Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study.

PURPOSE: Malnutrition is a predictor of poor outcomes in patients with cancer. Little is known about the benefit of nutritional support in these patients. The purpose of this study was to assess the impact of home parenteral nutrition (HPN) on quality of life (Qol) in cancer patients. METHODS: We performed an observational prospective study to determine the impact of HPN on Qol in a population of patients with heterogeneous cancer. Physicians, patients and family members had to complete a questionnaire before HPN administration and 28 days after the course of HPN. Qol was evaluated using the self-administered questionnaire FACT-G. RESULTS: We included 767 patients with cancer of whom 437 ended the study. Mean patient age was 63±11.4 years and 60.5% were men. Primary gastrointestinal cancer was reported in 50% of patients and 65.3% were presenting metastases. Malnutrition was reported in 98.3%. After 28 days of HPN intake, significant improvement was observed in the Qol (49.95±5.82 vs. 48.35±5.01 at baseline, p<0.0001). The mean weight, serum albumin and the nutrition risk index had also improved significantly. Most patients (78%) had perceived a positive impact of the HPN. A significant improvement in patient's well-being was perceived also by family members and physicians. CONCLUSIONS: Our data suggest that preventing and correcting malnutrition using HPN in patients with cancer might have a significant benefit on their well-being. Randomized controlled studies are required to confirm this finding.

Is diabetes a risk factor for central venous access port-related bloodstream infection in oncological patients?

It was a dogma that patients with diabetes mellitus (DM) are at increased risk of infection or death associated with an infection. However, in cancer patients, this has not been well investigated. The aim was to investigate whether diabetic patients with cancer are at high risk of central venous access port (CVAP)-related bloodstream infection (BSI), and to analyse mortality after CVAP-BSI. A total of 17 patients with type 1 DM (T1DM), 66 with type 2 DM (T2DM) and 307 non-diabetic patients were included. Each patient was followed up until the first late CVAP-BSI or for a maximum for 1 year in the absence of a CVAP-BSI. Fifty-three CVAP-BSIs occurred in 66,528 catheter-days. The cumulative incidence of CVAP-BSI was not higher in T1DM (5.9 %; p = 0.17) and T2DM (19.7 %; p = 0.70) compared with the non-diabetic patients (12.7 %). However, in patients with CVAP-BSI, the 1-month crude mortality rate was higher in DM patients (42.9 % vs. 15.4 %; p = 0.04), whereas the mortality in patients without CVAP-BSI was similar in both groups of patients (19.8 % vs. 17.1 %; p = 0.58). Of the 12 deaths that occurred within 1 month of CVAP-BSI, 16.66 % was attributable to CVAP-BSI. The predictive factor of 1-month mortality was DM (p = 0.04). Parenteral nutrition (PN) was independently associated with CVAP-BSI in diabetic patients (p = 0.001). In this study, diabetes did not increase the risk of CVAP-BSI, but mortality was higher in diabetic patients who had a CVAP-BSI. This suggests, in addition to medical treatment, CVAP should be withdrawn after infection onset.

Umbrella review of the efficacy of perioperative immunonutrition in visceral surgery.

INTRODUCTION: Immunonutrition (IN) is used in major visceral surgery to reduce postoperative complications. This umbrella review (review of reviews) collects and analyses data on the efficacy of perioperative IN. METHODS: The review was conducted in accordance with PRISMA 2020 guidelines. Inclusion criteria were meta-analyses comparing IN with normal diet or isocaloric isonitrogenous feeding. The primary outcome was infectious complications. Secondary outcomes were overall morbidity, hospital length of stay and mortality. Methodological quality was evaluated using AMSTAR-2. Overlap and certainty of evidence (GRADE) were assessed. RESULTS: Twenty meta-analyses (MAs) were included in the umbrella review: eleven on various abdominal surgeries (one MA was considered twice) and eight on pancreatic, oesophageal, hepatic, or colorectal surgeries. Overall, IN was associated with significantly fewer postoperative infectious complications (OR 0.60 [0.54-0.65], random effect model) but with substantial heterogeneity (I2 = 64%), and less postoperative morbidity (OR 0.78 [0.74-0.81], I2 = 30.3%). Excluding three MAs with heterogeneity did not alter the results. The overlap between the MAs was slight, with a corrected covered area of 0.13. There was no significant difference in the timing of IN (preoperative, postoperative or perioperative). CONCLUSION: This umbrella review confirms the beneficial effect of IN in visceral surgery. Some practical questions remain unanswered: optimal timing of IN, in which surgical speciality it is best used, and its utility in enhanced recovery programmes. REGISTRATION IN PROSPERO: CRD42021255177.

