Total parenteral nutrition in surgical patients

Malnutrition is common in the hospitalized surgical patient. There is a strong association between improved nutritional status and a favorable postoperative recovery, while malnutrition has an adverse effect on surgical outcome (Driscoll & Blackburn, 1990; Souba, 1997). Advances in providing parenteral nutrition have had a positive impact on nutrition care of these patients and will be reviewed in this article.     

Total parenteral nutrition and its effects on bone metabolism

Total parenteral nutrition (TPN) may affect bone metabolism in a variety of ways. These may include potential indirect effects such as on gastrointestinal hormone secretion, liver function, especially cytochrome P450 isoenzymes, metabolic biorhythms where established, and the continuous compared with the intermittent supply of nutrients. More substantial evidence exists for the reduction of bone formation, parathyroid hormone secretion, and calcitriol production in TPN patients along with high urinary calcium excretion. This review considers both aluminum loading and vitamin D sensitivity as etiologic factors and suggests that aluminum may have played a primary role in the pathogenesis of these abnormalities in bone and mineral metabolism, but that vitamin D may have potentiated the deleterious actions of aluminum. While the sources of aluminum contamination of TPN solutions have been identified and efforts are under way to reduce its contamination of TPN solutions, the persistence of low bone mass measurement in TPN patients is a problem that has been identified repeatedly, does not have a current explanation, and requires further study.     

Gastric emptying in humans: influence of different regimens of parenteral nutrition

The origins of the -28 A->C and frameshift Cd 11 - T(Fs CD 11-T)alleles were investigated by beta-globin cluster haplotype analysis. These alleles were found in a Mexican mestizo family with beta-thalassemia (beta-thal). The -28 A->C mutation was described previously in Kurdish Jews linked to the most common haplotype in the world(+----++),the same haplotype observed in this Mexican family. Therefore, it is not possible to assess a new origin of the -28 A->C mutation in our population. The Fs Cd 11 -T allele, not reported to date in any other populations, was linked to the -++--+-haplotype (sixth in frequency in the world). This haplotype has not been reported in association with any beta-thal mutant, suggesting a Mexican origin for the Cd 11 -T mutation.     

Total parenteral nutrition in the absence of kidney function for the treatment of the complications of gastrointestinal surgery

This is a preliminary report on an eight-year-old child with uremia (terminal renal failure) on chronic dialysis, that developed a postoperative high output small bowel fistula associated with sepsis and malnutrition. She was successfully treated with a Total Parenteral Nutrition (TPN) scheme including an amino acid solution with 60% essential amino acids and 40% non-essential amino acids, now available in Peru, without increasing the frequency of hemodialysis for a 72-day period on TPN. Attention is drawn to Nutritional Support Team Approach.     

Efficacy and safety of total parenteral nutrition in pediatric patients

Pediatric patients differ from adult patients because of active musculoskeletal growth and development of visceral organs and because they have a proportionately smaller nutritional reserve, especially premature infants. Measures of outcome of effective nutritional support in pediatric patients who have experienced trauma or medical disease or who have undergone surgical procedures include weight gain, increased height and circumference of the head, increased hepatic synthesis of plasma proteins, immunocompetence, decreased morbidity, improved survival, and fast recovery. If a pediatric patient cannot eat or be tube-fed enterally after 3 days of recovery and support with fluids, parenteral nutrition is indicated. Examples in which this treatment has dramatically decreased morbidity include gastroschisis, short-bowel syndrome, necrotizing enterocolitis, and Hirschsprung's disease. Contraindications to its use include severe congenital (usually genetic) defects and terminal cancer, conditions in which life expectancy and quality of life are severely decreased. The team approach to parenteral and enteral nutrition in pediatric patients is preferred, and stable patients receiving long-term nutritional support, including infants, should be considered for home parenteral nutrition. When administered by protocol, parenteral nutrition is safe in pediatric patients. In properly selected pediatric patients, direct and indirect costs for such therapy may be significantly less than those in adults, and the cost-to-benefit ratio is appreciably higher when life expectancy, parental pleasure, and potential work productivity are considered. Ethical and social issues in initiating and discontinuing parenteral nutrition are best decided during thorough empathic discussions between physicians and parents.     

