A medical cause of death validation study of adult aboriginal deaths in the Northern Territory of Australia in 1992

Branched-chain amino acid (BCAA)-enriched nutrient solutions reduce gut atrophy associated with parenteral nutrition. We hypothesized that this effect was mediated by phosphate-dependent glutaminase. Thirty male Wistar rats (300-350 g) underwent a standardized surgical procedure and were then randomized into three groups to receive 6 days of ad libitum enteral nutrition. The animals were fed a solution of conventional nutrients, a solution of conventional nutrients enriched with 2.0% BCAA or a solution of conventional parenteral nutrients enriched with 2.5% glutamine. When compared with rats fed conventional nutrients, rats fed BCAA and glutamine had less jejunal atrophy (P < 0.05) and a greater specific activity of phosphate-dependent glutaminase in the jejunum (131%; P < 0.05). It is concluded that enteral BCAA reduce atrophy of the jejunum via the generation of glutamine.     

The interfacial behavior of cytochrome c studied by pendant-drop technique

Malnutrition is common and often undiagnosed in affected patients, especially those in the hospital, and is associated with impaired organ function, increased morbidity, and prolongation of hospital stay. It should be recognized and treated appropriately, because artificial nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome. There are multiple methods to provide nutrition, some by simply keeping the esophageal lumen patent, others by providing additional or all nutrients, including enteral and parenteral routes. The enteral route is preferred due to patient acceptance, lesser expense, and lower risk of complications. The addition of specific nutrients over standard diets may add benefit. Preoperative nutrition may reduce the risk of postoperative complications. Lastly, in the terminally ill patient, minimal intervention may be all that is needed to achieve the patient's comfort, perhaps the most important goal.     

Nutritional management of enteropathy

The prognosis for nutritional management of enteropathy in children is good when the enteropathy is reversible with the use of a food elimination diet, such as cow's-milk-sensitive enteropathy, but is poor when enteropathy is irreversible, such as microvillous atrophy. However, nutritional management is central to the care of all children with small intestinal enteropathy. Enteral nutrition (provision of liquid formula diets by mouth or by tube) is possible in most cases, but in some children with intractable diarrhea, parenteral nutrition needs to supplement enteral feeding. The choice of enteral feeding ranges from elemental to partial hydrolysate.     

Nutritional considerations in children undergoing bone marrow transplantation

Bone marrow transplantation is often associated with multiple organ failure which is usually reversible. Oral mucositis and dysphagia, vomiting, diarrhoea, protein losing enteropathy, transient exocrine pancreatic impairment, hypoalbuminaemia, biochemical trace element and mineral deficiencies are all common following transplantation and have profound nutritional consequences. Malnutrition affects negatively the clinical outcome. Nutritional support is provided to malnourished patients and those who suffer deterioration in nutritional status despite the provision of dietetic counselling. Only a few randomised studies comparing enteral with parenteral nutrition after transplant exist. Both enteral tube feeding (in the absence of mucositis) and parenteral nutrition are effective in maintaining nutritional status. However, enteral nutrition is associated with a better nutritional response and fewer complications than parenteral. With existing enteral and parenteral nutrition regimens close monitoring of trace element and mineral status is required.     

Home parenteral nutrition in the management of patients with chronic idiopathic intestinal pseudo-obstruction

Home parenteral nutrition is indicated in all those patients who are unable to cover all their needs orally or enterally during prolonged periods of time, and who do not require any other general care other than the parenteral nutrition. Our objective is to prove the use of home parenteral nutrition as a nutritional support in patients with severe forms of chronic idiopathic intestinal pseudo-obstruction. In our unit, three patients with this disease, have received home parenteral nutrition between 1993 and the present date. One patient received it during four months, with the catheter being removed due to a fungemia. At present she is being maintained with oral and enteral nutrition. The other two patients continue in the program: one since October 93 and the other since July 94. The hydroelectric alterations caused during the episodes of sub-occlusion make more frequent changes in the composition of the parenteral nutrition necessary, compared to other types of patients. The low incidence of complications and the degree of acceptance by the patient makes this technique an ideal method for the long term nutritional support.     

Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial

BACKGROUND: Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. METHODS: Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (n = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. RESULTS: Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0.05) and were at lower risk of developing septic complications (P < 0.01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. CONCLUSION: This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis.     

