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Baker M, French C, Hann M, Lal S, Burden S. A scoping review of parenteral requirements (macronutrients, fluid, electrolytes and micronutrients) in adults with chronic intestinal failure receiving home parenteral nutrition. J Hum Nutr Diet 2024; 37:788-803. [PMID: 38409860 DOI: 10.1111/jhn.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/19/2024] [Accepted: 02/05/2024] [Indexed: 02/28/2024]
Abstract
INTRODUCTION Home parenteral nutrition (HPN) prescriptions should be individualised in adults with chronic intestinal failure (IF). The aims of the review were to explore HPN requirements and available guidelines and to determine whether adults (≥ 18 years) receive recommended parenteral nutrient doses. METHODS Online databases searches identified empirical evidence (excluding case-reports), reviews and guidelines (Published 2006-2024 in English language). Additional reference lists were hand-searched. Older studies, cited in national guidelines were highlighted to map evidence source. Two reviewers screened 1660 articles independently, with 98 full articles assessed and 78 articles included (of which 35 were clinical studies). Citation tracking identified 12 older studies. RESULTS A lack of evidence was found assessing parenteral macronutrient (amounts and ratios to meet energy needs), fluid and electrolyte requirements. For micronutrients, 20 case series reported serum levels as biomarkers of adequacy (36 individual micronutrient levels reported). Studies reported levels below (27 out of 33) and above (24 out of 26) reference ranges for single micronutrients, with associated factors explored in 11 studies. Guidelines stated recommended parenteral dosages. Twenty-four studies reported variable proportions of participants receiving HPN dosages outside of guideline recommendations. When associated factors were assessed, two studies showed nutrient variation with type of HPN administered (multichamber or individually compounded bags). Five studies considered pathophysiological IF classification, with patients with short bowel more likely to require individualised HPN and more fluid and sodium. CONCLUSIONS This review highlights substantial evidence gaps in our understanding of the parenteral nutritional requirements of adult receiving HPN. The conclusions drawn were limited by temporal bias, small samples sizes, and poor reporting of confounders and dose. Optimal HPN nutrient dose still need to be determined to aid clinical decision-making and further research should explore characteristics influencing HPN prescribing to refine dosing recommendations.
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Affiliation(s)
- Melanie Baker
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
| | - Chloe French
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
| | - Mark Hann
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
| | - Simon Lal
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
- Salford Royal Hospital, Northern Care Alliance NHS Trust, Manchester, UK
| | - Sorrel Burden
- School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
- Salford Royal Hospital, Northern Care Alliance NHS Trust, Manchester, UK
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Shannon CE, Merovci A, Fourcaudot M, Tripathy D, Abdul-Ghani M, Wang H, Han X, Norton L, DeFronzo RA. Effects of Sustained Hyperglycemia on Skeletal Muscle Lipids in Healthy Subjects. J Clin Endocrinol Metab 2022; 107:e3177-e3185. [PMID: 35552423 PMCID: PMC9282260 DOI: 10.1210/clinem/dgac306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Sustained increases in plasma glucose promote skeletal muscle insulin resistance independent from obesity and dyslipidemia (ie, glucotoxicity). Skeletal muscle lipids are key molecular determinants of insulin action, yet their involvement in the development of glucotoxicity is unclear. OBJECTIVE To explore the impact of mild physiologic hyperglycemia on skeletal muscle lipids. DESIGN Single group pretest-posttest. PARTICIPANTS Healthy males and females with normal glucose tolerance. INTERVENTIONS 72-hour glucose infusion raising plasma glucose by ~50 mg/dL. MAIN OUTCOME MEASURES Skeletal muscle lipids, insulin sensitivity, lipid oxidation. RESULTS Despite impairing insulin-mediated glucose disposal and suppressing fasting lipid oxidation, hyperglycemia did not alter either the content or composition of skeletal muscle triglycerides, diacylglycerides, or phospholipids. Skeletal muscle ceramides decreased after glucose infusion, likely in response to a reduction in free fatty acid concentrations. CONCLUSIONS Our results demonstrate that the major lipid pools in skeletal muscle are unperturbed by sustained increases in glucose availability and suggest that glucotoxicity and lipotoxicity drive insulin resistance through distinct mechanistic pathways.
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Affiliation(s)
- Christopher E Shannon
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
- UCD Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland
| | - Aurora Merovci
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Marcel Fourcaudot
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Devjit Tripathy
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
- Audie L Murphy VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Muhammad Abdul-Ghani
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Hu Wang
- Barshop Institute for Longevity and Aging Studies, UT Health San Antonio, San Antonio, TX, USA
| | - Xianlin Han
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
- Barshop Institute for Longevity and Aging Studies, UT Health San Antonio, San Antonio, TX, USA
| | - Luke Norton
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Ralph A DeFronzo
- Division of Diabetes, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
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Silva-Gburek J, Zhu PH, Mansour M, Walding D, Coss-Bu JA. A methodological and clinical approach to measured energy expenditure in the critically ill pediatric patient. Front Pediatr 2022; 10:1027358. [PMID: 36353257 PMCID: PMC9638495 DOI: 10.3389/fped.2022.1027358] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
The metabolic response to injury and stress is characterized initially by a decreased energy expenditure (Ebb phase) followed by an increased metabolic expenditure (Flow phase). Indirect calorimetry is a methodology utilized to measure energy expenditure and substrate utilization by measuring gas exchange in exhaled air and urinary nitrogen. The use of indirect calorimetry in critically ill patients requires precise equipment to obtain accurate measurements. The most recent guidelines suggested that measured energy expenditure by indirect calorimetry be used to determine energy requirements. This article reviews the methodological and clinical use of indirect calorimetry in critically ill pediatric patients.
