure, number of days fed, duration of ICU stay, duration of mechanical ventilation, days with fever, and days of antibiotic therapy. The jejunal tube (JT) group had more patients who were in circulatory shock on admission (79%) than the gastric feeding (GT) group (68.4%). Additionally, the JT group had higher Acute Physiology Scores (24.0 vs 21.7) and fewer patients with pneumonia at the time of entry into the study (26.3% us 31.6%). The JT patients received a signi...

Effect of Glutamine on Protein Synthesis in Isolated Intestinal Epithelial Cells

Abstract: The influence of glutamine on protein synthesis in small-bowel enterocytes was tested. Enterocytes were isolated from different levels of the villi of rat jejunum and were incubated in the presence of different glutamine concentrations, up to 3.4 mmol/L. Protein synthesis was determined by measuring incorporation of 3H-phenylalanine into trichloroacetic acid-precipitated proteins. Glutamine, but no other amino acids, stimulated protein synthesis in enterocytes from all levels of the villi. A maximal effect was noted at a glutamine concentration of 0.67 mmol/L, which is the normal plasma concentration. The amino acid stimulated the synthesis of both secreted and nonsecreted proteins. The stimulatory effect of glutamine on protein synthesis was blocked by the glutaminase inhibitor 6-diazo-5-oxo-L-norleucine and was duplicated by equimolar concentrations of acetoacetate or 3-hydroxybutyrate. The results suggest that glutamine stimulates protein synthesis in small-bowel enterocytes and that this effect of glutamine is related to provision of energy. The findings are important because they suggest that increased protein synthesis may be one of the mechanisms by which glutamine exerts its protective effect on gut mucosa during critical illness.

Serious Renal Impairment Is Associated With Long-Term Parenteral Nutrition

Abstract: Thirty-three current long-term total parenteral nutrition (TPN) patients (13 men, 20 women) aged 21 to 79 years were prospectively studied to evaluate their change in glomerular filtration rate since beginning TPN. Creatinine clearance (CrCl) from the subject's initial home TPN clinic visit and at present were estimated from standard formulas and compared. The CrCl in 12 patients who had received home TPN for > 10 years was estimated retrospectively on a yearly basis. The estimated CrCl as an accurate measure of glomerular filtration rate was confirmed by measuring plasma indium-111 diethylenetriamine pentaacetic acid clearance. The mean daily intravenous protein intake and days during which nephrotoxic medications were used and number of bacteremic/fungemic episodes were determined for each subject. CrCl declined by 3.5 +/- 6.3% per year (p = .004). Twenty-nine of 33 patients had decreases of 0.6% to 15.4% per year. Tubular function, as determined by the tubular reabsorption of phosphate, was impaired in 52% of the subjects. The intravenous protein load averaged 1.28 +/- 0.32 g/kg per day, nephrotoxic drug use averaged 3.4 +/- 4.0% of all days on home TPN, and each patient averaged 2.3 episodes of bacteremia or fungemia since home TPN was started (0.5 +/- 0.5 episodes per year). When all factors were assessed simultaneously, nephrotoxic drug use, episodes of bacteremia/fungemia, and age accounted for approximately 46% of the variability in CrCl. When bacteremia/fungemia was expressed as a yearly rate, nephrotoxic drug use assumed no role in the glomerular filtration rate determination; infection rate and age alone accounted for 53% of the CrCl variability. We describe a profound decrease in renal function associated with long-term TPN, most of which is largely unexplained.

Effect of Glutamine-Supplemented Total Parenteral Nutrition on Recovery of the Small Intestine After Starvation Atrophy

