Trace metal and essential fatty acid deficiency during total parenteral nutrition.

While deficiences of trace metals and essential fatty acids are rare in humans fed orally, the widespread use of total parenteral nutrition (TPN) has increased the likelihood of encountering these deficiences. A 14-year-old boy, with total villous atrophy of the small intestine, suffered from severe malnutrition and was placed on a conventional TPN regimen. Although not immediately recognized, he rapidly developed deficiencies of zinc, copper and essential fatty acids. Careful monitoring of the course of the illness and the responses to sequential treatments with zinc, lipid, and copper given intravenously allowed examination of the effects of the deficiencies on skin, intestine, liver, and hemopoietic systems and helped to establish normal requirements for the metals. The progress of the illness suggested that patients with intestinal malabsorption may be especially at risk of developing some of these lesser known complications of TPN.     

Essential and non-essential amino acid requirement in injured patients receiving total parenteral nutrition

The metabolic derangements of injury are known to influence nitrogen (N) requirements whilst less is known about individual amino acid (AA) requirements. This study was designed to investigate prospectively N vs AA requirement in 36 injured patients treated with total parenteral nutrition (TPN). The non-protein caloric input was 30 kcal kg^-1 day^-1 and three AA solutions were assessed containing the same AAs but in different proportion. Overall N intake was set at 0.35 g N kg^-1 day^-1 for solution A and B and 0.24 g N kg^-1 day^-1 for solution C. Solution B was similar to A, both being enriched in branched chain AAs (BCAA: 0.69 g kg^-1 day^-1 in B compared with 0.55 g kg^-1 day^-1 in A) while decreased in aromatic and sulphurated forms (1.75 times the normal need). Solution C was designed to maintain a daily input of BCAA similar to A (0.52 g kg^-1 day^-1) but with the supply of aromatic and sulphurated AA between solutions A and B, the supply of other AAs (lysine, theonine, histidine, arginine, glycine) being dependent on the selected N intake. For all the essential AAs the supply was always greater than normal allowances. Increasing BCAA over 0.55 g kg^-1 day^-1 did not improve N balance when N intake was 0.35 g kg^-1 day^-1, whilst nutrition with solution C was unable to maintain N balance. Moreover we found indirect evidence that this N intake, 0.52g kg^-1 day^-1 was more sparing than 0.37 g kg^-1 day^-1 of BCAA. N balance of the three groups suggests that injured patients need more than 0.24 g N kg^-1 day^-1 probably for non-essential AA synthesis. The study of plasma AA values support the increased non-essential N need in group C and allows us to suggest the proper AA composition of the overall optimal daily N intake (0.28–0.30 g N kg^-1 day^-1) in catabolic patients: BCAA about 0.5 g kg^-1 day^-1, phenylalanine, methionine, tryptophane, threonine and lysine from 2–3 to 5–10 times the normal allowance, the remainding N supply (about 0.14 g kg^-1 day^-1) should be made up from histidine, arginine, tyrosine, serine, proline, glycine, glutamic and aspartic acid. Presented in abstract form at the 3rd European Congress on Intensive Care Medicine, Hamburg, June 11–14, 1986     

Haematological changes during parenteral nutrition of malnourished patients with an enteral disease

The present study assesses the blood haemoglobin concentration, the mean corpuscular haemoglobin concentration and the mean corpuscular volumes, as well as the serum iron levels and the total iron binding capacities in 28 malnourished patients with an enteral disease before and after 10-12 days of pre-operative parenteral nutrition of three different kinds: one with glucose, a second with glucose and fat as energy source, and a third rich in amino acids. About half of the patients in each group also received intramuscular iron supplementation of 1.79 mmol every 2 days. Before the nutritional therapy, 54% of the patients had a subnormal serum iron level; on average, serum iron was 10.5 (SD 7.4) mumol/l. In spite of this, 50% of the patients had a TIBC level less than normal and 43% of the patients within the normal range. Ninety-three percent of the patients had an anaemia which, in most cases, was normochromic and normocytic. On average, blood haemoglobin was 110 (SD 12) g/l. After 10-12 days of parenteral nutrition, the blood haemoglobin concentration decreased independently of the quality of the intravenous alimentation, the serum iron level and the intramuscular iron supplementation. The fall in the blood haemoglobin level was on average 11.2%.(ABSTRACT TRUNCATED AT 250 WORDS)     

A concentrated mixture of amino acids and dipeptides for total parenteral nutrition