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Affiliation(s)
- Jaime Silva-Gburek
- Pediatric Critical Care Medicine, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Paola Hong Zhu
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Hospital, Houston, TX, United States
| | - Marwa Mansour
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Hospital, Houston, TX, United States
| | - David Walding
- Texas Children's Hospital, Houston, TX, United States.,Department of Biomedical Engineering, Texas Children's Hospital, Houston, TX, United States
| | - Jorge A Coss-Bu
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Hospital, Houston, TX, United States
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Al-Karagholi MAM, Ghanizada H, Nielsen CAW, Ansari A, Gram C, Younis S, Vestergaard MB, Larsson HB, Skovgaard LT, Amin FM, Ashina M. Cerebrovascular effects of glibenclamide investigated using high-resolution magnetic resonance imaging in healthy volunteers. J Cereb Blood Flow Metab 2021; 41:1328-1337. [PMID: 33028147 PMCID: PMC8142144 DOI: 10.1177/0271678x20959294] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Glibenclamide inhibits sulfonylurea receptor (SUR), which regulates several ion channels including SUR1-transient receptor potential melastatin 4 (SUR1-TRPM4) channel and ATP-sensitive potassium (KATP) channel. Stroke upregulates SURl-TRPM4 channel, which causes a rapid edema formation and brain swelling. Glibenclamide may antagonize the formation of cerebral edema during stroke. Preclinical studies showed that glibenclamide inhibits KATP channel-induced vasodilation without altering the basal vascular tone. The in vivo human cerebrovascular effects of glibenclamide have not previously been investigated.In a randomized, double-blind, placebo-controlled, three-way cross-over study, we used advanced 3 T MRI methods to investigate the effects of glibenclamide and KATP channel opener levcromakalim on mean global cerebral blood flow (CBF) and intra- and extracranial artery circumferences in 15 healthy volunteers. Glibenclamide administration did not alter the mean global CBF and the basal vascular tone. Following levcromakalim infusion, we observed a 14% increase of the mean global CBF and an 8% increase of middle cerebral artery (MCA) circumference, and glibenclamide did not attenuate levcromakalim-induced vascular changes. Collectively, the findings demonstrate the vital role of KATP channels in cerebrovascular hemodynamic and indicate that glibenclamide does not inhibit the protective effects of KATP channel activation during hypoxia and ischemia-induced brain injury.
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Affiliation(s)
- Mohammad Al-Mahdi Al-Karagholi
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Hashmat Ghanizada
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Cherie Amalie Waldorff Nielsen
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Assan Ansari
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Christian Gram
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Samaria Younis
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Mark B Vestergaard
- Functional Imaging Unit, Faculty of Health and Medical Sciences, Department of Clinical Physiology, Nuclear Medicine and PET, University of Copenhagen, Rigshospitalet, Denmark
| | - Henrik Bw Larsson
- Functional Imaging Unit, Faculty of Health and Medical Sciences, Department of Clinical Physiology, Nuclear Medicine and PET, University of Copenhagen, Rigshospitalet, Denmark
| | - Lene Theil Skovgaard
- Department of Biostatistics, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Faisal Mohammad Amin
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark
| | - Messoud Ashina
- Department of Neurology, Faculty of Health and Medical Sciences, Danish Headache Center, University of Copenhagen, Rigshospitalet Glostrup, Denmark.,Danish Headache Knowledge Center, Rigshospitalet, Glostrup, Denmark
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Al-Karagholi MAM, Ghanizada H, Kokoti L, Paulsen JS, Hansen JM, Ashina M. Effect of K ATP channel blocker glibenclamide on levcromakalim-induced headache. Cephalalgia 2020; 40:1045-1054. [PMID: 32806954 DOI: 10.1177/0333102420949863] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Administration of ATP-sensitive potassium channel opener levcromakalim triggers headache in healthy volunteers and migraine attacks in migraine patients. Here, we investigated the effect of ATP-sensitive potassium channel blocker glibenclamide on levcromakalim-induced headache in healthy volunteers. METHODS In a randomized, double-blind, placebo-controlled, three-way cross-over study, 15 healthy volunteers aged 18-40 years were randomly allocated to receive glibenclamide and levcromakalim (day 1), glibenclamide and placebo (day 2), and placebo and placebo (day 3) on three different days separated by at least 1 week. The primary endpoints were the difference in incidence of headache and the difference in area under the curve for headache intensity scores (0-12 hours) between the days. RESULTS Fifteen healthy volunteers completed the 3 days of the study. More participants (12/15, 80%) developed headache on the glibenclamide-levcromakalim day compared to the glibenclamide-placebo day (5/15, 33%) (p = 0.01; mean difference 47%; 95% confidence interval 18-75%) and compared to the placebo-placebo day (1/15, 7%) (p = 0.001; mean difference 73%; 95% confidence interval 48-99%). We found no difference in headache incidence between glibenclamide-placebo day and placebo-placebo day (p = 0.12; mean difference 27%; 95% confidence interval 1.3-52%). The area under the curve for headache intensity was significantly larger on the glibenclamide-levcromakalim day compared to the glibenclamide-placebo day (p = 0.003); and compared to the placebo-placebo day (p = 0.001). We found no difference in the area under the curve between the glibenclamide-placebo day compared to the placebo-placebo day (p = 0.07). The median time to onset for headache after levcromakalim infusion with glibenclamide pretreatment was delayed (180 min) compared to levcromakalim without pretreatment (30 min) from a previously published study. CONCLUSION Glibenclamide administration did not cause headache, and glibenclamide pretreatment did not prevent levcromakalim-induced headache. However, glibenclamide delayed the onset of levcromakalim-induced headache. More selective blockers are needed to further elucidate the role of the ATP-sensitive potassium channel in headache initiation.Trial Registration: ClinicalTrials.gov NCT03886922.
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Affiliation(s)
- Mohammad Al-Mahdi Al-Karagholi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Hashmat Ghanizada
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Lili Kokoti
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Joachim S Paulsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Jakob Møller Hansen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark.,Danish Headache Knowledge Center, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark.,Danish Headache Knowledge Center, Rigshospitalet Glostrup, Glostrup, Denmark
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Yee J, Mohiuddin N, Gradinariu T, Uduman J, Frinak S. Sodium-Based Osmotherapy in Continuous Renal Replacement Therapy: a Mathematical Approach. ACTA ACUST UNITED AC 2020; 1:281-291. [DOI: 10.34067/kid.0000382019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cerebral edema, in a variety of circumstances, may be accompanied by states of hyponatremia. The threat of brain injury from hypotonic stress-induced astrocyte demyelination is more common when vulnerable patients with hyponatremia who have end stage liver disease, traumatic brain injury, heart failure, or other conditions undergo overly rapid correction of hyponatremia. These scenarios, in the context of declining urinary output from CKD and/or AKI, may require controlled elevations of plasma tonicity vis-à-vis increases of the plasma sodium concentration. We offer a strategic solution to this problem via sodium-based osmotherapy applied through a conventional continuous RRT modality: predilution continuous venovenous hemofiltration.