Abstract: Intestinal atrophy was induced in rats by infusion of 5% dextrose for 7 days with only oral water allowed. Compared with control animals fed standard rat chow (Purina Mills, St. Louis), the starved animals lost 30.5% of their initial body weight, 34.7% mucosal wet weight, 68.3% mucosal nitrogen content, 36.7% mucosal thickness, and 38.6% villous height and had variable losses of mucosal disaccharidase activities. Three groups of depleted rats were then refed with different regimens. One group was refed with standard Purina rodent chow (n = 15); a second group with a standard total parenteral nutrition (TPN) solution containing 16% glucose, 2.8% fat, and 4.25% standard amino acids (Travasol 8.5%, Baxter Healthcare Corporation, Deerfield, IL) (n = 15); and the third group with a TPN solution of 16% glucose, 2.8% fat, 2.75% standard amino acids, and 1.5% glutamine (n = 15). After 7 days of refeeding, rats were killed to determine the degree of intestinal recovery. Animals refed with standard TPN solution showed no significant recovery of intestinal mucosal weight, mucosal nitrogen content, villous height, mucosal thickness, or mucosal disaccharidase activities. Animals refed with glutamine-supplemented TPN solution demonstrated significant recovery of all parameters but not back to normal. Oral rodent chow completely restored intestinal anatomy and function. The addition of glutamine to TPN solutions significantly improved recovery of the intestine from starvation atrophy, and additional efforts to make it commercially available are indicated. This study again confirms the preferable use of a regular oral diet when clinically feasible and safe.

Quality of life in long-term total parenteral nutrition patients and their family caregivers.

Abstract: The purpose of this study was to identify individual and family variables associated with patient and caregiver quality of life. Perceived quality of life has been associated with improved outcomes and compliance. Methods included telephone interviews of 178 families, randomly selected from academic, hospital, and infusion agencies across the United States, with 116 follow-up questionnaires returned. Patients had varied bowel disorders requiring total parenteral nutrition for an average of 4.6 years. Patients were an average of 52.0 years old; caregivers averaged 52.5 years of age. Coded interview data indicated that caregivers assist patients daily (for a mean of 4.2 hours) and provide emotional support. Problems such as loss of friends, loss of employment, and depression were reported in two thirds of the families. Overall low quality of life was associated with length of time on total parenteral nutrition, fewer family coping skills, and inability to get along on income, whereas higher quality of life was associated with higher self-esteem and quality in the relationship. Preparing families for potential social problems or situations related to depression while also enhancing financial assistance, self-esteem, quality in the relationship, and coping skills may increase both patient and caregiver quality of life.

Alanyl Glutamine-Enriched Total Parenteral Nutrition Restores Intestinal Adaptation After Either Proximal or Distal Massive Resection in Rats

Abstract: This study was designed to determine whether alanyl glutamine-containing total parental nutrition (TPN) can restore the impaired adaptive process of the remaining intestine, observed with administration of conventional TPN, after massive small-bowel resection. Seventy-four male Sprague-Dawley rats weighing 250 g were randomly divided into seven groups. Group I rats (n = 10) were killed after overnight fasting. Group II animals (n = 32) underwent massive small bowel resection (85%) with preservation of the first 15 cm of jejunum. Group III animals (n = 32) were also submitted to massive small-bowel resection with preservation of 15 cm of terminal ileum. Three different TPN solutions were prepared. Solution A was a conventional formulation that did not contain glutamine. Solution B contained 1.88 times the amino acid concentration of solution A. Solution C was prepared by adding alanyl glutamine (2 g/100 mL) to solution A. Solutions B and C were isonitrogenous and isocaloric. Each solution was infused to groups II and III, which were subdivided into groups IIA (n = 10), IIB (n = 11), IIC (n = 11), IIIA (n = 10), IIIB (n = 11), and IIIC (n = 11). After 1 week of TPN (270 kcal/kg per day), the experimental animals were killed and the intestine was taken for examination. Final body weight did not differ significantly among the groups, and there was no difference in nitrogen balance among the animals that received solution B or C.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspirating Gastric Residuals Causes Occlusion of Small-Bore Feeding Tubes

Abstract: A frequent mechanical problem encountered with small-bore feeding tubes is lumenal obstruction of the tube. A number of studies have described methods to prevent tube occlusion and restore patency once the tube becomes occluded. It has been observed that most intact protein formulas will clot when acidified to a pH of less than 5.0. This study evaluated the question of whether gastric feeding tubes occlude more frequently when they are used for checking gastric residuals by aspirating acidic gastric juices into the tube than when gastric residuals are not checked. Patients who were fed intragastrically via a small-bore feeding tube with intact protein formulas were divided into two groups. Gastric residuals were checked in group A patients every 4 hours, whereas no residuals were checked in group B patients. Fifteen patients in group A were followed for a total of 138 patient days and 13 patients in group B were followed for 154 patient days. Ten occlusive episodes occurred in the group A patients, whereas only one occlusive episode occurred in the group B patients. This difference was statistically significant (p = .0171). We concluded that small-bore feeding tubes occlude more frequently when used to aspirate gastric residuals.

