摘要:

A 1987 report by the US Office of Technology Assessment (OTA),Life‐Sustaining Technologies and the Elderlydiscusses current utilization of tube feeding and total parenteral nutrition (TPN) for elderly people and the related issues of patient access to treatment, decision making practices, and quality of care. Factors that limit access for some elderly patients include negative attitudes of some health professionals about whether elderly people can benefit from tube feeding and TPN, lack of adequate nutritional standards for the elderly and lack of staff in some treatment settings who are trained and have enough time to assess nutritional status in elderly patients, and payment problems. Public controversy about life‐sustaining technologies for elderly people now focuses on decisions about withholding or withdrawal of tube feeding, but debate about the legal and ethical issues involved in these decisions tends to obscure the relevant clinical considerations. Research issues and clinical practice concerns related to decision making and quality of care for elderly patients on tube feeding and TPN are discussed. (Journal of Parenteral and Enteral Nutrition12:425–432, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005425

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

We have determined iostopically the effect of either glucose or lipid infusion on rates of glucose turnover, glucose oxidation, and net protein catabolism (NPC) in three groups of surgical patients. Kinetic measurements were performed using the primed constant infusion of3H‐glucose, and either14C‐glucose or “C‐urea. The three groups included patients with: (1) sepsis and/or trauma (ST); (2) upper gastrointestinal cancer (UGI); (3) lower gastrointestinal cancer (LGI). In each patient group the effect of either glucose infusion (approximately 4 mg/kg·min) or lipid infusion (20% Intralipid lipid emulsion infused to provide calories approximately iso‐caloric to the glucose infusion) was assessed.The infusion of calories as either glucose or lipid was equally effective as a means of suppressing NPC in each individual patient group, and the degree of response was governed by the clinical disease state. In the LGI and ST patients the infusion of either glucose or fat resulted in a significant suppression of NPC (p<0.005) of approximately 15%. However, the ongoing rate of NPC that occurred despite substrate infusion was more than twice as great in the ST patients as in the LGI patients. In contrast to what was seen in the ST and LGI patients, in the UGI patients neither glucose infusion nor lipid infusion significantly decreased NPC.Glucose infusion resulted in at least a 55% suppression of endogenous glucose production in all three groups studied. In contrast, lipid infusion had only a minor effect on glucose metabolism: lipid infusion did not significantly decrease the rate of glucose oxidation in any of the patient groups, and although lipid infusion was associated with a decrease in glucose production in all groups, this effect was minor (<9% suppression).The major hormonal response following glucose infusion was a significant increase in the plasma insulin level (plasma cortisol levels did not change), although in contrast lipid infusion did not significantly alter the plasma insulin level, but serum cortisol decreased significantly.We conclude from these studies the following: (1) “calorie for calorie,” glucose and lipid are equally effective in decreasing NPC in severely ill patients; (2) following glucose infusion, the plasma insulin level increased, and serum cortisol levels did not change, whereas in response to lipid infusion plasma insulin levels did not change and the plasma cortisol level decreased. (3) In contrast to the profound effect of glucose infusion to suppress free fatty acid appearance and utilization, lipid infusion has a minor inhibitory effect on both glucose production and glucose oxidation. (Journal of Parenteral and Enteral Nutrition12:433–440, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005433

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

The effect of a protein‐free diet (PF) or a restricted intake of chow (RI) and subsequent host repletion with total parenteral nutrition (PF‐TPN, RI‐TPN) on tumor growth and polyamine metabolism of fibrosarcoma‐bearing rats was examined. Host weight was significantly reduced by PF and RI. Tumor growth was reduced in malnourished rats with the PF regimen resulting in the greatest decrease. Rats receiving TPN after 14 days of the RI or PF regimens had higher host weight and plasma albumin levels than malnourished rats. Tumor growth during TPN was evaluated as the percent increase and compared with that of the respective malnourished rats. The percent increase for RI‐TPN rats was significantly greater although a trend toward an increase was also evident for PF‐TPN rats. Tumor ornithine decarboxylase (ODC) activity and putrescine levels were increased for PF rats and decreased for RI rats while tumor ODC activity was consistently increased by TPN. Tumor growth, ODC activity, and putrescine levels were simultaneously increased only for those rats fed the RI regimen prior to TPN. These results show a disparity in tumor ODC activity, putrescine levels, and tumor growth in malnourished rats. The results of this study suggest that the nutritional origin of cachexia influences the response of the tumor to TPN and emphasizes the importance of considering the methods to induce malnutrition in designing therapeutic regimens. (Journal of Parenteral and Enteral Nutrition12:441–444, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005441

