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The role of NIGMS P50 sponsored team science in our understanding of multiple organ failure. J Trauma Acute Care Surg 2017; 83:520-531. [PMID: 28538636 DOI: 10.1097/ta.0000000000001587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The history of the National Institute of General Medical Sciences (NIGMS) Research Centers in Peri-operative Sciences (RCIPS) is the history of clinical, translational, and basic science research into the etiology and treatment of posttraumatic multiple organ failure (MOF). Born out of the activism of trauma and burn surgeons after the Viet Nam War, the P50 trauma research centers have been a nidus of research advances in the field and the training of future academic physician-scientists in the fields of trauma, burns, sepsis, and critical illness. For over 40 years, research conducted under the aegis of this funding program has led to numerous contributions at both the bedside and at the bench. In fact, it has been this requirement for team science with a clinician-scientist working closely with basic scientists from multiple disciplines that has led the RCIPS to its unrivaled success in the field. This review will briefly highlight some of the major accomplishments of the RCIPS program since its inception, how they have both led and evolved as the field moved steadily forward, and how they are responsible for much of our current understanding of the etiology and pathology of MOF. This review is not intended to be all encompassing nor a historical reference. Rather, it serves as recognition to the foresight and support of many past and present individuals at the NIGMS and at academic institutions who have understood the cost of critical illness and MOF to the individual and to society.
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Abstract
Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. The purpose of this paper is to critically review the literature studying the use of enteral vs parenteral nutrition (PN) and to provide the rationale for early enteral nutrition. Additional controversies confronting clinicians are reviewed, including the use of immune-enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence-based recommendations for clinical practice are presented when available.
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Affiliation(s)
- S Rob Todd
- Acute Care Surgery, The Methodist Hospital-Houston/Weill Medical College of Cornell University, 6550 Fannin Street, Smith Tower 1661, TX 77030, USA.
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Daly JM. 10th Anniversary Presidential Address: Parenteral Feeding (1966— 1986)-Growth and Development of an Individual, a Scientific Discipline and an Organization. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/014860718601000401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ford EG, Jennings M, Andrassy RJ. Hourly Urine Nitrogen Values Do Not Reflect 24-Hour Totals in Injured Children. Nutr Clin Pract 2016. [DOI: 10.1177/088453368700200504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Rosenthal MD, Moore FA. Persistent inflammatory, immunosuppressed, catabolic syndrome (PICS): A new phenotype of multiple organ failure. ACTA ACUST UNITED AC 2015; 1. [PMID: 26086042 DOI: 10.14800/janhm.784] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A new phenotype of multiple organ failure has appeared: Persistent Inflammatory, Immunosuppressed, Catabolic Syndrome (PICS). Comorbidities and age >65 years have been established as the leading risk factors for PICS. As the percentage of elderly people continues to increase the prevalence of PICS in our ICUs will surely grow. Malnutrition (despite appropriate supplementation), recurrent nosocomial infections, frailty, ventilator dependence, and an indolent death depicts the central theme that plagues PICS patients. Aligned with the recently awarded P50 grant by NIGMS entitled, "PICS: A New Horizon for Surgical Critical Care", and the University Of Florida's Sepsis and Critical Illness Research Center will investigate the genetic make-up of PICS patients, better understand frailty and the implication in trauma patients, and hopefully elucidate new therapies. Currently, there are no therapies to combat PICS aside from nutritional inference elaborated after reviewing the literature on Burns, Cachexia, and Sarcopenia.
