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Kudsk KA. Catabolic states and immune dysfunction: relation to gastrointestinal feeding. Nestle Nutr Workshop Ser Clin Perform Programme 2002; 3:157-69; discussion 169-72. [PMID: 11490605 DOI: 10.1159/000061806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- K A Kudsk
- Department of Surgery, University of Tennessee, Memphis, Tenn., USA
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Zarzaur BL, Kudsk KA, Carter K, Pritchard FE, Fabian TC, Croce MA, Minard G. Stress ulceration requiring definitive surgery after severe trauma. Am Surg 2001; 67:875-9. [PMID: 11565768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 +/- 1.2 days after admission, 7.2 +/- 1.2 days before definitive operative therapy, and requiring 7.1 +/- 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 +/- 41 vs 158 +/- 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.
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Affiliation(s)
- B L Zarzaur
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, USA
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Kudsk KA, Laulederkind A, Hanna MK. Most infectious complications in parenterally fed trauma patients are not due to elevated blood glucose levels. JPEN J Parenter Enteral Nutr 2001; 25:174-9. [PMID: 11434646 DOI: 10.1177/0148607101025004174] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the relationship between hyperglycemia and infectious complications in nutritional studies of trauma patients. METHODS Retrospective review of serum glucose values in two published randomized, prospective studies of patients receiving either enteral or parenteral feeding (trial 1) or isonitrogenous, isocaloric enteral diets (trial 2). Trial 2 also included patients prospectively followed who received little or no enteral feeding. RESULTS Patients randomized to enteral or parenteral feeding in trial 1 exhibited no significant differences in the highest recorded serum glucose (SG) until the fourth or fifth day after protocol entry. SG tended to be higher in infected than non-infected patients in the first 4 hospital days, but SG was far below values considered to increase the risk for infection (SG > 220 mg/dL). In trial 2, glucose levels tended to be slightly higher in infected than in noninfected patients within the first 5 days reaching statistical significance by day 5. Unfed control patients had similar SG values but significantly more major infectious complications. CONCLUSIONS Patients developing infections had slightly higher SG levels than noninfected patients early in admission, but these SG values were far below levels considered a risk for infective complications. Significant hyperglycemia does not explain differences in infectious complications in critically ill trauma patients randomized to various routes and types of nutrition.
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Affiliation(s)
- K A Kudsk
- University of Tennessee, Memphis, USA.
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Abstract
Nearly 50% of the immune cells in the body lie just beneath the moist mucosal surfaces at intestinal and extra-intestinal sites. The study of this mucosal immune system in response to shock and to route and type of nutrition provides a cogent explanation for the reduced incidence of pneumonia with enteral feeding. Changes in immune cell mass and function are associated with deterioration of previously established immunity at mucosal surfaces, especially the respiratory tract. By understanding the mechanisms involved in this breakdown, therapeutic strategies can be developed to reduce septic complications in critical illness.
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Affiliation(s)
- B L Zarzaur
- The University of Tennessee Health Science Center, Memphis, USA
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Abstract
OBJECTIVE To determine whether parenteral feeding (IV-TPN) influences the local and systemic response to an intestinal insult. SUMMARY BACKGROUND DATA Parenteral feeding increases ICAM-1 expression and attracts neutrophils (PMNs) to the intestine compared with enterally fed animals. Because the gut is a priming bed for PMNs, the authors hypothesized that IV-TPN may affect organ injury after gut ischemia-reperfusion (I/R). METHODS Mice were randomized to chow, IV-TPN, intragastric TPN, or complex enteral diet for 5 days' feeding. In experiment 1, 162 mice underwent 15 or 30 minutes of gut I/R, and death was recorded at 72 hours. In experiment 2, 43 mice underwent 15 minutes of gut ischemia and permeability was measured by 125I-labeled albumin at 3 hours after reperfusion. Lung PMN accumulation was measured by myeloperoxidase assay. In experiment 3, albumin leak was tested in the complex enteral diet group (n = 5) and the intragastric TPN group (n = 5) after 30 minutes of gut ischemia and 1 hour of reperfusion. RESULTS In experiment 1, enteral feeding significantly reduced the death rate compared with IV-TPN after 15 minutes of I/R. After 30 minutes of gut ischemia, the IV-TPN and intragastric TPN groups showed a higher death rate than the chow and enteral diet groups. In experiment 2, IV-TPN significantly increased pulmonary and hepatic 125I albumin leak compared with enteral feeding without increasing pulmonary myeloperoxidase levels. In experiment 3, there were no differences in 125I albumin leak between the complex enteral diet and intragastric TPN groups. CONCLUSION Enteral feeding reduced the death rate and organ permeability after 15 minutes of ischemia. However, prolonged ischemia (30 minutes) eliminated any benefits of intragastric TPN on survival.
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Affiliation(s)
- K Fukatsu
- Departments of Surgery and Pharmacology, The University of Tennessee, Memphis, Tennessee, USA.
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Fukatsu K, Zarzaur BL, Johnson CD, Lundberg AH, Hanna MK, Wilcox HG, Kudsk KA. Lack of enteral feeding increases expression of E-selectin after LPS challenge. J Surg Res 2001; 97:41-8. [PMID: 11319878 DOI: 10.1006/jsre.2001.6109] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Total parenteral nutrition (IV-TPN) increases neutrophil accumulation in the small intestine, expression of intestinal ICAM-1 and P-selectin, and upregulates E-selectin expression in the lung. Endothelial activation induced by lack of enteral nutrition may change the response to injury or infection. This study investigated whether nutrition influenced the expression of the adhesion molecule, E-selectin and ICAM-1, following endotoxin challenge. MATERIALS AND METHODS Forty-three mice were injected with saline, 2, 20, 200, 2000, or 10000 microg/kg lipopolysaccharide (LPS) intraperitoneally. E-selectin expression in the lung, small intestine, and heart was quantified at 3 h after challenge, while ICAM-1 was measured at 5 h, using the dual-radiolabeled monoclonal antibody technique. Next, 80 mice were fed chow, intragastric (IG)-TPN, or IV-TPN for 5 days, and then received intraperitoneal 2 or 200 microg/kg LPS. E-selectin and ICAM-1 expression in organs was measured at 3 and 5 h after endotoxin, respectively. RESULTS E-selectin expression in organs increased LPS dose dependently. ICAM-1 levels reached early peaks in the lung and in the intestine. Also, IV-TPN significantly increased E-selectin expression in the small intestine and tended to increase pulmonary E-selectin, when compared to chow or IG-TPN animals. There were no significant differences in E-selectin expression among three diet groups after 200 microg/kg LPS challenge. No differences in ICAM-1 expression were observed in any organ among the three groups after 2 or 200 microg/kg LPS injection. CONCLUSIONS E-selectin rather than ICAM-1, because of the expression pattern after various dosages of LPS challenge, may be a determining factor for the degree of LPS-induced inflammation at the early phase. Lack of enteral nutrition may increase inflammatory response through enhanced gut E-selectin levels after a small dose of LPS.
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Affiliation(s)
- K Fukatsu
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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Dickerson RN, Gervasio JM, Sherman JJ, Kudsk KA, Hickerson WL, Brown RO. A comparison of renal phosphorus regulation in thermally injured and multiple trauma patients receiving specialized nutrition support. JPEN J Parenter Enteral Nutr 2001; 25:152-9. [PMID: 11334065 DOI: 10.1177/0148607101025003152] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To compare phosphorus intake and renal phosphorus regulation between thermally injured patients and multiple trauma patients, 40 consecutive critically ill patients, 20 with thermal injury and 20 with multiple trauma, who required enteral tube feeding were evaluated. Phosphorus intakes were recorded for 14 days from the initiation of tube feeding which was started 1 to 3 days postinjury. Serum for determination of phosphorus concentrations was collected at days 1, 3, 7, and 14 of the study period. A 24-hour urine collection was obtained during the first and second weeks of nutrition support for urinary phosphorus excretion, fractional excretion of phosphorus, renal threshold phosphate concentration, and phosphorus clearance. Average total daily phosphorus intake during the 14-day study for thermally injured patients and multiple trauma patients was 0.99+/-0.26 mmol/kg/d vs 0.58+/-0.21 mmol/kg/d, respectively, p < .001. Serum phosphorus concentration on the third day of observation was significantly lower in the thermally injured group than those with multiple trauma (1.9+/-0.8 mg/dL vs 3.0+/-0.8 mg/dL, p < or = .01). A trend toward hypophosphatemia in the thermally injured group persisted by the seventh day of feeding (2.7+/-1.2 mg/dL vs 3.3+/-0.6 mg/dL, p < or = .04). Differences in urinary phosphorus excretion was not statistically significant between the thermally injured and multiple trauma groups (271+/-213 mg/d vs 171+/-181 mg/d for week 1, and 320+/-289 mg/d vs 258+/-184 mg/d for week 2, respectively). Urinary phosphorus clearance, fractional excretion of phosphorus, or renal threshold phosphate concentrations were also not significantly different between thermally injured and multiple trauma patients. During nutrition support, serum phosphorus concentrations are lower in thermally injured patients compared with multiple trauma patients despite receiving a significantly greater intake of phosphorus. Renal phosphorus regulation does not significantly contribute to the profound hypophosphatemia observed in thermally injured patients when compared with multiple trauma patients during nutrition support.
