Showing papers in "Journal of Parenteral and Enteral Nutrition in 1996"
TL;DR: High-risk patients for loss of nutritional autonomy were defined as those with jejunoileal anastomosis and a remaining small bowel length < 35 cm, patients withJejunocolic anastOMosis and remaining small intestine length < 60 cm, and patients with an end jejunostomy and remainingsmall bowel length< 115 cm.
Abstract: Background : It is difficult to predict which patients with a postsurgical short bowel will require long-term parenteral nutrition. Methods : We performed a retrospective prognostic study for the time to home parenteral nutrition or death from malnutrition (nonautonomy), on the basis of 103 patients with a residual short bowel of 17 to 150 cm. The influence of anatomic variables was summarized through the use of Cox regression model. Results: Of the 103 patients included, 24 lost nutritional autonomy. Three anatomic variables were identified as having independent predictive information ; remaining small bowel length (measured on small bowel x-rays ; p =.0001), and jejunoileal anastomosis (p =.01) promoted autonomy, whereas end jejunostomy (p =.002) increased the risk of losing nutritional autonomy. Conclusions : On the basis of these results and on the relative weight of these variables, high-risk patients for loss of nutritional autonomy were defined as those with jejunoileal anastomosis and a remaining small bowel length < 35 cm, patients with jejunocolic anastomosis and remaining small bowel length < 60 cm, and patients with an end jejunostomy and remaining small bowel length < 115 cm. This classification was thereafter validated on a prospective series of 32 patients.
225 citations
TL;DR: It is suggested that it is the volume of food rather than the energy that limits voluntary energy intake of hospital food in elderly hospitalized patients.
Abstract: Background: It was hypothesized that energy intake in hospitalized elderly patients could be improved by increasing the density of energy of the food and that the volume of food actually consumed, even with a higher energy content than the normal, would not change with servings of high energy-dense hospital food. Methods: Thirty-six elderly patients (52 to 96 years) of both sexes, long-term treated at two comparable wards, participated in this study. The patients were given 6 weeks of regular hospital food (RHF, 1670 kcal/d, 7.0 MJ) and 6 weeks of high-energy food (HE, 2520 kcal/d, 10.5 MJ). The volume of food was kept constant. A crossover study design was used. Food intake, energy intake, body weight, and modified functional condition (Norton scale) were measured. Results: Regardless of type of food (RHF or HE) and time of day (lunch or dinner), the food portion size (volume of food) intake was the same, approximately 80% of the portions consumed. HE led to a 40% increase in energy intake (from 25 ± 1 d...
199 citations
TL;DR: Glutamine appears to be safe for use in prematurely infants and seems to be conditionally essential in premature infants with extremely low birth weights.
Abstract: Background: Glutamine (GLN) is the primary fuel for rapidly dividing cells, yet it is not a constituent of parenteral nutritional formulas administered to newborns. The aims of this prospective, randomized, double-blind trial were (1) to confirm the safety of glutamine supplementation for premature infants and (2) to examine the effects of glutamine-supplemented parenteral nutrition on length of stay, days on total parenteral nutrition (TPN), days on the ventilator, and other clinical outcomes. Methods: Premature infants received either standard or glutamine-supplemented TPN and were monitored throughout length of stay for various health and biochemical indices. The group was examined as a whole (n = 44; birth weight range: 530 to 1250 g) and in two weight subgroups, <800 and ≥800 g. Results: Serum ammonia, blood urea nitrogen, and glutamate tended to be higher in the GLN groups, but the levels were well within normal limits. In the <800-g cohort (n = 24), glutamine-supplemented infants required fewer day...
157 citations
TL;DR: Pulmonary embolization of a precipitate containing calcium phosphate resulted in the death of two patients and the pH of the amino acid component, transient elevation of calcium and phosphorus concentrations during mixing, and the lack of agitation during automated preparation of the formulation were identified as the etiologic factors producing the fatal precipitate.
Abstract: Background: Paroxysmal respiratory failure and death occurred in two young adult females with pelvic infections. Autopsy revealed an amorphous material containing calcium obstructing the pulmonary microvasculature of each patient. Both patients received an identical total nutrient admixture (TNA) solution before their deaths. Methods: Infusion of TNA into an animal model was undertaken in an effort to reproduce the clinical effect. Laboratory investigation was also performed to isolate a precipitate and identify the factors contributing to precipitation. Results: A nonvisible precipitate containing calcium, phosphorus, and organic material was isolated from the TNA solution. Infusion of the formulation into healthy pigs resulted in sudden death within 4 hours. Alteration of the amino acid component, mix sequence, agitation technique, and mixing container influenced precipitate formation. Conclusion: Pulmonary embolization of a precipitate containing calcium phosphate resulted in the death of two patients....
126 citations
TL;DR: The upregulation of proglucagon and ornithine decarboxylase gene expression may be the mechanism by which SCFAs facilitate intestinal adaptation.