Glutamine-supplemented parenteral nutrition improves gut mucosa integrity and function in endotoxemic rats

Seventy-seven pancreatic adenocarcinomas (60 Spanish and 17 Italian) were tested for Ki-ras gene mutations by analysis of polymerase chain reaction amplified sequences. Mutations involving codon 12 (GGT; gly) were detected in 16 Italian and 46 Spanish cases (80.5% in total). All Italian mutations involved the second base and were G to A transitions (GAT; asp) in 8 cases and G to T transversions (GTT; val) in the remaining 8. Forty-two Spanish mutations were characterized. Thirty-eight were at the second and 4 at the first base: asp in 24 cancers, val in 14, arg (CGT) in 2 and cys (TGT) in 2. Previous European studies and our present data show that 149 of the 186 pancreatic cancers harbored a codon 12 Ki-ras mutation (80%), the large majority affecting the second base (73%), with a transitions/transversions ratio of 1.3:1. However, the mutational pattern of cancers of the different European countries shows remarkable differences, both in the site of the mutation (first or second base) and in the ratio of transitions over transversions. Moreover, a significant subgroup of pancreatic carcinomas do not harbor Ki-ras mutations. The classification of pancreatic cancers, according to the presence or absence, and type of Ki-ras mutation, may be of importance in epidemiological studies. A critical reappraisal of existing epidemiological data, through a retrospective genotypic study using paraffin-embedded cancer samples, may reveal significant correlations with specific genotoxic agents.     

Effect of intradialytic parenteral nutrition on quality of life in hemodialysis patients

The purpose of this study was to determine the effect of intradialytic parenteral nutrition (IDPN) on the quality of life of malnourished patients with end-stage renal disease on high-efficiency and high-flux hemodialysis therapy. Patients, who met the Medicare eligibility requirements for IDPN, were asked to fill out and extensive questionnaire covering several measures of quality of life prior to initiating and again after completing four months of IDPN therapy. Although the IDPN improved serum albumin levels significantly, aside from improved sleep patterns, no significant improvements in quality of life could be demonstrated. The mortality rate of these enrolled patients was as high as 28% within 4 months. We concluded that the limited amount of nutrition delivered over the course of a short dialysis session may not be enough to appreciably change the lives of our malnourished patients.     

Total parenteral nutrition on energy metabolism in children undergoing autologous peripheral blood stem cell transplantation

The resting energy expenditure (REE) and the respiratory quotient (RQ) were measured longitudinally using indirect calorimetry to examine the effects of total parenteral nutrition (TPN) on energy metabolism in children undergoing autologous peripheral blood stem cell transplantation (PBSCT). There were six children (two males and four females) and the age ranged from five to 13 years (median, eight yrs). The diagnosis included acute lymphocytic leukemia (ALL; 4), neuroblastoma (NBL; 1) and primitive neuroectodermal tumor (PNET; 1). TPN was started after the patients were stabilized following PBSCT (group A; n = 3) or before the initiation of high-dose cytoreductive chemotherapy (HCC) (group B; n = 3). Duration of HCC before PBSCT was identical between the two groups (six to eight days). Average total calorie and protein intake during HCC was significantly higher for group B than for group A. The %REE, the percentage of REE to the predicted basal energy expenditure (BEE), in group A showed 133 +/- 19%, 129 +/- 14% and 146 +/- 11% during three periods of HCC (days -8 to -1 of PBSCT), bone marrow suppression (days 0 to 11 of PBSCT) and bone marrow recovery (days 12 to 22 of PBSCT), respectively. In contrast, those in group B were 10% to 20% lower than those in group A at all periods. Carbohydrate oxidation rates during HCC in group A were significantly lower than those in group B, and those were not different between both groups during post-PBSCT periods. Fat oxidation rates in both groups were similar at all stages of periods. In contrast, protein degradation rates in group A were significantly higher than those in group B at all stages of the period. From these results, we concluded that commencement of TPN administration prior to HCC in the patients undergoing PBSCT provides beneficial effects to maintain better energy metabolic and nutritional status.     

The effects of short-term parenteral nutrition on human liver protein and amino acid metabolism during laparoscopic surgery

Almost 2000 bovine milk fats were analysed by gas chromatography to investigate the influence of typical barn and pasture feeding of cows on trans-C18:2 isomers (with at least one trans double bond) including the conjugated linoleic acid cis delta9, trans delta11 (c9,t11) as well as the cis delta9, cis delta12 linoleic acid. Moreover, small cow herds were used to determine the influence of pasture Feeding with young and older grass as well as the impact of an energy deficit or the variation of quantity and technical treatment of fed rape-seed on the content of C18:2 isomers in milk fat. The contents of trans-C18:2 (w/o c9,t11) and c9,t11 in 1756 milk fats on average amounted to 0.63% resp. 0.75%. These contents increased from barn feeding, in winter with 0.46% resp. 0.45% over the transiton period in spring and late autumn with 0.66% resp. 0.76% to pasture feeding in summer with 0.87% resp. 1.20%. Milk fat samples from bulk milk obtained weekly during one year from 4 large West German milk collection areas confirmed and completed the data found for the 1756 milk fats. The percentage of linoleic acid with a mean value of 1.24 (n = 1756) varied irregularly during the different feeding periods. The content of the conjugated linoleic acid c9,t11 could be raised considerably up to triple the normal amount by different changes in feeding. However, the content of trans-C18:1 fatty acids was strongly increased as well, respectively.     