Glutamine Enhancement of Structure and Function in Transplanted Small Intestine in the Rat

Abstract: Total parenteral nutrition is required by all patients in need of small bowel transplantation. Untoward side effects of total parenteral nutrition include atrophy and hypofunction of the small intestine. Glutamine, the preferred fuel for the enterocyte, is presumably present in insufficient amounts in diets given to patients with intestinal dysfunction. In a rat model of total parenteral nutrition and small bowel transplantation, this study investigated the following: (1) whether glutamine improves graft structure and function, (2) the optimal route of glutamine delivery (intravenous vs direct infusion into the graft), and (3) the effect of glutamine on ultrastructure of the graft enterocyte. Lewis rats underwent small bowel transplantation as a Thiry-Vella graft and received total parenteral nutrition for 14 days while assigned to one of four infusion groups: 2% intravenous glutamine; 2% intravenous isonitrogenous mixture, nonessential amino acids (control); 2% glutamine into the graft; or 2% nonessential amino acids into the graft (control). Graft mucosal villous height, villous surface area, crypt depth, weight, protein, deoxyribonucleic acid content, glucose absorption, and enterocyte ultrastructure were then evaluated. Infusion of glutamine directly into the graft significantly increased mucosal villous height (p = .045), surface area (p = .029), and glucose absorption (p = .004) when compared with controls. Intravenous glutamine infusion significantly increased mucosal villous height (p = .002), surface area (p = .001), weight (p = .005), and glucose absorption (p = .04) when compared with controls. Most enterotrophic and functional benefits of glutamine were not significantly different between intravenous infusions and direct administration into the graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Detrimental Effects of an ω-3 Fatty Acid-Enriched Diet on Wound Healing

Abstract: The omega-3 fatty acids contained in fish oils have anti-inflammatory effects with potential beneficial clinical applications. However, these same effects may alter wound healing, a process dependent upon an adequate inflammatory response. The hypothesis that a diet enriched with omega-3 fatty acids could be detrimental to wound healing was tested in male rats fed complete diets differing only in their fat composition (17% menhaden oil + 3% corn oil vs 20% corn oil by weight) for 21 days before wounding and for 10 or 30 days after wounding (n = 16 per group). The wounding protocol included a dorsal 5-cm skin incision used for mechanical testing and a 2-cm incision used for subcutaneous polyvinyl alcohol sponge implantation. At 10 or 30 days postinjury, the 5-cm skin wounds were harvested and mechanically tested. The sponges were removed at 30 days and analyzed for collagen content. Food consumption and weight gain were the same in the two dietary groups. No differences in the mechanical properties of the wounds were detectable 10 days after injury. At 30 days, however, wounds harvested from rats fed the menhaden oil diet were significantly weaker than those from corn oil-fed animals. This difference in tensile strength was not explained by differential collagen accumulation, inasmuch as the collagen content of the sponges at 30 days was the same in both groups. Dietary consumption of a diet rich in omega-3 fatty acids may conspire against the quality of wounds by altering the fibroplastic or maturational phases of the healing response.

The Influence of Parenteral Glutamine and Branched-Chain Amino Acids on Total Parenteral Nutrition—Induced Atrophy of the Gut

Abstract: We tested the hypothesis that the provision of glutamine and branched-chain amino acids would reverse the gut atrophy that accompanies parenteral nutrition. Three hundred seventy-five rats were randomized into 15 groups to receive either conventional parenteral nutrition, rat food, glutamine-enriched parenteral nutrition (0.5% to 2.5%), branched-chain amino acid-enriched parenteral nutrition (0.8% to 2.0%), or glutamine plus branched-chain amino acid-enriched parenteral nutrition (0.5%/0.4% to 1.25%/1/0%). When compared with effects of conventional parenteral nutrition, the infusion of either glutamine or branched-chain amino acids partially reversed, in a dose-dependent manner, atrophy of the small bowel as assessed by gut weight (p < .05), mucosal weight (p < .05), villous height (p < .05), crypt cell production rate (p < .05), and mucosal protein concentration (p < .05). There was no effect on the large bowel. These results suggest that the parenteral infusion of either glutamine or branched-chain amino acids partially reverses the small-bowel atrophy that is associated with the infusion of solutions of conventional parenteral nutrients.