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Affiliation(s)
- Martin D Rosenthal
- Departments of Surgery, Division of Acute Care Surgery and Center For Sepsis and Critical Illness Research, University of Florida College of Medicine; Gainesville, Florida
| | - Frederick A Moore
- Departments of Surgery, Division of Acute Care Surgery and Center For Sepsis and Critical Illness Research, University of Florida College of Medicine; Gainesville, Florida
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Rosenthal MD, Vanzant EL, Martindale RG, Moore FA. Evolving paradigms in the nutritional support of critically ill surgical patients. Curr Probl Surg 2015; 52:147-82. [PMID: 25946621 DOI: 10.1067/j.cpsurg.2015.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/29/2015] [Accepted: 02/11/2015] [Indexed: 12/12/2022]
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MOORE FA, MOORE EE, HAENEL JB. Clinical benefits of early post-injury enteral feeding. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.6.1.21.27] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The most prominent contributions to multiple organ failure, multiple organ dysfunction syndrome, and systemic inflammatory response syndrome are described in this article. However, it is quite possible that there are others that have been missed. The problem of organ failure continues to perplex clinicians and scientists, and it contributes to fatal outcomes for patients with illnesses, infections, and injuries after operations. Although we know a fair bit about these problems, we frequently can do little about it. The best approach remains support to prevent failure.
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Affiliation(s)
- Arthur E Baue
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Quintana Díaz M, Cabestrero Alonso D, García De Lorenzo Y Mateos A. Coagulación y hemorragia en el paciente crítico. Parte II. Factor pronóstico y tratamiento. Med Intensiva 2003. [DOI: 10.1016/s0210-5691(03)79992-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Moore FA. Effects of immune-enhancing diets on infectious morbidity and multiple organ failure. JPEN J Parenter Enteral Nutr 2001; 25:S36-42; discussion S42-3. [PMID: 11288922 DOI: 10.1177/014860710102500209] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- F A Moore
- Department of Surgery, University of Texas--Houston Medical School and Memorial Hermann Hospital, 77030, USA
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Zauner C, Gendo A, Kramer L, Kranz A, Grimm G, Madl C. Metabolic encephalopathy in critically ill patients suffering from septic or nonseptic multiple organ failure. Crit Care Med 2000; 28:1310-5. [PMID: 10834671 DOI: 10.1097/00003246-200005000-00009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluation of changes in the peak latencies of sensory evoked potentials in different patient groups, to evaluate differences in metabolic encephalopathy of critically ill patients with multiple organ failure as a result of septic or nonseptic conditions. DESIGN Prospective cohort study. SETTING Intensive care units of the university hospital, Vienna. PATIENTS Patients (n = 103) treated on an intensive care unit because of multiple organ failure with additional metabolic encephalopathy. Multiple organ failure was induced by sepsis (group A; n = 56), surgery (group B; n = 29), or both (group C; n = 18). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Metabolic encephalopathy was determined by measuring median nerve-stimulated short-latency and long-latency sensory evoked potentials. No differences in the peak latencies of the sensory evoked potentials were detected among the groups. Septic patients had a N70 peak latency of 131+/-21 msecs, nonseptic postsurgical patients of 132+/-17 msecs, and septic postsurgical patients of 134+/-17 msecs. The cervicomedullary N13 to cortical N20 conduction times were 6.4+/-1 msec, 6.4+/-1.4 msecs, and 6.8+/-1.2 msecs, respectively. All measured peak latencies were significantly prolonged compared with peak latencies of healthy controls. The severity of illness assessed by the Acute Physiology and Chronic Health Evaluation III score was not different between the three groups. An increase of the delay of N70 peak latencies was significantly correlated with the severity of illness (r2 = .15; p < .00005). CONCLUSION There was no difference in sensory evoked potential measurements detectable among septic patients with multiple organ failure, nonseptic postsurgical patients with multiple organ failure, and septic postsurgical patients with multiple organ failure. The N70 peak latency was significantly correlated with the severity of illness but not with the presence or absence of sepsis. In postsurgical patients with multiple organ failure and superimposed sepsis, the N70 peak latencies were not further prolonged compared with postsurgical patients without sepsis.
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Affiliation(s)
- C Zauner
- Department of Internal Medicine IV, University of Vienna, Austria.
