bluuebunny/crossref_metadata_2025 huggingface dataset:
Nutritional Support Team vs Nonteam Management of Enteral Nutritional Support in a Veterans Administration Medical Center Teaching Hospital
Authors: Powers Douglas A. , Brown Rex O. , Cowan George S.M. , Luther R. Wayne , Sutherland David A. , Drexler P. Gregory
Published: May 2008

One hundred one patients receiving enteral nutritional support (ENS) by tube feeding during a 5‐month period were prospectively studied. Fifty patients were managed by a nutritional support team (T) and 51 patients were managed by the nonteam approach (NT). Demographics, primary diagnosis, chronic diseases, medical service, calculated basal energy expenditure (BEE), duration of ENS, and final patient disposition were recorded. Enteral formula, formula modifications, results of laboratory tests and calories delivered were obtained daily. Results of nitrogen balance studies were obtained when available and each patient was monitored for pulmonary, mechanical, gastrointestinal, and metabolic abnormalities.

No significant difference was found between the team and nonteam managed groups in regard to total feeding days, mean feeding days per patient, total laboratory tests, laboratory tests per patient or laboratory tests per day. Significantly more team patients attained 1.2 times BEE (T = 47, NT = 38, p < 0.05) for a significantly greater period of time (T = 398 days, NT = 281 days, p < 0.05). Significantly more team patients achieved a measured positive nitrogen balance than nonteam patients (T = 42, NT = 1, p < 0.05). Formula modifications to correct nutritional or metabolic aberrations were made in 15 (30%) team patients and five (9.8%) nonteam patients (p < 0.05).

The number of individual abnormalities (pulmonary, mechanical, gastrointestinal, and metabolic), as well as total abnormalities occurring in the team‐managed group, was significantly lower than in the nonteam managed group (160 us 695, p < 0.05). The results of the study indicate that team‐managed enteral nutritional support reduced abnormalities and is nutritionally more efficient when compared to a nonteam approach. (Journal of Parenteral and Enteral Nutrition 10:635–638, 1986)
A Model for the Prediction of Osmolalities of Modular Formulas
Authors: Anderson Kathryn , Kennedy Barbara
Published: May 2008

A model is proposed for evaluation of osmolality of multicomponent formulas composed of modular ingredients. Nonlinear curve‐fitting techniques applied to empirical data result in prediction of the osmolality of ingredients for any concentration desired. Osmolality of a multicomponent formula can be obtained by adding osmolalities of ingredients. Data handling is made possible by the use of simple microcomputer programs. The model is tested with products available for construction of amino acid‐restricted diets. (Journal of Parenteral and Enteral Nutrition 10:646–649, 1986)
Rabbit Care Unit for Intravenous Feeding and Metabolic Studies
Authors: Haukipuro Kari , Harju Esko
Published: May 2008

A simple rabbit care unit for peripheral intravenous feeding and metabolic studies was developed. The unit consists of six aluminum boxes with a common cover. Inverted T‐shaped mobile supports hanging from the upper horizontal part of a frame hold the infusion lines. The side walls of the box prevent the rabbit from turning around, but other movements are possible. After initial training with 21 surgically treated animals, there was only one early anesthetic death among the subsequent 21 rabbits (4.8%). There was one late death (4.8%), and one animal was slightly, and two animals clearly, deteriorated. The ear vein cannula had to be changed in one‐third of the animals not more than 3 days from the outset. Problems associated with the infusion systems or urinary bladder catheterization were minor. The results showed that it is practical to infuse rabbits via a peripheral intravenous route in a semi‐restraining metabolic unit. The cases of late death and deterioration can be explained in part by the stress of experimental conditions with starvation and surgery, rather than by the effect of the metabolic unit alone. With previous experience in treating rabbits, we find the period required to learn this technique is short. (Journal of Parenteral and Enteral Nutrition 10: 670–672, 1986)
Energy expenditure and motor activity in rats receiving total parenteral nutrition
Authors: Popp MB , Brennan MF , Morrison SD
Published: May 2008

Rats with intravascular catheters connected to infusion systems are frequently used in the investigation of nutritional and metabolic problems. Although the animal is often referred to as “unrestrained,” there is no information on the effect of the catheter assembly or total parenteral nutrition (TPN) on total (TEE), activity (AEE), and resting (REE) energy expenditure (TEE = REE + AEE). Male Fischer 344 rats were studied in an analytical respiration calorimeter. Normal unoperated rats, aseptically catheterized orally fed rats from postoperative day 1 to 7, and TPN rats were studied. Orally fed catheterized rats had weight loss, negative nitrogen balance, negative energy balance, elevated REE, and normal AEE during the first 4 postoperative days. Their weight gain, positive nitrogen balance, AEE, and REE were almost identical to those of normal rats over postoperative days 5 through 7. REE and AEE in TPN rats were similar to values in normal rats. These data indicate that catheter operation and TPN cause no abnormality in AEE and REE if adequate time is allowed for recovery from catheter operation and strict attention is given to asepsis.
Nutritional effectors of hepatic steatosis induced by parenteral nutrition in the rat
Authors: Keim NL
Published: May 2008