Review: First Choice for Total Parenteral Nutrition: The Peripheral Route

Abstract: Historically, total parenteral nutrition (TPN) has been administered by the central venous route because of the rapid development of thrombophlebitis when TPN solutions are administered into peripheral veins The insertion and placement of central venous catheters is, however, associated with morbidity and mortality and is the main cause of TPN-related complications By avoiding central venous catheterization, TPN can be made safer Current awareness about the pathophysiology of peripheral vein thrombophlebitis and the use of a number of techniques that prevent or delay onset of peripheral vein thrombophlebitis mean it is now possible to administer TPN via the peripheral route These techniques and changes in the practice of TPN in recent years (eg, reduction of caloric loads and use of lipid emulsions) mean peripheral parenteral nutrition is a technique that is now applicable to the majority of hospitalized, nutritionally compromised patients for whom intravenous feeding is anticipated for less than 10 to 14 days

Total Energy Expenditure in Patients With Crohn's Disease: Measurement by the Combined Body Scan Technique

Abstract: A combined body scan technique for measuring total energy expenditure (TEE) from energy intake and changes in energy stores is presented. The TEE of 13 patients with Crohn's disease who required nutrition support over a 14-day period was measured. They had a mean TEE of 33 kcal/kg per day. The components of the TEE in these 13 patients were also measured. Seventy percent of the TEE was made up by resting metabolic expenditure, 10% by diet-induced thermogenesis, and the remaining 20% by activity energy expenditure. These patients had a mean activity energy expenditure of 369 kcal/day. The diet-induced thermogenesis was a mean 12.6% increase on the resting metabolic expenditure. Each percent increase was caused by a mean of 210 kcal of energy in either the intravenous nutrition or the enteral nutrition. There was no difference in diet-induced thermogenesis between those having enteral nutrition and those receiving intravenous nutrition. Decreased activity was significantly correlated with increased activity of the disease (r = .7, p < .01). This confirms the belief that patients with Crohn's disease require no more energy (ie, 33 kcal/kg per day) than other patients. If the resting metabolic expenditure is increased through illness, then the activity energy expenditure decreases. The combined in vivo neutron activation-dual energy x-ray absorptiometry technique has allowed for the first time measurements in ward patients with Crohn's disease. The measurements confirm that TEE is not raised and that 30 to 35 kcal/kg per day is sufficient to achieve energy balance in such patients.

Patients Receiving Glutamine-Supplemented Intravenous Feedings Report an Improvement in Mood

Abstract: Nutritional effects have traditionally focused on outcomes, such as nitrogen balance, wound healing, or muscle strength. Little emphasis has been placed on how biochemical or physical improvements translate into functional changes as perceived by the patient. Because glutamine (GLN)-supplemented nutrition promotes protein synthesis and improves nitrogen balance, we assessed the mood of individuals participating in a randomized controlled blinded trial receiving GLN solutions. Patients (n = 23) undergoing marrow transplantation were randomized by the research pharmacist to receive either standard total parenteral nutrition (TPN) (control) or GLN-containing TPN (40 g of glutamine total). The solutions were isocaloric and isonitrogenous and were administered until the patient was eating 50% of estimated requirements. Before TPN and on admission to the hospital, the patient completed the Profile of Mood States questionnaire, a standardized test quantifying the degree of tension, depression, anger, vigor, fati...

Effect of a Liquid Diet With and Without Soluble Fiber Supplementation on Intestinal Transit and Cholecystokinin Release in Volunteers