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Skipper A, Tupesis N. Is There a Role for Nonprotein Calories in Developing and Evaluating the Nutrient Prescription? Nutr Clin Pract 2017; 20:321-4. [PMID: 16207670 DOI: 10.1177/0115426505020003321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The concept of nonprotein calories has been used in a variety of ways by nutrition support clinicians. Nonprotein calories may refer to the combined energy from lipid and carbohydrate but are also used to describe the balance between energy and protein in the form of the nonprotein calorie-to-nitrogen ratio. Nonprotein calories have been used as the basis for calculating nutrient needs, but this practice is no longer recommended as it may result in overfeeding. The purpose of this paper is to examine the nonprotein calorie concept using a clinical scenario and review of the literature.
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8
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Fell GL, Cho BS, Pan A, Nose V, Anez-Bustillos L, Dao DT, Baker MA, Nandivada P, Gura KM, Puder M. A Comparison of Fish Oil Sources for Parenteral Lipid Emulsions in a Murine Model. JPEN J Parenter Enteral Nutr 2016; 41:181-187. [PMID: 26993989 DOI: 10.1177/0148607116640275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fat emulsions are important components of parenteral nutrition (PN). Fish oil (FO) emulsions reverse cholestasis in PN-associated liver disease. There are 2 FO monographs. One is "FO; rich in omega-3 fatty acids" (NFO). The other, "omega-3 acids," (PFO), is enriched in omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The purpose of this study is to compare the effects of 20% NFO and PFO emulsions produced in the laboratory in a murine model. METHODS Emulsions were compounded containing different oils: soybean oil (SO), NFO, and two PFOs differing in percentage of fatty acids as triglycerides (PFO66 and PFO90). Chow-fed mice received saline, one of the above emulsions, or a commercial FO (OM) intravenously (2.4 g/kg/day) for 19 days. On day 19, animals were euthanized. Livers, spleens, and lungs were procured for histologic analysis. RESULTS OM, SO, NFO, and PFO90 were well-tolerated clinically. PFO66 resulted in tachypnea and lethargy for ~1 minute following injections. At euthanasia, PFO66 and PFO90 groups had organomegaly. Histologically, these groups had splenic and hepatic fat-laden macrophages, and lungs had scattered fat deposits. Other groups had normal organs. CONCLUSIONS PFO emulsions present an attractive possibility for improving inflammation in PN-dependent patients by concentrating anti-inflammatory EPA and DHA. However, 20% PFO emulsions were poorly tolerated and precipitated adverse end organ sequelae, suggesting that they may not be safe. Development of novel manufacturing methods may achieve safe 20% PFO parenteral emulsions, but by established formulation methods, these emulsions were clinically suboptimal despite meeting pharmacopeial standards.
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Affiliation(s)
- Gillian L Fell
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Bennet S Cho
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy Pan
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Vania Nose
- 2 Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lorenzo Anez-Bustillos
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Duy T Dao
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meredith A Baker
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Prathima Nandivada
- 3 Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kathleen M Gura
- 4 Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark Puder
- 1 Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Fell GL, Nandivada P, Gura KM, Puder M. Intravenous Lipid Emulsions in Parenteral Nutrition. Adv Nutr 2015; 6:600-10. [PMID: 26374182 PMCID: PMC4561835 DOI: 10.3945/an.115.009084] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Fat is an important macronutrient in the human diet. For patients with intestinal failure who are unable to absorb nutrients via the enteral route, intravenous lipid emulsions play a critical role in providing an energy-dense source of calories and supplying the essential fatty acids that cannot be endogenously synthesized. Over the last 50 y, lipid emulsions have been an important component of parenteral nutrition (PN), and over the last 10-15 y many new lipid emulsions have been manufactured with the goal of improving safety and efficacy profiles and achieving physiologically optimal formulations. The purpose of this review is to provide a background on the components of lipid emulsions, their role in PN, and to discuss the lipid emulsions available for intravenous use. Finally, the role of parenteral fat emulsions in the pathogenesis and management of PN-associated liver disease in PN-dependent pediatric patients is reviewed.
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Affiliation(s)
| | | | | | - Mark Puder
- Vascular Biology Program and Departments of Surgery and
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10
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Schricker T, Lattermann R. Perioperative catabolism. Can J Anaesth 2015; 62:182-93. [PMID: 25588775 DOI: 10.1007/s12630-014-0274-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 11/07/2014] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress. PRINCIPLE FINDINGS The key clinical features of perioperative catabolism are hyperglycemia and loss of body protein, both metabolic consequences of impaired insulin function. Muscle weakness and (even moderate) increases in perioperative blood glucose are associated with morbidity after major surgery. Although the optimal glucose concentration for improving clinical outcomes is unknown, most medical associations recommend treatment of random blood glucose > 10 mmol·L(-1). Neuraxial anesthesia blunts the neuroendocrine stress response and enhances the anabolic effects of nutrition. There is evidence to suggest that the avoidance of preoperative fasting prevents insulin resistance and accelerates recovery after major abdominal surgery. CONCLUSIONS Current anticatabolic therapeutic strategies include glycemic control and perioperative nutrition in combination with optimal pain control and the avoidance of preoperative starvation. All these elements are part of Enhanced Recovery After Surgery (ERAS) programs.
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Affiliation(s)
- Thomas Schricker
- Department of Anesthesia, Royal Victoria Hospital, McGill University, 687 Pine Avenue West, Room C5.20, Montreal, QC, H3A 1A1, Canada,
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Abstract
The ideal set of variables for nutritional monitoring that may correlate with patient outcomes has not been identified. This is particularly difficult in the PICU patient because many of the standard modes of nutritional monitoring, although well described and available, are fraught with difficulties. Thus, repeated anthropometric and laboratory markers must be jointly analyzed but individually interpreted according to disease and metabolic changes, in order to modify and monitor the nutritional treatment. In addition, isotope techniques are neither clinically feasible nor compatible with the multiple measurements needed to follow progression. On the other hand, indirect alternatives exist but may have pitfalls, of which the clinician must be aware. Risks exist for both overfeeding and underfeeding of PICU patients so that an accurate monitoring of energy expenditure, using targeted indirect calorimetry, is necessary to avoid either extreme. This is very important, since the monitoring of the nutritional status of the critically ill child serves as a guide to early and effective nutritional intervention.