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

The effects of decreased food intake and degree of surgical trauma on total, myofibrillar and sarcoplasmic muscle protein synthesis and degradation were assessed in two experiments (A and B). Trauma consisted of an abdominal incision with or without hysterectomy. The degree of trauma in experiment B was increased relative to that in experiment A by extending the length of the incision, operative manipulation and time required to perform the surgery. To account for postoperative diminutions in food intake on protein turnover, a group of nonoperated rats were pair‐fed to the level of food consumed by hysterectomized rats. Traumatized rats in experiment B lost more weight, ate less, and had a lower muscle total protein concentration than corresponding rats in experiment A, confirming a more severe trauma in experiment B. In both experiments, trauma depressed total protein content of muscle. Synthesis was measured by the incorporation of L‐[U‐14C] tyrosine from a single meal into total, sarcoplasmic and myofibrillar proteins of gastrocnemius muscle. Degradation was calculated as the difference between the growth rate and the synthetic rate. Synthetic rate (ks) of total protein was depressed by surgical trauma; the more severe the trauma, the greater the depression. In mild trauma, the depression in kswas due only to a decrease in sarcoplasmic protein synthesis (ke), whereas with more severe trauma, synthetic rates of both sarcoplasmic (kes) and myofibrillar (kem) proteins were decreased. Protein degradation (kd,) was increased on day 2 in experiments A and B, had returned to control values on day 4 in experiment A and had decreased below control values in experiment B. Postoperative food restriction did not alter muscle protein turnover rates although growth rate was reduced. (Journal of Parenteral and Enteral Nutrition12:445–451, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005445

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

Skeletal muscle protein synthesis and degradation were measured simultaneously in perfused hindquarters of adult female rats 0, 2, and 4 days after surgical trauma. In order to explore the role of decreased postoperative nutrient intake on muscle protein turnover, a group of rats were pair‐fed to the level of food consumed by surgical traumatized animals. Protein synthesis was measured by the incorporation of3H‐L‐phenylalanine into the myofibrillar (contractile) and sarcoplasmic (soluble) proteins of gastrocnemius muscle. Protein degradation rates were calculated from the release of myofibrillar 3‐methyl histidine (3MH) during the perfusion. Surgical trauma significantly depressed myofibrillar and sarcoplasmic protein synthetic rates by 33 and 29%, respectively. Protein degradation, as assessed by 3MH release into perfusate, increased 25% on the second postoperative day but returned to control levels by the 4th day after surgery. Food restriction of the pair‐fed control rats did not alter protein synthesis, however, protein degradation decreased significantly. In conclusion, the effect of trauma on protein turnover appears not to be due to decreased nutrient consumption. (Journal of Parenteral and Enteral Nutrition12:452–456, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005452

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

We have conducted a randomized double crossover study over 4 days in six parenterally fed patients with portasystemic encephalopathy (PSE) in which the nonprotein energy source of otherwise identical feeds was alternately all glucose or predominantly fat. Concentrations of plasma branched chain amino acids (BCAA), plasma insulin, and blood glucose were measured after an initial fast and subsequently after each of the four 24‐hr periods of isonitrogenous feeding. The grade of PSE was assessed clinically and by the number connection test, BCAA concentrations were significantly lower during the glucose infusion than during fasting or the lipid infusion. PSE was significantly less with the lipid than with the glucose infusion. Trials testing the effect of infused BCAA must take account of the opposing effect on BCAA concentrations of simultaneous glucose infusion. A high lipid feed may have advantages in the short‐term treatment of PSE. (Journal of Parenteral and Enteral Nutrition12:457–461, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005457