The relative importance of three nutritional variables, nonprotein energy level, glucose‐lipid calorie distribution and amino acid nitrogen level, in contributing to the steatosis that develops during a short course of parenteral nutrition was studied in intravenously fed rats. Eight infusates were tested that contained various combinations of glucose, lipid emulsion and amino acids. The infusate nonprotein energy level was the predominant effector of liver lipid content. The excessive energy level was associated with significant increments in steatosis, ranging from a 26% increase for high‐fat, adequate‐nitrogen infusates to a 95% increase for low‐fat, adequate‐nitrogen infusates. An interaction of amino nitrogen level and glucose‐lipid calorie distribution also affected the severity of steatosis. The steatosis observed with inadequate‐nitrogen infusates was accentuated in combination with the high‐fat calorie distribution and was attenuated with the low‐fat calorie distribution. The most striking effect of nitrogen inadequacy was a 3‐fold increase in liver lipid content with the excessive calorie, high‐fat infusates. The infusate that minimized steatosis provided energy and nitrogen at adequate levels and was low in fat content. This infusate also led to liver lipid composition and plasma lipid levels that most closely resembled those of rats fed stock diet.
Enteral nutritional support management in a university teaching hospital: team vs nonteam
Authors: Brown RO , Carlson SD , Cowan GS , Powers DA , Luther RW
Published: May 2008

Current hospital cost containment pressures have prompted a critical evaluation of whether nutritional support teams render more clinically effective and efficient patient care than nonteam management. To address this question with regard to enteral feeding, 102 consecutive hospitalized patients who required enteral nutritional support (ENS) by tube feeding during a 3 1/2‐month period were prospectively studied. Fifty patients were managed by a nutritional support team; the other 52 were managed by their primary physicians. Choice of enteral formula, formula modifications, frequency of laboratory tests, and amounts of energy and protein received were recorded daily. In addition, each patient was monitored for pulmonary, mechanical, gastrointestinal, and metabolic abnormalities. Team‐managed (T) and nonteam‐managed (NT) patients received ENS for 632 and 398 days, respectively. The average time period for ENS was significantly longer in the team‐managed patients (12.6 +/‐ 12.1 days vs 7.7 +/‐ 6.2 days, p less than 0.01). Significantly more of the team patients attained 1.2 X basal energy expenditure (BEE) (37 vs 26, p less than 0.05). Total number of abnormalities in each group was similar (T = 398, NT = 390); however, the abnormalities per day were significantly lower in the team group (T = 0.63 vs NT = 0.98, p less than 0.01). Mechanical (T = 0.05 vs NT = 0.11, p less than 0.01), gastrointestinal (T = 0.99 vs NT = 0.14, p less than 0.05), and metabolic (T = 0.49 vs NT = 0.72, p less than 0.01) abnormalities per day all were significantly lower in the team‐managed patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Aminoglycoside serum concentration sampling via central venous catheters: a potential source of clinical error
Authors: Franson TR , Ritch PS , Quebbeman EJ
Published: May 2008

Two patients receiving aminoglycosides via central venous Silastic catheters were noted to have serum drug concentrations markedly divergent from expected results. Study of these patients, and of four additional patients prospectively selected for study, demonstrated that three of five patients had higher peak and/or trough aminoglycoside serum concentrations‐‐when blood was obtained from the central venous catheter‐‐than were contained in simultaneous samples from peripheral blood; these divergent results were noted after the catheter had been in use for more than 1 week; divergent results were not improved by additional catheter flushing prior to central venous blood sampling. These observations suggest that spurious aminoglycoside serum concentration results may sometimes be obtained when blood sampling is performed from central venous Silastic catheters, and can result in improper drug dosage alterations. It is necessary to access the timing, processing, and reliability of serum drug‐monitoring practices on a routine basis to preclude such problems, and to reassess individual patient‐monitoring studies which are inconsistent with anticipated results.
Colocutaneous fistula: an unusual complication of percutaneous endoscopic gastrostomy
Authors: Saltzberg DM , Anand K , Juvan P , Joffe I
Published: May 2008

We describe an unusual complication of percutaneous endoscopic gastrostomy, the formation of a colocutaneous fistula. The complication resulted from penetration of both the colon and stomach at the time of catheter placement. This problem went unrecognized for several months until the feeding catheter was removed, and its replacement could be advanced only as far as the colon. Complications of percutaneous endoscopic gastrostomy are reviewed, and the problem of gastrocolic fistula formation secondary to gastrostomy placement is discussed.
Effect of Alanine Infusion on Glucose and Urea Production in Man
Authors: Wolfe Robert R. , Jahoor Farook , Shaw James H.F.
Published: May 2008

We have tested the response to a primed constant infusion of alanine (2 mg/kg·min infusion, 120 mg/kg prime) on glucose and urea kinetics in overnight fasted volunteers by using primed‐constant infusions of 6,6‐d2‐glucose and15N2‐urea. When no alanine was infused, plateaus in glucose and urea concentration and enrichment were maintained for the final 3 hr of a 4‐hr infusion of tracers. When alanine was infused over the final 2 hr of a second protocol, urea enrichment decreased significantly, indicating an increase in urea production from 4.4 ± 0.31 to 7.0 ± 0.63 μmol/kg·min. This corresponded to a potential increase in gluconeogenesis from alanine of 20%. Nonetheless, the alanine infusion had no significant effect on either the plasma concentration or enrichment of glucose, which means that hepatic glucose output was not affected. We conclude, therefore, that increasing gluconeogenic precursor availability does not stimulate hepatic glucose output in overnight‐fasted man. (Journal of Parenteral and Enteral Nutrition 11:109–111, 1987)
Reversibility of Elemental Liquid Diet‐Enhanced Methotrexate Toxicity by Refeeding with Chow
Authors: Harvey Lillian P. , McAnena Oliver J. , Mehta Bipin M. , Daly John M.
Published: May 2008