[Refeeding syndrome]. / Syndrome de renutrition inappropriée.

Refeeding syndrome (RS) is a rare but severe condition that is poorly understood, often under-diagnosed and can lead to death. It occurs within 5 days after refeeding in patients after prolonged fasting or in a context of undernutrition. As a consequence of the abrupt transition from catabolism to anabolism, RS is defined as a decrease in plasma levels of phosphorus, potassium and/or magnesium, whether or not associated with organ dysfunction resulting from a decrease in one of the electrolytes or a thiamine deficiency, after refeeding. The clinical symptoms are varied and non-specific and are related to hydro electrolyte disorders, sodium-hydroxide retention or failure of one or more organs. Patient management should be appropriate with regular clinical examination and careful biological monitoring, including hydro electrolyte monitoring. The correction of hydroelectrolytic disorders and systematic thiamine supplementation are essential during refeeding, that must be done carefully and very progressively, whatever its form (oral, enteral or parenteral). The severity of the refeeding syndrome indicates that its prevention and screening are the corners of its management in at-risk patients.

Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study.

BACKGROUND & AIMS: Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors. METHODS: We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model. RESULTS: At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes. CONCLUSIONS: Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.

Home parenteral nutrition (HPN) in patients with post-bariatric surgery complications.

BACKGROUND & AIMS: Obesity is a worldwide health problem. Bariatric surgery (BS) is becoming one of the most commonly used methods for fighting obesity and its associated comorbidities. However, current BS techniques can be associated with early or late complications that may require nutritional support. The aim of this retrospective observational study was to determine the indications and outcomes for patients on Home parenteral nutrition (HPN) due to post-bariatric surgery complications. METHODS: A specific questionnaire was designed by the ESPEN HAN/CIF working group and submitted to HPN centers. This questionnaire included: patient demographics, type of surgery, BMI before surgery and at start of HPN, indications for HPN including technical and nutritional complications (early within 2 months after surgery or late), outcome, PN regimen, and HPN complications. Patients were retrospectively included from January 2008 to June 2014. RESULTS: Eighteen HPN centers responded to the survey. A total of 2880 HPN patients were treated during the study period, 77 of whom had BS (65 females; mean age 51 ± 7 years); gastric bypass was performed in 69% of the patients; mean BMI was 44.4 before surgery and 23.2 at the start of HPN. Indications for HPN were early complications in 17 cases and late complications in 60 cases. Early complications were mostly anastomotic leakage/fistula; late complications were hypoalbuminemia, and vitamin and trace element deficiencies. Out of 77 patients, 16 needed a surgical re-intervention, 29 were weaned off HPN, and 6 died (no HPN-related deaths). During the HPN period, 58% of the patients were re-hospitalized and central venous complications were observed in 41%. Diabetes mellitus was described in 17/77 patients. HPN was supportive in 60 patients and exclusive in 17 patients (mean caloric intake: 23 ± 6 kcal/k BW/day and 1.2 g/kBW/day). Only 7/77 patients resumed their professional activities on HPN. CONCLUSIONS: This is the largest observational multicenter study describing the use of HPN in patients with post-BS complications. Severe hypoalbuminemia is a major late complication. Rates of re-hospitalization and CVC infection were high. HPN may be a "bridge therapy" before surgical revision after BS. The high mortality rate reflects the complexity of these cases.

Structured triglyceride emulsions in parenteral nutrition.

Over the past 3 decades, various concepts for IV fat emulsions (IVFE) have been developed. A randomized, structured-lipid emulsion based on an old technology has recently become available. This structured-lipid emulsion is produced by mixing medium-chain triglycerides and long-chain triglycerides, then allowing hydrolysis to form free fatty acids, followed by random transesterification of the fatty acids into mixed triglyceride molecules. Studies in animals have shown an improvement in nitrogen balance with the use of these lipid emulsions. Only 8 human clinical studies with these products have been performed. The results of these human clinical studies have been less promising than the animal studies; however, an improvement in nitrogen balance and lipid metabolism exceeds results associated with infusion of long-chain triglycerides (LCT) or a physical mixture of long-chain triglycerides and medium-chain triglycerides (LCT-MCT). Structured-lipid emulsion seems to induce less elevation in serum liver function values compared with standard IVFEs. In addition, structured-lipid emulsions have no detrimental effect on the reticuloendothelial system. Further studies are necessary in order to recommend the use of structured-lipid emulsions. The clinical community hopes that chemically defined structured triglycerides will make it possible to determine the distribution of specific fatty acids on a specific position on the glycerol core and therefore obtain specific activity for a specific clinical situation.

