ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719903

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

The physiological and biochemical responses of the body following major injury or severe infection are characterized by hypermetabolism, accelerated gluconeogenesis, and the mobilization of substrates from the carcass to be utilized by visceral organs. These responses in the febrile patient are supported by an elevated cardiac output which insures perfusion of vital organs and provides additional bloodflow to the area of inflammation and/or injury. Because of the accelerated substrate flux and increased catabolism, weight loss and negative nitrogen balance are profound. Cumulative losses rapidly approach near-lethal limits if adequate nutritional support is not instituted. Nutritional maintenance will support the febrile response, maintain body nitrogen and acute phase protein synthesis, and assure an ongoing energy supply. Reparative tissue appears to preferentially utilize substrate, but if malnutrition occurs, wound healing and tissue repair may be limited. The effects of nutritional support on immunological function in these critically ill patients are only now being dissected. Clearly, immunosuppression is related to the initial insult and abnormalities in host defense mechanisms occur almost immediately in patients well nourished before illness. In addition, nutrient depletion and erosion of body mass are also associated with immunological dysfunction so that these two factors combine to impair the patient's resistance to subsequent infection. Present therapy should maintain balance of essential nutrients while complications associated with specialized techniques of nutrient support are minimized. Control of the patient's environment, minimizing pain and discomfort, preventing“bad rest”effect through exercise are all techniques of supportive care, but responses are ablated with resolution of the infection or wound closure, and every effort should be directed toward this goal.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719904

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

A consensus definition of malnutrition does not exist. We define“clinically relevant malnutrition”as the state of altered nutritional status that adversely affects clinical outcome. Over four years we have attempted to delineate a clinically applicable and validated nutritional assessment approach. This was accomplished through multiple clinical studies on a large number of surgical patients many of whom were seriously ill. Although an initial prospective study in 64 patients confirmed the relationship between certain nutritional markers and outcome, we found that 97% of patients had at least one abnormality, while 35% had three or more abnormalities, clearly documenting the imprecision in unselected battery testing. In a subsequent retrospective analysis of 161 patients, serum albumin (Alb), serum transferrin (TFN), triceps skinfold (TSF), and skin test reactivity (DH) proved to be the best markers of clinically relevant malnutrition and their relative quantitative importance is embodied in our Prognostic Nutritional Index (PNI), where PNI (% risk) = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.20 (TFN) - 5.8 (DH). In numerous prospective studies of different patient groups, a large percentage of which were critically ill, the PNI has been shown to be a reliable nutritional assessment tool for diagnosing clinically relevant malnutrition. Furthermore, we have shown that seriously malnourished patients classified by the PNI will clinically benefit from preoperative nutritional support. The relevance of baseline and serial nutritional assessment to the nutritional care of the critically ill patient is discussed.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719905

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

Respiratory function in mechanically ventilated patients (VP) is adversely affected by starvation and hypermetabolic stress. These patients are more successfully managed and extubated if proper nutritional support is provided. The features of metabolism and respiratory function in VP require moderation in glucose, fat, and protein administration. In delivering energy to VP, attention must be given to nearby tracheostomy sites complicating the parenteral route and airway-cuff problems that may inhibit effective enteral feeding.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719906

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

Nutritional support in the patient with acute renal failure is of great importance in lessening the degree of catabolism when energy demands are high and may also result in salutary metabolic effects. Overall treatment considerations in the posttraumatic or postsurgical patient with acute renal failure will be discussed, including fluid and electrolyte balance and energy and nutritional considerations. The application of the Giordano and Giovannetti principles to the field of parenteral nutritional support enables modifications of treatment programs of total parenteral nutrition to be applied to patients with acute renal failure. Utilizing an intravenous mixture of eight essential l-amino acids, hypertonic dextrose, and vitamins, we observed salutary biochemical effects in surgical patients. A prospective, randomized double-blind study of that treatment regimen compared to patients receiving hypertonic dextrose and vitamins alone resulted in improved survival and a decreased duration of renal failure in the treated group. Management considerations of these patients and possible application of these principles to other patients in renal failure will be discussed.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719907

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

The high nitrogen demands imposed by severe trauma may quickly render the injured patient malnourished. Nutritional assessment of these patients is confused by tissue damage, shock, blood loss, operation, and anesthesia. Consequently, standard nutritional markers do not correlate well with immunocompetence and postoperative morbidity. For this reason we devised an abdominal trauma index (ATI) based on the anatomical severity of injury. The ATI is calculated by assigning a risk factor (1-5) to each organ injured and then multiplying this by a severity-of-injury estimate (1-5). The sum of the individual organ scores comprises the final ATI. The incidence of postlaparotomy complications is low (5%) with an ATI less than 15, intermediate (15%) with 15-25, and high (50%) with greater than 25. Having identified the high-risk trauma patient, we initiated a prospective randomized study to assess the cost-benefit of early nutritional support. Patients with an ATI greater than 15 were allocated to a control group (no supplemental nutrition during first five postoperative days) or enteral-fed group. The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy. The constant infusion of an elemental diet (Vivonex HN) was begun at 18 hours postoperatively and advanced to 3,000 cc/day within 72 hours. To date 26 patients (14 control, 12 enteral) have been entered in this study. At one week, nitrogen balance in the control group (−12.9 to -11.1 g/day) continues to be negative compared to a positive trend (−12.2 to +3.3 g/day) in the fed group. In control patients serum albumin (3.54 +/−0.16 to 3.19 +/−0.15 g%) and transferrin (227 +/−11 to 204 +/−10 mg%) decrease while in the enteral patients albumin (3.27 +/−0.11 to 3.34 +/−0.15 g%) and transferrin (229 +/−10 to 234 +/−12 mg%) remain stable. Although the incidence of overall morbidity is similar, septic complications occurred in 29% (4/14) of the control group compared to none in the enteral group. Our experience suggests the following: (1) Anatomical severity of injury is a better predictor of postinjury septic morbidity than standard nutritional markers; (2) immediate postoperative feeding by NCJ is safe and feasible; and (3) early nutritional support decreases the incidence of septic complications in the severely injured patient.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719908