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12
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Casaer MP, Wilmer A, Hermans G, Wouters PJ, Mesotten D, Van den Berghe G. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med 2012. [PMID: 23204255 DOI: 10.1164/rccm.201206-0999oc] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Early parenteral nutrition to supplement insufficient enteral feeding during intensive care (early PN) delays recovery as compared with withholding parenteral nutrition for 1 week (late PN). OBJECTIVES To assess whether deleterious effects of early PN relate to severity of illness or to the dose or type of macronutrients. METHODS Secondary analyses of a randomized controlled trial (EPaNIC; n = 4,640) performed in seven intensive care units from three departments in two Belgian hospitals. In part 1, all patients were included to assess the effect of the randomized allocation to early PN or late PN in subgroups of patients with increasing-on-admission severity of illness. In part 2, observationally, the association of the amount and type of macronutrients with recovery was documented in those patient cohorts still present in intensive care on Days 3, 5, 7, 10, and 14. MEASUREMENTS AND MAIN RESULTS The primary end point was time to live discharge from the intensive care unit. For part 1, a secondary end point, acquisition of new infections, was also analyzed. All statistical analyses were performed by univariable and adjusted multivariable methods. In none of the subgroups defined by type or severity of illness was a beneficial effect of early PN observed. The lowest dose of macronutrients was associated with the fastest recovery and any higher dose, administered parenterally or enterally, was associated with progressively more delayed recovery. The amount of proteins/amino acids rather than of glucose appeared to explain delayed recovery with early feeding. CONCLUSIONS Early combined parenteral/enteral nutrition delayed recovery irrespective of severity of critical illness. No dose or type of macronutrient was found to be associated with improved outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 00512122).
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Affiliation(s)
- Michael P Casaer
- Laboratory and Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Doley J, Mallampalli A, Sandberg M. Nutrition management for the patient requiring prolonged mechanical ventilation. Nutr Clin Pract 2011; 26:232-41. [PMID: 21586408 DOI: 10.1177/0884533611405536] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Patients requiring prolonged mechanical ventilation are often medically complex and present with a wide range of pulmonary conditions, including neuromuscular diseases, chronic pulmonary diseases, and chronic critical illness. These patients present the nutrition support professional with many challenges. However, accurate nutrition assessment, timely and effective nutrition interventions, and careful monitoring will help patients meet their medical and nutrition goals.
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Abstract
OBJECTIVE To examine the role of targeted indirect calorimetry in detecting the adequacy of energy intake and the risk of cumulative energy imbalance in a subgroup of critically ill children suspected to have alterations in resting energy expenditure. We examined the accuracy of standard equations used for estimating resting energy expenditure in relation to measured resting energy expenditure in relation to measured resting energy expenditure and cumulative energy balance over 1 week in this cohort. DESIGN A prospective cohort study. SETTING Pediatric intensive care unit in a tertiary academic center. INTERVENTIONS A subgroup of critically ill children in the pediatric intensive care unit was selected using a set of criteria for targeted indirect calorimetry. MEASUREMENTS Measured resting energy expenditure from indirect calorimetry and estimated resting energy expenditure from standard equations were obtained. The metabolic state of each patient was assigned as hypermetabolic (measured resting energy expenditure/estimated resting energy expenditure >110%), hypometabolic (measured resting energy expenditure/estimated resting energy expenditure <90%), or normal (measured resting energy expenditure/estimated resting energy expenditure = 90-110%). Clinical variables associated with metabolic state and factors influencing the adequacy of energy intake were examined. MAIN RESULTS Children identified by criteria for targeted indirect calorimetry, had a median length of stay of 44 days, a high incidence (72%) of metabolic instability and alterations in resting energy expenditure with a predominance of hypometabolism in those admitted to the medical service. Physicians failed to accurately predict the true metabolic state in a majority (62%) of patients. Standard equations overestimated the energy expenditure and a high incidence of overfeeding (83%) with cumulative energy excess of up to 8000 kcal/week was observed, especially in children <1 yr of age. We did not find a correlation between energy balance and respiratory quotient (RQ) in our study. CONCLUSIONS We detected a high incidence of overfeeding in a subgroup of critically ill children using targeted indirect calorimetry The predominance of hypometabolism, failure of physicians to correctly predict metabolic state, use of stress factors, and inaccuracy of standard equations all contributed to overfeeding in this cohort. Critically ill children, especially those with a longer stay in the PICU, are at a risk of unintended overfeeding with cumulative energy excess.
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Annamalai AK, Mankia S, Kandasamy N, Donald S, Adler AI. Continuous subcutaneous insulin usage in a patient with no gut. Diabet Med 2010; 27:364-6. [PMID: 20536503 DOI: 10.1111/j.1464-5491.2010.02927.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Abstract
A significant proportion of critically ill children admitted to the pediatric intensive care unit (PICU) present with nutritional deficiencies. Malnourished hospitalized patients have a higher rate of complications, increased mortality, longer length of hospital stay, and increased hospital costs. Critical illness may further contribute to nutritional deteriorate with poor outcomes. Younger age, longer duration of PICU stay, congenital heart disease, burn injury, and need for mechanical ventilation support are some of the factors that are associated with worse nutritional deficiencies. Failure to estimate energy requirements accurately, barriers to bedside delivery of nutrients, and reluctance to perform regular nutritional assessments are responsible for the persistence and delayed detection of malnutrition in this cohort.
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Affiliation(s)
- Nilesh M. Mehta
- Instructor, Harvard Medical School, Faculty in Division of Critical Care, Anesthesia, Children's Hospital, Boston MA 02115
| | - Christopher P. Duggan
- Associate Professor of Pediatrics – Harvard Medical School, Director, Clinical Nutrition Service - Children's Hospital, Boston, Division of Gastroenterology/Nutrition, Children's Hospital, Boston MA 02115
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17
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Campbell SJ. Nutritional considerations for animals with pulmonary disease. Vet Clin North Am Small Anim Pract 2007; 37:989-1006, viii. [PMID: 17693211 DOI: 10.1016/j.cvsm.2007.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recent publications in the human and veterinary literature have indicated that patients with pulmonary disease require specific nutritional consideration to ensure that optimal benefit is derived with nutrition support. Although additional research is needed in this area, preliminary recommendations can be made using information from the scant studies performed thus far in veterinary medicine and from information extrapolated from the human literature. These recommendations are likely to provide significant clinical benefit to patients with pulmonary disease. This article aims to provide the reader with a summary of the available information and links to other relevant sources.