Using a subhuman primate (baboon) we have investigated the utility of a 20% mixture of amino acids and dipeptides as the nitrogen source for total parental nutrition. The mixture, besides containing all 8 essential amino acids and a number of non-essential amino acids (glutamate, aspartate, arginine, histidine, serine, ornithine and alanine), contained 6 dipeptides (Gly-Ile, Gly-Leu, Gly-Val, Gly-Tyr, Gly-Gln, and Ala-Gln) and acetyl-cysteine. A week of total parenteral nutrition was preceded by one week of oral feeding. The caloric intake and composition during the two periods was identical except for the nitrogen source, which was intact protein during the oral period, and the mixture of amino acids and dipeptides during the parenteral period. There was no significant difference between gain in body weight or nitrogen balance during the two periods. There were selective increases in plasma and muscle concentrations of amino acids during the parenteral period, which appeared to reflect the amino acid enrichment of the nitrogen source. The efficient utilization of dipeptides was evidenced by their small concentrations in plasma and urine. The urinary excretion of dipeptides was about 1% of the amount infused. This efficiency of dipeptide utilization persisted even when the infusion rate of the amino acid and dipeptide mixture was increased by 7-fold. There was no alteration in liver, kidney, and immune function during the parenteral period. The data indicate the efficacy and safety of the mixture of amino acids and dipeptides as the nitrogen source for parenteral nutrition.     

The use of a fatty emulsion for determining blood lipids in parenteral nutrition]

The author has investigated the possibility of using as the reference agent in estimation of the resorption rate from vascular bed of fatty emulsions the very agent that is introduced or the oil, one of the ingredients of this agent. Fatty emulsions for parenteral nutrition intralipid (Sweden), lipofundin-C (Finland), venolipid (Japan), lipidin and lipidin-2 (USSR), and specially purified sunflower oil were used to plot the calibration curve.     

Hormonal changes in catabolic patients during parenteral nutrition

This study assesses the hormonal changes in 23 catabolic surgical patients during the three different regimens of parenteral nutrition: one with glucose, another with glucose and fat as energy sources, and a third one rich in amino acids. Before treatment, plasma insulin and cortisol concentrations, as well as daily urinary excretion of 17-oxogenic steroids and catecholamines, were normal. Plasma growth hormone concentration was close to normal. Plasma testosterone and daily urinary excretion of 17-oxosteroids were decreased. The response of plasma cortisol concentration to glucagon was impaired but the responses of insulin and growth hormone were close to normal. During the glucose regimen plasma insulin increased by 270% and plasma testosterone by 60%. There was a 55% decrease in plasma growth hormone concentration and a 31% rise in plasma cortisol concentration. The lipid regimen enhanced plasma insulin by 120%. During the amino acid regimen plasma insulin concentration was 150% higher, but plasma growth hormone concentration 45% lower than initially. The glucose and amino acid regimens augmented the response of insulin to glucagon by 180 and 50%, respectively, but decreased that of growth hormone by 59 and 80%, respectively. The lipid programme caused no significant change in the hormonal response to glucagon.     

肠外营养支持对肠瘘患者凝血指标的影响

目的研究全肠外营养（TPN）对肠瘘患者凝血指标的影响。方法实验对象分2组,对照组30例为普通饮食的健康志愿者,肠瘘TPN组30例为行TPN支持1～3个月。测定其肝功能指标、血小板计数（PLT）、临床常用血凝指标,以及患者P-选择素阳性血小板百分数。结果TPN组血小板计数和临床常用血凝四项与对照组均无显著差异。TPN组P-选择素阳性血小板百分数显著高于对照组（P〈0．01）,血小板计数显著低于对照组（P〈0．05）。TPN组ALT和AST水平明显升高（P〈0．01）。结论长期TPN可导致血小板活化程度增高和血小板计数减少,患者有出血倾向。     

Effect of L-lysine-induced amino acid imbalance on nitrogen balance in patients treated by total parenteral nutrition

Cumulative nitrogen balances of 109 patients in 3 groups under total parenteral nutrition were studied with regard to their daily intake of l-lysin. Patients in group 1 who received a mean daily amount of 4.5 g l-lysin exclusively from the amino-acid solution showed a cumulative nitrogen balance of -51.9 g N 10 days into the study. Patients in groups 2 and 3 received, additionally, l-lysin HCl for prophylaxis or therapy of metabolic alkalosis. Thus patients in group 2 received 5.3 g l-lysin (nitrogen balance -101.4 g N/10 days) and in group 3, 8.5 g l-lysin (nitrogen balance -97.6 g N/10 days). The markedly higher negative nitrogen balance in these groups is interpreted as the effect of an amino acid imbalance due to inadequate l-lysin intake; therefore, l-lysin should no longer be used for treatment of metabolic alkalosis in patients under total parenteral nutrition.     