Abstract: Background : Intestinal adaptation is a complex physiological process that is not completely understood. Systemic administration of short-chain fatty acids (SCFAs) has been shown to facilitate adaptation to small bowel resection ; however the mechanisms underlying this phenomena are unknown. Methods : Forty-six male Sprague-Dawley rats underwent an 80%jejunoileal resection and jugular catheterization. After surgery, rats were randomly assigned to receive standard total parenteral nutrition (TPN) or an isoenergetic, isonitrogenous TPN supplemented with SCFAs. On day 3 or 7 after surgery, ileal samples were removed for determination of mucosal wet weight, DNA, RNA, and protein concentrations. Total cellular RNA was extracted for use in Northern blot analysis to quantify proglucagon and ornithine decarboxylase messenger RNAs (mRNAs). Results : Total, mucosal, and submucosal weights were increased (p <.05) in the SCFA group both 3 and 7 days after surgery. Ileal DNA and RNA concentrations were increased (p <.05) in the SCFA group at both time points ; however ileal protein concentration did not differ between groups until 7 days after resection. Levels of proglucagon and ornithine decarboxylase messenger RNAs were higher (p < .05) in the SCFA group at both time points. Conclusion : The upregulation of proglucagon and ornithine decarboxylase gene expression may be the mechanism by which SCFAs facilitate intestinal adaptation.
104 citations
TL;DR: The experience supports use of the long arm catheter as an effective device for parenteral therapy after placing a long arm-catheter's tip in the central venous circulation reduces the risk of thrombosis.
Abstract: Background: This two-part study initially evaluated complications associated with catheters inserted via upper extremity veins. The second prospective phase compared thrombotic risk of peripheral catheter tips vs a central vein terminus. Methods: Patients from public institutions with infectious diseases were observed throughout their inpatient and outpatient use of IV catheters. Seventy-two and 39 patients enrolled in phase 1 and phase 2, respectively. Phase 1 consisted of prospective observations and analysis of complications and associated risk factors. Phase 2 randomized patients to a catheter tip location in the superior vena cava or the axillosubclavian-innominate vein and compared the incidence of thrombosis, phlebitis, and infection. Results: In phase 1, there was an increased risk of thrombosis with peripheral tip localization (61% vs 16%, p < .05). Phase 2 confirmed increased thrombosis with tips in the axillosubclavian-innominate vein compared with the superior vena cava (60% vs 21%, p < .05) w...
103 citations
TL;DR: The results suggest that the optimal nutritional regimen for patients with acute renal failure may require a high-protein regime and a relatively low-energy content and the interaction between protein and energy provision were predictive of the normalized protein catabolic rate.
Abstract: Background: Patients with acute renal failure are in substantial negative nitrogen balance as a result of their extremely high protein catabolic rates. We prospectively evaluated a series of patients with acute renal failure managed with continuous venovenous hemofiltration to determine which nutritional and nonnutritional variables might influence protein catabolism and nitrogen balance. Methods: Forty consecutive patients (aged 52 ± 20 years; mean ± SD) were monitored for 357 treatment days (average treatment duration 8.9 ± 8.6 days). All data (including nutritional regimen, laboratory values, APACHE II score, administered blood products, hemofiltration parameters, and medications) were collected daily. Results: For all patients, the mean normalized protein catabolic rate was 1.4 ± 0.5 g/kg per day. The rate did not differ between those who received nutrition support and those who did not. The net nitrogen deficit was less in those patients receiving nutrition support (-6.0 ± 5.2 vs -14.0 ± 5.6 g N/d; p...
103 citations
TL;DR: Early enteral feedings are feasible, well tolerated, and cost effective in critically ill pediatric patients and developed regular stool patterns despite periodic absence of bowel sounds.
Abstract: Background: The purpose of this study was to evaluate the feasibility and safety of early enteral feedings of critically ill pediatric patients. Methods: The subject population of 42 critically ill patients ranged in age from 5 days to 18 years (mean 5.8 years), mean weight 17 kg. Transpyloric nasoenteric tubes were placed in all patients by a nonfluoroscopic bedside technique. All subjects were mechanically ventilated; 32 (76%) were on one or more vasoactive medications. Six (15%) patients were fed for more than 13 days while on vasoactive support and pharmacological paralysis. Results: There were no documented complications of early enteral feeding, including aspiration. All patients were able to achieve caloric goals within 48 hours of beginning enteral feedings. All patients developed regular stool patterns despite periodic absence of bowel sounds. Enteral feedings replaced 256 days of total parenteral nutrition. Estimated patient charge savings averaged $425 for each day of enteral feedings. Conclusi...
94 citations
TL;DR: The large negative energy balance in the subjects studied was largely due to the inadequate nasogastric feeding, which was associated with a twofold reduction in the rate of gastric emptying and frequent regurgitation of feed.
