Suitability of non-glucose-carbohydrates for parenteral nutrition

Which carbohydrates should we recommend for intravenous nutrition?

In a short review solutions of glucose, fructose and invertose have been compared in regard to protein sparing effects, side effects and infusion rates. It is concluded that fructose alone offers no advantage to glucose neither in the normal nor in the stressed organism. Compared with pure glucose and fructose solutions, higher amounts of carbohydrate can be administered as invertose, without increasing the risk of side effects.

Treatment of jaw cysts with an irrigational method. (II). The effect on the nature of cyst walls and surrounding bone

Cysts in jaws are generally excised by Partsch II when they are small. When they are large, they are excised by Partsch I to form a paranasal sinus in an oral cavity, or by an operation based on Caldwell-Luc's method to form it from nostrils, as Partsch II forms dead space after the operation and the cyst increases by the pressure of intracystic fluid. However, with Partsch I, the bone needs many days to regenerate, and since a surgical ciliated cyst of the maxilla is often formed after an operation of the maxillary sinus, Partsch I is not necessarily a good method. Therefore, in order to control cyst inflammation, the irrigation of cyst cavities was repeated, as it is held that prostaglandin-like (PG-like) substances are generated in the cyst walls when a cyst is inflamed by bacterial infection; prostaglandin E2 (PGE2) especially acts on the resorption of bone and enlarges the cyst. As a result of repeated irrigations, infection of the cyst cavities disappeared simultaneously with decreasing the pressure of intracystic cavities, the values of thiobarbituric acid, Prostaglandin E, Prostaglandin F2 alpha (TBA, PGE, PGF2 alpha), and the free radical intensity at g = 2.003 decreased. The bone regenerated around the cyst walls, and finally the cyst diminished in size. In the case of the viscous cyst fluids, a solution containing hyaluronidase enabled complete disappearance. It would be better to apply Partsch II after the cyst has become smaller through irrigation. After the irrigational method, irregular formation and tendency toward malignancy could be found in none of the cyst wall cells.

Metabolic effects of glucose compared with invertose and a mixture of fructose, glucose and xylitol before and after moderate surgical trauma

The metabolic and clinical effects of different isocaloric carbohydrate infusions were studied perioperatively in 54 female patients undergoing cholecystectomy. The patients were randomized to six treatment groups, who received infusions only postoperatively (group 1, 2 and 3) or pre- as well as postoperatively (group 4, 5 and 6). One litre was given during 8 h as a 12% infusion solution. Glucose (group 1 and 4) was compared to invertose (group 2 and 5) and to a mixture of fructose, glucose and xylitol 2:1:1 i.e. Triofusin (group 3 and 6). The glycogen content in liver biopsies, taken peroperatively, was significantly higher when infusions were given preoperatively. No significant differences were found between groups, when comparing the different carbohydrate infusions. A minor glucose intolerance was noticed postoperatively, especially in group 4, whereas no fructose or xylitol intolerance was seen. Lactataemia was insignificant and acid-base balance normal in all groups. Serum urea concentrations were lower when preoperative infusions were given but without differences between groups 4, 5 and 6. Electrolytes, creatinine, hemoglobin, hematocrite and liver function tests were unaltered and the clinical course was uncomplicated in all cases. No side effects were observed. It is concluded that the infusion of one litre 12% Triofusin can be used as effectively and safely as 12% glucose and invertose before and after moderate surgical trauma. But no obvious advantage with Triofusin was revealed.

Fructose, xylitol and glucose in total parenteral nutrition

A comparison was made between isocaloric amounts of 24% glucose and 24% Triofusin (composed of 120 g fructose, 60 g glucose and 60 g xylitol per liter) during the course of a 6-day, 3-phase crossover study of 15 patients undergoing total parenteral nutrition. The patients received a total of 0.5 g carbohydrate per kg per day. Plasma glucose as significantly higher during glucose infusion (7-22 mmol/l, median: 9 mmol/l,) than during Triofusin infusion (5-16 mmol/l, median: 6 mmol/l). A moderate to severe glucosuria was detected in three patients during infusion of 24% glucose, and this declined considerably during the Triofusin period. The total renal carbohydrate loss during the glucose period was 0-143 g, median: 6 g per day, and during the Triofusin period was 6-68 g, median: 10 g per day. The nitrogen balance and carbamide production rate were the same in the two infusion regimes. Changes in biochemical liver parameters were observed in most of the patients, but these could not be attributed to parenteral nutrition. None of the patients developed symptoms of metabolic acidosis. There was a slightly but significantly higher urinary excretion of oxalate in the Triofusin period (0.1-1.1 mmol per day, median: 0.5 mmol per day) than in the glucose period (0.1-1.0 mmol per day, median: 0.4 mmol per day). Most of the patients exhibited a slightly increased urinary excretion of urate, irrespective of the infusion regimen. Serum urate remained normal. It was concluded that Triofusin infused in the described dosage is a suitable calorie source for parenteral nutrition, but that it does not present a distinct advantage over the use of pure glucose solution. In patients suffering from reduced glucose tolerance, however, Triofusin represents a more easily manageable calorie course.

[Problems with hyperalimentation in intensive care units (author's transl)]

The application of parenteral nutrition in patients in intensive care units can be limited by shock, septicemia and metabolic disorders. Stress- or trauma-induced glucose intolerance sometimes makes it difficult to maintain the caloric requirements with glucose. Sugar substitutes seem to be of advantage in these cases. Meticulous care is essential to avoid severe complications arising from the use of the central venous feeding catheters.