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Abstract
Despite intensive investigation, the pathogenesis of postinjury multiple organ failure (MOF) remains elusive. Laboratory and clinical research strongly implicate that the gastrointestinal tract plays a pivotal role. Shock with resulting gut hypoperfusion appears to be one important inciting event. While early studies persuasively focused attention on bacterial translocation as a unifying mechanism to explain early and late sepsis syndromes that characterize postinjury MOF, subsequent studies suggest that other gut-specific mechanisms are operational. Based on our Trauma Research Center observations and those of others, we conclude that: 1) bacterial translocation may contribute to early refractory shock; 2) for patients who survive shock, the reperfused gut appears to be a source of proinflammatory mediators that may amplify the early systemic inflammatory response syndrome; and 3) early gut hypoperfusion sets the stage for progressive gut dysfunction such that the gut becomes a reservoir for pathogens and toxins that contribute to late MOF.
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Affiliation(s)
- F A Moore
- Department of Surgery, University of Texas-Houston Medical School, Hermann Hospital, 77030, USA
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Yang Q, Birkhahn RH. Branched-chain transaminase and keto acid dehydrogenase activities in burned rats: evidence for a differential adaptation according to sex. Nutrition 1997; 13:640-5. [PMID: 9263256 DOI: 10.1016/s0899-9007(97)83006-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Female and male rats show differences in nitrogen metabolism after trauma, and the contribution of the branched-chain amino acid oxidizing pathway following thermal injury was evaluated. Female and male rats were subdivided into baseline, burned and unburned, pair-fed groups. Burned and pair-fed rats were sacrificed on days 1, 2, and 3 postburn, and branched-chain amino acid transaminase (BCTA), branched-chain alpha-keto acid dehydrogenase (BCKDH) activated and total, and succinate dehydrogenase (SDH) activities were measured in red and white muscle and in liver, BCTA was not measured in liver. Baseline and pair-fed groups had similar enzyme activities. Changes following thermal injury were: (1) elevated SDH in all tissues for both sexes; (2) increased BCTA activity in red and white muscles from male rats; and (3) increased percentage of activated BCKDH in red and white muscles on days 2 and 3 for male rats. All other activities were unchanged. These findings agree with previous post trauma differences in urinary nitrogen losses in female and male rats. The results show that the enzymes for oxidation of the branched-chain amino acids in males respond to injury while those do not in females.
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Affiliation(s)
- Q Yang
- Department of Surgery, Medical College of Ohio, Toledo 43699-0008, USA
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Godin PJ, Buchman TG. Uncoupling of biological oscillators: a complementary hypothesis concerning the pathogenesis of multiple organ dysfunction syndrome. Crit Care Med 1996; 24:1107-16. [PMID: 8674321 DOI: 10.1097/00003246-199607000-00008] [Citation(s) in RCA: 249] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To present a complementary hypothesis concerning the pathogenesis of the multiple organ dysfunction syndrome. DATA SOURCES Primary reports and reviews published in peer-reviewed medical and scientific journals. HYPOTHESIS We suggest that healthy organs behave as biological oscillators, which couple to one another during human development, and that this orderly coupling is maintained through a communications network, including neural, humoral, and cytokine components. We suggest that the systemic inflammatory response syndrome initiates disruption of communication and uncoupling, and further suggest that progression into the multiple organ dysfunction syndrome reflects progressive uncoupling that can become irreversible. Resolution of the inflammatory response and reestablishment of the communications network are necessary but may not be, by itself, sufficient to allow organs to appropriately recouple. This hypothesis is testable using existing laboratory and clinical tools.