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Affiliation(s)
- Scott J Campbell
- WALTHAM UCVMC-SD Clinical Nutrition Program, University of California Veterinary Medical Center-San Diego, San Diego, CA 92121, USA.
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18
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Abstract
The metabolism of critical illness is characterised by a combination of starvation and stress. There is increased production of cortisol, catecholamines, glucagon and growth hormone and increased insulin-like growth factor-binding protein-1. Phagocytic, epithelial and endothelial cells elaborate reactive oxygen and nitrogen species, chemokines, pro-inflammatory cytokines and lipid mediators, and antioxidant depletion ensues. There is hyperglycaemia, hyperinsulinaemia, hyperlactataemia, increased gluconeogenesis and decreased glycogen production. Insulin resistance, particularly in relation to the liver, is marked. The purpose of nutritional support is primarily to save life and secondarily to speed recovery by reducing neuropathy and maintaining muscle mass and function. There is debate about the optimal timing of nutritional support for the patient in the intensive care unit. It is generally agreed that the enteral route is preferable if possible, but the dangers of the parenteral route, a route of feeding that remains important in the context of critical illness, may have been over-emphasised. Control of hyperglycaemia is beneficial, and avoidance of overfeeding is emphasised. Growth hormone is harmful. The refeeding syndrome needs to be considered, although it has been little studied in the context of critical illness. Achieving energy balance may not be necessary in the early stages of critical illness, particularly in patients who are overweight or obese. Protein turnover is increased and N balance is often negative in the face of normal nutrient intake; optimal N intakes are the subject of some debate. Supplementation of particular amino acids able to support or regulate the immune response, such as glutamine, may have a role not only for their potential metabolic effect but also for their potential antioxidant role. Doubt remains in relation to arginine supplementation. High-dose mineral and vitamin antioxidant therapy may have a place.
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Affiliation(s)
- Jeremy Powell-Tuck
- Department of Human Nutrition, The Royal London Hospital, Whitechapel, London E1 1BB, UK.
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Ali AB, Chapman-Kiddell C, Reeves MM. Current practices in the delivery of parenteral nutrition in Australia. Eur J Clin Nutr 2006; 61:554-60. [PMID: 17106450 DOI: 10.1038/sj.ejcn.1602547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine current practice in the delivery of parenteral nutrition (PN) in Australian hospitals. DESIGN A cross-sectional mail survey. SETTING Acute-care adult hospitals with greater than 200 beds in Australia. SUBJECTS A total of 67 hospitals (65.7% response rate). INTERVENTION Surveys were posted to hospitals. A reminder letter with a second copy of the survey was posted 3 weeks later to non-respondents. RESULTS Twenty-seven (40.3%) of the hospitals have a PN team and 50 (74.6%) have a hospital protocol for PN delivery. An inaccessible or non-functional gastrointestinal tract is the most common indicator for commencing PN. Fat infusion is calculated by 24 (38.7%) respondents with a mean (s.d.) maximum amount of fat provided of 2.0 (0.7) g/kg/day. Over half (n=35) reported calculating carbohydrate infusion at a maximum amount of 5.4 (1.0) mg/kg/min. Two-thirds (n=41) reported commencing PN at a rate of 50% or less of goal rate. Blood glucose levels (BGL) were monitored at least once per day by the majority of respondents (n=56, 83.6%). Insulin infusion was commenced at varying BGL. Most respondents (n=40, 59.7%) reported ceasing PN when at least half of the patient's requirements are being met either orally or enterally. A number of practice guidelines were identified and the results of the survey were compared with these guidelines. CONCLUSIONS Where there are clear practice guidelines, current practice appears to be in line with these recommendations, however, where evidence is lacking, practice is varied.
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Affiliation(s)
- A B Ali
- Nutrition and Dietetic Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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20
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Havalad S, Quaid MA, Sapiega V. Energy expenditure in children with severe head injury: lack of agreement between measured and estimated energy expenditure. Nutr Clin Pract 2006; 21:175-81. [PMID: 16556928 DOI: 10.1177/0115426506021002175] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The purpose of this study was to test the hypotheses that estimates of resting energy expenditure (REE) vary significantly from measured energy expenditure in a population of head-injured children and are not accurate for use in determining nutrition needs in this population. METHODS This is a retrospective study of 30 children with severe head injury, with Glasgow Coma Scale (GCS) score of <8 and needing mechanical ventilation. Measured REE was obtained using indirect calorimetry. Estimated REEs were calculated using Harris-Benedict, World Health Organization (WHO), Schofield, and White formulas. Severity of illness was calculated using Pediatric Risk of Mortality (PRISM) score. Agreement between measured REE and estimated REE was tested using the Bland-Altman method. Correlation coefficient between PRISM score and measured REE was calculated using Spearman test. RESULTS More than half of the estimates of REE differed from measured REE by >10%. Significant disagreement between estimated REE and measured REE was demonstrated using the Bland-Altman method. There was no correlation between severity of illness and measured REE to explain the inaccuracies of REE estimates. CONCLUSION Energy expenditure in critically ill children cannot be estimated accurately; hence, nutrition for critically ill children with head injury should be provided according to measurement of REE to avoid the consequences of overfeeding or malnutrition.
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Affiliation(s)
- Suresh Havalad
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Advocate Lutheran General Children's Hospital, 1775 Dempster St, Park Ridge, IL 60068, USA.
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21
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Abstract
An understanding of energy expenditure in hospitalized patients is necessary to determine optimal energy supply in the care of individuals who require nutritional support. A review was conducted of 19 studies in which resting energy expenditure (REE) had been measured using indirect calorimetry and compared with estimated basal energy expenditure (BEE) from the Harris-Benedict equation. Studies of patients with burns, head injuries, and fever were excluded because REE is known to be increased in these conditions. The studies reported data on 1256 patients with the following diagnoses: postoperative (28%), trauma or sepsis (26%), cancer (18%), pulmonary disease (9%), cardiovascular disease (2%), miscellaneous (9%), and unspecified (6%). The average REE in the 19 studies was 113% of the BEE. The mean +/- SD REE/BEE ratio was higher in 11 studies in which the REE was measured during feeding than in 5 studies in which the measurement was made during fasting (117% +/- 3% vs 105% +/- 4%; P = .047). In those 11 studies, overfeeding may have contributed to higher REE values than otherwise would have been observed. Some evidence indicated that the REE/BEE ratio is higher in more severe illness, but results were inconsistent. Unfortunately, little information is available concerning total energy expenditure, which includes the contribution of physical activity. It appears that most patients can be fed adequately with energy equal to 100% to 120% of estimated BEE. Hypoenergetic feeding may be appropriate in some overweight and obese individuals. Additional research in hospitalized patients on total energy expenditure and on the relationship between severity of illness and energy expenditure is needed.