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Affiliation(s)
- R N Dickerson
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis 38163, USA
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Fukatsu K, Kudsk KA, Zarzaur BL, Wu Y, Hanna MK, DeWitt RC. TPN decreases IL-4 and IL-10 mRNA expression in lipopolysaccharide stimulated intestinal lamina propria cells but glutamine supplementation preserves the expression. Shock 2001; 15:318-22. [PMID: 11303733 DOI: 10.1097/00024382-200115040-00012] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Total parenteral nutrition (TPN) decreases intestinal IgA and levels of Th2 cytokines, interleukin (IL)-4, and IL-10 within the supernatants of intestinal homogenates. These cytokines are known to stimulate IgA production in vitro by cells of the gut-associated lymphoid tissue (GALT). Glutamine (GLN) supplementation of TPN normalizes GALT mass and cytokine levels. Because intestinal homogenates contain mucosa which itself is a source of cytokines, it was unclear whether cytokines change within the GALT itself. This study investigates dietary effects on IL-4 and IL-10 cytokine mRNA expression within isolated GALT lamina propria cells after lipopolysaccharide (LPS) stimulation. Prospective randomized experimental trials were used in this study. Fifty-nine mice were randomized to chow, intravenous TPN (IV-TPN), intragastric TPN (IG-TPN), complex enteral diet (CED), or 2% GLN-supplemented TPN (GLN-TPN). In experiment 1, animals were fed chow, IV-TPN, IG-TPN, or CED for 5 days and received intraperitoneal LPS (100 microg/kg BW), and then were sacrificed 1 h later. Intestine was harvested for GALT lamina propria. Total RNA was extracted from lamina propria cells and cytokine mRNA for IL-4, and IL-10 was measured by reverse transcriptase polymerase chain reaction. IgA levels of intestinal washing were also measured with ELISA. In experiment 2, mRNA for IL-4 and IL-10, and intestinal IgA levels were measured in mice fed chow, IV-TPN, or GLN-TPN as in experiment 1. Both IL-4 and IL-10 mRNA expression decreased significantly in IV-TPN mice compared to chow or CED feeding. IG-TPN resulted in IL-10 mRNA expression significantly lower than chow or CED but significantly better than IV-TPN. GLN preserved IL-4 and IL-10 mRNA levels, which correlated with intestinal IgA levels. Route and type of nutrition as well as GLN influence message for the Th2 type IgA-stimulating cytokines, IL-4 and IL-10, within the primary site of GALT IgA production, the lamina propria.
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Affiliation(s)
- K Fukatsu
- The University of Tennessee Health Science Center, Memphis 38163, USA
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Kudsk KA. Discrepancies between nutrition outcome studies: is patient care the issue? JPEN J Parenter Enteral Nutr 2001; 25:S57-60. [PMID: 11288925 DOI: 10.1177/014860710102500212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- K A Kudsk
- University of Tennessee, Memphis, USA.
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Renegar KB, Johnson CD, Dewitt RC, King BK, Li J, Fukatsu K, Kudsk KA. Impairment of mucosal immunity by total parenteral nutrition: requirement for IgA in murine nasotracheal anti-influenza immunity. J Immunol 2001; 166:819-25. [PMID: 11145655 DOI: 10.4049/jimmunol.166.2.819] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Secretory IgA (SIgA) is the primary mucosal Ig and has been shown to mediate nasotracheal (NT) mucosal immunity in normal immune BALB/c mice. This finding has been challenged by a report of NT immunity without IgA in knockout mice, suggesting that IgA may not be necessary for the protection of mucosal surfaces. Although other protective mechanisms may become active in the congenital absence of SIgA, these mechanisms are not the primary means of protection in normal mice. In this paper we show that feeding chemically defined total parenteral nutrition (TPN) to genetically normal, immune ICR mice by the i.v. route results in loss of nasal anti-influenza immunity and a significant drop in influenza-specific SIgA in the upper respiratory tract compared with chow-fed mice (p < 0.005), while the serum influenza-specific IgG titer is unaffected. Loss of upper respiratory tract mucosal immunity is not related to serum Ab, because 10 of 13 TPN-fed mice shed virus into their nasal secretions despite adequate serum anti-influenza IgG titers. The number of IgG Ab-secreting cells in the nasal passages and spleens of TPN-fed mice was unaffected, while both the number and the percentage of splenic IgA-secreting cells were decreased relative to those in chow-fed animals. The loss of immunity is due to the route of nutrition, not the composition of the diet, because TPN solution fed orally via gastrostomy instead of i.v. maintains NT anti-influenza mucosal immunity. We hypothesize that delivery of nutrition via the gut triggers the release of gastrointestinal neuropeptides necessary for maintenance of the mucosal immune system.
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Affiliation(s)
- K B Renegar
- Department of Surgery, University of Tennessee, Memphis, TN 38163, USA
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Abstract
The gut primes neutrophils (PMNs) during injury, which can then induce distant organ damage after a second insult. ICAM-1 is an important adhesion molecule in PMN attachment to the vascular endothelium. Parenteral nutrition (TPN) decreases gut levels of interleukin (IL)-4 and IL-10, two cytokines that are normal inhibitors of ICAM-1 expression. TPN also increases gut ICAM-1 expression and PMN accumulation. Since glutamine (GLN) and bombesin (BBS) prevent TPN-associated impairment of mucosal immunity, we hypothesized that GLN and BBS would modulate organ ICAM-1 expression in association with normalization of IL-4 and IL-10 levels. Forty-four mice were fed chow, TPN, or GLN-TPN (isonitrogenous 2% GLN-enriched TPN). After 5 days of diets, ICAM-1 expression was quantified in organs using the dual radiolabeled monoclonal antibody technique. In the next experiment, 29 mice were fed chow, TPN, or BBS-TPN (BBS 15 microg/kg TID) for 5 days to measure organ ICAM-1 expression. Total IL-4 and IL-10 levels were measured with ELISA from intestinal homogenates of another set of 52 mice fed chow, TPN, GLN-TPN, or BBS-TPN. TPN significantly increased ICAM-1 expression in the lung, kidney, and intestine compared with chow mice. GLN-TPN decreased intestinal, but not lung, ICAM-1 expression, while BBS-TPN reduced pulmonary, but not gut, ICAM-1 levels. GLN- and BBS-TPN returned gut IL-4 levels to normal, but failed to increase IL-10 levels. GLN and BBS had different effects on organ ICAM-1 expression induced by lack of enteral nutrition. Mechanisms other than recovery of IL-4 alone may be responsible for gut ICAM-1 expression.
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Affiliation(s)
- K Fukatsu
- Department of Surgery, The University of Tennessee, Memphis, USA
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Renegar KB, Kudsk KA, Dewitt RC, Wu Y, King BK. Impairment of mucosal immunity by parenteral nutrition: depressed nasotracheal influenza-specific secretory IgA levels and transport in parenterally fed mice. Ann Surg 2001; 233:134-8. [PMID: 11141235 PMCID: PMC1421172 DOI: 10.1097/00000658-200101000-00019] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the effects on mucosal selective transport of polymeric IgA (pIgA) and the ability of exogenous pIgA to provide protection despite altered mucosal transport. SUMMARY BACKGROUND DATA Parenteral nutrition significantly impairs established antipseudomonal immunity and IgA-mediated antiviral immunity in association with gut-associated lymphoid tissue mass atrophy. Lack of enteral feeding also induces mucosal effects. METHODS After immunization, nasotracheal levels of influenza-specific IgA were measured in cannulated mice randomized to chow feeding or parenteral nutrition. Nonimmune animals were randomized to chow or total parenteral nutrition, and after 5 days of diet were given a mixture of two antiinfluenza monoclonal antibodies, pIgA and IgG. Four hours after injection, nasal washes were collected and influenza-specific antibody levels were determined by enzyme-linked immunosorbent assay to calculate the selective transport index of IgA relative to IgG. In the final experiment, immunized animals were randomized to chow or parenteral feeding, and after 5 days, parenterally fed animals received either normal mouse serum or antiviral pIgA before viral challenge. Viral shedding was measured at 42 hours after challenge. RESULTS Parenteral nutrition significantly reduced virus-specific IgA in nasotracheal washes. Parenteral nutrition depressed the selective transport index, demonstrating impaired mucosal transport of pIgA. Parenterally fed animals given specific antiviral pIgA but not normal mouse serum eliminated virus from the airway and regained mucosal protection, demonstrating adequate residual transport for immunity if adequate pIgA is present. CONCLUSION Although both decreased IgA production due to gut-associated lymphoid tissue atrophy and impaired mucosal transport occur when enteral feeding is not provided, residual transport can provide antiviral protection if exogenous antiviral pIgA is available. Production, rather than transport, may be the most important factor in maintaining established respiratory tract IgA-mediated immunity.
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Affiliation(s)
- K B Renegar
- Department of Surgery, University of Tennessee--Memphis, Memphis, Tennessee, USA
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Abstract
There has been an explosion of research in the field of nutrition over the past quarter century. Clinical studies have demonstrated the effectiveness of providing nutrition by the enteral route in reducing septic morbidity in critically ill patients. These improved outcomes have been substantiated by animal models that show that enteral nutrition decreases gut permeability while maintaining the gut-associated lymphoid tissue (GALT) in mucosal immunity. Evidence points to the important immunological role of the gut in the maintenance of mucosal immunity at both intestinal and extraintestinal sites. The preservation of this mucosal immunity by enteral nutrition is consistent with the lower morbidity seen in severely injured patients who receive nutrition via the gastrointestinal tract. For patients who are unable to be fed by the enteral route and who require parenteral nutrition, several supplements show promise in enhancing the mucosal immune system defenses. The nutritional and pharmacological tactics that may enhance the GALT and thereby maintain mucosal immunity are examined.