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Affiliation(s)
- P J Godin
- National Institutes of Health, Bethesda, MD, USA
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Affiliation(s)
- L G Thijs
- Medical Intensive Care Unit, Free University Hospital, Amsterdam, The Netherlands
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Border JR. Death from severe trauma: open fractures to multiple organ dysfunction syndrome. THE JOURNAL OF TRAUMA 1995; 39:12-22. [PMID: 7636902 DOI: 10.1097/00005373-199507000-00002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J R Border
- Department of Surgery, University at Buffalo, Erie County Medical Center, New York 14215, USA
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Abstract
Early epidemiologic studies concluded that infection with systemic sepsis was the common pathway for the development of ARDS and eventual MOF. As a consequence, research investigation from 1977 to 1987 focused on later clinical events (e.g., immunosuppression, persistent hypercatabolism, and bacterial translocation). Now, it is believed that an initial massive traumatic insult can create severe SIRS independent of infection (one-hit model). Alternatively, a less severe traumatic insult can create an inflammatory environment (i.e., primes the host) such that a later, otherwise innocuous, secondary inflammatory insult precipitates severe SIRS (two-hit model). As a result of these newer inflammatory models, research interest during the last 5 years has shifted to investigating earlier clinical events (e.g., unrecognized flow-dependent oxygen consumption, ischemia/reperfusion, and priming/activation of the inflammatory response).
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A Scoring System for Multiple Organ Dysfunction Syndrome. UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 1994. [DOI: 10.1007/978-3-642-85036-3_4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Pathophysiologische Veränderungen nach Polytrauma. Eur Surg 1992. [DOI: 10.1007/bf02602057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, Kellum JM, Welling RE, Moore EE. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992; 216:172-83. [PMID: 1386982 PMCID: PMC1242589 DOI: 10.1097/00000658-199208000-00008] [Citation(s) in RCA: 915] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.
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Affiliation(s)
- F A Moore
- Department of Surgery, Denver General Hospital, Colorado 80204
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Abstract
Metabolic support is an integral component in the care of the critically injured patient. When hypermetabolism occurs, there are increases in energy demands along with changes in substrate utilization. This article reviews the prospective randomized clinical trials that were undertaken at Denver General Hospital over the past decade that address both the timing of nutritional support and the route of administration in this critically injured population. Also discussed is a review of a meta-analysis that attests to the feasibility of early postoperative enteral feeding with the possibility of decreased septic morbidity in high-risk surgical patients. With the clinical knowledge gained from these trials, an algorithm for nutritional intervention was developed that represents our current standard of practice.
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Inoue T, Obata M, Mishima Y. Polymorphonuclear leukocyte function and serum opsonic activity in surgical patients. Surg Today 1992; 22:233-43. [PMID: 1392327 DOI: 10.1007/bf00308828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Thirty-six patients who underwent major surgery were studied in order to clarify the perioperative changes in polymorpho - nuclear leukocyte (PMNL) function and serum opsonic activity. In patients without postoperative infection, the PMNL phagocytic-bactericidal capacity and plasma elastase levels significantly increased, while the serum opsonic index remarkably decreased just after surgery, however, all returned to the preoperative levels within 1 or 2 weeks. Conversely, in patients with postoperative infection, the PMNL bactericidal capacity and plasma elastase levels remained at high levels even after 1 or 2 weeks, while the PMNL phagocytic capacity and serum opsonic index substantially decreased after 2 weeks compared with the patients without postoperative infection. Plasma leukotriene B4, which is a potent chemo-attractant for PMNL, noticeably decreased in the patients with postoperative infection on the first postoperative day compared with that in the patients without postoperative infection. Our data suggests that the most important predisposing factors to postoperative infection may be a depressed PMNL phagocytic capacity and a lower serum opsonic activity after surgery, and that the increased PMNL bactericidal capacity and high plasma elastase levels during postoperative infection may contribute to the susceptibility to multiple organ failure.