The toxic effects of methotrexate administration [20 mg/kg, bolus intraperitoneally (ip)] to rats fed a regular chow diet (n = 10) was compared with results in animals fed an elemental, chemically defined, liquid diet (n = 10) for 7 days. All animals receiving an elemental diet became anorectic and lethargic within 60 hr of methotrexate injection. All animals in this group subsequently developed enteritis and died within 150 hr. There was no clinical evidence of enteritis in rats fed a regular chow diet and mortality as zero in this group (p < 0.001). In a second study one group of rats (n = 9) was fed a regular chow diet for 7 days; four groups were fed an elemental, chemically defined, liquid diet (n = 9 per group) for 7 days. At 24 hr and 8 hr prior to, or 24 hr after methotrexate administration, one group was refed a regular chow diet; the fourth group was maintained on an elemental liquid diet throughout the study period. All rats fed a regular chow diet survived following methotrexate injection (20 mg/kg, ip). All rats fed an elemental diet throughout the study period died. Those rats refed a regular diet 24 or 8 hr prior to methotrexate injection demonstrated a significant improvement in survival (100% in the 24‐hr group, 55% in the 8‐hr group). However, those animals refed a regular diet 24 hr after methotrexate injection demonstrated a 100% mortality.

A similar study evaluated changes in plasma and bowel methothrexate levels in rats refed either 24 hr or 8 hr prior to 24 hr after methotrexate administration. Serum and bowel tissue methotrexate levels were significantly elevated in rats refed 24 hr after methotrexate injection compared with the other groups.

The administration of an elemental, chemically defined liquid diet to rats results in a marked increase in mortality from severe enteritis following methotrexate administration compared with regular chow diet fed animals. These animals demonstrated delayed clearance of methotrexate from serum and from small intestine tissue. This enhanced toxicity is readily reversible by refeeding a regular diet to these animals within 24 hr prior to methotrexate injection. Elemental, chemically defined liquid diets do not afford protection to the gastrointestinal mucosa from the toxic effects of methotrexate. (Journal of Parenteral and Enteral Nutrition 11: 119–123, 1987)
Vitamin D Requirement in Infants Receiving Parenteral Nutrition
Authors: Koo Winston W.K. , Tsang Reginald C. , Steichen Jean J. , Succop Paul , Oestreich Alan E. , Noseworthy John , Farrell Michael K.
Published: May 2008

The adequacy of low dose vitamin D (25 IU/dl) parenteral nutrition (PN) solution was studied in 18 infants. All infants had surgical indications for PN. The birth weights were 2810 ± 135 g and gestational ages 37.4 ± 0.5 wk (mean ± SEM). Duration of study ranged from 5 to 175 days. Thirteen infants were studied for up to 6 weeks and five infants for 71 to 175 days. Results showed that studied infants maintained growth along normal percentiles for weight, length, and head circumference. Vitamin D status as indicated by serum 25 hydroxyvitamin D (25 OHD) rose from 15 ± 1.9 ng/ml to 26 ± 2.8 ng/ml, mean ± SEM (p < 0.001) after 9 days, and remained normal up to 6 months. Five infants with biochemical liver dysfunction also had normal serum 25 OHD concentrations, indicating the hepatic 25 hydroxylation process was not severely impaired. Serum total and ionized calcium, phosphorus, and vitamin D‐binding protein concentrations were normal. Serum magnesium was mildly elevated in five infants (2.6 to 3 mg/dl) on one occasion and resolved spontaneously. Serum alkaline phosphatase (AP) concentrations rose above baseline values in 12 of 17 infants, but remained within normal range (<400 IU/liter at 30°C). Another infant with markedly elevated AP values died from liver dysfunction. Radiographs of the forearms were normal except for marked demineralization in one infant in spite of normal 25 OHD concentrations. We conclude that 25 IU vitamin D/dl of nutrient infusate is adequate to maintain normal vitamin D status, as indicated by normal serum 25 OHD concentrations in infants receiving PN for as long as 6 months. (Journal of Parenteral and Enteral Nutrition 11:172–176, 1987)
Compatibility of Medications with Enteral Feedings
Authors: Holtz Lee , Milton John , Sturek Jorja K.
Published: May 2008

Administration of medications to patients with nasogastric tubes has traditionally been done in a bolus fashion. An alternative to this would be to mix the medications in the continuous drip enteral feeding with subsequent continuous administration. The purpose of this study was to determine the compatibility of select medications with Ensure, Ensure Plus, and Osmolite. We observed neither visible abnormalities in the mixtures nor change in pH of the enteral products after the addition of digoxin, theophylline, phenytoin, methyldopa, or furosemide. The addition of theophylline to all three enteral products caused a substantial increase in the osmolality. We also examined the concentrations of the mixtures to detect any changes occurring over the 12‐hr infusion time. A wide variation in concentrations after the addition of phenytoin suspension was corrected by adding the injectable form to the enteral products. Digoxin and furosemide concentrations were essentially unchanged; however, the methyldopa concentration decreased up to 23% over the 12‐hr study period. We, therefore, cannot recommend the addition of theophylline, phenytoin suspension, or methyldopa to the three enteral products tested. (Journal of Parenteral and Enteral Nutrition 11:183–186, 1987)
Treatment Effects of Parenteral Vitamins in Total Parenteral Nutrition Patients
Authors: Dempsey Daniel T. , Mullen James L. , Rombeau John L. , Crosby Lon O. , Oberlander June L. , KNox Linda S. , Melnik George
Published: May 2008