Abstract: Background: Although intolerance to nasogastric feeding is commonly observed after head injury, quantitative measurements of gastric emptying are lacking. Concepts about energy requirements are limited by the lack of long-term measurements of total energy expenditure. Methods: Six male subjects with severe head injury had their gastric emptying measured by the phenol red technique. N and energy balances were measured by classic balance techniques, which included continuous indirect calorimetry for up to 24 hours (days 3 to 5). Measurements of body composition were made on days 3 to 5 and 12 to 19 (4 subjects only). Results: The subjects lost a mean of 9.8 kg of which 2.3 kg was estimated to be due to fat (equivalent to — 14 g N/d and —1690 kcal/d). On days 3 to 5, basal metabolic rate (BMR) was 130% to 135% of predicted. The low dietary intake (650 kcal and 4.2g N/d) was associated with negative energy (— 1710 ± 520 kcal/d) and N balances (-19 ± 5 g N/d). Gastric emptying was delayed twofold (days 3 to 5)...
94 citations
TL;DR: E is effective in facilitating placement of a nasoenteric feeding tube into the duodenum in ICU patients and is clearly beneficial in those patients with normal mental status and may be useful in patients with diabetes mellitus.
Abstract: Background: To determine whether administration of erythrornycin (E) could facilitate passage of a nasoenteric feeding tube into the duodenum for postpyloric feedings, this randomized, double-blind, placebo-controlled trial was performed. Methods: Fifty-seven patients were accrued from the surgical intensive care units (ICUs) of a tertiary-care university hospital. Patients enrolled were categorized as to the presence or absence of diabetes mellitus (DM). Those patients without DM were then subdivided into those with normal or depressed mental status. The three groups, normal (NMS), depressed mental status (DMS), or diabetes mellitus (DM), were then randomized independently to receive either E or placebo (P), followed by blind placement of a feeding tube. Tube placement was verified by an abdominal radiograph. Results: Overall, the rate of postpyloric placement was 61% (19/31) in the E group, significantly better than 35% (9/26) in the P group (p < .05). In patients with NMS, the success rate with E was i...
76 citations
TL;DR: Based on the results of the two largest, long-term studies, the use of oral branched-chain amino acids in the prevention and treatment of chronic encephalopathy may only be proposed for patients with advanced cirrhosis, intolerant to alimentary proteins.
Abstract: Background : The role of oral branched-chain amino acid supplements in the prevention and treatment of chronic hepatic encephalopathy is not yet established, and conflicting opinions are expressed in authoritative textbooks. We aimed to review and pool the published controlled studies by means of meta-analytical techniques. Methods : A computerized search of published papers identified nine studies, controlled against placebo, energy, alimentary proteins, or casein. Their quality score was calculated according to the protocol of Chalmers. The value of the portal-systemic encephalopathy index was chosen as main outcome, because of lack of more significant clinical outcomes. To cope with differences in trial design and data presentation, individual data were requested to authors. Results : After 18 months, we received the individual data of only two studies, thus precluding any meta-analysis. Two studies, accounting for over 60% of total enrolled patients, were in favor of branched-chain amino acids. Their quality score was much better than that of the remaining seven negative small studies, carrying a significant risk of type II error. Conclusions : Based on the results of the two largest, long-term studies, the use of oral branched-chain amino acids in the prevention and treatment of chronic encephalopathy may only be proposed for patients with advanced cirrhosis, intolerant to alimentary proteins. Large, multicenter, long-term studies, considering more important clinical outcomes, are needed to provide definite answers to an aged question.
TL;DR: Plasma levels of IGF-1, transferrin, and prealbumin are not useful for following changes in protein stores early in the course of critical illness.
Abstract: Background: Our group wanted to test the hypothesis that plasma levels of insulin-like growth factor 1 (IGF-1), transferrin, and prealbumin are useful markers of nutritional progress in severe sepsis and multiple injury. Methods: Measurements of IGF-1 and plasma proteins were made in critically ill patients as soon as they were hemodynamically stable and 5, 10, 15, and 21 days later. The magnitude and direction of the measured changes were compared with the magnitude and direction of the change in total body protein in the same time period. Results: Fourteen patients with severe sepsis and 10 multiply injured patients were studied. As a group they had an increased metabolic expenditure that peaked at 153% of normal and lost ~12.0% of total body protein. An early fall in IGF-1 and plasma proteins accompanied a marked acute phase response, and recovery occurred while hypermetabolism and net proteolysis continued. No correlation existed between changes in IGF-1 or plasma proteins and the change in total body...
TL;DR: The in vivo effects on surface proliferation are consistent with a potential protective role for butyrate and a promotive role for deoxycholate in colon carcinogenesis and suggest that direct or indirect modulation of protooncogene expression may be the mechanism by which these dietary byproducts regulate proliferation in vivo.