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Affiliation(s)
- T Inoue
- Second Department of Surgery, Tokyo Medical and Dental University, Japan
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Abstract
Metabolic support is an integral component of surgical critical care. Although prompt restoration of oxygen availability is clearly essential, the timing, composition, and route of nutritional support may also be decisive factors. The ensuing discussion will focus on: (a) timing of substrate delivery and (b) route of administration based on our clinical investigation over the past decade. The acutely injured patient was selected as a model of ICU hypermetabolism because of relative homogeneity with respect to age, comorbid factors, and stress level. Our first study hypothesis was that early nutritional support would improve outcome in the severely injured, but previously well-nourished patient. During an 18-month period, all patients undergoing laparotomy with a abdominal trauma index (ATI) greater than 15 were randomized to a control or total enteral nutrition (TEN) group. The control patients were given total parenteral nutrition (TPN) after POD 5, whereas the TEN cohort had a needle catheter jejunostomy (NCJ) inserted at laparotomy and received an elemental diet within 12 hours. The control (n = 31) and TEN (n = 32) groups were otherwise comparable with respect to risk stratification. The TEN patients, of course, shared improved nitrogen balance (p less than 0.001), but also had significantly (p less than 0.025) less septic morbidity. Nine (29%) of the controls developed major infections, contrasted to three (9%) of the TEN patients. Acknowledging the benefit of early nutrition, the next issue we addressed was the optimal route of substrate delivery; i.e., TEN vs TPN. The hypothesis was that TEN, compared to TPN, would reduce the injury stress response as reflected by the prioritization of hepatic protein synthesis. TEN given via NCJ and a nutritionally matched TPN solution were administered during the same postoperative period. Indeed, the TEN patients (n = 23) had significantly (p less than 0.05) higher constitutive proteins and lower acute-phase proteins, whereas the TPN patients manifested the opposite protein profile as measured by crossed immunoelectrophoresis. In view of these findings, we continued the study to ascertain clinical impact. Ultimately, 75 patients were randomized, providing groups with equivalent risk factors. Eleven (37%) of the TPN patients developed septic complications compared to five (17%) of the TEN group, and the incidence of major infection was six (20%) following TPN vs one (3%) with TEN. Thus, immediate TEN provided an additional clinical benefit compared to early TPN in these high-risk surgical patients.
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Affiliation(s)
- E E Moore
- Department of Surgery, Denver General Hospital, Colorado 80204
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Abstract
Sepsis and organ failure produce profound metabolic changes that contribute to hepatic and musculoskeletal failure. When multiple organ failure develops, the mortality rate is high, and therapy is unlikely to be effective unless the causative process (e.g., infection, low cardiac output) can be eliminated. Thus, the prevention of multiple organ failure and the prevention or early treatment of infection are paramount. Organ and nutritional support to prevent complications is necessary. The gastrointestinal tract should be used for nutrition whenever possible with a blenderized regular diet with fiber, glutamine, and short-chain fatty acids to protect and preserve the gut. If parenteral nutrition is necessary, special solutions may be necessary for the liver, kidneys, or lungs. If not, protein with 45% branched-chain amino acid, medium- and short-chain triglycerides, glutamine supplementation, and carbohydrates seem best. Other substances are being evaluated that may be helpful in nutrition and organ support, including arginine, xylitol, growth hormone, and anabolic steroids. Multiple organ failure should be prevented, if at all possible, by stopping or controlling the injury, removing as much necrotic tissue as possible, improving blood flow and oxygen consumption, supporting metabolism, and preventing infection or treating it early and adequately. Nutritional support plays a key role in preventing metabolic failure.
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Affiliation(s)
- A E Baue
- Department of Surgery, St. Louis University School of Medicine, Missouri
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Affiliation(s)
- A J Rich
- Department of Surgery, Medical School, Newcastle upon Tyne
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Amos RJ, Deane M, Ferguson C, Jeffries G, Hinds CJ, Amess JA. Observations on the haemopoietic response to critical illness. J Clin Pathol 1990; 43:850-6. [PMID: 2229434 PMCID: PMC502838 DOI: 10.1136/jcp.43.10.850] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Peripheral blood cytopenias are common in patients receiving intensive care, particularly in those with multiple organ failure. To assess the contribution of bone marrow hypoplasia in such patients 44 bone marrow samples from 24 patients under intensive care were studied by standard morphological techniques and by the granulocyte-macrophage colony forming cell (GM-CFC) assay. Frequently observed morphological abnormalities in the bone marrow included the following: (i) a reduction in overall cellularity in seven patients, with a progressive decrease in most patients studied sequentially; (ii) an increase in the number of actively phagocytic macrophages; and (iii) a disruption of normal bone marrow architecture with the accumulation of intercellular hyaluronic acid glycosaminoglycan. Mean GM-CFC growth was significantly reduced when compared with that in a group of normal controls. In four of five patients studied sequentially GM-CFC growth became subnormal in association with a reduction in bone marrow cellularity. Inhibitory serum factors were not identified. These morphological abnormalities are similar to the changes observed in gelatinous degeneration of the bone marrow. In both situations disruption of the haemopoietic microenvironment, with the accumulation of hyaluronic acid proteoglycan, may be an important factor in the inhibition of haemopoietic progenitor cell growth. The proliferation of macrophages, by the release of a variety of cytokines or reactive oxygen intermediates, may also be implicated in impaired haemopoiesis and the development of disordered erythropoiesis.