To determine the prevalence of abnormal vitamin levels in an adult hospitalized population requiring total parenteral nutrition (TPN) and to assess the effect of routine parenteral vitamin therapy on vitamin levels, we studied 35 general surgical patients. Assays for 12 vitamins were performed both before and after a standard 10‐day course of TPN. Patients were given nothing by mouth. The first 25 patients received a daily parenteral vitamin mixture tailored to the recommendations of the Nutrition Advisory Group of The American Medical Association (maintenance dose). The final 10 patients were given a parenteral multivitamin dose providing substantially greater amounts of most vitamins (repletion dose). Only 58% (190/324) of pre‐TPN vitamin levels were normal, 25% were low, and 17% were high. No patient had fewer than two abnormal baseline levels. Vitamin levels did not correlate with serum albumin, body weight, or nitrogen balance. After 10 days of treatment, only 39% of low pre‐TPN vitamin levels improved; most (45/62) of the low posttreatment levels were low at baseline. The higher repletion dose resulted in a significantly (p < 0.01) greater percent increase in vitamin A, C, and pyridoxine levels.

The prevalence of abnormal vitamin levels in this population is high (42%). Standard parenteral vitamin therapy leads to marginal improvement in abnormally low pre‐TPN vitamin levels. (Journal of Parenteral and Enteral Nutrition 11:229–237, 1987)
Maintenance of Vitamin and Trace Element Status in Intravenous Nutrition using a Complete Nutritive Mixture
Authors: Shenkin A. , Fraser W.D. , McLelland A.J.D. , Fell G.S. , Garden O.J.
Published: May 2008

Complete nutritive mixtures (CNM) of all intravenous nutrients including fat emulsions are being used increasingly because of their convenience. However, this may lead to chemical interactions and reduce the amount of active vitamins and trace elements made available to the patient. We have studied the effects on micronutrient status of provision of all nutrients in one 3‐liter bag (CNM: amino acids, dextrose, Intralipid 20%, a nine‐element trace metal mixture, and complete fat‐ and water‐soluble vitamin mixtures) in 10 postoperative surgical patients [median intravenous nutrition (IVN) 14.5 days, range 7–38]. A similar group received the fat emulsion plus water‐ and fat‐soluble vitamins as a separate infusion (SI) from a 3‐liter bag (median IVN 14.0 days, range 8–28). Serum and urine magnesium, zinc, copper, manganese, chromium, and selenium, serum vitamins A, E, C, folate, and B12, RBC B1, B2 B6, and folate and leukocyte vitamin C were measured at weekly intervals. All patients in both groups maintained or improved their status for all the micronutrients analyzed. No significant differences between the CNM and SI groups were found in blood concentrations of any of the elements or vitamins. Only for urine copper did the CNM lead to increased excretion (1.51 ± 0.59 μmol/24 hr; copper input 20 μmol/day), compared to SI (1.00 ± 0.70 μmol/day, p < 0.001 Mann‐Whitney test) suggesting possible interaction. It is concluded that micronutrient status was maintained during short‐term IVN with the CNM and that it did not lead to a significantly greater loss of vitamins or essential trace elements than the SI system. (Journal of Parenteral and Enteral Nutrition 11: 238–242, 1987)
Effect of Enteral Nutrition on Human Pancreatic Secretions
Authors: Grant John P. , Davey‐Mccrae Joann , Snyder Phyllis J.
Published: May 2008

The influence on pancreatic secretion of four enteral feeding products was evaluated in a unique patient with an isolated duodenal fistula for whom enteral feeding access was obtained via a gastrostomy with a small Silastic catheter passed through the gastrostomy and through a surgically created gastrojejunostomy. The patient was totally supported by intravenous nutrition during the study. Each enteral feeding solution was administered at full strength at 50 ml/hr for 2 days with a 24‐hr collection of pancreatic secretions by the duodenal cutaneous fistula taken on the second day Infusion of the enteral feeding solutions did not alter volume of fistula drainage. All solutions decreased bicarbonate and amylase secretion but increased lipase and total nitrogen excretion. From this study, it would appear reasonable to administer Vivonex HN and Criticare HN via the jejunum in patients with pancreatic disease, whereas Osmolite would appear less satisfactory, due to its much stronger stimulation of lipase secretion. (Journal of Parenteral and Enteral Nutrition 11: 302–304, 1987)
Cardiac Tamponade in a Newborn: A Complication of Hyperalimentation
Authors: Sullivan Cornelius A. , Konefal Stanley H.
Published: May 2008

Perforation of the heart by central venous catheters is an uncommon but life‐threatening complication in the neonatal age group. Prevention requires an open insertion technique, the use of soft Silastic catheters, and the maintenance of the catheter tip above the right atrium. Rapid clinical deterioration with signs of tamponade suggests the diagnosis. Catheter withdrawal, early pericardiocentesis, and pericardiotomy with myocardial repair in selected cases contribute to survival. (Journal of Parenteral and Enteral Nutrition 11:319–321,1987)
Effect of Amino Acid Solutions on Total Nutrient Admixture Stability
Authors: Barat Agnes C. , Harrie Kathleen , Jacob Mary , Diamantidis Thomas G. , Mcintosh Norma L.
Published: May 2008