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Affiliation(s)
- John M Miles
- Endocrine Research Unit, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA.
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Ahrens CL, Barletta JF, Kanji S, Tyburski JG, Wilson RF, Janisse JJ, Devlin JW. Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: A randomized, controlled trial. Crit Care Med 2005; 33:2507-12. [PMID: 16276174 DOI: 10.1097/01.ccm.0000186746.64572.8a] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the effect of a low-calorie parenteral nutrition (PN) regimen on the incidence and severity of hyperglycemia and insulin requirements. DESIGN Prospective, randomized, clinical trial. SETTING Urban, university-affiliated, level-I trauma center. PATIENTS Consecutive surgical patients requiring PN. INTERVENTIONS Patients were randomized to receive either a low-calorie PN formulation (20 nonprotein kilocalories per kg per day) or a standard PN formulation (30 nonprotein kilocalories per kg per day). Lipid-derived calories were standardized to 1000 kilocalories three times weekly for all patients; consequently, the number of calories varied only by the amount of carbohydrate administered. Protein requirements were individualized on the basis of estimated metabolic stress. Hyperglycemia was defined as a blood glucose level > or = 200 mg/dL. MEASUREMENTS AND MAIN RESULTS Forty patients were evaluated (low-calorie PN, n = 20; standard PN, n = 20). Demographics of the two groups were similar. The incidence of hyperglycemic events was significantly lower in the low-calorie group (0% [0-0.5] vs. 33.1% [0-58.4]; p = .001]. Additionally, the severity of hyperglycemia was also lower in the low-calorie group (mean glucose area under the curve = 118 +/- 22 [mg x hr]/dL vs. 172 +/- 44 [mg x hr]/dL; p < .001). This resulted in lower average daily insulin requirements (0 [0-0] units vs. 10.9 [0-25.6] units; p < .001.). The only predictor of hyperglycemia was a dextrose administration rate >4 mg/kg/min. CONCLUSIONS : Administration of a low-calorie PN formulation resulted in fewer and less-severe hyperglycemic events and lower insulin requirements. PN regimens should not exceed a dextrose administration rate of 4 mg/kg/min to avoid hyperglycemic events.
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Affiliation(s)
- Christine L Ahrens
- Department of Pharmacy, The Cleveland Clinic Foundation, Cleveland, OH, USA
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23
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Abstract
The prevalence of obesity in the general population is high and it is inevitable that artificial feeding will be needed from time to time in the obese patient, particularly in the critical care setting. Against a background of generous endogenous stores of energy as adipose tissue and the ability of obese individuals to survive starvation longer than non-obese individuals, emphasis is placed on preserving lean body mass and optimizing physiological function. Insulin resistance is typical of the obese individual and is exacerbated by stress; overfeeding is dangerous, particularly if it results in hyperglycaemia. Refeeding syndrome also has to be avoided. Weight may be difficult to measure and lean body mass difficult to assess. Calculation of energy requirements is therefore problematic in practice in the obese individual and there is substantial evidence from controlled clinical trials of the safety of feeding at or below resting energy expenditure. If this approach is taken it is wise to provide a more generous than normal protein intake and to beware of patients with a very high baseline urinary N excretion.
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Affiliation(s)
- Jeremy Powell-Tuck
- St. Bartholomew's and the Royal London Hospital Medical College, Queen Mary University of London, UK.
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24
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Abstract
BACKGROUND A previous report suggested that glucose administration in total parenteral nutrition (TPN) should not exceed 4 mg/kg/min with a respiratory quotient (RQ) >1.0. This rate would not be exceeded, in most patients, with a TPN glucose concentration of 15%. Our previous survey of hospitals, 7 years ago, of TPN composition revealed use of excessive glucose. Our purpose was to reevaluate glucose usage in TPN. METHODS A subset of data from 45 hospitals participating in Novation's Medication Use Evaluation program, "Parenteral Nutrition for Adults and Neonates" study, was analyzed to document glucose administration in TPN. RESULTS Data of 629 adult patients from 44 hospitals receiving TPN were analyzed. Of these, 30 hospitals with 478 patients had 100 patients (15.9% of the total) with TPN glucose infusion rates >4 mg/kg/min, whereas 27 hospitals, or 61%, had average TPN glucose concentrations above 15%. This could be associated with an RQ >1.0, implying increased net lipogenesis. CONCLUSIONS The majority of hospitals surveyed were found, as in a previous survey, to be using amounts of glucose in TPN which would be expected to be associated with an RQ >1.0, implying increased net lipogenesis.
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Affiliation(s)
- Paul R Schloerb
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas 66160, USA.
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25
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Ghabril MS, Aranda-Michel J, Scolapio JS. Metabolic and catheter complications of parenteral nutrition. Curr Gastroenterol Rep 2004; 6:327-34. [PMID: 15245703 DOI: 10.1007/s11894-004-0086-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Since its introduction in the 1960s, total parenteral nutrition (TPN) has played a vital role in improving clinical outcomes for patients with acute and chronic illnesses. The evolution of TPN solutions and vascular access techniques, combined with an increased awareness and better understanding of the physiology of TPN, have improved the safety of this therapy. Nevertheless, complications are not uncommon and can be life threatening. This article provides an updated review on the metabolic and catheter complications associated with TPN.