Abstract: Background Studies on colon carcinogenesis suggest that the short-chain fatty acid butyrate may be protective, whereas the secondary bile acid deoxycholate may promote tumor development. Crypt surface hyperproliferation is regarded as a biomarker of colon cancer risk and can be modulated in vitro by the differentiation inducer butyrate and the tumor promoter deoxycholate. We hypothesized that butyrate decreases and deoxycholate increases crypt surface proliferation in vivo and that these effects are mediated by changes in the expression of the protooncogenes c-Fos and c-Jun, which are known to regulate proliferation and differentiation. Methods Twenty-five adult Sprague-Dawley rats underwent colonic isolation and 24-hour intraluminal instillation of 10 mmol/L sodium chloride, 10 mmol/ L sodium butyrate, or 10 mmol/L sodium deoxycholate. Proliferation of the whole crypt and five crypt compartments from base to surface was assessed by proliferating cell nuclear antigen immunohistochemistry. The oh value, an index of "premalignant" hyperproliferation, was calculated as the ratio of labeled cells in the two surface compartments divided by the labeled cells in the entire crypt. Expression of c-Fos and c-Jun was evaluated by Western blot. Results Crypt surface proliferation and the oh value were significantly decreased by butyrate and increased by deoxycholate. Butyrate increased colonic expression of c-Jun, whereas deoxycholate significantly induced c-Fos. Conclusions The in vivo effects on surface proliferation are consistent with a potential protective [corrected] role for butyrate and a promotive role for deoxycholate in colon carcinogenesis. The concurrently observed effects on colonic c-Jun and c-Fos expression represent a novel finding and suggest that direct or indirect modulation of protooncogene expression may be the mechanism by which these dietary byproducts regulate proliferation in vivo.
TL;DR: Short-chain fatty acids improve components of nonspecific immune responses and may be beneficial in reducing certain aspects of TPN-associated immunosuppression after major surgery.
Abstract: Background : Total parenteral nutrition (TPN) alters both specific and nonspecific immune functions, resulting in immunosuppression. Short-chain fatty acids have been shown to improve the adaptive responses of the gut after surgery. The following study investigates the effects of adding short-chain fatty acids to TPN on the immune system after an 80% small bowel resection. Methods : Rats (237 ± 3 g) were infused with either TPN (n = 25) or TPN supplemented with short-chain fatty acids (n = 26) for 3 or 7 days. Hematologic analysis was performed on peripheral blood and splenocytes were isolated to characterize cell phenotypes, natural killer cell cytotoxicity and to estimate proliferative response. Results : The relative percent of T (CD3 + ) cells increased (p <.05) and the relative percent of macrophages decreased (p <.001, n = 13) in the spleens of the 3-day TPN-fed rats. By day 7, these differences disappeared. The natural killer cells from rats that were supplemented with short-chain fatty acids had higher (p <.0001) cytotoxic activity than the TPN groups at day 3. Mitogenic response did not differ between groups but were depressed compared with sham-treated rats. By day 7, rats on standard TPN had larger (p <.0001) spleens than all other groups. This group also had a higher total white blood cell count because of increased numbers of macrophages and neutrophils (p <.02). Conclusion : Short-chain fatty acids improve components of nonspecific immune responses and may be beneficial in reducing certain aspects of TPN-associated immunosuppression after major surgery.
TL;DR: The translucent to white sheath that forms around chronically implanted catheters is not composed of fibrin and is therefore not likely to be dissolved by fibrinolytic agents such as urokinase, streptokinase, or tissue plasminogen activator.
Abstract: Background: Chronically implanted catheters often become covered with a thin, white adherent covering of tissue that has been referred to as a fibrin sheath This tissue often interferes with catheter function Methods: To chronicle the development of this sheath, rats were implanted with silicone rubber central venous catheters Five rats were euthanized at 3, 7, and 60 days postimplantation so that gross necropsy and histology could be performed on the catheterized vessels Results: The coating that developed around the external portion of the catheter started as a dark red thrombus containing fibrin and progressed into vascularized, fibrous connective tissue Conclusions: The translucent to white sheath that forms around chronically implanted catheters is not composed of fibrin and is therefore not likely to be dissolved by fibrinolytic agents such as urokinase, streptokinase, or tissue plasminogen activator (Journal of Parenteral and Enteral Nutrition20:156-158, 1996)
TL;DR: Peptide-based diets may be useful in restoring the fat free body mass and improving the disease activity in patients with Crohn's disease.
Abstract: Background: The effect of nasogastric feeding with high- and low-fat, peptide-based diets on body composition and disease activity was studied in adolescents with active Crohn's disease. Methods: Fourteen patients with active Crohn's disease (12 to 17 years) were fed exclusively through nasogastric feedings with two isocaloric, isonitrogenous, peptide-based diets, either with low- or high-fat content, for 3 weeks each in a randomized manner then were "crossed over" to the other diet for another 3 weeks of feeding. At the end of each 3-week period, urine and stools were collected for 72 hours for measuring energy absorption and nitrogen utilization (n = 6). Weight, height, triceps skin folds, fat free body mass, and disease activity were also monitored (n = 14). Results: There was no difference in any parameter of energy absorption or nitrogen utilization between the two formulas irrespective of the order in which they were administered. The changes in nutritional parameters were also comparable with both ...