The stability of total nutrient admixture (TNA) systems containing a soybean oil emulsion (Soyacal) has been reported with only one amino acid (AA) solution. This study was conducted to compare the physical stability of 10 TNA systems varied only by the AA solution used. All systems contained electrolytes, vitamins, trace elements, and heparin. The volume ratios of AA, dextrose 70% and lipid emulsion 20% were 1:1:1. Solutions were stored at 4°C for 14 days and then held at ambient temperature for an additional 4 days. Each TNA was serially analyzed on days 0, 1, 3, 5, 7, 14, 15, 16, 17, and 18 for gross visual appearance, pH, osmolality, mean particle diameter, and particle size distribution. The AA solutions evaluated include: Travasol 8.5% and 10%; Aminosyn 8.5% and 10%, Aminosyn RF 5.2%; FreAmine III 8.5% and 10%; FreAmine HBC 6.9%; HepatAmine 8.0%; and NephrAmine 5.4%. The pH values of the Aminosyn solutions were lower than those of other products; however, the pH values of all TNA systems were >5.7, which supported particle stability. The osmolality was not affected by the AA solutions. Based upon particle size distribution, 95% of all particles were <0.608 μm in diameter, with means ranging from 0.286 μm to 0.309 μm. The largest particle observed by light microscopy was 6.9 μm. These data indicate that TNA systems prepared with the 10 AA solutions and Soyacal 20% are physically stable. (Journal of Parenteral and Enteral Nutrition 11:384–388, 1987)
The Effect of Vitamin B6 Deficiency on Food Intake, Growth, and Renal Function in Chronically Azotemic Rats
Authors: Wolfson Marsha , Kopple Joel D.
Published: May 2008

Chronically uremic patients appear to have an increased nutritional requirement for vitamin B6, and vitamin B6 deficiency occurs frequently when such individuals do not receive supplements of this vitamin. Since manifestations of vitamin B6 deficiency in renal failure are not well defined, this study examined two aspects of the chronic renal failure syndrome which might be influenced by vitamin B6: impaired growth and progressive loss of renal function. We examined food intake, weight gain, the food efficiency ratio, degree of azotemia, and renal function in chronically azotemic rats pair‐fed for 6 weeks either a vitamin B6‐deficient diet or a diet containing a surfeit of vitamin B6. In the azotemic vitamin B6deficient rats, as compared to the azotemic B6‐replete rats, there was evidence of reduced appetite, decreased weight gain, a lower food efficiency ratio, increased azotemia, and a reduced glomerular filtration rate as estimated from the urea clearance or the mean of the urea and creatinine clearances. These findings suggest that vitamin B6 deficiency may contribute to decreased food intake, reduced growth, and lower renal function in animals with chronic renal insufficiency. (Journal of Parenteral and Enteral Nutrition 11:398–402, 1987)
Reversal of Severe Serous Atrophy of the Bone Marrow in Anorexia Nervosa
Authors: Steinberg Stephen E , Nasraway Stanley , Peterson Loann
Published: May 2008

The patient described in this case report had anorexia nervosa, which ultimately was fatal. She presented with complete serous atrophy of the bone marrow associated with pancytopenia. After 2 weeks of intensive nutritional support, her peripheral blood counts had returned to normal. At autopsy on day 24, the serous atrophy had resolved and the bone marrow was populated by normal numbers of hematopoietic precursors. This case is unique in demonstrating that starvation‐induced severe serous atrophy of the bone marrow is reversible with nutritional intervention. (Journal of Parenteral and Enteral Nutrition 11:422–423, 1987)
Predicting Nutrition‐Associated Complications for Patients Undergoing Gastrointestinal Surgery
Authors: Detsky Allan S. , Baker Jeffrey P. , O'Rourke Keith , Johnston Nancy , Whitwell Jocelyn , Mendelson Rena A. , Jeejeebhoy Khursheed N.
Published: May 2008

We studied 202 patients admitted to two major teaching hospitals for planned gastrointestinal surgery to assess the ability of several techniques of nutritional assessment to predict major postoperative complications (infection and/or wound problems). Subjective global assessment (SGA) and albumin were both of predictive value, and combinations of these variables were useful in differentiating low‐risk from high‐risk patients. Transferrin, creatinine‐height index, percent ideal weight, percent body fat, and total lymphocyte count were not useful in predicting complications.

We conclude that SGA and albumin are useful “nutritional assessment techniques” for patients undergoing major gastrointestinal surgery if the purpose of such an assessment is to predict postoperative “nutrition‐associated complications.” The second major finding of this study was the unexpectedly low rate of complications (10%) which was found in both hospitals. We suggest that these low complication rates may be more generalizable to patient populations derived from a wide community base, rather than those described in other studies in which veterans or patients of lower socioeconomic status comprised the sample. (Journal of Parenteral and Enteral Nutrition 11:440–446,1987)
Enteral and Parenteral Branched Chain Amino Acid‐Supplemented Nutritional Support in Patients with Encephalopathy Due to Alcoholic Liver Disease
Authors: O'Keefe S. J. D. , Ogden J. , Dicker J.
Published: May 2008