Abstract: The effect of adding fiber to liquid formula diets on gastrointestinal transit is still controversial. Different fiber types (soluble vs insoluble) and different methodology of transit time measurements yielded variable results. Factors affecting transit include colonic fermentation, neural, and hormonal factors. We have therefore compared the effects of a standardized normal diet and two liquid formula diets with and without supplementation of a soluble fiber (21 g/L) on orocecal transit time measured by the hydrogen lactulose breath test, colonic transit time measured by radiopaque markers with an abdominal x-ray, bowel movements, stool consistency, and cholecystokinin release in 12 healthy male volunteers. The diets were consumed in a randomized order, each one for 7 days. The addition of soluble fiber did not affect orocecal transit time. Colonic transit time, however, was significantly prolonged (55 h) with fiber supplementation compared with the liquid diet (39 h) and the self-selected diet (30 h) (p < .01). Stool frequency and consistency was not significantly affected. During administration of both liquid diets, fasting cholecystokinin concentrations were significantly elevated compared with the concentrations found with a self-selected diet (p < .05). The fasting cholecystokinin concentration correlated significantly with the increase of segmental (right colon) colonic transit time (p = .02). The prolongation of colonic transit time in liquid diet-fed volunteers might be caused by the combined effect of increased colonic fermentation and high basal cholecystokinin concentrations.

Symptomatic vitamin A and D deficiencies in an eight-year-old with autism.

Abstract: An 8-year-old boy with autism developed a limp and periorbital swelling. He was found to have hypocalcemia and radiographic evidence of rickets. Ophthalmologic examination revealed xerophthalmia and corneal erosions. Serum vitamin A was undetectable and serum 25-hydroxyvitamin D was decreased. Dietary history revealed a markedly altered intake consisting of only french fried potatoes and water for several years. All biochemical and physical abnormalities reversed with appropriate supplementation. The nutritional content of french fries is reviewed. Feeding dysfunction is an integral part of autism and closer attention should be paid to potential nutritional deficiencies.

Effect of glutamine-supplemented intravenous nutrition on survival after Escherichia coli-induced peritonitis.

Abstract: Current solution formulations for total parenteral nutrition (TPN) do not contain glutamine (GLN). The purpose of this study was to examine whether GLN supplementation of TPN would improve survival in experimental Escherichia coli peritonitis in Fischer 344 rats (190-210 g). Initial experiments were performed to determine the degree of stress and to evaluate survival after intraperitoneal E coli injection. The E coli colony used was isolated from a culture of human blood. Graded doses were injected intraperitoneally in Fischer 344 rats (190-210 g). The response of white blood cell count, plasma insulin, glucagon, and corticosterone levels, and urinary excretion of vanillylmandelic acid reflected a significant stress response for at least 3 days. Survival was dose-dependent, with 60% mortality at 3 days after injection of 5 x 10(5) colony forming units of E coli/200 g body weight. To determine whether GLN supplementation of TPN would alter survival in this E coli peritonitis model, Fischer 344 rats were randomized to receive TPN containing 4.25% standard amino acids (group STD, n = 38) or the same solution with 1.5% of the amino acid content replaced with L-GLN (group GLN, n = 38). After 7 days of TPN, 5 x 10(5) colony forming units of E coli/200 g body weight were injected intraperitoneally under direct vision through a small laparotomy. Survival was monitored for 3 days. Surviving rats were killed to determine various nutritional parameters including plasma albumin and GLN concentration, the weight and nitrogen content of the gastrocnemius muscle, and biochemical and histological composition of the small intestine.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Composition in Patients With Acquired Immunodeficiency Syndrome: A Validation Study of Bioelectric Impedance Analysis

Abstract: The objective of this validation study was to explore bioelectric impedance analysis (BIA) as a way to assess nutritional status and body composition. The study was done in the outpatient department of the AIDS unit at University Hospital Dijkzigt, Rotterdam, The Netherlands. Eleven clinically stable patients with AIDS were studied. Total body water, body fat, lean body mass, and body cell mass were measured and calculated with multiple dilution techniques and BIA. With linear regression analysis, a strong correlation was found between total body water and lean body mass derived from BIA and multiple dilution techniques (r2 = .96 and .98, respectively), and slightly weaker correlation was found for body cell mass and body fat ( r2 = .88 and .76, respectively). These results suggest that BIA is a suitable method for the assessment of body cell mass in HIV-infected patients without opportunistic infections. The technique is safe, noninvasive, fast, and inexpensive. (Journal of Parenteral and Enteral Nutriti...