TL;DR: It is suggested that, in comparison with standard glutamine-free TPN, Ala-Gln-supplemented TPN increases protein synthesis in the liver and skeletal muscle, protects the morphology of the intestinal mucosa, and improves survival in protracted bacterial peritonitis.
Abstract: Background: The effects of glutamine-enriched total parenteral nutrition (TPN) solution on survival, and protein turnover in the whole body and in individual organs were investigated in a rat protracted peritonitis model. Methods: Twenty-three rats underwent venous catheter insertion. Osmotic pumps were implanted in the peritoneal cavity to allow continuous delivery of Escherichia coli (4 × 108 CFU/d). The conventional TPN group received a conventional amino acid solution. The Ala-Gln TPN group received an alanyl-glutamine-enriched TPN solution. The two TPN solutions were isocaloric and isonitrogenous. Results: Over the 5 days of TPN treatment, the survival rate of the Ala-Gln group was significantly higher than that of the conventional group. The Ala-Gln group tended to have increased whole-body protein turnover compared with the conventional group. Fractional protein synthetic rates (FSR) in the liver and gastrocnemius muscle of the Ala-Gln group were significantly higher than those of the conventional ...
TL;DR: Factors such as the general integration of parenteral nutrition into tertiary medical care, standard protocols and order forms, automatic Nutrition Support Service consultations in an affiliated hospital, and nutrition curricula may be responsible for the improvements seen since 1979.
Abstract: Background: The effectiveness of Nutrition Support Services in optimizing parenteral nutrition has not been evaluated since the 1980s. Methods: We prospectively monitored medical and surgical patients on total parenteral nutrition (TPN) in a university hospital who did not receive Nutrition Support Service recommendations to compare the incidence of metabolic complications in 1979 (group 1, n = 100) with that in 1992 (group 2, n = 106). The Service provided automatic recommendations on a subsequent group of medical service patients (group 3, n = 128) and compared them with the patients in group 2 who were on the medical service (group 2B, n = 29). Results: Statistically significant changes between 1979 and 1992 included a decline in the incidence of hyperglycemia from 47% to 22% and in hypokalemia from 12% to 3% of surgical patients and an increase in hypomagnesemia from 0% to 23% of surgical patients and from 2% to 14% of medical patients. The incidence of hypophosphatemia remained >20% in both medical a...
TL;DR: Neuropathy and glucose intolerance may occur despite increased serum chromium levels and respond to chromium infusion, and the previous use of drugs such as metronidazole should not exclude chromium as a potential treatment for neuropathy in HPN patients.
Abstract: Background: We previously described a patient on home parenteral nutrition (HPN) who developed glucose intolerance and neuropathy that only responded to an infusion of chromium. A patient on HPN who had neuropathy and glucose intolerance was studied. He was also on metronidazole, which could have caused the neuropathy, but the symptoms and signs persisted. Methods: Baseline clinical examination, nerve conduction studies, serum vitamin and trace element levels, and glucose tolerance were measured. Then, 250 μg of trivalent chromium as the chloride salt was infused daily for 2 weeks. The above studies were repeated. Results: The patient at baseline had peripheral neuropathy of the axonal type and was glucose intolerant. Serum chromium was raised in this patient above the reference range. Despite raised serum levels, the infusion of chromium resulted in clinical remission that was marked 4 days after starting the infusion. Normalization of nerve conduction also occurred within 3 weeks of the initial study. C...
TL;DR: Despite evidence of significant metabolic effects on eicosanoid and cytokine production, widespread clinical use of FO for HIV-infected patients is not warranted without further study, particularly given the trend toward a decline in CD4 cell numbers at this dose and with this type of fish oil.
Abstract: Background Dietary fish oil (FO) has been shown to modulate the immune system. The purpose of this study was to explore the effects of FO supplementation on the production of dienoic eicosanoids and cytokines in patients with human immunodeficiency virus (HIV) infection. Methods This was a randomized, prospective, double-blind study that included homosexual males with HIV infection. Patients were asked to consume voluntarily five food bars daily containing FO (n = 10) or safflower oil (SO) (n = 9) for 6 weeks. At baseline and week 6, plasma was obtained to measure incorporation of omega-3 fatty acids. At baseline, week 3, and week 6, measurements were made of changes in dienoic eicosanoids and cytokines from lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMC) or spontaneously releasing cells. Results In the FO group but not the SO group, there was increased incorporation of the omega-3 fatty acid docosahexaenoic acid (DHA) into the phospholipids of the fatty acids of the plasma. In the FO group, there was a significant decrease (p = .01) in 6-keto prostaglandin (PG) F1 alpha released from PBMC. There was a significant increase (p = .01) in interleukin (IL)-6 released from the PBMC in the FO group between baseline and week 3 and between week 3 and week 6. At week 6, there was significantly more IL-6 (p = .01) released from the PBMC in the FO group compared with the SO group. There was no change in CD4 cell counts by analysis of variance. Conclusions The FO-containing food bars were well tolerated and allowed incorporation of omega-3 fatty acids to occur. Despite evidence of significant metabolic effects on eicosanoid and cytokine production, widespread clinical use of FO for HIV-infected patients is not warranted without further study, particularly given the trend toward a decline in CD4 cell numbers at this dose and with this type of fish oil.