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Affiliation(s)
- R J Amos
- Department of Haematology, St Bartholomew's Hospital, West Smithfield, London
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Teasley KM, Buss RL. Do parenteral nutrition solutions with high concentrations of branched-chain amino acids offer significant benefits to stressed patients? DICP : THE ANNALS OF PHARMACOTHERAPY 1989; 23:411-6. [PMID: 2499131 DOI: 10.1177/106002808902300510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The critically ill, stressed patient has been characterized as having altered cellular metabolism. Altered protein metabolism is manifested as negative nitrogen balance, reduced whole-body protein synthesis, and increased proteolysis. An increased oxidation of the branched-chain amino acids (BCAA) leucine, isoleucine, and valine has also been observed. Exogenous administration of BCAA as part of a total parenteral nutrition (TPN) regimen has been proposed to compensate for the altered protein metabolism in the stressed patient by sparing endogenous sources of BCAA, thereby reducing skeletal muscle catabolism and increasing protein synthesis. Numerous clinical studies have been performed investigating this theory. The results are controversial. Differences in study outcomes appear to be related to study design, especially patient selection. Our review of those studies which were randomized, prospective, and controlled indicates that an improvement in nitrogen retention and visceral protein status can be achieved in stress-stratified patients who receive a TPN regimen containing a BCAA-enriched formula. The significance of these outcomes on morbidity, length of hospital stay, and mortality has not been evaluated.
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Affiliation(s)
- K M Teasley
- College of Pharmacy, University of Minnesota Hospital and Clinics, Minneapolis 55455
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Lambert ME, Shipley K, Holbrook I, Faragher EB, Irving MH. Serum carnitine levels in normal individuals. JPEN J Parenter Enteral Nutr 1988; 12:143-6. [PMID: 3361681 DOI: 10.1177/0148607188012002143] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Serum carnitine levels have been measured in 178 samples from 75 normal volunteers. We report a wide range of values (10-70 mumol/liter and 8-74 mumol/liter for free and acetylated carnitine, respectively) and a distinct difference between the ranges for males and females (p less than 0.001). There is also substantial, seemingly random fluctuation in any one individual's levels, when measured serially over several weeks.
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Affiliation(s)
- M E Lambert
- Department of Surgery, Hope Hospital, Salford, U.K
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39
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Affiliation(s)
- T W Hensle
- Department of Urology, College of Physicians and Surgeons of Columbia University, New York, New York
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Abstract
Multiple system organ failure represents the final common pathway to a fatal outcome in severely infected patients. Despite the development of extensive support technology, the mortality rate in this group of patients remains high: in excess of 50 per cent. This rate underscores the need for newer treatment modalities. Numerous mediators/effectors appear to play a role in the complex evolution of the process. The independent and interactive effects of these numerous mediators/effectors remain to be elucidated. Future therapies will need to address immunomodulation of the host and biochemical manipulation of the fundamental process before significant improvement in outcome can be expected.