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Affiliation(s)
- Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Drive, Jacksonville, FL 32224, USA
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26
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Dickerson RN, Karwoski CB. Endotoxin-mediated hepatic lipid accumulation during parenteral nutrition in rats. J Am Coll Nutr 2002; 21:351-6. [PMID: 12166533 DOI: 10.1080/07315724.2002.10719234] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the effect of endotoxemia on hepatic lipid content during parenteral nutrition (PN) in rats. METHODS Twenty male Sprague-Dawley rats (185-230 gm) were randomized to receive PN (n=9) or PN plus a continuous infusion of E. coli 026:B6 lipopolysaccharide (LPS; n= 11). All animals received isocaloric (170 kcal/kg/day), isonitrogenous (1.1 g N/kg/day), glucose-based PN for the next 78 hours. After 30 hours of adaptation to TPN, the animals were randomized to receive PN or PN plus LPS at 6 mg/kg/day for the remaining 48 hours of study. The animals were euthanized and the livers were harvested. RESULTS Liver weight increased significantly (by 60%) from 7.5+/-0.6 g to 12.1+/-2.4 g (p < or = 0.01) in the animals who received PN versus LPS, respectively. The proportion of liver water remained the same for PN and LPS groups (72.9+/-3.2% versus 72.3+/-3.8%, respectively, p = N.S.). However, liver fat increased disproportionately (by about 130%) from 0.20+/-0.05 g to 0.46+/-0.20 g (p < or = 0.01) total fat weight or from 9.6+/-1.8% to 13.6+/-4.1% (p < or = 0.02) lipid content (g/g) of the dry liver weight for the PN and LPS groups, respectively. CONCLUSION Endotoxin, when given concomitantly with parenteral nutrition, increases hepatic lipid accumulation and thus augments the development of parenteral nutrition-associated fatty liver in rats.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, The University of Tennessee Health Sciences Center, Memphis 38163, USA
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27
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Mechanick JI, Brett EM. Endocrine and metabolic issues in the management of the chronically critically ill patient. Crit Care Clin 2002; 18:619-41, viii. [PMID: 12140916 DOI: 10.1016/s0749-0704(02)00005-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The metabolic syndrome of chronic critical illness (CCI) consists of multisystem organ dysfunction resulting from the initial acute injury and chronic immune-neuroendocrine axis activation, adult kwashiorkor-like malnutrition, and prolonged immobilization with suppression of the PTH-vitamin D axis and hyper-resorptive metabolic bone disease. CCI patients can also present unique challenges in the management of diabetes mellitus, thyroid and adrenal diseases, electrolyte abnormalities and hypogonadism.
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Affiliation(s)
- Jeffrey I Mechanick
- Division of Endocrinology, Diabetes, and Bone Disease, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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29
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Abstract
The use of indirect calorimetry in the design of nutritional support regimens is poorly appreciated by clinicians, who fail to recognize the importance of providing a sufficient volume of enteral feeding to critically ill patients. In contrast to the overfeeding that routinely occurred in the past with the provision of total parenteral nutrition, patients placed on the enteral route of support tend to be underfed because of problems with intolerance and frequent cessation. Clearly identifying and coming as close as possible to the caloric goal may be required to achieve the therapeutic endpoints of enteral tube feeding (which include maintenance of gut integrity, attenuation of the stress response, prophylaxis against stress-induced gastropathy, and stimulation of immune function). Indirect calorimetry is a convenient, accessible, and highly accurate instrument for the measurement of caloric requirements and is a valuable tool for the optimization of nutritional support in the intensive care unit.
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Affiliation(s)
- S A McClave
- University of Louisville School of Medicine, Department of Medicine, Division of Gastroenterology/Hepatology, 550 South Jackson Street, Louisville, KY 40202, U.S.A.
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30
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Abstract
Stress hyperglycemia is common and likely to be associated with at least some of the same complications as hyperglycemia in true diabetes mellitus, such as poor wound healing and a higher infection rate. The predominant cause is the intense counterregulatory hormone and cytokine responses of critical illness, often compounded by excessive dextrose administration, usually as TPN. Although randomized data suggesting benefit of controlling hyperglycemia in hospitalized patients are paltry, prospective controlled trials are feasible and should be initiated. In the interim, the practice at the authors' institution is to use insulin to lower plasma glucose concentrations to a safe range of 150 mg/dL to 200 mg/dL in all patients.
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Affiliation(s)
- K C McCowen
- Departments of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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31
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Abstract
Lipid provides two major advantages for total parenteral nutrition (TPN). First, it provides essential fatty acids, thus avoiding essential fatty acid deficiency, and secondly, it is a useful energy source, providing 9 kcal/g. However, we describe a patient who had TPN containing Intralipid, where problems of lipid clearance developed. We also review the literature of lipid clearance problems in TPN patients and suggest ways by which such problems can be managed. We suggest that patients taking TPN should have their plasma lipids (triacylglycerols) measured before and during TPN initiation. This is particularly important in patients who are at high risk of impaired fat clearance, such as those who are hyperlipidemic, diabetic, septic, or with impaired renal or hepatic function, or those who are critically ill.
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Affiliation(s)
- M A Crook
- Department of Chemical Pathology, Guy's and St. Thomas' Hospital, London, UK.
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32
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Abstract
Most patients with pancreatic cancer suffer from a variety of severe metabolic and nutritional disturbances. Despite this fact, the role of perioperative nutritional support for these patients remains controversial. This review highlights the results of randomized prospective clinical trials, and meta-analyses that have addressed this issue. The 'current opinion' put forth in this discussion is based on these reviews, and on personal observations in treating more than 500 patients.
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Affiliation(s)
- A M Cooperman
- Institute for Liver, Biliary and Pancreatic Surgery, Community Hospital of Dobbs Ferry, New York 10522, USA
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Abstract
BACKGROUND With reports of deleterious effects of total parenteral nutrition (TPN) in adults in addition to our surveys, which indicated that 1/4, and as many as 1/2, of US academic medical centers were using excess glucose in TPN, our objective was to devise a computer program to optimize nutrients in parenteral and enteral nutrition in adult and pediatric patients. METHODS From review of the literature, body composition, including total body water and body cell mass (BCM), were calculated from large published databases. A computer program, based on a previous algorithm, was developed to determine optimum parenteral and enteral nutritional support, based on calculated BCM as the reference. Flexibility to permit any nutrients, in accordance with individual patient requirements, was included. RESULTS With entry of simple anthropometric values and an average stress factor equivalent to 20% greater than the Harris-Benedict energy calculation, energy and nutrients were calculated for TPN as follows: amino acids, 3.4 g/kg BCM/d; carbohydrate, 12 g/kg BCM/d; and fat for remaining energy, usually 2.3 g/kg BCM/d. The program, available on any personal computer, is available using Netscape 3.0 or higher or from Microsoft Internet Explorer 4.0, at http://epen.kumc.edu. It permits rapid calculation and display of body composition values, a standardized TPN formula, an alternate TPN prescription, enteral nutrition options, a section that explains the calculations, and a list of references. CONCLUSIONS The program, http://epen.kumc.edu, provides rapid definition of the TPN or enteral prescription for adult and pediatric patients, with reduced likelihood of providing excessive glucose and energy in parenteral or enteral nutrition.