The effects of PEG-interleukin-2 and interleukin-2 on essential hypertension and cellular immune function in the spontaneously hypertensive rat

The effects of recombinant human interleukin-2 covalently linked to polyethylene glycol (PEG-IL-2) or interleukin-2 (IL-2) on hypertension and in vitro suppressor T cell function in the spontaneously hypertensive rats (SHR) were investigated. Male young prehypertensive (4 weeks old) SHRs and adult (10 weeks old) SHRs with established hypertension were injected with low (5,000 units (u)/kg) or high (50,000-100,000 u/kg) dose of PEG-IL-2 or IL-2 as a single bolus or repeated injections. Systolic blood pressure was measured twice weekly using the tail-cuff technique. Systolic blood pressure in the PEG-IL-2 or IL-2 treated animals, irrespective of age, dose, or route of injection, did not differ significantly from that measured in vehicle-treated controls over a 10 week period. Mean arterial pressure measured by intra-arterial catheter was 159 +/- 7 mm Hg 10 weeks after treatment with repeated injections of 5,000 u/kg of PEG-IL-2 and 158 +/- 9 mm Hg in vehicle-treated controls. All rats injected with IL-2 had IL-2-specific IgG antibody in their sera. None of the PEG-IL-2 treated rats had any detectable anti-IL-2 antibodies in their sera. Thus, PEG-IL-2 showed far less immunogenicity than IL-2. Suppressor T (Ts) cells generated from adult SHR spleen cells failed to suppress pokeweed mitogen (PWM)-driven immunoglobulin G (IgG) synthesis. PEG-IL-2 or IL-2 supplementation both in vitro and in vivo restored the ability of adult SHR to generate Ts cells able to inhibit IgG synthesis. Our data suggest that PEG-IL-2 or IL-2 administration does correct a prominent defective Ts cell activity found in adult SHR, but that correction of this immune abnormality is not attended by an attenuation of hypertension.     

The potential use of parenteral dipeptides in clinical nutrition

The metabolic effects of intravenous peptides have undergone extensive investigation in recent years. Dipeptide solutions provide a mechanism for the provision of selected amino acids that may be conditionally indispensable under certain clinical conditions. In particular, amino acids such as cystine, glutamine, and tyrosine may be difficult to provide in their free form, but their availability can be increased substantially when they are supplied in the form of a dipeptide. Animal and human studies have demonstrated that parenteral dipeptides are cleared rapidly from the plasma compartment and favorably influence nitrogen equilibrium in healthy volunteers and catabolic patients. Certain dipeptides offer the potential for tailoring tissue-specific nutrition therapy. It seems likely that parenteral peptides will offer a major change in the delivery of intravenous nutrients.     

Biochemical and ultra-structural reactions to parenteral nutrition with two different fat emulsions in rats

OBJECTIVE: To compare the effects on fat metabolism and Kupffer cell morphology by total parenteral nutrition (TPN) with two different fat emulsions. DESIGN: Thirty-two male Sprague-Dawley rats, divided into three groups, were investigated. Rats fed orally were used as a reference group, and a group of rats receiving TPN with fat emulsions containing pure long-chain triglycerides (LCT) was compared to a group of rats receiving fat emulsions containing both long-chain triglycerides and medium-chain triglycerides (MCT/LCT). The TPN regimens were equicaloric and administered continuously via a jugular catheter for 10 days. INTERVENTIONS: After suffocation, blood of the rats was collected for the determination of serum lipids. Epididymal fat and heart were collected for the analysis of lipoprotein lipase (LPL) activities, and liver specimens were saved for analyses of hepatic triglyceride concentration, as well as activities of hepatic lipase (HL) and lysosomal enzymes. Light and electron microscopy were used for examination of the Kupffer cell reaction. RESULTS: Directly after termination of parenteral feeding, the levels of serum triglycerides and high density lipoprotein (HDL) triglycerides were higher in the MCT/LCT group than in the LCT group, while no differences concerning cholesterol and phospholipid concentrations were found. No significant difference in liver steatosis was found between the two TPN groups. Comparison of the TPN groups showed that the MCT/ LCT group had significantly decreased LPL activity in adipose tissue, while the LCT group had significantly increased LPL activity in the heart. The activity of HL was low in both groups, but significantly lower in the LCT group. Lipid accumulation and an increased number of lysosomes were found in all Kupffer cell when TPN with LCTemulsions was used. Moreover, TPN induced a pronounced increase in various liver lysosomal enzyme activities, but there was no notable difference between LCT and MCT/LCT effects. CONCLUSIONS: Compared to treatment with pure LCTemulsions, treatment with MCT/LCT emulsions evoked weaker biochemical reactions in terms of lower activity of lipoprotein lipase in fat and heart together with higher serum and HDL triglyceride levels. Morphological signs of increased Kupffer cell activity such as the appearance of multiple lysosomes and fat vacuoles in the cytoplasm followed treatment with pure LCT emulsions. However, both TPN groups showed a marked increase in activities of liver lysosomal enzymes.     