Effects of early amino acid administration during total parenteral nutrition on protein metabolism in pre-term infants.

1. We investigated the effects of starting amino acid administration on post-natal day 2 on protein turnover and nitrogen balance in appropriate-for-gestational-age, very-low-birth-weight infants. Eighteen infants were divided into two groups. Group A received from day 2 onwards an amino acid solution, whereas group B started on this solution after day 4. Both groups were exclusively parenterally fed, 200 kJ day-1 kg-1 on post-natal days 3 and 4. Group A (birth weight 1.5 +/- 0.3 kg) received 4.6 g of glucose, 1.9 g of fat and 2.3 g of amino acids day-1 kg-1 body weight. Group B (birth weight 1.4 +/- 0.2 kg) received 7.0 g of glucose and 1.9 g of fat day-1 kg-1 body weight. 2. At post-natal day 3, a primed constant infusion of 3 mg of [15N]glycine day-1 kg-1 was given. Protein flux, protein synthesis and protein breakdown were calculated from the 15N enrichment in urinary ammonia. In five out of nine infants in group B no plateau of 15N enrichment in urinary urea could be detected, whereas in group A two out of nine infants did not reach a plateau. For this reason we did not use the end product urea for our calculations. 3. The administration of the amino acids resulted in a higher protein flux (6.9 +/- 1.5 g day-1 kg-1 versus 5.2 +/- 0.9 g day-1 kg-1) and a higher protein synthesis rate (6.0 +/- 1.4 g day-1 kg-1 versus 4.6 +/- 0.8 g day-1 kg-1) in group A.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hyperammonemia during parenteral nutrition of intensive-care patients]

Metabolic features of parenteral feeding with conventional amino acid solutions were examined in 47 patients over a long period. 30 patients were kept alive by artificial respiration. The metabolic parameters ammonium, blood urea nitrogen, GOT, alkaline phosphatase were carried out, in 6 patients the pattern of amino acids was analysed. All patients showed a significant increase of ammonium during the course of parenteral feeding. The amino acids demonstrated pattern of imbalance. The other other parameters were not changed significantly. Traumatic, hypoxic or toxic liver damage might influence the reduction of liver function.     

肠外营养对胃癌术后患者营养和免疫功能的影响

目的探讨化疗期间肠外营养对胃癌术后患者营养及免疫功能的影响。方法 80例胃癌术后需行化疗的患者,随机分为对照组和观察组,每组40例。对照组给予单纯化疗(FAM方案),观察组在化疗同时接受肠外营养。观察2组化疗后的临床疗效、外周血血清白蛋白(ALB)、转铁蛋白(TRF)、前白蛋白(PAB)水平、T淋巴细胞亚群数量。结果与化疗前比较,2组化疗后血清ALB、PAB、TRF水平明显降低(P<0.01);观察组化疗后血清ALB、PAB、TRF水平明显高于对照组(P<0.05,P<0.01)。与化疗前比较,观察组化疗后CD3+、CD4+淋巴细胞亚群数量及CD4+/CD8+比值明显增加(P<0.01)。观察组化疗后CD3+、CD4+淋巴细胞亚群数量及CD4+/CD8+比值明显高于对照组(P<0.01)。结论胃癌患者化疗期间给予肠外营养可改善患者营养状态和免疫功能。     

Evaluation of a glycine-rich amino acid solution for parenteral nutrition in endotoxemic rats