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

Frequent guidewire changes of single‐lumen (SLC) and triple‐lumen (TLC) catheters have been proposed to decrease catheter sepsis. We placed TLC in 126 patients needing total parenteral nutrition (TPN) and multiple venous access, prospectively randomizing them to two groups: group I received a guidewire change every 3 days, and group II received guidewire changes for mechanical or septic complications only. Tips were cultured at each line change and tips and blood for each septic episode. Catheter sepsis was defined by the criteria of the Association for Practitioners in Infection Control (APIC). There were 67 positive cultures in 52 patients, but most produced very few colonies or grew the same organisms in other infection sites. Forty‐seven% of all cultures grewStaphylococci,and 23% grewCandida.APIC‐defined catheter sepsis was detected in 12.7% of group I and 15.9% of group II. Although we observed no statistically significant difference in the two techniques, if we assume that a 20% difference in the incidence of catheter‐induced sepsis would be important to detect, the probability of failing to detect such a difference is 0.24 with an 0.05 level of significance (two‐sided). Prophylactic guidewire changes did not alter the incidence of catheter sepsis in patients with TLC who required TPN. The high rate of sepsis andCandidainfection may be due to the critical illness of the immunocompromised population studied. (Journal of Parenteral and Enteral Nutrition12:462–464, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005462

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

Diarrhea is a common complication of enteral feeding in critically ill patients. This placebo‐controlled clinical trial assessed the effect of adding fiber in the form of ‘Fybogel’ (Ispaghula husk), one sachet twice daily, on the occurrence of diarrhea during enteral feeding. Sixty‐eight patients without prospectively defined exclusion criteria were enterally fed with ‘Osmolite’ in the Intensive Care Unit during the study period, 35 receiving ‘Fybogel’, and 33 placebo. Nineteen patients in each group had diarrhea on at least 1 day during enteral feeding, with 66 (23%) feeding days complicated by diarrhea in the ‘Fybogel’ group, and 68 (23%) in the placebo group. Narcotic infusions, thiopentone infusions, ’Mylanta', H2‐antagonists, and nystatin suspension did not significantly affect the incidence of diarrhea. Weak correlations were found between diarrhea and the number of antibiotics each patient received (r = 0.2,p<0.05) and also the number of positive nonenteral bacterial cultures (r = 0.2,p<0.05). The addition of fiber in the form of ‘Fybogel’ to enteral feeds did not affect the occurrence of diarrhea. (Journal of Parenteral and Enteral Nutrition12:465–468, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005465

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

We studied the diagnosis‐related groups (DRG) impact of nutrition support on 80 consecutive cardiac surgery patients operated upon during a 6‐month period. Six of 80 patients were nutritionally depleted preoperatively. Seven received postoperative supplemental nutrition, all of whom had major postoperative complications. Patients were arbitrarily placed into three outcome groups: group I consisted of seven patients who received postoperative nutrition support; group II included 38 patients who received no nutrition support and did not develop complications; Group III consisted of 35 patients who received no nutrition support but developed postoperative complications. All group I patients were length of stay (LOS) outliers. Group I patients were significantly older than groups II and III (p<0.0003) and had a significantly longer average length of stay (ALOS) (p<0.001), ALOS in SICU (p<0.0001) and greater incidence of both septic complications (p<0.02) and mortality (p<0.02). Nutrition support in cardiac surgery patients warrants special DRG consideration in light of the significantly increased hospitalization and resource utilization as compared with all other patients in cardiac surgery. (Journal of Parenteral and Enteral Nutrition12:473–477, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005473

出版商:SAGE Publications    

年代:1988

数据来源: WILEY

摘要:

This study was designed to determine the stability of certain vitamins added to total parenteral nutrition (TPN) admixtures with or without Intralipid iv fat emulsion and with each of four amino acid solutions stored in either glass bottles or plastic bags at either ambient room (25°C) or refrigerator (5°C) temperature for a 48‐hr period. Riboflavin and folacin were not affected by the experimental conditions. The presence of Intralipid resulted in higher levels of vitamin E due to Intralipid's inherent vitamin E content; no other experimental conditions affected vitamin E. Thiamin levels decreased in admixtures containing the amino acid solution C and stored at 25°C. Vitamin A levels were lower in admixtures stored in plastic but were maintained in admixtures containing Intralipid and stored in glass bottles at either temperature. Vitamin C levels were maintained in admixtures stored at 5°C for all experimental conditions. The greatest vitamin C losses occurred in admixtures containing amino acid solutions C or D stored in plastic bags, or containing D stored in glass bottles at 25°C. (Journal of Parenteral and Enteral Nutrition12:478–483, 1988)

ISSN:0148-6071    

DOI:10.1177/0148607188012005478

出版商:SAGE Publications    

年代:1988

数据来源: WILEY