Microbiological control in parenteral nutrition mixtures. Indices of contamination

Potential contamination of nutritional mixtures during preparation in the Pharmacy Services has led to the need for microbiological controls. In our study, we set out the techniques used in the Son Dureta Hospital between 1986 and 1991. During those six years 11,023 nutritional mixtures were prepared, and 1,714 bacteriological controls were carried out, representing 15.5% of the total. Between January 1986 and June 1989, the simple culture technique was used (culture of 10 ml of the prepared mixture). The contamination rate was 1.27%. Between July 1989 and December 1991, the double sample technique was applied, involving a culture of 10 ml of the mixture, keeping a further 10 ml for subsequent verification culture. With this technique, the contamination rate was fixed at 0.34%. The advantages and drawbacks of the techniques used are described, along with the problem of initial false positives, and a review is made of the 39 germs isolated during the period of study.     

Nutritional depletion in staged spinal reconstructive surgery. The effect of total parenteral nutrition

STUDY DESIGN: A prospective randomized study evaluating nutritional depletion in spine surgery patients. OBJECTIVE: To determine whether use of total parenteral nutrition (TPN) in patients undergoing staged spinal reconstructive procedures could affect their nutritional parameters or decrease their complication rates. SUMMARY OF BACKGROUND DATA: Several studies have shown that nutritional depletion occurs after major spinal surgery and that patients undergoing staged spinal surgery may be at particular risk of nutritional loss and its complications. METHODS: Forty adult patients undergoing staged spinal reconstructive surgery were randomized as to whether they received TPN postoperatively. Nutritional parameters, including skin fold measurement and albumin, pre-albumin, transferrin, and total lymphocyte counts, were obtained pre-operatively and at regular intervals. RESULTS: Five patients did not complete the study, leaving 35 patients for analysis. There was a significant decrease in incidence of albumin and pre-albumin depletion for the patients who did not receive TPN compared with those who did receive TPN (P < 0.025, P < 0.006, respectively). Patients with depleted albumin or pre-albumin counts were more likely to develop other postoperative infectious complications such as pneumonia or urinary tract infections (P < 0.035). There were no statistically significant differences in wound complications in this small patient study. There were no complications secondary to use of the TPN. CONCLUSIONS: For complex patients requiring staged anterior/posterior surgery, TPN appears to significantly lessen the decrease in nutritional parameters. Because depletion of nutritional parameters appears to correlate with an increased likelihood of perioperative infectious complications, use of TPN may result in a decrease of such complications in these patients.     

Effect of severity of stress on whole-body protein kinetics in surgical patients receiving parenteral nutrition

A study was conducted to clarify the quantitative relationship between the alteration of protein metabolism and the severity of surgical stress to further understand the mechanisms of body nitrogen losses in surgical trauma. Twenty-one patients undergoing esophagectomy for esophageal cancer (group E), and 22 undergoing gastrectomy or colorectal operations for gastric or colorectal cancer (Group GC) were studied. All patients were fed exclusively by parenteral nutrition (PN) providing 1.5 g protein.kg-1.d-1 and 35 kcal.kg-1.d-1 before and after the operation. The measurements of whole-body protein turnover, synthesis, and breakdown were performed preoperatively and on postoperative days (PODs) .3 and 10. Urinary excretion of total nitrogen and total catecholamines was also measured. Urinary excretion of the total catecholamines of group E was twice as high as that of group GC on the POD 3 and well reflected the severity of surgical stress. Negative correlation of nitrogen retention to urinary excretion of the total catecholamines was also observed (r = 0.64; P < 0.01). The correlations between the urinary excretion of the total catecholamines and the whole-body protein flux, synthesis, and breakdown were statistically significant (r = 0.57, 0.27, and 0.57, respectively; P < 0.01 in all). Rate of elevation in breakdown according to the stress level was greater than that of synthesis. Consequently the progressive aggravation of nitrogen balance according to the severity of surgical stress was observed.     