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Affiliation(s)
- M K Hanna
- The University of Tennessee, Memphis, USA
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Fukatsu K, Lundberg AH, Hanna MK, Wu Y, Wilcox HG, Granger DN, Gaber AO, Kudsk KA. Increased expression of intestinal P-selectin and pulmonary E-selectin during intravenous total parenteral nutrition. Arch Surg 2000; 135:1177-82. [PMID: 11030875 DOI: 10.1001/archsurg.135.10.1177] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Intravenous total parenteral nutrition (TPN) induces intestinal polymorphonuclear neutrophil recruitment with increased intestinal intercellular adhesion molecule-1 expression. While intercellular adhesion molecule-1 causes firm adhesion of leukocytes to the endothelial cells, P- and E-selectin mediate leukocyte recruitment via rolling. Therefore, manipulation of nutrition may also affect P- and E-selectin expression in organs. DESIGN Prospective randomized experimental trials. SETTING Laboratory. MATERIALS Male mice. INTERVENTIONS Fifty-three mice were randomized to chow, intravenous TPN, or intragastric TPN. MAIN OUTCOME MEASURES After 5 days of diet, mice were administered iodine 125-labeled anti-P-selectin antibody (or iodine 125-labeled anti-E-selectin antibody) and iodine 131-labeled nonbinding antibody to quantify P-selectin (or E-selectin) expression in organs (lung, liver, kidney, small intestine, colon, stomach, pancreas, mesentery, heart, and skeletal muscle). RESULTS P-selectin in small intestine, colon, stomach, and pancreas in the intravenous TPN group increased significantly as compared with the chow and the intragastric TPN groups. E-selectin expression was up-regulated after intravenous TPN in the lung but not in other sites. CONCLUSIONS In a time frame (5 days) when intercellular adhesion molecule-1 expression and neutrophil recruitment are increased, intestinal expression of P-selectin remains up-regulated. Early lung inflammatory changes are reflected by increases in E-selectin. This change may reflect early pulmonary dysfunction with intravenous TPN, but its significance requires further study.
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Affiliation(s)
- K Fukatsu
- Departments of Surgery, University of Tennessee, Memphis, TN, USA
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Keith Hanna M, Zarzaur BL, Fukatsu K, Chance DeWitt R, Renegar KB, Sherrell C, Wu Y, Kudsk KA. Individual neuropeptides regulate gut-associated lymphoid tissue integrity, intestinal immunoglobulin A levels, and respiratory antibacterial immunity. JPEN J Parenter Enteral Nutr 2000; 24:261-8; discussion 268-9. [PMID: 11011780 DOI: 10.1177/0148607100024005261] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Total parenteral nutrition (TPN) leads to atrophy of the gut-associated lymphoid tissue (GALT) and a significant decrease in intestinal immunoglobulin A (IgA) levels, a major constituent of mucosal immunity. Bombesin (BBS) prevents TPN-induced GALT atrophy and maintains intestinal IgA levels. BBS, a neuropeptide analogous to gastrin-releasing peptide in humans, stimulates the release of other gut neuropeptides including cholecystokinin (CCK), gastrin, and neurotensin (NT). This study investigates the ability of CCK, gastrin, or NT to individually prevent TPN-induced GALT atrophy and preserve respiratory immunity. METHODS Experiment 1: Male mice were randomly assigned to receive chow, TPN, TPN plus CCK, TPN plus gastrin, or TPN plus NT. After 5 days of feeding, Peyer's patches (PP) from the proximal and distal small bowel were harvested and analyzed for cell yields. PP cells were also analyzed for GALT cell type. Small bowel IgA levels were measured by enzyme-linked immunosorbent assay (ELISA). Experiment 2: Mice were randomly assigned to receive either liposomes containing Pseudomonas antigen or liposomes without antigen. After 10 days, mice were randomly assigned to the same five treatment groups, fed for 5 days, and then given intratracheal Pseudomonas. Mortality was assessed after 48 hours. RESULTS Experiment 1: GALT cell reductions due to IV-TPN were greater in the distal than proximal small bowel. All three neuropeptides prevented most TPN-induced GALT atrophy due mainly to the maintenance of the B-cell and T-cell populations in the PP of the distal bowel. Intestinal IgA levels were significantly higher in the animals treated with neuropeptides than animals treated with TPN only; however, these IgA levels were not maintained at levels observed in chow-fed animals. Experiment 2: Immunization resulted in significantly lower mortality in animals fed chow, TPN plus CCK, and TPN plus gastrin. TPN alone and TPN plus NT resulted in loss of immunity and mortality rate at comparable levels to unimmunized animals. CONCLUSIONS Supplementation of IV-TPN with CCK, gastrin, and NT prevents GALT atrophy, primarily in the distal bowel. Intestinal IgA levels improve but not to normal levels. CCK and gastrin reversed IV-TPN-induced effects on antibacterial pneumonia in immunized animals while NT did not.
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Affiliation(s)
- M Keith Hanna
- Department of Surgery, University of Tennessee, Memphis, USA
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Kudsk KA, Wu Y, Fukatsu K, Zarzaur BL, Johnson CD, Wang R, Hanna MK. Glutamine-enriched total parenteral nutrition maintains intestinal interleukin-4 and mucosal immunoglobulin A levels. JPEN J Parenter Enteral Nutr 2000; 24:270-4; discussion 274-5. [PMID: 11011781 DOI: 10.1177/0148607100024005270] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Total parenteral nutrition (TPN) prevents progressive malnutrition but fails to maintain intestinal gut-associated lymphoid tissue (GALT) or established respiratory antiviral or antibacterial mucosal immunity. Our previous work demonstrated that decreases in intestinal immunoglobulin A (IgA) were associated with decreases in Th2-type IgA-stimulating cytokines, interleukin (IL)-4 and IL-10. Because glutamine supplementation of TPN partially preserves respiratory defenses and normalizes GALT, we investigated the ability of parenteral glutamine to normalize respiratory and intestinal IgA levels and measured Th2 cytokines in intestinal homogenates. METHODS Animals were cannulated and randomly assigned to receive chow (n = 17), TPN (n = 18), or an isonitrogenous, isocaloric TPN solution formulated by removing the appropriate amount of amino acids and replacing them with 2% glutamine (n = 18) for 5 days. Respiratory tract and intestinal washings were obtained for IgA and the intestine homogenized and analyzed for IL-4 and IL-10. RESULTS TPN decreased intestinal and respiratory IgA in association with decreases in intestinal IL-4 and IL-10 compared with chow-fed animals. Glutamine significantly improved respiratory and intestinal IgA levels, significantly improved IL-4 compared with TPN animals, and maintained IL-10 levels midway between chow-fed and TPN animals. CONCLUSIONS Glutamine-enriched TPN preserved both extraintestinal and intestinal IgA levels and had a normalizing effect on Th2-type IgA-stimulating cytokines.
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Affiliation(s)
- K A Kudsk
- University of Tennessee, Memphis, USA
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Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, Pritchard FE. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 2000; 231:804-13. [PMID: 10816623 PMCID: PMC1421069 DOI: 10.1097/00000658-200006000-00004] [Citation(s) in RCA: 194] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. SUMMARY BACKGROUND DATA Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. METHODS Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). RESULTS All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. CONCLUSIONS Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.
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Affiliation(s)
- A K Malhotra
- Department of Surgery, University of Tennessee-Memphis, Memphis, Tennessee 38163, USA
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Minard G, Kudsk KA, Melton S, Patton JH, Tolley EA. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN J Parenter Enteral Nutr 2000; 24:145-9. [PMID: 10850938 DOI: 10.1177/0148607100024003145] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although early enteral feeding clearly reduces septic morbidity after blunt and penetrating trauma, data for head-injured patients are conflicting. This study examines the effects of early vs delayed enteral feedings on outcome in patients with severe closed-head injuries with a Glasgow Coma Scale (GCS) score greater than 3 and less than 11. METHODS Thirty patients were prospectively randomized to receive an immune-enhancing diet (Impact with fiber) early (initiated < 72 hours after trauma) delivered via an endoscopically placed nasoenteric tube (Stay-Put) or late (administered after gastric ileus resolved). This formula was continued for 14 days or until the patient tolerated oral feeding. Goal rate of nutrition was 21 nonprotein cal/kg/d and 0.3 g N/kg/d. RESULTS Two patients in the early group were excluded due to inability to place the tube, and one patient in the late group died before 72 hours. Five of the remaining 27 died, 1 in the early group and 4 in the late group. There were no significant differences between the groups in length of stay, intensive care unit (ICU) days, significant infection, or GCS score. However, major infection correlated inversely with admission GCS score (R = -0.6, p < .003). Time to reach a GCS score of 14 was significantly longer in patients with significant infections compared with those without (p < .02). CONCLUSIONS No difference in length of stay or infectious complications is shown in patients with severe closed-head injury when they are given early vs delayed feeding using an immune-enhancing formula. Severity of the head injury is closely associated with significant infection.
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Affiliation(s)
- G Minard
- Department of Surgery, The University of Tennessee, Memphis, USA.