TL;DR: This study shows for the first time that a complete enteral diet, deficient only in glutamine, is associated with significant early morphologic and functional changes in the small intestine.
Abstract: Background: The importance of L-glutamine as metabolic fuel for enterocytes and its role in prevention of mucosal atrophy during total parenteral nutrition is well documented. No data are available to date that document whether a glutamine-free complete enteral diet, requiring full energy expenditure for hydrolysis and absorption, is associated with changes in the morphology and function of the small intestine. Our aim was to examine the effect of such a diet during a 4-week period on the morphology and function of the small intestine of rats. Methods: Three isocaloric solid rat food, containing 0%, 4%, and 8% of glutamate, respectively, were fed to three groups of rats. On the 7th and 28th days the morphology of the jejunum, the subcellular structure of enterocytes on transmission electron microscopy, enzyme activities, blood, and muscle glutamine were examined and compared in the three groups. Results: The rats on the glutamine-free diet had significantly lower mucosal wet weight, protein and DNA conten...
TL;DR: Data support the importance of proactive measures to prevent fluid and electrolyte imbalances in patients with ARF, and evidence suggests that both essential and nonessential amino acids should be employed.
Abstract: The clinical status of patients with acute renal failure (ARF) varies greatly. Some individuals have only mild or moderate ARF or may have only mild perturbations of their metabolic status. Other patients exhibit a severe reduction in renal function with oliguria or anuria Depending upon their comorbid conditions, ARF patients may be among the most hypercatabolic patients in the hospital. Clinical trials have not clearly shown a beneficial effect of nutrition support on morbidity or mortality in patients with ARF, although limitations in sample size and experimental design and inclusion of patients with widely disparate clinical conditions may have contributed to the difficulty in demonstrating benefits. Several recent therapeutic approaches that have been studied either in experimental animals with ARF or in small numbers of humans with ARF hold promise for improving clinical outcome. Continuous arteriovenous or venovenous hemofiltration with or without dialysis is such a therapy. In comparison to intermittent hemodialysis this former treatment more safely removes large quantities of water and solutes from critically ill patients with unstable hemodynamics and allows them to receive rather large quantities of nutrients, including amino acids. Also promising are studies in experimental animals with ARF which indicate that several growth factors may accelerate the recovery of renal function. In rats with ARF, insulin-like growth factor 1 both enhances recovery of renal function and suppresses their enhanced catabolism. For most patients with ARF requiring nutrition support, evidence suggests that both essential and nonessential amino acids should be employed. However, there appears to be a therapeutic role for small quantities of essential amino acids, without nonessential amino acids, in selected patients. Data support the importance of proactive measures to prevent fluid and electrolyte imbalances in patients with ARF.
TL;DR: This study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician-directed multidisciplinary advisory group.
Abstract: Background : Parenteral nutrition (PN) is a form of nutrition that can be life-saving, but its use has inherent risks and it is expensive. Nutrition support teams have been shown to reduce both the rate of complications and excessive use of PN. Methods : Criteria were established to evaluate the appropriateness of PN use in a 487-bed community teaching hospital. A prospective study of 50 consecutive patients, who received either central or peripheral PN, was conducted. Results : The 50 patients received 469 days of PN. We found that 233 (49.7%) of the 469 days of PN were avoidable. This resulted in the creation of a formal approval process that required prior approval by a physician-directed multidisciplinary advisory committee before PN could be instituted. The amount of PN subsequently decreased from 500 patient days of PN per month to less than 100. Conclusions : This study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician-directed multidisciplinary advisory group.
TL;DR: The purpose of this study was to compare the effects of different doses of the drug on weight gain and other parameters in acquired immunodeficiency syndrome (AIDS) patients who presented with weight loss.
Abstract: Weight loss occurs in almost all patients with human immunodeficiency virus (HIV) infection, and its causes are multifactorial. One of the most common causes is anorexia, and there are presently two drugs available for these patients: megestrol acetate (Megace; Bristol-Myers Oncology Division, Princeton, NJ) and dronabinol (Marinol; Roxane Labs, Columbus, OH). A randomized, double-blind, placebo-controlled, multicenter study using megestrol acetate is reviewed here.1 The purpose of this study was to compare the effects of different doses of the drug on weight gain and other parameters in acquired immunodeficiency syndrome (AIDS) patients who presented with weight loss. In an outpatient setting, 270 patients were evaluated for safety of the drug. Only 195 patients could be used for evaluation of both safety and efficacy. The megestrol acetate was administered at 100, 400, or 800 mg daily for 12 weeks. Patients had lost either 20% or their premorbid weight or were ≤90% of their ideal body weight. No one was...
