Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team.

OBJECTIVE: To compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in ICU patients randomized to gastric tube feeding vs. patients fed by an endoscopically placed jejunal tube. DESIGN: Randomized, prospective study. SETTING: Medical and surgical ICUs at Boston City Hospital; surgical ICU at University Hospital. PATIENTS: Of the 38 study patients, 19 were randomized to gastric tube feeding and 19 were randomized to an endoscopically placed jejunal tube. The two groups were similar in age, sex, race, underlying disease, and type of surgery. RESULTS: The two patient groups were similar in number of days fed, duration of ICU stay, duration of mechanical ventilation, days of antibiotic therapy, and days with fever. Compared with the gastric group, the jejunal group had more patients with circulatory shock on admission (79% vs. 68.4%), higher admission Acute Physiology Score (24.0 vs. 21.7), and fewer patients with pneumonia at randomization (26.3% vs. 31.6%). The jejunal group received a significantly higher percentage of their daily goal caloric intake (p = .05), and had greater increases in serum prealbumin concentrations (p < .05) than the patients with gastric tube feeding. Although the jejunal tube group had more days of diarrhea (3.3 +/- 6.6 vs. 1.8 +/- 2.9), this difference was not statistically significant. Nosocomial pneumonia was diagnosed clinically in two (10.5%) patients in the gastric tube group and in no patients in the jejunal tube group. CONCLUSIONS: Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.

Transhepatic cannulation of the inferior vena cava.

Problems frequently develop in maintaining central venous access in patients who require long-term total parenteral nutrition. The authors describe transhepatic placement of a silicone rubber catheter into the inferior vena cava (IVC) in a patient with thrombosis of the superior vena cava, infrarenal IVC, and the great veins. The technique and potential complications are described.

Leucine meal increases glutamine and total nitrogen release from forearm muscle.

To assess the consequences of elevated branched chain amino acid levels on alanine, glutamine, and ammonia metabolism in muscle, L-leucine meals (14.7 g) were consumed by six normal postabsorptive individuals. Bilateral forearm studies were performed, and the dominant arm was subjected to 15 min of light exercise, using a calibrated dynamometer, beginning 45 min after the ingestion of the meal. Large uptakes of leucine were seen across both forearm muscle beds within 30 min of the meal. After exercise, blood flow in the dominant arm increased from 3.1 +/- 0.4 to 5.2 +/- 0.9 ml/100 ml forearm per minute (mean +/- SEM, P less than 0.005). Glutamine flux out of the dominant forearm increased threefold after the ingestion of the leucine meal and increased eightfold over base line after exercise. Less marked changes (significant only at 90 min) in the nonexercised, nondominant arm were also seen. Alanine flux out of the dominant forearm muscle bed increased modestly at 75 and 90 min. No significant change in ammonia flux across either forearm muscle bed was noted. Unexpectedly, large and significant net nitrogen loss from both forearm muscle beds was documented. Thus, following the ingestion of a leucine meal and light exercise, the primary means by which excess nitrogen is routed out of muscle is via glutamine formation and release with alanine and ammonia pathways playing relatively minor roles. More importantly, the ingestion of significant amounts of leucine by normal subjects, presumably in optimal nitrogen balance, results in a net loss of nitrogen from muscle.

Intravenous amino acids as the sole nutritional substrate. Utilization and metabolism in fasting normal human subjects.

The fasting normal human volunteer subject provides an ideal experimental setting for the initial investigation of foodstuffs whose use is proposed for the acutely ill surgical patient. In the normal human subject many variables can be controlled; the achievement of an ideal body fuel economy is quite simple; if a favorable utilization of injected foodstuffs cannot be achieved in this setting, it is unlikely, and remains to be proven, that utilization will be satisfactory under the challenges of acute surgical trauma. In this experimental model, employing four normal human volunteer subjects, nutrition has been provided by the intravenous infusion of isotonic amino acids (FreAmine(R) II) at a 3.4% concentration. No other source of calories or nutrients was provided. In this setting, utilization was very poor; the subjects were in negative nitrogen balance throughout. The nitrogen excretion was significantly greater than the total of infused nitrogen. The changes in protein, fat and carbohydrate intermediates, as well as the alteration in hormone concentrations, suggest the following endocrine governance of fuel economy in this setting: a sharp rise in glucagon with maintenance of insulin concentration; rapid gluconeogenesis at the expense of both injected and endogenous amino acids; a progressive ketosis without any associated improvement in protein economy; fat oxidation to meet caloric need. The changes in plasma amino acid concentrations are of outstanding interest. They demonstrate changes appropriate to the infusion gradient with the exception of three amino acids whose concentrations did not respond to high infusate levels (serine, lysine, and alanine); likewise, by the fact that methionine rose remarkably though present in only low concentrations in the infusion. These data, taken with other information reported in the literature, as well as continuing studies in these laboratories, strongly suggest that the utilization of infused amino acids for protein synthesis is favored by the provision of an additional caloric source such as glucose.

Glucagon infusion in normal man: effects on 3-methylhistidine excretion and plasma amino acids.