OBJECTIVE: It has been shown recently that high amounts of glycine might have some pharmacologic effects (reduction of injury and mortality in endotoxemic rats), but its effects on the nutritional status and protein metabolism during injury are still unknown. The aim of this study was to compare the nutritional effects of a glycine-rich amino acid solution for parenteral nutrition (AFD) with a standard one (Vintene) (glycine, 15 vs. 9 g/L) in endotoxemic rats. DESIGN: Laboratory investigation. SETTING: University laboratory. SUBJECTS: Male Wistar rats (198 +/- 11 g). INTERVENTIONS: Rats were operated to receive total parenteral nutrition (250 kcal/kg/day, 2 g N/kg/day) with amino acids supplied by either AFD (n = 9) or Vintene (V, n = 6). One day after surgery, corresponding to day 0 of the experiment and to the first day of full-strength total parenteral nutrition, the AFD and V group rats received an endotoxemic shock by intraperitoneal injection of lipopolysaccharide (Escherichia coli, 8 mg/kg). The rats were then studied over 3 days and compared with a healthy ad libitum-fed group (AL, n = 10). MEASUREMENTS AND MAIN RESULTS: The rats were weighed and urine was collected daily to determine nitrogen balance and 3-methylhistidine excretion. On day 3, the thymus, spleen, liver, intestinal mucosa, and muscles were weighed, and amino acids from plasma and tissues were analyzed. Lipopolysaccharide caused the classic endotoxemic shock, of similar intensity in the V and AFD groups (V and AFD not equal AL, p < .05): no weight gain, decreased nitrogen balance (day 3, AL 558 +/- 21, V 83 +/- 28, AFD 123 +/- 25 mg N/day), increased urinary 3-methylhistidine/creatinine excretion (day 3, AL 51 +/- 2, V 91 +/- 13, AFD 87 +/- 14 mumol/mmol), soleus (V -15% and AFD -26 % vs. AL) and thymus atrophy (V -36% and AFD -33%), and spleen hypertrophy (V 51% and AFD 83%). Compared with V solution, AFD has a reduced content of some essential amino acids and proline and an elevated content of glycine, aspartate, and glutamate. These differences were not reflected in tissue or plasma amino acids, except for plasma glycine, which in the AFD group was restored to the level of the AL group (AL 426 +/- 12 and AFD 379 +/- 50 vs. V 251 +/- 31 mumol/L, p < .05). CONCLUSIONS: In endotoxemic rats, the nutritional effects of a glycine-rich AFD solution are similar to those of a standard amino acid solution for parenteral nutrition.     

Effective use of third generation fat emulsion in total parenteral nutrition program in patients with severe sepsis

The aim of the current research was to measure the clinical efficacy of 3rd generation fat emulsion in the program of complete parenteral nutrition of patients with severe sepsis. The work demonstrates the results of treatment of 25 patients with severe sepsis divided into 2 groups depending on the way of parenteral nutrition. In the 1st group (13 patients) the parenteral nutrition was carried out by 20% glucose, 15% solution of crystallic aminoacids and 20% of 2nd generation fat emulsion. In the 2nd group (12 patients) parenteral nutrition was carried out by 20% glucose, 15% solution of crystallic aminoacids and 20% of 3rd generation fat emulsion. The parenteral nutrition of Ist and 2nd group contributed to the correction of hypermetabolism syndrome and stabilization of the nutritive status parameters. It was observed that the parenteral nutrition used in the 2nd group showed statistically higher positive effect on the parameters of systemic inflammation and cellular part of immunity, rather than parenteral nutrition used in the 1st group. It is revealed that, the used methods of complete parenteral nutrition in patients with severe sepsis effectively eliminate the hypermetabolism syndrome. Parenteral nutrition of patients with severe sepsis by 3rd generation fat emulsion has a positive effect of parapeters of systemic inflammation.     

Use of 20% fat emulsion in total parenteral nutrition

Sixteen elderly postoperative patients were randomized in a crossover study comparing isocaloric volumes of 20% and 10% fat emulsions used for total parenteral nutrition (TPN). The caloric intake was maintained constant during the two 7-day periods of each infusion. The indices measured after each period were total volume of fluid administered, change in body weight, hematocrit, serum sodium, creatinine, albumin, blood urea nitrogen, glucose, inorganic phosphate, and cholesterol. The total volume of 10% isocaloric nutrient solution was significantly (p less than .05) greater than that of the 20% solution. A rise in body weight and a fall in serum indices of hydration status were observed; five patients developed clinical signs of overhydration while on the 10% solution. These changes did not occur with the 20% solution. Thus, isocaloric substitution of a 20% fat emulsion for a 10% fat emulsion with TPN prevented overhydration and hemodilution without compromising nutrient intake.     

Behavior of the serum fatty acid patterns during administration of an MCT-containing fat emulsion

After a continuous intravenous 3-hour infusion of 500 ml fat emulsion containing MCT, composed of 25 g soybean oil and 25 g MCT oils, there was an infusion-induced increase of all fatty acids administered. The medium-chain fatty acids (C8-C12) revealed ideal steady-state conditions and were quickly eliminated after the infusion. The reaction of linoleic acid (C18:2) was not as favorable. Linoleic acid increased steadily during the infusion, and its elimination rate from the serum was delayed.     

Home parenteral nutrition for the child with cancer

Compliance with treatment is greatly increased when the caregiver(s) understand the treatment, the need for the treatment, and the need for strict adherence to sterile technique. When the caregiver is not ready to handle home care of the child, compliance is less than optimal and may be a threat to the child. Parenteral nutrition support can be both safe and effective in children with cancer when the family and health-care team work together. Nutrition support facilitates treatment of the whole child and can help improve his or her quality of life.