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MacLaren R, Kuhl DA, Gervasio JM, Brown RO, Dickerson RN, Livingston TN, Swift K, Headley S, Kudsk KA, Lima JJ. Sequential single doses of cisapride, erythromycin, and metoclopramide in critically ill patients intolerant to enteral nutrition: a randomized, placebo-controlled, crossover study. Crit Care Med 2000; 28:438-44. [PMID: 10708180 DOI: 10.1097/00003246-200002000-00025] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the comparative efficacy of enteral cisapride, metoclopramide, erythromycin, and placebo for promoting gastric emptying in critically ill patients with intolerance to gastric enteral nutrition (EN). DESIGN A randomized, crossover study. SETTING Adult medical intensive care unit at a university-affiliated private hospital and trauma intensive care unit at a university teaching hospital. PATIENTS Ten adult, critically ill, mechanically ventilated patients not tolerating a fiber-containing EN product defined as a single aspirated gastric residual volume >150 mL or two aspirated gastric residual volumes >120 mL during a 12-hr period. INTERVENTIONS Patients received 10 mg of cisapride, 200 mg of erythromycin ethylsuccinate, 10 mg of metoclopramide, and placebo as 20 mL of sterile water every 12 hrs over 48 hrs. Acetaminophen solution (1000 mg) was administered concurrently. Gastric residual volumes were assessed, and plasma acetaminophen concentrations were serially determined by TDx between 0 and 12 hrs to evaluate gastric emptying. MEASUREMENTS AND MAIN RESULTS Gastric residual volumes during the study were not significantly different between agents. No differences in area under the concentration vs. time curve or elimination rate constant were identified between agents. Metoclopramide and cisapride had a significantly shorter mean residence time of absorption than erythromycin (6.3+/-4.5 [SEM] mins and 10.9+/-5.8 vs. 30.1+/-4.5 mins, respectively [p<.05]). Metoclopramide (9.7+/-15.3 mins) had a significantly shorter time to peak concentration compared with erythromycin and placebo (60.7+/-8.1 and 50.9+/-13.5 mins, respectively [p<.05]). The time to onset of absorption was significantly shorter for metoclopramide vs. cisapride (5.7+/-4.5 vs. 22.9+/-5.7 mins [p<.05]). CONCLUSION In critically ill patients intolerant to EN, single enteral doses of metoclopramide or cisapride are effective for promoting gastric emptying in critically ill patients with gastric motility dysfunction. Additionally, metoclopramide may provide a quicker onset than cisapride.
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Affiliation(s)
- R MacLaren
- College of Pharmacy, Dalhousie University, NS, Canada
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DeWitt RC, Wu Y, Renegar KB, King BK, Li J, Kudsk KA. Bombesin recovers gut-associated lymphoid tissue and preserves immunity to bacterial pneumonia in mice receiving total parenteral nutrition. Ann Surg 2000; 231:1-8. [PMID: 10636095 PMCID: PMC1420958 DOI: 10.1097/00000658-200001000-00001] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To study the ability of bombesin (BBS) to recover gut-associated lymphoid tissue (GALT) and preserve immunity in a lethal model of Pseudomonas aeruginosa (Ps) pneumonia in mice receiving total parenteral nutrition (TPN). SUMMARY BACKGROUND DATA TPN causes depression of mucosal immunity compared with enterally fed animals, which may explain the increased incidence of pneumonia in parenterally fed trauma patients. BBS prevents this TPN-induced GALT atrophy, depressed gastrointestinal and respiratory tract IgA levels, and impaired antiviral IgA-mediated mucosal immunity. The authors examined whether some supplement could be added to TPN to avoid this GALT atrophy and lower the incidence of infectious complications in the parenterally fed animal. METHODS Male mice were randomized to chow or intravenous (IV) TPN. After 5 days of IV TPN, mice received 0, 1, 2, or 3 days of BBS IV three times a day and then were killed to harvest Peyer's patch, intraepithelium, and lamina propria for cell yields. Gastrointestinal and respiratory tract IgA levels were analyzed by enzyme-linked immunosorbent assay. Next, mice underwent intranasal inoculation with liposomes alone (nonimmune) or liposome-containing Ps polysaccharide. Ps immune mice were catheterized and randomized to chow, IV TPN, or IV TPN + BBS. The liposome group received chow but no IV catheter. These mice were given an LD90 dose of intratracheal Ps, and death rates were recorded. RESULTS GALT and gastrointestinal and respiratory tract IgA levels improved to those in chow-fed mice after 3 days of BBS. Immunization reduced the death rate from 92% in chow-fed liposome-only animals to 20% in immunized animals. TPN-fed animals lost their mucosal immunity, with a death rate of 86% compared with 21% in the TPN + BBS group. CONCLUSION The results demonstrate that BBS reverses TPN-induced changes in GALT and preserves mucosal immunity. Ps immunization reduces the death rate in a gram-negative pneumonia model and maintains gastrointestinal and respiratory immunity in Ps immune mice receiving IV TPN.
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Affiliation(s)
- R C DeWitt
- Department of Surgery, University of Tennessee, Memphis 38163, USA
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Affiliation(s)
- C D Johnson
- The University of Tennessee, Memphis, TN 38163, USA
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Fukatsu K, Lundberg AH, Hanna MK, Wu Y, Wilcox HG, Granger DN, Gaber AO, Kudsk KA. Route of nutrition influences intercellular adhesion molecule-1 expression and neutrophil accumulation in intestine. Arch Surg 1999; 134:1055-60. [PMID: 10522845 DOI: 10.1001/archsurg.134.10.1055] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS The levels of intestinal interleukin 10 and interleukin 4, inhibitors of intercellular adhesion molecule-1 (ICAM-1) expression, decline with total parenteral nutrition (TPN). These cytokine changes induced by lack of enteral nutrition may increase ICAM-1 expression, resulting in polymorphonuclear neutrophil accumulation in intestine. DESIGN Prospective randomized experimental trials. SETTING Laboratory. MATERIALS Male mice. INTERVENTIONS Sixty-three mice were randomized to chow, intravenous TPN, or intragastric TPN. MAIN OUTCOME MEASURES Experiment 1: After diet manipulation, iodine 125-labeled anti-ICAM-1 antibody and iodine 131-labeled nonbinding antibody were injected to quantify ICAM-1 expression on endothelial cells in the lung, liver, kidney, and small intestine. Measurement of myeloperoxidase was used to quantify polymorphonuclear neutrophil accumulation in the organs. Experiment 2: Intestine was harvested for both ICAM-1 and myeloperoxidase levels after chow refeeding of mice in the intravenous TPN group. RESULTS In experiment 1, uninjured mice fed intravenous TPN showed significantly increased intestinal ICAM-1 expression and polymorphonuclear neutrophil accumulation with no significant changes in the lung, liver, or kidney. No changes occurred in mice fed chow or intragastric TPN. In experiment 2, reinstitution of enteral feeding returned intestinal ICAM-1 and myeloperoxidase levels to normal. CONCLUSION Gut changes associated with lack of enteral feeding induce endothelial changes and an immunologic response, which may influence subsequent responses to injury.
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Affiliation(s)
- K Fukatsu
- Department of Surgery, The University of Tennessee, Memphis, USA
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DeWitt RC, Wu Y, Renegar KB, Kudsk KA. Glutamine-enriched total parenteral nutrition preserves respiratory immunity and improves survival to a Pseudomonas Pneumonia. J Surg Res 1999; 84:13-8. [PMID: 10334882 DOI: 10.1006/jsre.1999.5592] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Addition of 2% glutamine (GLN), a specific lymphocyte fuel, prevents deleterious effects of TPN on gut-associated lymphoid tissue and IgA while preserving IgA-mediated upper respiratory immunity to influenza virus. We examined whether a 2% GLN-enhanced TPN solution preserves respiratory immunity to a lethal and clinically relevant pneumonia challenge. MATERIALS AND METHODS Male ICR mice were randomized to chow (n = 20), TPN (n = 20), or an isonitrogenous, isocaloric TPN-2% GLN solution (n = 17). All groups were immunized 10 days before surgery with Pseudomonas polysaccharide-containing liposomes (LIP) to confer immunity except for a nonimmune chow-fed LIP control group (n = 21) which received LIP without Pseudomonas. Mice received 5 days of diet and then were given an LD90 dose of 1.2 x 10(8) intratracheal Pseudomonas bacteria, and mortality was recorded. RESULTS Immunization reduced mortality compared with LIP alone. TPN impaired immunity and reduced survival while GLN maintained immunization effectiveness. CONCLUSIONS Pseudomonas immunization reduces mortality to Pseudomonas pneumonia, but this immunity is lost with TPN. Addition of 2% GLN to TPN preserves immunity in the respiratory tract and reduces mortality to a lethal bacterial challenge compared with standard TPN.
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Affiliation(s)
- R C DeWitt
- Department of Surgery, University of Tennessee, Memphis, Tennessee, 38163, USA
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Abstract
The gastrointestinal tract functions not only to absorb nutrients, it also plays an important immunologic role during health and critical illness. Under experimental and certain clinical conditions, stimulating the gut attentuates the stress response and avoids mucosal atrophy and increases permeability. Gut stimulation prevents atrophy of the gut-associated lymphoid tissue, the body's major defender of moist mucosal surfaces. A better understanding of gut function and improved nutrient delivery has clinical implications in the treatment of critically ill patients.