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

Methyl linoleate (18:2 omega 6) was administered to rats deficient in essential fatty acids (EFA) and the effects on osmotic fragility and lipid composition of their red blood cells were studied. Even if they remained deficient in omega-3 fatty acids, the fragile red cells of EFA-deficient rats were remarkably strengthened by the linoleate treatment. It is concluded that omega-3 fatty acids are not essential for the maintenance of cell membrane integrity in rats. Since the cholesterol/phospholipid ratio in red cells was lower in untreated than in treated rats, it is suggested that this factor might be responsible in part for the higher fragility of red cells in EFA-deficient rats. Despite the prolonged administration of overload quantities of methyl linoleate, the proportion of 18:2 omega 6 in the red blood cell phospholipids of treated rats was actually lower than that in rats fed a regular stock diet, while the relative content of other omega-6 fatty acids (20:4 omega 6, 22:4 omega 6, and 22:5 omega 6) increased. These results indicate that the metabolic processes of omega-6 fatty acids in treated rats were stimulated, probably as a result of the lack of competition from omega-3 fatty acids for the same enzyme systems.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719909

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

The use of continuous, low-dose heparin in total parenteral nutrition (TPN) formulas to limit central venous thrombosis was retrospectively evaluated. Seven of 129 patients (5.4%) developed central vein thrombosis when TPN solutions provided less than 6,000 units (usually 1,000 units/liter) heparin per day. In the subsequent period when heparin was increased to 6,000 units per day, 10 of 858 (less than 1.2%) patients developed a TPN-related thrombosis (P less than 0.0005). The incidence of antithrombin III (AT III) deficiency in a subset of high-risk patients scheduled to receive TPN was 51% (23 of 55). Twelve of the 23 had clinical evidence of thrombosis, whereas only 3 of 22 patients with normal AT III levels did (P less than 0.01) A major contributing factor to the development of thrombosis in TPN appears to be depression in antithrombin III levels, which is commonly found in patients who require this therapy. Low-dose heparin appears to reduce the incidence of thrombosis with TPN when provided continuously in sufficient amounts.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719910

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

With both enteral and parenteral feedings, the amount of nutrients required depends on the degree of nutritional depletion, level of hypermetabolism, and the phase of the patient's response to illness or injury. Protein requirements are significantly increased in the critically ill. In skeletal trauma, energy needs are increased approximately 25%, in sepsis, 50%, and in severe burns, 75-100%. Energy requirements increase also but in part are met by body fat reserves. While D5W solutions were once thought to spare body proteins by reducing gluconeogenesis, it is now known that such semi-starvation regimes are deficient by omitting protein intake. Enteral and parenteral feeding techniques have developed as precise methods for administering a balance of required protein and calories. A comprehensive nutritional assessment will determine patient nutrient requirements. The marasmic patient without significant stress will generally require 30-40 kcal/kg and 1.5 g protein/kg of ideal body weight. Such support should lead to a slow weight gain and positive nitrogen balance of 2-6 g nitrogen. In the hypoalbunemic patient with concomitant stress, nitrogen retention will be limited until the stress, i.e. acute injury or infection, is relieved. Nitrogen (g):calorie (kcal) intake will average 1:80. During therapy, nutritional assessment parameters must be measured periodically to evaluate the effectiveness of the nutritional regime.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719911

出版商:Routledge    

年代:1983

数据来源: Taylor

摘要:

Failure to mix 24.5 mM of magnesium, added as 50% MgSO4 in 1 liter of intravenous fluid, results in a high concentration of Mg in the initial 10-cc aliquot: 1,145.7 mM/liter. Adequate dispersion can be obtained after three inversions. We conclude that because of the extremely high concentrations of Mg that can result if no mixing is done, it is imperative that hospital personnel ensure that added Mg is adequately dispersed in intravenous fluid prior to administration. A method of signalling the inadequacy of mixing is to color code additives with a harmless dye to alert personnel to the problem of inadequate dispersement.

ISSN:0731-5724    

DOI:10.1080/07315724.1983.10719912

出版商:Routledge    

年代:1983

数据来源: Taylor