A randomized study of radiotherapy alone versus radiotherapy plus 5-fluorouracil and platinum in patients with inoperable, locally advanced squamous cancer of the esophagus

Crohn's disease is frequently complicated by protein-calorie malnutrition. Four common clinical presentations of Crohn's disease include acute exacerbations or flares of disease, intestinal obstruction, fistulizing disease, and perianal disease. In this review, we examine the role of nutritional support in these clinical scenarios. Nutritional support is important for maintaining functional status and preventing loss of lean tissue. Determinants of lean-tissue loss include severity of underlying injury, baseline nutritional status, and duration of inadequate nutrition. One of the clinically useful measures of nutritional status is the nutritional risk index (NRI) defined on the basis of the serum albumin and weight loss. Nutritional support is important in severely malnourished patients (NRI < 83). Enteral nutrition is the route of choice, provided there are no contraindications to using the gastrointestinal tract. In acute exacerbations of Crohn's disease, enteral nutrition also has a role in the primary management of disease although it is not as effective as corticosteroids in inducing remission. The mechanisms are poorly understood and the most effective enteral formulation needs to be determined. Total parenteral nutrition is justified in severely malnourished Crohn's disease patients who are unable to tolerate enteral feeding or in whom enteral feeding is contraindicated. More clinical studies are needed on the assessment of malnutrition in Crohn's disease, the effects of nutritional management on functional status, and the timing of nutritional intervention.     

The effect of minimum luminal nutrition on mucosal cellularity and immunity of the gut

Many catabolic patients can only consume small volumes of enteral nutrients. The aim of this study was to evaluate markers of cellularity and immunity in the small intestine of rats randomized to receive 6 days of parenteral nutrition, 25% enteral and 75% parenteral nutrition (i.e. minimum luminal nutrition) or enteral nutrition. The same glutamine-enriched solution was used for both parenteral and enteral nutrition. Enteral nutrition was associated with the least amount of jejunal atrophy (P<0.01), with the results from the minimum luminal nutrition group approximating those of the parenteral nutrition group. Parenteral nutrition was associated with the greatest number of CD2+ cells (P< 0.05) and the lowest CD4/CD8 cell ratio (P< 0.01) in the jejunal mucosa. In essence, we failed to demonstrate that there are any appreciable benefits associated with the enteral consumption of 25% of a nutrient load.     

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.     

Nutritional support in patients with relapsing chronic respiratory failure

The authors review the scientific data on nutritional problems in patients with acute decompensation of COPD and present their own experience in the nutritional management of such condition. Artificial nutrition (enteral and parenteral) allowed a reduction in the duration of hospitalization, a lower incidence of infections, and a shorter weaning time from mechanical ventilation in comparison to a homogeneous group of patients treated in the same unit in an earlier period, when less attention was paid to nutritional problems. The importance of artificial nutrition in patients with acute decompensation of COPD is highlighted.     

Glutamine dipeptides in clinical nutrition

Glutamine is a conditional indispensable amino acid during stress. However, limited solubility and instability of glutamine prevent its addition to presently available nutritional preparations. To overcome these drawbacks, we propose the dipeptide concept by which stable and highly soluble synthetic glutamine containing dipeptides are used. The synthetic dipeptides fulfill all chemical/physical properties to be considered as parenteral substrates. Numerous experimental studies show rapid clearance of parenteral supplied glutamine containing dipeptides without accumulation in tissues; the loss via the urine being inconsequential. Differences related to the dipeptide structure are not observed. There is overwhelming evidence existent that a nutritional support with supplemental glutamine dipeptide positively influences nitrogen excretion, immune status, gut integrity, morbidity, rehabilitation and outcome. Consequently, omission of glutamine from conventional TPN and its subsequent administration should be considered as a replacement of a deficiency rather than a supplementation. It might thus be conceivable that the beneficial effects observed with glutamine nutrition are simply a correction of disadvantages produced by an inadequacy of conventional amino acid solutions. The availability of stable glutamine containing preparations will certainly facilitate an adequate amino acid nutrition in routine clinical setting during episodes of stress and malnutrition.     

Bow, range, and sequential effects in absolute identification: a response-time analysis

Large burn patients make up a subgroup of critical patients in whom the nutro-metabolic support reaches its maximum importance, due to the fact thermal aggression induces a hypermetabolic response which is prolonged until the wounds heal. In fact, there are few deubt with regard to the importance of nutritional support tin the management of these patients for reducing the complications and facilitating the closing of the wounds and the recovery of the patients. Thermal trauma induces the release of counter-regulatory hormones and of other mediators which favor proteineic catabolism, mainly muscular, lipolysis, and gluconeogenesis; as well, there is an alteration of thermoregulation, raising the equilibrium point. The estimate of the energetic requirements may be done by means of predictive equations, although these tend to over-estimate it; indirect calorimetry is the most exact method and this permits monitorization of the evolution, which is very variable in time, it gives the metabolic response to the thermal aggression, at the same time as permitting the analysis of the use of the administrated substrates. Its use has meant a dramatic decrease in the supply of calories administered to burn patients, with the present recommendation being 35-40 kcal/kg/d. The supply of non-proteineic calories has also been modified: It is recommended that at least 60-70% of the calories administered, be in the form of carbohydrates, without surpassing 1600 kcal/kg/d. The optimal relation of non-proteineic kcal:nitrogen, is 150:1. The administration route of the artificial nutrition support should be individualized in each patient, with the enteral route being the route of choice, as this is the most physiologic, the cheapest, and the safest; its use prevents the appearance of certain complications (Curling ulcer, cholecystitis, bacterial translocation); however, if his does not cover nutritional requirements of the burn patient, parenteral nutrition should be associated to this.     