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Affiliation(s)
- R C DeWitt
- Department of Surgery, University of Tennessee College of Medicine, Memphis, USA
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Abstract
OBJECTIVE To examine the levels of a Th1 IgA-inhibiting cytokine (interferon gamma) and the Th2 IgA-stimulating cytokines (interleukin [IL]-4, IL-5, IL-6, and IL-10) within the intestine of animals manipulated with enteral or parenteral nutrition, and to correlate these cytokine alterations with intestinal IgA levels. SUMMARY BACKGROUND DATA Enteral feeding significantly reduces the incidence of pneumonia in critically injured patients compared with intravenous total parenteral nutrition (IV TPN) or no nutritional support. Experimentally, complex diets prevent impairments in mucosal immunity induced by IV TPN. These impairments include decreases in intestinal and respiratory tract IgA levels, impaired IgA-mediated antiviral defenses, and increases in the mortality rate against established immunity to Pseudomonas pneumonia. Intragastric (IG) TPN maintains antiviral defenses but only partially preserves protection against Pseudomonas pneumonia. Because IgA levels depend on interactions between Th1 IgA-inhibiting and Th2 IgA-stimulating cytokines, the authors postulated differences in gut cytokine balance in enterally and parenterally fed mice. METHODS Sixty-one mice were randomized to receive chow, IV TPN, IG TPN, or an isocaloric, complex enteral diet. After 5 days of feeding, animals were killed and supernatants from samples of intestine were harvested, homogenized, and assayed for Th1 and Th2 cytokines by enzyme-linked immunosorbent assay. RESULTS The Th2 cytokines, IL-5 and IL-6, and the Th1 cytokine, interferon gamma, remained unchanged by diet. IL-4 levels decreased significantly in both IV and IG TPN groups versus the chow or complex enteral diet groups, whereas IL-10 decreased only in IV TPN mice. Decreases in Th2 cytokines correlated with intestinal IgA levels. CONCLUSION Chow and complex enteral diets maintain a normal balance between IgA-stimulating and IgA-inhibiting cytokines while preserving normal antibacterial and antiviral immunity. The IgA-stimulating cytokine IL-4 drops significantly in mice receiving IG and IV TPN in association with reduced IgA levels, whereas IL-10 decreases significantly only in mice receiving IV TPN. These data are consistent with severely impaired mucosal immunity with IV TPN and partial impairment with IG TPN and provide a cytokine-mediated explanation for reduction in diet-induced mucosal immunity.
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Affiliation(s)
- Y Wu
- Department of Surgery, The University of Tennessee, Memphis, USA
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Abstract
OBJECTIVE To develop a model of established respiratory immunity against Pseudomonas aeruginosa pneumonia and to investigate the effects of route and type of nutrition on this immunity. SUMMARY BACKGROUND DATA Diet influences the ability of gut-associated lymphoid tissue (GALT) to maintain mucosal immunity. Complex enteral diets and chow maintain normal GALT populations against established IgA-mediated antiviral respiratory immunity. Both intravenous and intragastric total parenteral nutrition (TPN) produce GALT atrophy, but only intragastric TPN preserves established antiviral immunity. The authors hypothesized that both GALT-depleting diets (intragastric and intravenous TPN) would impair immunity against bacterial pneumonia. METHODS P. aeruginosa was administered intratracheally to determine the mortality rate at increasing doses, and liposomes containing P. aeruginosa antigens were used to generate effective respiratory immunization. In the final experiment, mice received liposomes containing P. aeruginosa antigens to establish immunity and then were randomized to chow, complex enteral diets, intragastric TPN, or intravenous TPN. After 5 days of diet, mice received live intratracheal P. aeruginosa, and the death rate was recorded at 24 and 48 hours. RESULTS The LD50 and LD100 were 9 x 10(7) and 12 x 10(7), respectively. Immunization reduced the mortality rate from 66% to 12%. This immunization was maintained in mice fed chow or a complex enteral diet and was lost in animals receiving intravenous TPN. Intragastric TPN partially preserved this respiratory immunity. CONCLUSIONS Protection against bacterial pneumonia can be induced by prior antigenic immunization. This protection is lost with intravenous TPN, partially preserved with a chemically defined enteral diet, and completely preserved with chow or complex enteral diets. Both route and type of nutrition influence antibacterial respiratory tract immunity.
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Affiliation(s)
- B K King
- Department of Surgery, The University of Tennessee, Memphis, USA
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Croce MA, Fabian TC, Patton JH, Lyden SP, Melton SM, Minard G, Kudsk KA, Pritchard FE. Impact of stomach and colon injuries on intra-abdominal abscess and the synergistic effect of hemorrhage and associated injury. J Trauma 1998; 45:649-55. [PMID: 9783599 DOI: 10.1097/00005373-199810000-00001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Colon wounds are recognized to be highly associated with intra-abdominal abscess (IAA) after penetrating trauma, whereas gastric wounds are thought to contribute minimally to abscess because of the bactericidal effect of low pH. This study evaluated the impact of stomach or colon wounds, the contribution of other risk factors, and associated abdominal injuries on IAA. METHODS Patients with penetrating colon or stomach wounds during a 10-year period were reviewed and stratified by age, Injury Severity Score, transfusions, and associated abdominal injuries. Early deaths (<48 hours) from hemorrhage were excluded. Outcomes analyzed were IAA and death. RESULTS A total of 812 patients were identified. There were 32 late deaths (4%), of which 28% were attributable to IAA and multiple organ failure. IAA rates for isolated stomach or colon wounds were 0 and 4.2%, respectively. The presence of associated injuries increased IAA rates to 7.5 and 8.8%, respectively. Independent predictors of IAA determined by multivariate analysis included age, transfusions, gunshot wounds, and associated injuries to the liver, pancreas, and kidney. CONCLUSION Gastric injuries are equivalent to colon wounds in their contribution to IAA. Contamination from either organ without associated injury is minimally associated with IAA, but injury to both appears synergistic. The immunosuppressive effects of age and hemorrhage, in addition to significant associated injury, enhance the development of IAA.
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Affiliation(s)
- M A Croce
- Presley Regional Trauma Center, Department of Surgery, University of Tennessee, Memphis 38163, USA
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Affiliation(s)
- K A Kudsk
- Department of Surgical Research, University of Tennessee, Memphis 38163, USA
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Abstract
This article briefly reviews the literature supporting the use of enteral nutrition, which appears to be the preferred method of nutritional support in critically ill patients. Patients who benefit the most from this type of support, as well as the administration and route preferences in enteral nutrition, are discussed. In addition, the different types of enteral formulas and the more frequently associated complications that occur with tube feedings are reviewed.
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Affiliation(s)
- R C DeWitt
- Department of Surgery, University of Tennessee, Memphis, USA
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Abstract
There is increasing evidence that delivery of nutrients via the gastrointestinal tract reduces the septic morbidity in severely injured patients. This article reviews the most current data and also reviews the importance of the gut-associated lymphoid tissue as an important factor in maintaining the host defenses.
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Affiliation(s)
- K A Kudsk
- Department of Surgery, University of Tennessee, Memphis, USA
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Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G, Kudsk KA, Pritchard FE. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998; 44:1008-13; discussion 1013-5. [PMID: 9637156 DOI: 10.1097/00005373-199806000-00013] [Citation(s) in RCA: 207] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms. METHODS The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management. RESULTS Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. CONCLUSIONS Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).
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Affiliation(s)
- K A Davis
- Department of Surgery, Presley Regional Trauma Center, University of Tennessee Health Science Center, Memphis 38163, USA
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Croce MA, Fabian TC, Waddle-Smith L, Melton SM, Minard G, Kudsk KA, Pritchard FE. Utility of Gram's stain and efficacy of quantitative cultures for posttraumatic pneumonia: a prospective study. Ann Surg 1998; 227:743-51; discussion 751-5. [PMID: 9605666 PMCID: PMC1191359 DOI: 10.1097/00000658-199805000-00015] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This prospective trial examined the efficacy of using bronchoalveolar lavage (BAL) for the diagnosis of pneumonia (PN) and the utility of Gram's stain (GS) for dictating empiric therapy. SUMMARY BACKGROUND DATA Posttraumatic nosocomial PN remains a significant cause of morbidity and mortality. However, its diagnosis is elusive, especially in multiply injured patients. The systemic inflammatory response syndrome of fever, leukocytosis, and a hyperdynamic state is common in trauma patients, especially patients with pulmonary contusion. Bronchoscopy with BAL with quantitative cultures of the lavage effluent may distinguish between PN and systemic inflammatory response syndrome, and GS of the lavage effluent may guide empiric therapy before quantitative culture results. METHODS Mechanically ventilated trauma patients with a clinical diagnosis of PN (fever, leukocytosis, purulent sputum, and new or changing infiltrate on chest radiograph) underwent bronchoscopy with BAL. Effluent was sent for GS and quantitative cultures. The diagnostic threshold for PN was > or =10(5) colony-forming units (CFU)/mL, and antibiotics were continued. Antibiotics were stopped for < 10(5) CFU/mL and the diagnosis of systemic inflammatory response syndrome was made. Causative organisms for PN were compared to GS. RESULTS Over a 2-year period, 232 patients underwent 443 bronchoscopies with BAL (71% men, 29% women; mean age, 41). The mean injury severity score was 30. Sixty percent of the patients had pulmonary contusion, and 59% were cigarette smokers. The overall incidence of PN was 39% and was no different regardless of the number of BALs a patient had. The false-negative rate of BAL was 7%. GS identified gram-positive organisms in 80% of patients with gram-positive PN and 40% of patients with gram-negative PN. GS identified gram-negative organisms in 52% of patients with gram-positive PN and 77% with gram-negative PN. The duration of the intensive care unit stay relative to the timing of BAL was beneficial for guiding empiric therapy. BAL in week 1 primarily identified Haemophilus influenzae and gram-positive organisms; Acinetobacter sp. and Pseudomonas sp. were more common after week 1. CONCLUSIONS Bronchoscopy with BAL is an effective method to diagnose PN and avoids prolonged, unnecessary antibiotic therapy. Empiric therapy should be adjusted to the duration of the intensive care unit stay because the causative bacteria flora changes over time. GS of BAL effluent correlates poorly with quantitative cultures and is not reliable for dictating empiric therapy.