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Affiliation(s)
- D E Fry
- Case Western Reserve University, Cleveland, Ohio
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Dennison AR, Ball M, Hands LJ, Crowe PJ, Watkins RM, Kettlewell M. Total parental nutrition using conventional and medium chain triglycerides: effect on liver function tests, complement, and nitrogen balance. JPEN J Parenter Enteral Nutr 1988; 12:15-9. [PMID: 3125352 DOI: 10.1177/014860718801200115] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Conventional long chain triglyceride (LCT) was compared with a new emulsion containing 50% medium chain triglyceride (5% MCT/5% LCT) in a randomized cross-over trial of 10 days duration. Plasma concentrations of albumin, prealbumin, the complement components C3 and C4, and prothrombin times measured daily at 8 am, before lipid infusion, showed no progressive change during the 10 days of the trial, nor in each separate 5-day period when LCT or MCT/LCT was infused. Aspartate transaminase and alkaline phosphatase activities were similar over the two periods. There was a significant increase (compared with preinfusion levels) in C3 and C4 levels after 5 hr of either lipid infusion. Nitrogen balance was improved, and plasma bilirubin levels were lower on the regimen containing MCT/LCT.
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Affiliation(s)
- A R Dennison
- Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford, England
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Mann HJ, Fuhs DW, Cerra FB. Pharmacokinetics and pharmacodynamics in critically ill patients. World J Surg 1987; 11:210-7. [PMID: 3296480 DOI: 10.1007/bf01656404] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Askanazi J, Mathews D, Rothkopf M. Patterns of fuel utilization during parenteral nutrition. Surg Clin North Am 1986; 66:1091-103. [PMID: 3097841 DOI: 10.1016/s0039-6109(16)44076-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Utilization of fuel in clinical conditions has become an important area of interest to the clinician. Injury and sepsis cause predictable changes in the metabolism of fuel, favoring a shift toward the oxidation of fat. Similar considerations apply to the tumor-bearing host.
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Shaw JH, Wolfe RR. Glucose, fatty acid, and urea kinetics in patients with severe pancreatitis. The response to substrate infusion and total parenteral nutrition. Ann Surg 1986; 204:665-72. [PMID: 3098198 PMCID: PMC1251422 DOI: 10.1097/00000658-198612000-00008] [Citation(s) in RCA: 74] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Rates of glucose turnover and oxidation in normal volunteers (N = 16) and in severely ill patients with pancreatitis (N = 9) were isotopically determined. Glucose turnover was determined using primed constant infusions of either 6-3H-glucose or 6-d2-glucose, and glucose oxidation with either U-14C-glucose or U-13C-glucose after appropriate priming of the bicarbonate pool. Urea kinetics were determined using primed constant infusions of either (15N2)-urea or U-14C-urea, whereas free fatty acid (FFA) kinetics were determined by the constant infusion of 1,2-13C palmitate. Basal rates of glucose production and plasma glucose clearance were significantly higher in the patients than in the volunteers. During glucose infusion (4 mg/kg/min) endogenous glucose production was virtually totally suppressed in the volunteers (94 +/- 4%). There was significantly less suppression in the patients, however (44 +/- 1%). In addition, the percentage of available glucose oxidized (i.e., percentage of uptake oxidized) was significantly less in the patients than in the volunteers. The basal rate of urea production was significantly higher in the patients; however, in both patients and volunteers, glucose infusion resulted in a significant decrease. The rate of FFA turnover was similar in the patients and volunteers, and the patients and volunteers were equally sensitive to the suppressive effects of glucose infusion. When the patients were studied during total parenteral nutrition (TPN), there was no further suppression of endogenous glucose turnover than that seen during 2 hours of glucose infusion, and the mean rate of urea turnover measured during TPN (7.0 +/- 1.9 mumol/kg/min) was also not significantly different than the value determined during glucose infusion (8.9 +/- 1.8 mumol/kg/min). It was concluded from these studies that patients with pancreatitis are metabolically similar to septic patients, have an impairment in their ability to oxidize infused glucose when compared with normal volunteers, have an elevated rate of net protein catabolism, and have FFA kinetics similar to those seen in normal humans.