TL;DR: In combination with an endoluminal brush, the AOLC test was much more sensitive and has the potential to provide a simple, rapid, and accurate diagnostic test for catheter-related sepsis, which does not require removal of the catheter.
Abstract: Background : In neonates, the acridine orange leukocyte cytospin (AOLC) test has been found to be a highly sensitive test for the detection of infected IV catheters in situ, which provides a result in less than 1 hour. Preliminary data suggested that the AOLC test was of limited value in adults. We report here a modification of the test for adult patients with indwelling central venous catheters. Methods : A prospective study was performed on two groups of 50 adult patients with suspected sepsis and a central venous catheter. The AOLC test was carried out after the clinical decision to remove the catheter had been made. In group 1 patients, a blood sample was withdrawn from the catheter for the AOLC test. In the patients in group 2, an endoluminal brush was used to sweep the catheter before the collection of the blood sample. Results of the AOLC test were compared with culture of the removed catheter tip. Results : From the catheters in group 1 (no brush), 17 catheter tips were found to be infected, but the AOLC was positive in only two patients (12%). In group 2 (brush), 18 tips were infected, and the AOLC test was positive in 15 patients (83%). The use of the endoluminal brush significantly improved the yield of the AOLC test (p <.01) to levels reported in neonates. The AOLC test produced no false positives in either group. Conclusion : When used independently, the AOLC test was not sensitive enough to detect catheter-related sepsis. However, in combination with an endoluminal brush, the AOLC test was much more sensitive and has the potential to provide a simple, rapid, and accurate diagnostic test for catheter-related sepsis, which does not require removal of the catheter.
TL;DR: Bedside placement of transpyloric feeding tubes is a safe and effective method to institute enteral feedings in critically ill pediatric patients.
Abstract: Background:The purpose of this study was to demonstrate the feasibility of placing transpyloric feeding tubes at the bedside without fluoroscopy in critically ill pediatric patients. Methods: The patient population consisted of 90 patients (ages 1 week to 15 years, median age 9 months) admitted to a 26-bed pediatric intensive care unit in a university-affiliated pediatric hospital. Patient weights ranged from 2.4 to 100 kg with a median weight of 7.5 kg. Seventy-six patients were endotracheally intubated and mechanically ventilated; one patient had a tracheotomy. A total of 24 patients were pharmacologically paralyzed; 38 patients were receiving catecholamine infusions, and 17 patients had intracranial monitoring devices in place. All had concurrent nasogastric suctioning. Nonweighted Silicone Rubber 6F or 8F nasoenteric tubes were inserted at the bedside using metoclopramide, air insufflation, and positioning to achieve transpyloric passage. Blue-dyed water was instilled in 58 patients to test for reflux...
TL;DR: Hypoalbuminemic patients receiving TPN have markedly shortened plasma albumin half-lives, but the albumin catabolized per day is similar to normal patients, arguing for both a synthetic and catabolic defect that explains the hypoalbuminemia in this patient group.
Abstract: Background: By using undenatured purified albumin preparations radiolabeled with iodine, the half-life of serum albumin in well patients who are stable is known to be approximately 17 days. However, when a patient is suffering with an acute illness such as sepsis, trauma, burns or after an extensive operative procedure, the serum albumin level decreases. It is not known whether this fall in serum albumin is due to increased catabolism, decreased synthesis, or a combination of both factors. This study explores the kinetics of albumin catabolism under these circumstances to clarify the issue. Methods: 125I-labeled albumin was administered intravenously to 10 critically ill, hypoalbuminemic patients receiving total parenteral nutrition (TPN). Each subject had frequent blood samples taken for at least 10 days to measure the decline of plasma radioactivity over time. None was receiving unlabeled albumin during the investigation. It was assumed that the plasma decay would follow first-order kinetics after the e...
TL;DR: A continuous and ongoing infusion of conventional TPN started immediately after surgery did not counteract the obligatory decline of muscle protein synthesis, observed 24 hours postoperatively.
Abstract: Background : Muscle protein synthesis rate is known to decrease postoperatively as apart of the catabolic response to trauma. Conventional total parenteral nutrition (TPN) in the postoperative period does not seem to counteract the decrease in protein synthesis. However, it is still unclear if ongoing TPN given continuously after surgery would inhibit this fall in muscle protein synthesis. Methods : The rate of protein synthesis in skeletal muscle was determined before and 24 hours after open cholecystectomy, used as a standardized human model of trauma. Patients (n = 14) were randomized to receive either TPN continuously throughout the postoperative period or saline as postoperative fluid therapy. The protein synthesis rate was calculated from the increase in enrichment of labeled phenylalanine in protein after an IV flooding dose of [ 2 H 5 ] phenylalanine, 45 mg/kg body weight. Results : The fractional synthesis rate decreased by 31% from 1.74 ± 0.13% to 1.15 ± 0.10% per 24 hours in the saline group (p <.02) and by 23% from 1.59 ± 0.10% to 1.22 ± 0.07% per 24 hours in the group receiving TPN (p <.01), showing no significant difference between the two groups. Conclusion : A continuous and ongoing infusion of conventional TPN started immediately after surgery did not counteract the obligatory decline of muscle protein synthesis, observed 24 hours postoperatively.