The effects of branched chain amino acid (BCAA)‐enriched diets (fed for 7 days) on encephalopathy, plasma amino acid concentrations, aromatic amino acid turnover, and protein synthesis rates were determined in eight patients with alcoholic liver failure. Four patients were given the diet intravenously (iv group) (total amino acids, 60–80 g/day, BCAA content 51%, energy 2000 kcal/day) and four patients (NG group) were given a semi‐elemental formulation via constant nasogastric (NG) infusion (amino acids 58 g, BCAA 43%, oligopeptides 19.5 g, energy 2000 kcal/day). The enteral diet was given at one‐half strength for the first 3 days. A 10‐hr constant infusion of [U‐14C]phenylalanine tracer was used in four patients to measure aromatic amino acid (AA) turnover and rates of incorporation into various body proteins. Seven of the eight patients made a good clinical recovery, with reversal of encephalopathy within 3 days of dietary intervention. One became septicemic and deteriorated. While plasma bilirubin concentrations dropped, liver enzymes remained elevated. Mean nitrogen balance was negative at the beginning and positive at the end of the study, in both groups. Initial amino acid profiles demonstrated low plasma BCAA content and BCAA:AA ratios. Significant improvements occurred in the iv group by day 2 and in both groups by day 7. Isotope studies showed that, whereas aromatic amino acid oxidation remained unchanged, greater quantities were incorporated in whole body protein, albumin, transferrin, fibrinogen, and immunoglobulins. (Journal of Parenteral and Enteral Nutrition 11:447–453, 1987)
Effects of Severity of Surgical Trauma on Whole Body Protein Turnover in Patients Receiving Total Parenteral Nutrition
Authors: Yamamori Hideo , Tashiro Tsuguhiko , Mashima Yoshiya , Okui Katsuji
Published: May 2008

This study was conducted to resolve discrepancies in the literature with regard to changes in protein metabolism following surgical stress. Twelve patients who had undergone abdominal surgery and six who were controls were studied. Whole body protein turnover was measured on the third and 10th postoperative day, during isonitrogenous and isocaloric total parenteral nutrition (TPN), by the method of constant infusion of [15N]glycine. Six patients who underwent abdominal surgery without any complications showed positive nitrogen balance on the 10th postoperative day (group I). However, nitrogen balance was still negative on the 10th postoperative day in another six patients who showed some critical complications after abdominal surgery (group II). A significant increase in whole body protein breakdown was seen in groups I and II on the third postoperative day (p > 0.02, p > 0.01, respectively), compared with control. Breakdown was greater in group II (p > 0.05) than in group I. Protein synthesis tended to increase in group II, whereas in group I, it was at the same level as control. It was concluded that protein synthesis was unchanged in moderate stress, concomitant with increment of breakdown, but it tended to increase with a greater increase of breakdown in severe stress. (Journal of Parenteral and Enteral Nutrition 11:454–457,1987)
Plasma and Erythrocyte Amino Acid Concentrations in Anorexia Nervosa
Authors: Halmi Katherine A. , Struss Andrea L. , Owen William P. , Stegink Lewis D.
Published: May 2008

Plasma and erythrocyte amino acid concentrations in seven female patients in the acute stage of anorexia nervosa were compared with values in the same subjects after refeeding, and with normal controls. We also compared these values with literature values from patients with protein‐calorie malnutrition and prolonged starvation in an attempt to identify a biological indicator of severity and prognosis. Our data indicate: (1) Routine laboratory analyses that reflect protein status do not differentiate normal subjects from patients with anorexia nervosa. (2) The plasma aminogram in the acute stage of anorexia nervosa differs from normal, and differs from values reported for both protein malnutrition and prolonged starvation. (3) The Whitehead ratio clearly separates the acutely ill anorectic state from the treated state and from normal controls. (4) Both erythrocyte and plasma amino acid concentrations differ from normal in anorexia nervosa, but changes in erythrocyte concentrations are more obvious. (5) Erythrocyte glycine concentrations are unique, in that values were persistently elevated at all stages of illness in anorexia nervosa. (6) Erythrocyte‐to‐plasma amino acid ratios do not provide a biological index of severity and prognosis for patients with anorexia nervosa, in contrast to data reported for individuals with protein malnutrition. (Journal of Parenteral and Enteral Nutrition 11:458–464,1987)
Multiple Nutritional Deficiencies and Metabolic Complications 20 Years after Jejunoileal Bypass Surgery
Authors: Bradley Jane E. , Brown Rex O. , Luther R. Wayne
Published: May 2008

We have reported a patient with multiple nutritional and metabolic abnormalities following JI bypass. Most of her biochemical abnormalities were corrected with cautious but vigorous supplementation, and her nutritional status improved, as documented by several positive nitrogen balances and normalization of most of her vitamin and trace element serum concentrations. This case clearly demonstrates many of the metabolic complications that can result from the JI bypass procedure and the meticulous followup that is needed during nutritional rehabilitation. (Journal of Parenteral and Enteral Nutrition 11:494–498,1987)
Hickman Catheter Dislodgement Due to Pendulous Breasts
Authors: Moorman Donald W. , Horattas Mark C. , Wright Dennis , Kaufman Keith , Ruf Walter
Published: May 2008

Dislodgement of Hickman, Broviac, and Mediport catheters is a rare but recognized complication. To date, no specific etiology for this has been cited. We present five cases of dislodgement due to positional changes in large‐breasted women and one man with gynecomastia. Apparently, motion in the subcutaneous tissue secondary to gravitational forces on large breasts causes downward and outward traction on the subcutaneous portion of the catheter. Variations in placement technique to help avoid this complication are described. (Journal of Parenteral and Enteral Nutrition 11:502–504,1987)
A Method to Prevent Unintentional Removal of a Hickman Catheter
Authors: Vazquez Richard M. , Racenstein Michael J.
Published: May 2008