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Affiliation(s)
- M A Croce
- Department of Surgery, University of Tennessee, Memphis, USA
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Abstract
Questions regarding the effects of the route of nutrition began to surface shortly after the introduction of total parenteral nutrition (TPN). Although TPN has become a life-saving therapy for patients who cannot tolerate enteral nutrition, it is not the panacea it was hoped to be. It appears that the enteral route of nutrition decreases rates of infectious complications compared with parenteral feeding. Reasons for this phenomenon are not clear, but it seems that enteral nutrition supports the gut barrier and gut-associated lymphoid tissue, which may have effects on infections at distant sites such as the lung. These effects do not appear to be due solely to prevention to malnutrition, as the infectious complications develop early after injury or illness. However, the lack of understanding of the mechanisms does not negate the fact that in many clinical studies the enteral route of nutrition is superior to the parenteral route in terms of reducing infectious complications in critically ill or injured patients.
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Affiliation(s)
- G Minard
- Department of Surgery, University of Tennessee, Memphis 38163, USA
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Abstract
Research in the area of the nutritional support of trauma patients has continued to focus on a few main areas: the effect that the route, timing and type of feeding has on patient outcome, nutritional assessment and mucosal immunity. This year a nutritional conference has released a paper, summarizing the current state of research in this area, that generated some controversy.
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Affiliation(s)
- G Minard
- Department of Surgery, University of Tennessee, Memphis 38163, USA
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Li J, King BK, Janu PG, Renegar KB, Kudsk KA. Glycyl-L-glutamine-enriched total parenteral nutrition maintains small intestine gut-associated lymphoid tissue and upper respiratory tract immunity. JPEN J Parenter Enteral Nutr 1998; 22:31-6. [PMID: 9437652 DOI: 10.1177/014860719802200131] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND i.v. administration of a total parenteral nutrition (TPN) solution results in small intestinal gut-associated lymphoid tissue (GALT) atrophy, lowers small intestinal immunoglobulin A (IgA) levels, and impairs upper respiratory tract secretory IgA-mediated mucosal immunity; isonitrogenous supplementation of TPN with 2% glutamine attenuates these changes. This experiment examines whether a 2% glycyl-L-glutamine-enriched TPN solution reverses i.v. TPN-induced changes as effectively as L-glutamine. METHODS Male Institute of Cancer Research (ICR) mice underwent intranasal inoculation with H1N1 influenza virus to establish immunity. After 3 weeks, mice were randomized to chow, i.v. feeding of a TPN solution, glutamine-enriched TPN, or glycyl-L-glutamine-enriched TPN. After 4 days of feeding, mice were challenged intranasally with influenza virus and killed at 40 hours to determine viral shedding from the respiratory tract; normal convalescent mice do not shed virus because they possess intact IgA-mediated mechanisms Lymphocytes were isolated from Peyer's patches, the intraepithelial layer, and lamina propria to determine cell yields. RESULTS Total lymphocyte yield in the Peyer's patches, the intraepithelial layer, and lamina propria decreased with TPN but remained normal with glutamine and glycyl-L-glutamine. Upon challenge, 70% of the mice in the TPN group shed virus in nasal secretions, whereas only 20% of the glutamine-treated group, 18% of glycyl-L-glutamine group and none of the Chow group were virus positive. CONCLUSIONS L-Glutamine and glycyl-L-glutamine have similar effects on i.v. administered TPN-associated (GALT) atrophy and decreased upper respiratory tract immunity.
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Affiliation(s)
- J Li
- Department of Surgery, University of Tennessee at Memphis 38163, USA
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King BK, Kudsk KA. Can an enteral diet decrease sepsis after trauma? Adv Surg 1997; 31:53-78. [PMID: 9408488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- B K King
- University of Tennessee, Memphis, USA
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37
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Abstract
BACKGROUND Total parenteral nutrition (TPN) is associated with decreases in small-intestinal gut-associated lymphoid tissue (GALT) T cells, B cells, and IgA levels and impairs IgA-mediated defenses in the respiratory tract. The impaired respiratory tract defenses are speculated to be due to reduced respiratory tract IgA levels. OBJECTIVES To determine the time course of GALT cell reductions and document any changes in respiratory tract IgA levels in mice receiving TPN. DESIGN Prospective randomized trial. SETTING Animal research laboratory. MATERIALS Thirty-five male ICR mice weighing 25 to 35 g. INTERVENTIONS Mice underwent cannulation with intravenous catheters and received chow for 2 days followed by TPN for 0 (n=6), 1 (n=6), 2 (n=6), 3 (n=6), 4 (n=6), or 5 (n=5) days. Mice were killed after receiving TPN their respective number of days. The small intestine was harvested, and washings were obtained from the small intestine and the respiratory tract. Lymphocytes and IgA levels were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively. MAIN OUTCOME MEASURES Lymphocyte yields from Peyer patches, intraepithelial spaces, and the lamina propria; IgA levels from the small intestine and the respiratory tract. RESULTS T- and B-cell yields in the Peyer patches and lamina propria were significantly reduced by day 2 (P<.05) and thereafter compared with day 0. The lamina propria CD4+/CD8+ ratio declined significantly by day 4 (P<.05) compared with day 0. Small-intestinal and respiratory tract IgA levels were significantly diminished by day 3 (P<.05) and thereafter compared with day 0. CONCLUSION Total parenteral nutrition produces rapid changes in GALT cell profiles and reduces respiratory tract IgA levels consistent with the impairment of respiratory IgA-mediated defenses.
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Affiliation(s)
- B K King
- Department of Surgery, The University of Tennessee, Memphis, USA
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Patton JH, Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic trauma: a simplified management guideline. J Trauma 1997; 43:234-9; discussion 239-41. [PMID: 9291366 DOI: 10.1097/00005373-199708000-00005] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Recent literature supports a conservative trend in the management of pancreatic injuries. Contrary to this trend, some recommend defining ductal integrity by pancreatography, implying that the results alter management. This study examines our recent 5-year experience with a simplified approach to all pancreatic injuries. METHODS Retrospective analysis of patients sustaining pancreatic injuries was performed. RESULTS One hundred thirty-four patients were identified. Overall mortality was 13%, and pancreatic-related mortality was 2%. Analyses were based on 124 pancreatic injuries among patients who survived >12 hours. Thirty-seven proximal injuries were treated with drainage alone, with a pancreatic morbidity of 11%. Eighty-seven distal pancreatic injuries occurred, 54 with indeterminate ductal status. Twenty-four had high probability for duct injury and were treated by distal resection; 30 with a low probability of ductal injury were drained. Pancreatic morbidity was not different between these groups. CONCLUSIONS Pancreatic injuries including those with indeterminate ductal status can be successfully managed with low morbidity and mortality using this simplified management protocol.
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Affiliation(s)
- J H Patton
- Department of Surgery, University of Tennessee, Memphis, USA
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Janu P, Li J, Renegar KB, Kudsk KA. Recovery of gut-associated lymphoid tissue and upper respiratory tract immunity after parenteral nutrition. Ann Surg 1997; 225:707-15; discussion 715-7. [PMID: 9230811 PMCID: PMC1190874 DOI: 10.1097/00000658-199706000-00008] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The authors characterize the recovery of parenteral nutrition-induced changes in gut-associated lymphoid tissue (GALT) and upper respiratory tract immunity with enteral nutrition and provide further information defining the effects of enteral feeding on mucosal immunity. SUMMARY BACKGROUND DATA The small intestine plays a prominent role in development and maintenance of mucosal immunity, both intestinal and extraintestinal, primarily through immunoglobulin A (IgA)-mediated mechanisms. Prior research has shown that mice fed total parenteral nutrition (TPN) have reduced GALT T and B cells, the cells responsible for IgA production, as well as impaired upper respiratory tract immunity to viral challenge of previously immunized animals. The recovery of TPN-induced changes in GALT and upper respiratory tract immunity after enteral refeeding is studied. METHODS Male institute of Cancer Research mice received 5 days of TPN followed by 0 to 4 days of chow. Small intestinal GALT was characterized by flow cytometry. In a second experiment, animals were immunized intranasally with moused-adapted influenza virus. Three weeks later, one group received a 5-day course of TPN followed by enteral refeeding for 5 days. A second group received TPN alone. Both groups were challenged with intranasal virus and killed 40 hours postchallenge to determine viral shedding from the upper respiratory tract. RESULTS Animals fed TPN only had significantly fewer GALT lymphocytes compared with those chow-fed control subjects. Peyer's patch counts increased after a single day of refeeding, returning to normal levels by 48 hours. Lamina propria counts remained significantly depressed after 24 hours of refeeding, but also returned to normal after 48 hours of refeeding. The T-cell and B-cell populations mimicked total cell patterns. Lamina propria CD4+/CD8+ ratio returned to normal only after 72 hours of refeeding. None of the 9 animals refed enterally for 5 days were positive for viral shedding, compared with 8 of 12 matched TPN-fed animals. CONCLUSIONS Enteral refeeding after TPN is associated with rapid repletion of GALT cellularity, initially within Peyer's patches and subsequently within the lamina propria. Refeeding corrects the impairment of IgA-mediated upper respiratory tract antiviral immunity occurring with TPN administration. This work further enhances the authors' knowledge of the underlying immunologic differences influenced by routes of nutrition.