The medical aspects of nutrition in minor casualties

It is recommended that a standard ration will be accompanied by "Unpit", natural casein concentrates, and "Glucosolan" vitaminized preparation to eliminate++ the disorders of trophological status of minimally wounded. There is a proposal to include the products of enteral nutrition for the ration of food supplies, because it would shorten the recovery time of minimally wounded, and, thus, accelerate their return to the ranks.     

Safety and efficacy of increasing dosages of glycyl-glutamine for total parenteral nutrition in polytrauma patients

Supplementation of parenteral nutrition with glutamine (GLN) has been suggested to improve the efficacy of nutritional support by stimulating protein synthesis and improving immunocompetence. In the present study we investigated the impact of infusing the dipeptide glycyl-glutamine (GLY-GLN) at increasing dosages on plasma amino acid concentrations in patients with polytrauma. Nine polytraumatized patients were randomly assigned according their age and their trauma score to three experimental groups. Group 1 received 280, group II 450, and group III 570 mg GLY-GLN per kg body weight/day for a period of four days (3rd to 7th posttraumatic day), resulting in a maximum daily GLN administration (calculated for a 70 kg patient) of 14 g, 21 g and 28 g, respectively. Seven polytraumatized patients receiving the nutrition solution without GLY-GLN supplementation served as controls. All patients received total parenteral nutrition with an average amino acid administration of 1.1 g/kg/day and a total energy intake of 30 kcal/kg/day. GLY-GLN infusion did not evoke any side effects. In comparison with the control group, arterial plasma GLN concentrations increased significantly on day I after start of infusion in groups II and III, but remained raised throughout the study period only in group III (p < 0.003). Similarly, plasma GLY concentrations were also significantly raised in group III (p < 0.04). The maximum increase of plasma GLY was found on the second infusion day, after which plasma concentrations of GLY fell to concentrations even below those observed in the control group at the end of the study period. Excretion of GLY-GLN, GLN or GLY in the urine during the GLY-GLN infusions was negligible. We conclude from this first available dose finding study on glutamine-containing dipeptides that in polytraumatized patients infusion of 570 mg/kg/day of GLY-GLN (corresponding to 28 g glutamine or 40 g dipeptide/70 kg, respectively) is necessary to induce a sustained effect on plasma glutamine concentrations. No pathological accumulation of free glycine or of the dipeptide was seen with any of the three dosage steps of GLY-GLN. Thus, the administration of even high doses of GLY-GLN is feasible and safe in patients with polytrauma and is not associated with any relevant renal substrate loss.     

Social support and immune function among spouses of cancer patients.

This study investigated whether social support was related to immune function among spouses of cancer patients. Effects of depression and negative life events were examined as potential mediators. Results showed evidence of greater immunocompetence on 2 of 3 dynamic measures: natural killer cytotoxicity and proliferation response to phytohemaglutinin among spouses who reported high levels of social support. All six components of social support assessed by the Social Provisions Scale (C. E. Cutrona and D. W. Russell, 1987) were strongly related to these indices of immune function. No evidence was found for mediation by either life events or depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of parenteral and enteral nutrition on hepatic albumin synthesis in rats

It is well known that surgery significantly decreases immune responses. Laparoscopic cholecystectomy (LC) is a "miniinvasive" surgical procedure; and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. Immune activity [neutrophils, total lymphocytes count, lymphocytes subpopulations, human leukocyte antigen-DR (HLA-DR)] was evaluated in 53 patients 1 day before surgery and respectively, 1, 3, and 6 days after surgery; 26 patients underwent "open" cholecystectomy and 27 LC. A day after surgery, patients with open cholecystectomy showed a significant increase (p < 0.05) in plasma neutrophils, while they were almost unchanged in LC patients. Monocyte antigen HLA-DR was reduced in patients with "open" cholecystectomy. We recorded two cases (7.6%) of respiratory tract infection in the "open" group. In conclusion, LC strongly reduces postoperative (p.o.) pain and hospitalization, and it promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with less p.o. morbidity compared to that seen with open surgery.