Many patients benefit from the use of tunneled Dacron‐cuffed central venous catheters. Operative insertion with the aid of fluoroscopy is required for the proper placement of these devices. Perioperative unintentional removal of the catheter is a reported complication. The outward migration of the device occurs before adequate tissue ingrowth into the Dacron cuff has taken place. The frequency with which this unfavorable outcome occurs can be reduced by placement of a subcutaneous absorbable restraining suture distal to the Dacron cuff during the insertion procedure. The authors advocate the routine use of this adjunctive measure for the insertion of all Dacron‐cuffed caval catheters. (Journal of Parenteral and Enteral Nutrition 11:509–510, 1987)
Adipose Tissue Response to Insulin following Injury
Authors: Rakinic Jan , Takimoto Glen , Barrett John A. , Lange Deborah A. , Robin Arnold P.
Published: May 2008

Derangements of posttraumatic glucose metabolism have long been recognized, with observed changes implicating abnormal action of insulin on target tissues. Insulin is important as well in fat metabolism, and “resistance” to insulin's effects on lipid metabolism after injury has been demonstrated. Although fat‐derived fuels are the body's major energy source during starvation and after injury, most studies of posttraumatic insulin “resistance” have focused on carbohydrate metabolism. This study investigated adipose tissue response to insulin in vitro in rats subjected to starvation and/or trauma. Relationships between various parameters, including adipocyte size and weight, plasma glucose, insulin, and glycerol, and basal and insulin‐suppressed lipolytic rates, were also studied. Results observed include a decrease in adipocyte size and an increase in basal lipolysis in both starved and traumatized rats, with both decreased sensitivity (T > S) and responsiveness (S > T) to insulin. These results support the concept that adipocytes of injured animals retain the ability to respond to insulin but lipolytic rates at maximal suppression are still quite high as compared to fed controls. Only minor differences were observed between starved animals and those with starvation and superimposed trauma. (Journal of Parenteral and Enteral Nutrition 11:513–520, 1987)
Continuous Nasoenteral Feeding: Inverse Relation Between Infusion Rate and Serum Levels of Bilirubin
Authors: Roongpisuthipong Chulaporn , Heymsfield Steven B. , Casper Katie , Hill James O.
Published: May 2008

The relation between nasoenteric formula caloric infusion rate and the serum bilirubin level was examined in 15 healthy subjects. The study protocol spanned 3 days and included fasting studies on day 1, continuous maintenance nasogasteric feeding of a formula diet on day 2, and continuous feeding at a rate twice the maintenance level on day 3. Blood studies were performed in the early morning of each day. Fifteen subjects underwent the fasting measurements and the maintenance infusion, while 11 underwent all 3 days of the protocol. With the maintenance infusion serum bilirubin fell from the fasting value of (X ± SD) 0.77 ± 0.53 to 0.63 ± 0.49 mg/dl for a reduction of 18% (p < 0.05). For the subgroup of 11 subjects receiving two levels of formula infusion, fasting and maintenance serum bilirubin levels were 0.81 ± 0.57 and 0.65 ± 0.47 mg/dl, respectively, (p < 0.05). With the twice maintenance infusion the plasma bilirubin decreased further to 0.46 ± 0.29 mg/dl, a decrement of 43% relative to fasting (p < 0.01). No other significant changes were detected during the protocol in the standard blood chemical and hematologic studies. Thus, the serum level of bilirubin is inversely related to the formula caloric infusion rate during continuous nasoenteric feeding. (Journal of Parenteral and Enteral Nutrition 11:544–546, 1987)
Effect of Parenteral Nutrition and Enteral Feeding on D‐Lactic Acidosis in a Patient with Short Bowel
Authors: Karton Mitchell , Rettmer Rebecca L. , Lipkin Edward W.
Published: May 2008

D‐Lactic acid can accumulate in blood in some patients with intestinal failure, leading to a clinical syndrome of severe acidosis and encephalopathy. The possible impact of parenteral nutrition on its clinical course has not been established. One patient with a severe short‐bowel syndrome supported by long‐term parenteral nutrition who suffered repeated episodes of ataxia and disorientation associated with elevated serum levels of D‐lactate was studied. Results demonstrated no impact of glucose‐ vs lipid‐based parenteral nutrition formulations on total acid production or serum D‐lactic acid levels, increased serum D‐lactate levels during administration of neomycin, but prompt resolution of both acidosis and clinical symptoms with discontinuation of oral intake. This study confirms the findings of other investigators that D‐lactic acidosis may be a significant, heretofore unappreciated complication in patients with severe short‐bowel syndrome, and that prompt resolution may be effected with abrupt discontinuation of oral intake. Furthermore, the present study suggests neither a detrimental nor a beneficial effect of parenteral nutrition on this syndrome. (Journal of Parenteral and Enteral Nutrition 11:586–589, 1987)
Total Parental Nutrition Using Conventional and Medium Chain Triglycerides: Effect on Liver Function Tests, Complement, and Nitrogen Balance
Authors: Dennison A.R. , Ball M. , Hands L.J. , Crowe P.J. , Watkins R.M. , Kettlewell M.
Published: May 2008