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Affiliation(s)
- P R Schloerb
- Department of Surgery, University of Kansas Medical Center, Kansas City 66160, USA
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34
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Powell-Tuck J. Nutrition. Best Pract Res Clin Anaesthesiol 1999. [DOI: 10.1053/bean.1999.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Nutrition support plays an important role in the management of nutritional deficiencies in properly selected critically ill patients. A full nutritional assessment allows the calculation of appropriate feeding goals. The route of feeding, enteral or parenteral, is determined by the presence or absence of a functioning intestine and hemodynamic status of the patient. The specific roles of carbohydrates, fats, and protein need to be considered in order to prevent overfeeding and other complications. The efficacy of certain disease-specific enteral formulas has been demonstrated in clinical trials, however, careful cost-benefit analyses are required.
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Affiliation(s)
- S Chan
- Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, USA
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36
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Abstract
Nutritional support has become a routine part of the care of the critically ill patient. It is an adjunctive therapy, the main goal of which is to attenuate the development of malnutrition, yet the effectiveness of nutritional support is often thwarted by an underlying hostile metabolic milieu. This requires that these metabolic changes be taken into consideration when designing nutritional regimens for such patients. There is also a need to conduct large, multi-center studies to acquire more knowledge of the cost-benefit and cost effectiveness of nutritional support in the critically ill.
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Affiliation(s)
- C Weissman
- Department of Anesthesiology and Critical Care Medicine, Hebrew University-Hadassah, School of Medicine, Jerusalem, Israel.
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37
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Abstract
This review of 23 papers involving indirect calorimetry published over the past 18 months shows how our understanding of the metabolic response to injury has changed, highlights the problems introduced by use of predictive equations and alterations in indirect calorimetry testing protocol, and emphasizes the need to monitor cumulative energy balance by comparing daily caloric intake to energy expenditure.
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Affiliation(s)
- S A McClave
- Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, KY 40292, USA
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38
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Aarsland A, Chinkes DL, Sakurai Y, Nguyen TT, Herndon DN, Wolfe RR. Insulin therapy in burn patients does not contribute to hepatic triglyceride production. J Clin Invest 1998; 101:2233-9. [PMID: 9593779 PMCID: PMC508811 DOI: 10.1172/jci200] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lipid kinetics were studied in six severely burned patients who were treated with a high dose of exogenous insulin plus glucose to promote protein metabolism. The patients were 20+/-2-yr-old (SD) with 63+/-8% total body surface area burned. They were studied in a randomized order (a) in the fed state on the seventh day of a control period (C) of continuous high-carbohydrate enteral feeding alone, and (b) on the seventh day of enteral feeding plus exogenous insulin (200 pmol/h = 28 U/h) with extra glucose given as needed to avoid hypoglycemia (I+G). Despite a glucose delivery rate approximately 100% in excess of energy requirements, the following lipid parameters were unchanged: (a) total hepatic VLDL triglyceride (TG) secretion rate (0.165+/-0.138 [C] vs. 0.154+/- 0.138 mmol/kg . d-1 [I+G]), (b) plasma TG concentration (1.58+/-0.66 [C] vs. 1. 36+/-0.41 mmol/liter [I+G]), and (c) plasma VLDL TG concentration (0. 68+/-0.79 [C] vs. 0.67+/- 0.63 mmol/liter [I+G]). Instead, the high-carbohydrate delivery in conjunction with insulin therapy increased the proportion of de novo-synthesized palmitate in VLDL TG from 13+/-5% (C) to 34+/-14% (I+G), with a corresponding decreased amount of palmitate from lipolysis. In association with the doubling of the secretion rate of de novo-synthesized fatty acid (FA) in VLDL TG during insulin therapy (P > 0.5), the relative amount of palmitate and stearate increased from 35+/-5 to 44+/-8% and 4+/-1 to 7+/-2%, respectively, in VLDL TG, while the relative concentration of oleate and linoleate decreased from 43+/-5 to 37+/-6% and 8+/-4% to 2+/-2%, respectively. A 15-fold increase in plasma insulin concentration did not change the rate of release of FA into plasma (8.22+/-2.86 [C] vs. 8.72+/-6.68 mmol/kg.d-1 [I+G]. The peripheral release of FA represents a far greater potential for hepatic lipid accumulation in burn patients than the endogenous hepatic fat synthesis, even during excessive carbohydrate intake in conjunction with insulin therapy.
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Affiliation(s)
- A Aarsland
- The Metabolism Unit, Shriners Burns Institute, Galveston, TX 77551, USA
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Porter C, Cohen NH. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 1996; 96:49-57. [PMID: 8537570 DOI: 10.1016/s0002-8223(96)00014-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Evaluation and interpretation of energy needs of critically ill patients require the expertise of clinical dietitians: Dietitians must be knowledgeable about the methods available to quantify energy needs and able to communicate effectively with physicians and nurses regarding nutritional requirements. Several prediction equations are available for calculating energy needs of critically ill patients. Indirect calorimetry is also used frequently to measure energy requirements in this patient population. This article defines when energy expenditure measured by indirect calorimetry may provide clinically useful information. Data obtained by indirect calorimetry must be interpreted carefully. Indirect calorimetry is based on the equations for oxidation of carbohydrate, protein, and fat. Errors in interpretation can be made when metabolic pathways other than oxidation dominate or when clinical conditions exist that affect carbon dioxide excretion from the lungs. Before incorporating data obtained from indirect calorimetry into a nutrition care plan, the clinical dietitian should carefully evaluate the following factors for a patient: clinical conditions when the measurement was made, desired weight loss or gain, tolerance to food or nutrition support, relationship between protein intake and energy need, and need for anabolism or growth. This article provides clinical examples illustrating how measured values compare with calculated values and recommendations for how to incorporate measured values into nutrition care plans.
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Affiliation(s)
- C Porter
- Department of Nutrition and Dietetics, University of California, San Francisco 94143-0212, USA
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