Amino acid loss and plasma concentration during continuous hemodiafiltration

Abstract: Amino acid loss, plasma concentration, and the relationship between amino acid intake and balance during continuous hemodiafiltration (CHD) were investigated in a prospective, nonrandomized study of trauma patients exhibiting the systemic inflammatory response with acute renal failure. Data were compared with those from a group of similar patients who had maintained renal function (control). Both groups received similar amounts of nonprotein calories (3015 +/- 753 nonprotein calories per day in the control group vs 3077 +/- 1018 nonprotein calories per day in the CHD group) and amino acids (2.24 +/- 0.36 g/kg per day in the control group vs 2.19 +/- 0.48 g/kg per day in the CHD group) via the parenteral route. Amino acid solutions were either 19% or 45% branched-chain amino acid enriched. Studies were performed every 12 hours for a maximum of 6 days. Amino acid loss was 2.5 +/- 2.3 g/12 h in the control group vs 6.6 +/- 2.4 g/12 h in the CHD group (p < .0001). Increasing the dialysate rate from 15 to 30 mL/min increased amino acid loss from 5.7 +/- 1.7 to 7.9 +/- 2.6 g/12 h (p < .0001). Amino acid loss was unrelated to amino acid intake but was directly related to plasma amino acid concentration, CHD effluent volume, and the efficiency of filtration as measured by the ratio of filtered urea nitrogen to blood urea nitrogen (R2 = .69). A linear relationship was found between amino acid intake and balance (R2 = .991). The patterns of plasma amino acid concentrations were consistent with metabolic changes wrought by a combination of sepsis and multiple organ dysfunction and type of amino acid intake but seemed unaffected by increased amino acid loss in CHD effluent. Amino acid losses were 2 to 3 times greater from CHD than from normal kidney. However, CHD amino acid losses may not be clinically significant unless amino acid intake is restricted to levels used typically in traditional hemodialysis.

Structured triglycerides to postoperative patients: a safety and tolerance study.

Abstract: Long-chain triglycerides are still the standard in fat emulsions, although medium-chain triglycerides have been suggested to have metabolic advantages even though pure medium-chain triglycerides are toxic in large doses. The next generation of fat emulsions may be structured triglycerides, which are assumed to provide a higher oxidation rate, faster clearance from blood, improved nitrogen sparing, and less of a tendency to accumulate in the reticuloendothelial system compared with long-chain triglyceride emulsions. This study was designed to evaluate the safety and tolerance of structured triglyceride fat emulsion 73403 (Kabi Pharmacia Parenterals, Stockholm, Sweden) compared with that of a standard long-chain triglyceride emulsion (Intralipid 20%) in postoperative patients requiring total parenteral nutrition after major surgery. The study was randomized and of the double-blind, parallel group type. Twenty patients were included and treated for 5 to 7 days. Safety and tolerance variables demonstrated no major differences between the study and control groups. Physiologic and biochemical variables suggested that structured lipids were rapidly cleared and metabolized. This study represents the first report of administration of structured triglycerides to postoperative patients. The structured triglyceride emulsion (73403) demonstrated no difference in safety and tolerance compared with Intralipid 20%. Therefore, it will now be possible to follow up with studies on metabolic efficiencies of structured triglycerides in postoperative patients.

Does perioperative total parenteral nutrition reduce medical care costs

Abstract: An economic analysis accompanied a multicenter Department of Veterans Affairs randomized, controlled trial of perioperative total parenteral nutrition (TPN). The cost of providing TPN for an average of 16.15 days before and after surgery was $2405, more than half of which ($1025) included costs of purchasing, preparing, and delivering the TPN solution itself; lipid solutions accounted for another $181, additional nursing care for $843, and miscellaneous costs for $356. Prolonged hospital stay added another $764 per patient to the $2405 cost of providing TPN, bringing the total to $3169. The incremental costs attributed to perioperative TPN were highest ($3921) for the patients least likely to benefit, that is, those who were less malnourished and at low risk of nutrition-related complications. Incremental costs were lowest ($3071) for high-risk patients. On the basis of the hospital-based method of administering TPN that was used in the clinical trial, perioperative TPN did not result in decreased costs for any subgroup of patients.