Conventional long chain triglyceride (LCT) was compared with a new emulsion containing 50% medium chain triglyceride (5% MCT/5% LCT) in a randomized cross‐over trial of 10 days duration. Plasma concentrations of albumin, prealbumin, the complement components C3 and C4, and pro‐thrombin times measured daily at 8 am, before lipid infusion, showed no progressive change during the 10 days of the trial, nor in each separate 5‐day period when LCT or MCT/LCT was infused. Aspartate transaminase and alkaline phosphatase activities were similar over the two periods. There was a significant increase (compared with preinfusion levels) in C3 and C4 levels after 5 hr of either lipid infusion. Nitrogen balance was improved, and plasma bilirubin levels were lower on the regimen containing MCT/LCT. (Journal of Parenteral and Enteral Nutrition 12:15–19, 1988)
Sterility Testing of Home and Inpatient Parenteral Nutrition Solutions
Authors: Bronson Michael H. , Stennett Douglass J. , Egging Paulette K.
Published: May 2008

The microbial contamination rate was compared for parenteral nutrition solutions prepared by patients for home use and by pharmacy personnel for inpatient use. Phase I validated the Ivex 0.22‐μm inline filter as a tool for microbiological testing by inoculating small numbers of organisms in 5% dextrose injection and testing for recovery. Phase II validated the same method for determining microbial contamination of total parenteral nutrition (TPN) solutions. Phase III compared inpatient and home TPN microbial contamination rates using the methodology validated in phase II.

Test organism inocula used in phase I and II were Candida albicans, Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pyogenes. All contaminated solutions in phase I showed visual turbidity within 48 hr, and all test organisms were recovered and identified.

All phase II‐contaminated TPN solutions showed visual turbidity after 96 hr, and all test organisms were recovered and identified.

One hundred postinfusion TPN samples were collected randomly during phase III from inpatient parenteral nutrition patients. Six patients and two hospitals participated in the study. None of the 44 home parenteral nutrition samples and none of the 56 inpatient TPN samples developed visible turbidity. Subcultures of each sample on blood agar were negative for microbial growth.

This described methodology offers an effective means to establish contamination rates of parenteral nutrition solutions after administration. (Journal of Parenteral and Enteral Nutrition 12:25–28, 1988)
Management of Catheter‐Related Infections in Pediatric Patients
Authors: Nahata Milap C. , King Denis R. , Powell Dwight A. , Marx Susan M. , Ginn‐Pease Margaret E.
Published: May 2008

Broviac catheters are commonly used to provide parenteral nutrition and access for infusion of blood products and drugs to pediatric patients. Sepsis is the most common serious complication of continued catheter use. Although removal of the catheter is generally recommended when it becomes contaminated, it may not be feasible to do so without compromising patient care. We evaluated the management of catheter‐related infections in pediatric patients with and without removal of catheter. Seventy‐seven episodes of catheter sepsis were evaluated in 61 pediatric patients; 24 were neonates and 37 were older children. The catheters were used for multiple purposes in 75% of cases. The most common microorganisms isolated were Staphylococcus epidermidis in 26%, Klebsiella pneumoniae in 9%, and Streptococcus viridans in 8% of cases; other pathogens included group D Enterococcus, Staphylococcus aureus, and Escherichia coli. Pseudomonas aeruginosa was isolated in four older children. Thirty‐five patients were treated with antibiotics without catheter removal. Thirty patients received appropriate antibiotic therapy based on the susceptibility data. Twenty‐six of these 30 patients responded within 5 days of therapy whereas the others required 15–39 days of treatment. Lack of response was mainly associated with the presence of abscess, immunocompromised status, and organisms P. aeruginosa and Candida albicans. Based on the sensitivity and minimum inhibitory concentration data, a combined regimen of gentamicin and vancomycin would be an effective initial therapy. These findings suggest that (1) catheter sepsis can be managed with appropriate antibiotics, and (2) when continued use of Broviac catheter is desired, a trial of antibiotic therapy should be attempted before catheter removal. (Journal of Parenteral and Enteral Nutrition 12:58–59, 1988)
Precipitate Analysis from an Indwelling Total Parenteral Nutrition Catheter
Authors: Stennett Douglass J. , Gerwick William H. , Egging Paulette K. , Christensen J. Mark
Published: May 2008

The composition of a precipitate obtained from a silastic right atrial catheter was determined. The precipitate was collected and washed with deionized water thoroughly before subjecting portions of it to organic and inorganic analysis.

Inorganic analysis was conducted using scanning electron microscopy and x‐ray spectroscopy for sodium, aluminum, silicone, sulfur, chlorine, and calcium. Phosphorus analysis was conducted by a commercial laboratory. Organic analysis was conducted by thin layer chromatography with cholesterol, phosphatidyl serine, phosphatidyl choline, phosphatidyl ethanolamine, and sphingomyelin as standards.

Silicone, calcium, and phosphorus and three organic compounds, which could not be conclusively identified, were found. The precipitate was most likely calcium phosphate intermixed with silicone oil lubricant and residual total parenteral nutrition (TPN) solution. This formed in the catheter at body temperature probably due to incomplete catheter flushing. (Journal of Parenteral and Enteral Nutrition 12:88–92, 1988)
Serum Carnitine Levels in Normal Individuals
Authors: Lambert M.E. , Shipley K. , Holbrook I. , Faragher E.B. , Irving M.H.
Published: May 2008

Serum carnitine levels have been measured in 178 samples from 75 normal volunteers. We report a wide range of values (10–70 μmol/liter and 8–74 μmol/liter for free and acetylated carnitine, respectively) and a distinct difference between the ranges for males and females (p < 0.001). There is also substantial, seemingly random fluctuation in any one individual's levels, when measured serially over several weeks. (Journal of Parenteral and Enteral Nutrition 12: 143–146, 1988)