In order to assess the role of glucagon in human protein metabolism and to examine its action as a "catabolic" hormone, studies were conducted in two normal male subjects over an 8-day period. After minimum and stable urinary nitrogen excretion had been produced by the continuous nasogastric administration of carbohydrate (720 g/day) for 8 consecutive days, a continuous intravenous infusion of glucagon (1.0 mg/24 hr) was superimposed on days 7 and 8. Excretion of total nitrogen (N) and urea-N increased significantly (p less than 0.05). Excretion of 3-methylhistidine was unaltered, suggesting that the source of the N losses produced by glucagon did not derive from increased muscle proteolysis. Although striking hypoaminoacidemia was produced, the reductions of extracellular amino acids alone could not account for all of the extra urea excreted. These data suggest that hyperglucagonemia in normal man induces mild nitrogen losses by stimulation of hepatic ureogenesis from free intracellular amino acid pools and not by increased rates of muscle protein breakdown.

Total body water and the exchangeable hydrogen. II. A review of comparative data from animals based on isotope dilution and desiccation, with a report of new data from the rat.

Total body water (TBW) determination by tritium space could be factitiously elevated by exchangeable H+ contained within water-soluble chemical configurations. Should this nonaqueous (molecular) exchangeable H+ turn out to be a large fraction of total exchangeable H+, TBW measurement by tritiated water (THO) dilution would display a systematic upward and non-random error. TBW was measured by THO dilution and subsequently by total body desiccation in 21 rats (weight 227+/-83 g, mean+/-SD). TBW was 71.38+/-2.4% by THO dilution and 70.20+/-1.5% by body desiccation. Analysis of variance of TBW vs. body weight showed a highly significant correlation both with desiccation (P less than 0.0005, r=-0.78) and dilution (P less than 0.03, r= -0.50). Convariance analysis of both methods showed no difference in slope (P greater than 0.9). There was a difference in variance (P less than 0.001) and means (P less than 0.03). Tritium space is 1.2% of body weight larger than TBW measured by desiccation. TBW measured by THO dilution gives a 1.71% overestimation of TBW as measured by desiccation. TBW measurement by THO dilution is accurate within less than 2% error. These findings have particular significance in the light of our theoretical model of the total nonaqueous exchangeable H+ in fat, protein, and carbodhydrate in the living vertebrate.

Rapid estimation of pulmonary extravascular water with an instream catheter.

An arterial catheter-bearing external conductivity electrodes and a thermistor was used for measurement of lung thermal volume (LTV) by the double-indicator method. Ten milliliters of 3% saline at room temperature were injected, dilution curves measured, and LTV calculated as mean transit time difference, less thermistor time constant, times cardiac output (CO). Comparisons were made, in dogs, between LTV, pulmonary extravascular lung water with Evans blue and tritiated water (PEVWtho), and weighed lung water (WLW). Pulmonary edema was induced with dextran and epinephrine. CO was measured by thermodilution in both the pulmonary artery (PA) and aorta (AO) and dye dilution in the AO. CO from dye dilution was compared with thermodilution (aortic detection) to detect irreversible loss of thermal indicator. Comparisons showed good correspondence of dye and thermal curves (Y = 0.91X - 0.16 1/min; r = 0.93). LTV is about 120% of WLW in near normal lungs, 90% of WLW in extreme edema. PEVWtho was 60-70% WLW.

Glycerol: major contributor to the short term protein sparing effect of fat emulsions in normal man.

Intravenous fat emulsions have been advocated as acceptable alternatives to hyperosmolar glucose solutions in parenteral nutrition. The ability of a fat emulsion (soy bean oil suspended in glycerol) to produce nitrogen sparing in the absence of nitrogen intake was examined in normal man. The protein conservation obtained by the fat emulsion can be duplicated by the infusion of glycerol alone in the same amount as that available from the fat emulsion.

Nitrogen sparing by carbohydrate in man: Intermittent or continuous enteral compared with continuous parenteral glucose.

To test whether oral carbohydrate would provide greater conservation of body protein than would intravenous carbohydrate, healthy normal human subjects were infused with high doses of glucose either continuously intravenously or by nasogastric tube in both continuous and intermittent regimes. Metabolic responses to high calorie, nitrogen-free infusions in normal man were documented in the blood hormone and substrate changes, and protein sparing was assessed by urinary nitrogen excretion. Continuous glucose produced a lower urinary "nitrogen floor" than did the intermittent regime, and intravenous glucose was more effective than was oral glucose. The insulin responses to continuous nasogastric and continuous intravenous glucose were similar, and nitrogen excretion did not differ between those two groups. The increased insulin levels seen with intermittent glucose were not accompanied by greater protein sparing.

Bedside determination of left atrial pressure.

An investigation was conducted to assess the accuracy of left heart filling pressures determined by a right heart catheter introduced at the bedside. Twelve patients were studied after open cardiac surgery by simultaneously recording pressures from both sides of the pulmonary capillary bed with a direct left atrial catheter and a flow-directed pulmonary arterial catheter. The mean pulmonary artery "occluded" pressure was shown to be a highly reliable index of mean left atrial pressure in all cases. It was much more accurate than pulmonary end-diastolic pressure, especially in six patients with pre-existing pulmonary hypertension.