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Affiliation(s)
- P Janu
- Department of Surgery, University of Tennessee at Memphis, USA
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Hatton J, Rapp RP, Kudsk KA, Brown RO, Luer MS, Bukar JG, Chen SA, McClain CJ, Gesundheit N, Dempsey RJ, Young B. Intravenous insulin-like growth factor-I (IGF-I) in moderate-to-severe head injury: a Phase II safety and efficacy trial. Neurosurg Focus 1997; 2:ECP1; discussion 1 p following ECP1. [PMID: 15096005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The purpose of this study was to determine the effect of insulin-like growth factor-I (IGF-I) on the catabolic state and clinical outcome of head-injured patients. Thirty-three patients between the ages of 18 and 59 years with isolated traumatic head injury and Glasgow Coma Scale (GCS) scores of 4 to 10 were randomized to one of two groups. All patients received standard neurosurgical intensive care plus aggressive nutritional support; the patients in the treatment group also received intravenous therapy with continuous IGF-I (0.01 mg/kg/hour). During the 14-day dosing period, the control patients lost weight, whereas treated patients gained weight despite a significantly higher measured energy expenditure and lower caloric intake (p = 0.02). Daily glucose concentrations and nitrogen outputs were greater in control patients (p = 0.03) throughout the study period. During Week 1, only treated patients achieved positive nitrogen balance. Fifteen of 17 treated and 13 of 16 control patients survived the 1st week. No deaths occurred in patients whose serum IGF-I concentrations were higher than 350 ng/ml. Dichotomized Glasgow Outcome Scale scores for patients with baseline GCS scores of 5 to 7 improved from poor to good for eight of 12 treated patients but for only three of 11 control patients (p = 0.06). Eight of 11 treated patients with serum IGF-I concentrations that were at least 350 ng/ml achieved moderate-to-good outcome scores at 6 months, compared to only one of five patients with lower concentrations (p < 0.05). These findings indicate that pharmacological concentrations of IGF-I may improve clinical outcome and nitrogen utilization in patients with moderate-to-severe head injury.
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Affiliation(s)
- J Hatton
- College of Pharmacy and the Department of Surgery, University of Kentucky Chandler Medical Center, Lexington, Kentucky 40536-0084, USA
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Melton SM, Croce MA, Patton JH, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage. Ann Surg 1997; 225:518-27; discussion 527-9. [PMID: 9193180 PMCID: PMC1190789 DOI: 10.1097/00000658-199705000-00009] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.
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Affiliation(s)
- S M Melton
- Department of Surgery, University of Tennessee at Memphis, Presley Regional Trauma Center, USA
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Hatton J, Rapp RP, Kudsk KA, Brown RO, Luer MS, Bukar JG, Chen SA, McClain CJ, Gesundheit N, Dempsey RJ, Young B. Intravenous insulin-like growth factor-I (IGF-I) in moderate-to-severe head injury: a phase II safety and efficacy trial. J Neurosurg 1997; 86:779-86. [PMID: 9126892 DOI: 10.3171/jns.1997.86.5.0779] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine the effect of insulin-like growth factor-I (IGF-I) on the catabolic state and clinical outcome of head-injured patients. Thirty-three patients between the ages of 18 and 59 years with isolated traumatic head injury and Glasgow Coma Scale (GCS) scores of 4 to 10 were randomized to one of two groups. All patients received standard neurosurgical intensive care plus aggressive nutritional support; the patients in the treatment group also received intravenous therapy with continuous IGF-I (0.01 mg/kg/hour). During the 14-day dosing period, the control patients lost weight, whereas treated patients gained weight despite a significantly higher measured energy expenditure and lower caloric intake (p = 0.02). Daily glucose concentrations and nitrogen outputs were greater in control patients (p = 0.03) throughout the study period. During Week 1, only treated patients achieved positive nitrogen balance. Fifteen of 17 treated and 13 of 16 control patients survived the 1st week. No deaths occurred in patients whose serum IGF-I concentrations were higher than 350 ng/ml. Dichotomized Glasgow Outcome Scale scores for patients with baseline GCS scores of 5 to 7 improved from poor to good for eight of 12 treated patients but for only three of 11 control patients (p = 0.06). Eight of 11 treated patients with serum IGF-I concentrations that were at least 350 ng/ml achieved moderate-to-good outcome scores at 6 months, compared to only one of five patients with lower concentrations (p < 0.05). These findings indicate that pharmacological concentrations of IGF-I may improve clinical outcome and nitrogen utilization in patients with moderate-to-severe head injury.
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Affiliation(s)
- J Hatton
- College of Pharmacy, University of Kentucky Chandler Medical Center, Lexington 40536-0084, USA
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Li J, Kudsk KA, Janu P, Renegar KB. Effect of glutamine-enriched total parenteral nutrition on small intestinal gut-associated lymphoid tissue and upper respiratory tract immunity. Surgery 1997; 121:542-9. [PMID: 9142153 DOI: 10.1016/s0039-6060(97)90109-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our prior work shows that total parenteral nutrition (TPN) causes small intestinal gut-associated lymphoid tissue (GALT) atrophy, lowers small intestinal immunoglobulin A (IgA) levels, and impairs secretory IgA-mediated mucosal immunity of the upper respiratory tract. These experiments examine whether an isonitrogenous 2% glutamine-enriched TPN solution prevents these changes. METHODS Institute of Cancer Research mice were randomized to chow (chow), intravenous feeding of a TPN solution (TPN), or glutamine-enriched TPN (glutamine) groups. After mice were fed for 5 days, lymphocytes were isolated from Peyer's patches, the intraepithelial layer, and lamina propria to determine cell yields and phenotypes. Total small intestinal IgA levels were analyzed by means of enzyme-linked immunosorbent assay. In a second series of experiments, mice underwent intranasal inoculation with H1N1 virus to establish immunity. After 3 weeks mice were randomized to chow, TPN, or glutamine groups. After feeding for 5 days, mice were rechallenged with intranasal virus and killed at 40 hours to determine viral shedding from the upper respiratory tract. RESULTS Total lymphocyte yield in the Peyer's patches, the intraepithelial layer, and lamina propria, small intestinal IgA levels, and the CD4+/CD8+ ratio in the lamina propria decreased with TPN but remained normal with glutamine. On rechallenge, 87% of the mice in the TPN group shed virus in nasal secretions, whereas only 38% of the glutamine-treated group (p < 0.05 versus TPN) and 7.1% of the chow group (p < 0.002 versus TPN) were virus positive. CONCLUSIONS Isonitrogenous supplementation of TPN with 2% glutamine improves IgA-mediated protection in the upper respiratory tract and normalizes GALT populations.
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Affiliation(s)
- J Li
- Department of Surgery, University of Tennessee at Memphis, USA
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Sacks GS, Brown RO, Dickerson RN, Bhattacharya S, Lee PD, Mowatt-Larssen C, Ilardi G, Kudsk KA. Mononuclear blood cell magnesium content and serum magnesium concentration in critically ill hypomagnesemic patients after replacement therapy. Nutrition 1997; 13:303-8. [PMID: 9178279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Magnesium (Mg) deficiency, commonly diagnosed as hypomagnesemia based upon low serum Mg concentrations, is a frequent electrolyte abnormality in critically ill patients. Intravenous replacement therapy is empiric and serum Mg concentrations have traditionally been used as guidelines for measuring efficacy. Recent studies have shown that the Mg content of mononuclear blood cells (MBCs) may provide a better index for Mg status than serum concentrations. The purpose of this study was to evaluate the effects of intravenous Mg replacement therapy on MBC Mg content and serum Mg concentrations in critically ill hypomagnesemic patients. Adult patients admitted to the trauma intensive-care unit (ICU) with serum Mg concentration < or = 0.6 mmol/L (< or = 1.5 mg/dL) were considered for study entry. Patients with severe renal disease (Scr > 133 mumol/L), pregnancy, or those who were seropositive for HIV were excluded. Ten patients with moderate (> 0.4-0.6 mmol/L [> 1.0-1.5 mg/dL]) and severe (< or = 0.4 mmol/L [< or = 1.0 mg/dL]) hypomagnesemia received 0.5 and 0.75 mmol/kg of intravenous MgSO4, respectively, over 24 h. MBC Mg content and serum concentrations of magnesium, phosphorus, calcium, sodium, potassium, blood urea nitrogen, creatinine, glucose, and albumin were measured at baseline (0 h), end of infusion (24 h), 36 h, and 48 h. Data were analyzed using ANOVA with repeated measures and a P value < 0.05 was considered significant. Serum Mg concentrations increased significantly from baseline to 48 h (0.5 +/- 0.1 to 0.8 +/- 0.2 mmol/L, P < 0.001). MBC Mg content did not change significantly within the study period (2.6 +/- 1.0 to 3.0 +/- 1.3 fmol/cell, P > 0.7). The doses of MgSO4 (0.5-0.75 mmol/kg) used in this study increased serum Mg concentrations, but did not result in a statistically significant change of MBC Mg content in this group of trauma ICU patients.