Elemental Diet-Induced Immune Suppression Is Caused by Both Bacterial and Dietary Factors:

Abstract: Because it is unclear whether elemental diet-induced immune suppression is an indirect effect caused by the translocating bacteria or is directly caused by the elemental diet, we tested whether prevention of diet-induced bacterial translocation or disruption of the gut microflora ecology would prevent diet-induced impaired lymphocyte function in a rat elemental diet model. Prevention of diet-induced bacterial translocation was accomplished by the addition of cellulose fiber or oral antibiotics (penicillin and streptomycin) to the elemental diet feeding regimen. Control groups consisted of rat food-fed and elemental diet-fed (4.25% amino acids; 28% glucose) rats. Immune function was quantitated by measuring the mitogen-induced blastogenic response of peripheral blood or splenic mononuclear cells to the mitogens concanavalin A and phytohemagglutinin. Bacterial translocation from the gut to the mesenteric lymph node and cecal bacterial population levels were measured in all groups. Although the incidence of elemental diet-induced bacterial translocation was reduced from 100% to 25% (p < .01) by the addition of dietary fiber, fiber did not prevent diet-induced impaired lymphocyte function. Because fiber supplementation of the elemental diet did not completely prevent diet-induced intestinal bacterial overgrowth or bacterial translocation, the experiment was repeated in antibiotic-decontaminated rats. Antibiotic decontamination completely prevented diet-induced intestinal bacterial overgrowth and bacterial translocation. Although antibiotic decontamination reduced the magnitude of lymphocyte mitogen suppression (p < .05), it was not fully effective in reversing the diet-induced lymphocyte suppression. These results indicate that elemental diet-induced lymphocyte blastogenic suppression is related to both bacterial and dietary factors.

Stability of Fat-Soluble Vitamins A (Retinol Palmitate), E (Tocopherol Acetate), and K1 (Phylloquinone) in Total Parenteral Nutrition at Home

Abstract: Our purpose was to extend previous studies of the stability of vitamins A (retinol palmitate), E (tocopherol acetate), and K1 (phylloquinone) to total parenteral nutrition at-home (TPNH) admixtures. First, stability over 20 days was tested. Experimental conditions included presence or absence of lipids, presence or absence of trace elements, and storage in a glass bottle or in a single or multi-layer plastic bag (ethylene vinyl acetate, polyvinyl chloride, Stedim 5, and Stedim 6). The 20-day storage studies were conducted at 4°C or at ambient air temperature. The second part of the study consisted of exposing to natural light TPNH admixtures with or without lipids, but with trace elements, in the same containers (except polyvinyl chloride). Finally, a clinical situation of TPNH was simulated with a TPNH admixture prepared 11 days before the test in a Stedim 6 plastic bag and stored at 4°C in total darkness. For vitamins A, E, and K1, we observed good stability for 20 days; the final concentrations ranged ...

Metabolic Bone Disease in Adults Receiving Long-Term Parenteral Nutrition: Longitudinal Study With Regional Densitometry and Bone Biopsy

Abstract: A syndrome of bone pain and fractures has been described in patients receiving long-term support from parenteral nutrition containing large quantities of aluminum or vitamin D2. Whether this same syndrome occurs in patients supported by current therapeutic regimens is controversial. In this study, bone health was longitudinally evaluated over 7 to 61 months in 14 subjects maintained on long-term parenteral nutrition. The parameters of bone health evaluated included bone mass as measured by single and dual photon absorptiometry and quantitative histomorphometry of bone biopsies. There was a striking heterogeneity in baseline measures of bone health. Mean bone density of parenteral nutrition patients was significantly below expected values on entry into the study at both the distal radius (z score = -0.76 ± 0.27) and the lumbar spine (z score = -1.17 ± 0.27). Mean areal density at the forearm was less severely depressed (z score = -0.62 ± 0.34). The longitudinal changes in bone density and morphology were h...

Comparison of gas exchange measurements with a mouthpiece, face mask, and ventilated canopy

Abstract: This study compared gas exchange measurements obtained by using a mask, mouthpiece, and ventilated canopy in 30 normal, healthy volunteers. The ventilated canopy and its gas analyzers had an accuracy for oxygen consumption of 98.0 +/- 0.8% and for carbon dioxide production of 100.1 +/- 1.1%. The study indicates that the apparatus used for gas exchange measurement will significantly affect the measurements. The magnitude of the effect is a significant 7.9% increase for oxygen consumption with a mouthpiece and a significant 7.1% increase with a face mask. Carbon dioxide production was significantly increased 10.2% with a mouthpiece and 4.1% with a face mask. There were no differences in the respiratory quotient. The specific purpose for collecting gas exchange measurements will determine whether these differences are of practical significance.