TL;DR: It is concluded that standard total parenteral nutrition formulas of higher osmolality than previously thought can be safely given via the peripheral route for short-term feeding and do not increase the risk of thrombophlebitis.
Abstract: Background Peripheral i.v. nutrition has been advocated for patients who require short-term i.v. nutrition support to avoid the complications and expense of central venous catheterization. Feeding formulas for peripheral administration have usually been modified by increasing the proportion of lipid, because increasing osmolality is reported to cause thrombophlebitis. The aim of this study was to determine whether standard feeding formulas can be given via the peripheral route and also to establish whether increasing osmolality does increase the incidence of thrombophlebitis under these conditions. Methods Thirty-six patients requiring parenteral nutrition were randomized to receive either a "high" (1700 mOsmol/L) or "standard" (1200 mOsmol/L) osmolality feeding containing 2000 kcal and 12 g nitrogen via a peripheral line. Results Twenty patients (mean age 55.6 years, range 16 to 78) received standard osmolality feedings using 20 peripheral feeding lines for a mean duration of 6.8 days (range 2 to 16) with 10 line failures (8 thrombophlebitis, 2 occlusion). Nineteen patients (mean age 56.1 years, range 27 to 83) received high osmolality feedings via 20 lines for a mean of 6.3 days (range 0 to 18) with five line failures (4 thrombophlebitis, 1 occlusion), one failed insertion, one line removed at the patient's request, and four lines that fell out. Forty lines were inserted overall of which 19 (47.5%) were removed electively, 12 (30%) developed thrombophlebitis, 3 (7.5%) occluded, 4 (10%) fell out, 1 (2.5%) was a failed insertion, and 1 (2.5%) was removed for nonmedical reasons. Conclusions Increasing osmolality of total parenteral nutrition did not increase episodes of thrombophlebitis in this trial and did not affect the success rate of the lines. We conclude that standard total parenteral nutrition formulas of higher osmolality than previously thought can be safely given via the peripheral route for short-term feeding and do not increase the risk of thrombophlebitis.
TL;DR: The TNA1 1.2-microns filter significantly reduced the total number and concentration of enlarged fat globules and the volume-weighted PFAT > 5 microns, suggesting that in-line TNA filtration should be a standard part of nutrition therapy.
Abstract: Background The recent Food and Drug Administration Safety Alert recommends in-line filtration for all total parenteral nutrition admixtures. Although rigid crystalline particulates can be effectively removed by in-line filters, the fate of flexible lipid droplets (LDs) enlarged through electromechanical destabilization is less clear. Lipid globules > 5 microns could lodge in the pulmonary microvasculature and produce an embolic syndrome. Recent evidence suggests that TNAs (Total Nutrient Admixtures) with LDs of 5 microns or more constituting > 0.4% of the final fat concentration are unstable. Methods Six pairs of 1.5-L TNA dispersions of varying degrees of stability were prepared in duplicate (n = 12) and studied over 30 hours. The number of enlarged fat globules was assessed by laser light extinction for all LDs > or = 1.75 microns at 0, 6, 24, and 30 hours after preparation. After LD assessments at time 0, admixtures were placed in a temperature-controlled chamber at 25 degrees C +/- 0.1 degree C. At 6 hours, a simulated patient infusion was begun using a 1.2-microns filter at a continuous flow rate of 55 mL/h. Pre- and postfiltration samples were taken at 6, 24, and 30 hours, equal to times 0, 18, and 24 hours of the simulated infusion. A repeated measure two-way analysis of variance assessing treatment and time was performed. Dependent variable analyses included number-weighting of fat globules as > 5 microns (LD1), total number > or = 1.75 microns (LD2), LD1-LD2 ratio (as %), and volume-weighted percent of fat (PFAT) > 5 microns. Results In all cases, time was a significant factor and was an expected finding as the stability of all extemporaneously prepared admixtures deteriorates with time. Of the number-weighted variables, a significant postfiltrate reduction was observed in LD1 (p = .041), LD2 (p 5 microns was significantly reduced by the in-line filter (p = .029). Conclusions The TNA1 1.2-microns filter significantly reduced the total number and concentration of enlarged fat globules. The higher LD1-LD2 ratio may reflect the effects of filtration on electrically destabilized fat globules. However, total exposure to unstable and very large LDs was significantly reduced, suggesting that in-line TNA filtration should be a standard part of nutrition therapy.