A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications

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.     

Nutrition support for the elderly

The increasing size and longevity of the geriatric patient population dictates that all health care practitioners become more cognizant of the unique requirements for nutritional assessment and support of the elderly. This review summarizes recent advances in the understanding of the nutrition support needs of the old and oldest-old patients requiring enteral or parenteral feeding. When a nutrition support formula individualized for the geriatric patient is being developed, there is a fine line between excess and deficit, requiring the involvement of the entire support team in monitoring the success of feeding. Indications for choosing enteral or parenteral feeding are considered excessively invasive by some and necessarily "heroic" by others. The patient and his or her family should be part of the decision-making process.     

The management of malnutrition in hospital

Treatable malnutrition may occur in up to 25% of hospital patients, depending on the specialty concerned. Nutritional status may also deteriorate during a prolonged hospital stay. The management and prevention of malnutrition requires a climate in which hospital managers have a positive policy towards nutritional care, a screening system to identify the patients at risk, and appropriate protocols for action. Catering services need to be reorganized to address the problems of the sick, so that appropriate food is not only prepared but delivered in a way which makes it likely to be consumed. For the optimal management of artificial nutrition by the enteral or parenteral route, a skilled nutrition team is both necessary and cost-effective.     

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.     

Nutritional support: formulas and delivery of enteral feeding. I. Enteral formulas

Hospital malnutrition is a recognized condition that may be treated with a variety of feeding modalities. It is possible to achieve the goal of nutritional repletion with enteral feedings. Enteral feedings can now be prescribed for more types of patients because of our ability to better manipulate nutrition sources and the availability of modules and formulas designed for special use. The lower costs associated with enteral feeding have made it an option when nutritional support is required for a patient who has a functioning gastrointestinal tract.     

Response to aggression: evaluation and therapeutic implications. Work Group on Metabolism and Nutrition of the SEMIUC

The metabolic response to stress/aggression is a complex process which is mainly mediated by the interaction between the neuro-endocrine system and the circulating cytokines. This interaction brings about physiological and metabolic alterations--severe metabolic-nutritional deficits--of the hypermetabolic type, muscular proteolysis, lipolysis, glycogenolysis, and gluconeogenesis among others, which should be studied and understood prior to initiating or not a nutritional support. The parenteral or enteral nutritional support is usually indicated to prevent a worsening of these situations of altered metabolism frequently associated with inanition, although one should not attempt to revert to normal preexisting deficit situations. On the other hand, and is this special context, we should not forget the advances in nutrients with pharmacological effects, and in pharmacological nutrition. At this II Consensus Conference of the SEMIUC (Sociedad Espa?ola de Medicine Intensiva y Unidades Coronarias = Spanish Society of Intensive Medicine and Coronary Units), we have proposed four objectives: i) To make recommendation, based both on the scientific evidence, as on the experience of the components. ii) Define the scientific terminology to be used in this specific context. iii) Give an answer to the different and assorted clinical problems which are secondary to a situation of stress which has a multiple etiology. iv) Provide new ideas for the development of clinical trails and studies of this specific context.     

Enteral or parenteral feeding after total gastrectomy: prospective randomised pilot study

OBJECTIVE: To compare the efficacy and cost of enteral and parenteral feeding after total gastrectomy. DESIGN: Prospective randomised open study. SETTING: University hospital, Finland. SUBJECTS: 29 patients undergoing curative total gastrectomy for gastric cancer. INTERVENTIONS: 13 patients were given early enteral feeding by nasojejunal tube and 16 patients parenteral nutrition by central venous catheter. MAIN OUTCOME MEASURES: Postoperative complications, duration of hospital stay, serum CRP and albumin concentrations, cost, and postoperative abdominal symptoms. RESULTS: One patient in the enteral feeding group discontinued the study on day 1. Oesophagojejunal leaks developed in one patient in each group. Infective complications occurred in 3 (23%) in the enteral group and 5 (31%) in the parenteral group. Serum CRP concentration on day six was lower in the enteral feeding group than in the parenteral feeding group (32 (16) g/L compared with 61 (41) g/L; p = 0.02). Enteral feeding was well tolerated. Diarrhoea developed earlier in the enteral than in the parenteral group (days 3-5 compared with 5-7, respectively) but there was a tendency to an increased risk of diarrhoea in the parenteral group. Parenteral feeding was more than four times as expensive as enteral feeding. CONCLUSION: Enteral nasojejunal feeding is safe and well tolerated after total gastrectomy. It is also cheaper than parenteral nutrition.