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Fujita H, Hirose K, Miyazaki I. Effects of branched chain enriched amino acid solutions on septic rats. Clin Nutr 1986; 5:171-7. [PMID: 16831766 DOI: 10.1016/0261-5614(86)90007-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/1985] [Accepted: 04/27/1986] [Indexed: 11/18/2022]
Abstract
An experimental study was performed to determine the effects of a BCAA enriched amino acid solution on sepsis in rats. After sepsis had been induced in male Wistar rats by caecal ligation and puncture the animals were divided into four groups according to the amino acid solutions infused: Group B-I, a solution containing no amino acid; Group B-II, a commercially available solution containing 21.1% branched chain amino acids (BCAA); Group B-III, a solution containing 38.7% BCAA and Group B-IV, that containing BCAA only. The control group of the animals received simple laparotomy and infusion without amino acids. Infusion was continued for 96 hours after the operation and all the solutions had the same caloric and nitrogen value. Group B-I had a plasma aminogram peculiar to sepsis; a significant rise in the concentration of the total 17 amino acids (TAA), BCAA and aromatic amino acid (AAA) together with a decrease in the BCAA/AAA ratio. Furthermore, the arterio-venous difference (AV-D) of AAA and BCAA showed a large negative value. In the three groups infused with amino acids, only Group B-III showed a significant improvement in the survival rate and nitrogen balance compared with Group B-I. Moreover, not only did the concentration of TAA and AAA significantly decline, but also the BCAA/AAA ratio increased. Therefore, the abnormal aminogram in sepsis tended to return to the control level. In Group B-IV despite the significant decrease of the peripheral TAA, no improvement in plasma aminogram, nitrogen balance or survival rate were shown. In Group B-II, in addition to the persisting plasma aminogram changes and peripheral efflux of amino acids, no improvement of survival rate were noted. Therefore, it was concluded that an amino acid composition richer in BCAA and lower in both AAA and SCAA is beneficial in the treatment of sepsis.
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Affiliation(s)
- H Fujita
- Department of Surgery II, School of Medicine, Kanazawa University, 13-1 Takaramachi, Kanazawa 920, Japan
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Townsend MC, Gauderer MW, Yokum MD, Fry DE. Alterations of hepatic mitochondrial function in a model of peritonitis in immature rats. J Pediatr Surg 1986; 21:521-4. [PMID: 3723304 DOI: 10.1016/s0022-3468(86)80224-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Severe intra-abdominal infection results in significant metabolic dysfunction, multiple systems failure, and mortality. Although the course of peritonitis is particularly rapid and severe in neonates and small children, its physiologic consequences have been poorly studied in these age groups. In order to assess hepatic mitochondrial integrity in a model of fulminant peritonitis in immature animals, the following study was undertaken. Thirty-three immature Sprague-Dawley rats (21 to 28 days of age) and 32 mature rats (weight greater than 250 g) were anesthetized and laparotomies performed. The animals received either cecal ligation and gross perforation (CLP) or cecal manipulation alone (sham). Animals were killed at 2 and 4 hours and livers removed. Mitochondria were isolated by differential centrifugation. Mitochondrial respirations were studied polarographically with glutamate and succinate as substrates in the presence (state 3) and absence (state 4) of adenosine diphosphate (ADP). The Respiratory Control Index (RCI) is the ratio of state 3 to state 4 respiration and is a sensitive indicator of mitochondrial coupling. Results revealed that in mature animals, peritonitis produced a significant increase in RCI with glutamate as substrate (5.2 +/- 0.2) by 4 hours duration as compared with sham operated rats (4.3 +/- 0.1, P less than 0.01). Succinate as substrate revealed no significant alteration in mitochondrial coupling in mature rat hepatic mitochondria in animals subjected to peritonitis. By contrast, peritonitis in immature animals produced a significantly decreased RCI (3.6 +/- 0.2) with glutamate as substrate as compared with sham operated animals (4.8 +/- 0.2, P less than 0.01) by two hours duration.(ABSTRACT TRUNCATED AT 250 WORDS)
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