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Affiliation(s)
- G S Sacks
- Department of Clinical Pharmacy, University of Tennessee, Memphis, USA
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Abstract
OBJECTIVE To determine the effect of the neuropeptide bombesin on total parenteral nutrition-induced impairment of upper respiratory tract immunity. DESIGN Randomized, controlled trial. PARTICIPANTS Thirty-six adult male Institute for Cancer Research mice weighing 25 to 35 g. INTERVENTIONS Mice were inoculated intranasally with H1N1 virus. At 3 weeks, mice were randomized to receive chow plus intravenous saline (n = 12), intravenous total parenteral nutrition (n = 12), or intravenous total parenteral nutrition plus bombesin (n = 12) administered 3 times daily at 15 micrograms/kg. After 5 days, mice were rechallenged with intranasal virus and killed at 40 hours to determine viral shedding from the respiratory tract; normal convalescent mice do not shed virus because of intact IgA-mediated mechanisms. MAIN OUTCOME MEASURES Viral shedding was determined by collection of nasal secretions. Samples were diluted and incubated with a suspension of Madin-Darby canine kidney cells. Viral growth was determined by hemagglutination. RESULTS Body weight was similar between the total parenteral nutrition and bombesin groups; however, both were significantly lower than that in the chow group (P < .05). After 6 days of feeding, no mice in the chow group shed virus, compared with 6 (50%) of the mice in the total parenteral nutrition group. Of the mice in the bombesin group, only 1 was positive for viral shedding. The total parenteral nutrition group showed increased viral shedding compared with both the chow group (P < .01) and the bombesin group (P < .05). CONCLUSIONS Exogenous administration of bombesin reversed the total parenteral nutrition-associated impairment of upper respiratory tract immunity to an IgA-mediated infectious challenge. These observations support the concept of a common mucosal immune system, since neuropeptides are endogenous to the gastrointestinal and respiratory tracts. Hormonal modulation of immunity is a promising avenue of treatment for patients who require total parenteral nutrition.
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Affiliation(s)
- P G Janu
- Department of Surgery, University of Tennessee at Memphis, USA
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Brown RO, Hamrick KD, Dickerson RN, Lee N, Parnell DH, Kudsk KA. Hyperkalemia secondary to concurrent pharmacotherapy in a patient receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr 1996; 20:429-32. [PMID: 8950745 DOI: 10.1177/0148607196020006429] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report a case of probable combined octreotide- and heparin-induced hyperkalemia. The patient had been receiving home parenteral nutrition, enoxaparin, and octreotide for 10 months. She required very little potassium in her PN solution to maintain serum potassium concentrations in the normal range. The patient reportedly did not receive other medications or have clinical conditions that, to our knowledge, cause hyperkalemia. She maintained normal renal function throughout the hospitalization and did not appear to have any significant acid-base disorders. Practitioners should be aware of the potential for octreotide and heparin to cause hyperkalemia. Regular monitoring of serum potassium concentrations should be done for patients receiving octreotide and heparin to avoid hyperkalemia.
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Affiliation(s)
- R O Brown
- Department of Clinical Pharmacy, University of Tennessee, Memphis 38163, USA
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Kudsk KA, Minard G, Croce MA, Brown RO, Lowrey TS, Pritchard FE, Dickerson RN, Fabian TC. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996; 224:531-40; discussion 540-3. [PMID: 8857857 PMCID: PMC1235418 DOI: 10.1097/00000658-199610000-00011] [Citation(s) in RCA: 308] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The authors randomized patients to an enteral diet containing glutamine, arginine, omega-3 fatty acids, and nucleotides or to an isonitrogenous, isocaloric diet to investigate the effect of septic outcome. A third group of patients, without enteral access but eligible by severity of injury, served as unfed controls and were studied prospectively to determine the risk of infection. SUMMARY BACKGROUND DATA Laboratory and clinical studies suggest that diets containing specialty nutrients, such as arginine, glutamine, nucleotides, and omega-3 fatty acids, reduce septic complications. Unfortunately, most clinical trials have not compared these diets versus isonitrogenous, isocaloric controls. This prospective, blinded study randomized 35 severely injured patients with an Abdominal Trauma Index > or = 25 or a Injury Severity Score > or = 21 who had early enteral access to an immune-enhancing diet ([IED] Immun-Aid, McGaw, Inc., Irvine, CA; n = 17) or an isonitrogenous, isocaloric diet (Promote [Ross Laboratories, Columbus, OH] and Casec [Mead-Johnson Nutritionals, Evansville, IN]; n = 18) diet. Patients without early enteral access but eligible by severity of injury served as contemporaneous controls (n = 19). Patients were evaluated for septic complications, antibiotic usage, hospital and intensive care unit (ICU) stay, and hospital costs. RESULTS Two patients died in the treatment group and were dropped from the study. Significantly fewer major infectious complications (6%) developed in patients randomized to the IED than patients in the isonitrogenous group (41%, p = 0.02) or the control group (58%, p = 0.002). Hospital stay, therapeutic antibiotics, and the development of intra-abdominal abscess was significantly lower in patients receiving the IED than the other two groups. This improved clinical outcome was reflected in reduced hospital costs. CONCLUSIONS An IED significantly reduces major infectious complications in severely injured patients compared with those receiving isonitrogenous diet or no early enteral nutrition. An IED is the preferred diet for early enteral feeding after severe blunt and penetrating trauma in patients at risk of subsequent septic complications. Unfed patients have the highest complication rate.
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Affiliation(s)
- K A Kudsk
- Department of Surgery, University of Tennessee, Memphis, USA
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Lee PD, Pivarnik JM, Bukar JG, Muurahainen N, Berry PS, Skolnik PR, Nerad JL, Kudsk KA, Jackson L, Ellis KJ, Gesundheit N. A randomized, placebo-controlled trial of combined insulin-like growth factor I and low dose growth hormone therapy for wasting associated with human immunodeficiency virus infection. J Clin Endocrinol Metab 1996; 81:2968-75. [PMID: 8768860 DOI: 10.1210/jcem.81.8.8768860] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Loss of body mass, or wasting, is a major cause of morbidity and a contributor to mortality in human immunodeficiency virus-1 (HIV-1) infection. Dietary supplements and appetite adjuvants have had limited effectiveness in treating this condition. GH and insulin-like growth factor I (IGF-I) have been shown to be anabolic in many catabolic conditions, and limited data suggest similar efficacy in HIV wasting. In addition, it appears that GH and IGF-I may have complementary anabolic effects with opposing glucoregulatory effects. We report results from a 12-week randomized, placebo-controlled trial of combination recombinant human GH (rhGH; Nutropin; 0.34 mg, sc, twice daily) and rhIGF-I (5.0 mg, sc, twice daily) in individuals with HIV wasting and without active opportunistic infection, cancer, or gastrointestinal disease. A total of 142 subjects (140 males and 2 females) were randomized using a 2:1, double blind treatment scheme and assigned to receive either active treatment or placebo injections. Eighty subjects completed the 12-week protocol. Nutritional intake and demographic and clinical characteristics did not differ between the groups at any study time point. At 3 weeks, the treatment group had a significantly larger weight increase (P = 0.0003), but this difference was not observed at any later time point. Similarly, fat-free mass, calculated from skinfold measurements, increased transiently in the treatment group at 6 weeks (P = 0.002). No significant differences in isokinetic muscle strength or endurance testing or in quality of life were observed between the groups. Resting heart rate was significantly higher in the treatment group at each time point post-baseline. GH and IGF-binding protein-3 levels did not change; however, IGF-I levels were higher in the treatment group at 6 and 12 weeks. There were no significant between-group differences in any of the measured biochemical or immunological parameters. rhGH plus rhIGF-I treatment was associated with an increased incidence of peripheral edema and other side-effects, possibly related to fluid retention. We conclude that the combination of rhIGF-I and low dose rhGH used in this study had no significant anabolic effect in HIV wasting.
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Affiliation(s)
- P D Lee
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
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Lowrey TS, Dunlap AW, Brown RO, Dickerson RN, Kudsk KA. Pharmacologic influence on nutrition support therapy: use of propofol in a patient receiving combined enteral and parenteral nutrition support. Nutr Clin Pract 1996; 11:147-9. [PMID: 9070015 DOI: 10.1177/0115426596011004147] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Propofol is a lipid-based sedative that provides 1.1 kcal/mL. Because propofol has rapid onset and quick recovery, it is becoming used widely in critical care units. A 15-year-old critically ill pregnant patient received specialized nutrition support concomitantly with propofol infusion for sedation. A serum triglyceride concentration obtained on day 6 of the propofol infusion was 1100 mg/dL with no previous history of hyperlipidemia. Caloric intakes from propofol averaged 1275 kcal/d (range 445 to 2354 kcal/d) over a 5-day period. Infusion of propofol or any other lipid-based drug must be monitored closely when given in conjunction with enteral or parenteral nutrition to avoid the pitfalls of overfeeding and hypertriglyceridemia. Enteral and parenteral formulas must be manipulated to provide optimal nutrient intakes while not overfeeding with fat when using increased amounts of lipid-based drugs.
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Affiliation(s)
- T S Lowrey
- Department of Food and Nutrition, University of Tennessee, Memphis 38163, USA
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Patton JH, Fabian TC, Croce MA, Minard G, Pritchard FE, Kudsk KA. Prophylactic Greenfield filters: acute complications and long-term follow-up. J Trauma 1996; 41:231-6; discussion 236-7. [PMID: 8760529 DOI: 10.1097/00005373-199608000-00006] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.
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Affiliation(s)
- J H Patton
- Department of Surgery, University of Tennessee College of Medicine, Memphis, USA
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