[Impact of the guidelines on clinical practice of artificial nutrition in intensive care unit after cardiovascular and thoracic surgery]. / Impact d'un protocole de nutrition artificielle en réanimation après chirurgie cardiovasculaire et thoracique.

OBJECTIVE: To analyze the impact of an artificial nutrition program in post-anaesthesia intensive care unit. STUDY DESIGN: Observational study. PATIENTS AND METHODS: Patients with length of stay greater than 8 days after cardiovascular and thoracic surgery: Group 1: 34 patients (4-month period in 2000); group 2: 15 patients (2-month period in 2001); group 3: 40 patients (4-month period in 2003). Between these 3 periods, informations of physicians and written protocol in order to improve their nutritional knowledge. After analysis of variance (P<0.05). Newman-Keuls tests to compare themselves each groups. RESULTS: Anthropometric, demographic and clinical parameters were similar in the 3 groups. Energic intakes were less than 80% of basal energetic expenditures in 33%, 33 and 22% of patient, respectively (NS). Caloric and nitrogen intakes were less than recommended, respectively 19+/-6 (mean+/-SD), 21+/-7 and 21+/-8 kcal/kg/24 h and 102+/-32, 111+/-31 and 92+/-40 mg/kg/24 h (NS). However enteral nutrition was administered in 49, 40 and 100% of patients respectively (P<0.001). The glucid/lipid ratio improved from 0.47 in group 1 up to 0.68 in group 3 (P<0.0001). Vitamins, oligoelements and clinical and biological monitoring of artificial nutrition improved (P<0.001). CONCLUSION: A clinical audit demonstrated an improvement in artificial nutrition parameters but no significant change in others.

Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis.

OBJECTIVE: Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. DESIGN: Multicentric prospective randomized study. PATIENTS: 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. INTERVENTIONS: Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. MEASUREMENTS AND RESULTS: We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686-2.048). Glycemia on day 4 and gamma-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. CONCLUSIONS: In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

A comparative study of peripherally-inserted and Broviac catheter complications in home parenteral nutrition patients.

BACKGROUND & AIMS: Peripherally inserted central venous catheters (PICC) have become increasingly popular for medium to long-term parenteral nutrition (PN) but there is limited data on the complication rates in this sub-group. We aimed to compare the rates of complications associated with tunneled catheters (Broviac) and PICC in home PN (HPN) patients. METHODS: All adult patients in an HPN program with a new Broviac or new PICC between 2009 and 2011 were included in this prospective observational study. Complication rates were compared by using Poisson regression and Kaplan Meier survival curves were used to compare the first complications that occurred. RESULTS: 204 catheters (133 Broviac and 71 PICC) were inserted in 196 adult patients. Mean follow-up from catheter insertions to their removal was 276 ± 219 days for Broviac (n = 86) vs. 74 ± 140.70 days for PICC (n = 56); p < 0.001. Complications were similar between Broviac and PICC (91/133 vs. 26/71). Catheter infection rate was lower in PICC (1.87 vs. 1.05 per 1000 catheter-days; p = 0.01). Catheter obstruction rates were similar for both catheters. Only PICC experienced venous thrombosis (0.4/1000). The proportion of catheters removed was lower in the Broviac group than in the PICC group (62.4% vs. 78.8%; p = 0.01) but those removed for complications were not different (28.6.7%vs. 25.3%; p = 0.64). CONCLUSIONS: In HPN patients, overall complications were similar in both the PICC and the Broviac groups. However, the Broviac catheter could be associated with an increase in catheter infection.

Effect of physiological concentrations of insulin and glucagon on the relationship between nonesterified fatty acids availability and ketone body production in humans.

To determine the effect of insulin and glucagon on the transformation of nonesterified fatty acids (NEFA) into ketone bodies (KB), we measured simultaneously in normal subjects NEFA and KB kinetics at different NEFA levels in the presence of basal (control test) or increasing insulin concentrations with glucagopenia (somatostatin + insulin infusion, insulin test) and without glucagopenia (somatostatin + insulin + glucagon infusion, glucagon test). NEFA levels were controlled during these tests by an intravenous (IV) infusion of a triglyceride emulsion. During the control test, a moderate increase of NEFA (464 +/- 30 to 715 +/- 56 mumol/L) increased the percentage of NEFA converted into KB (13.3% +/- 1.4% to 26.4% +/- 2.1%, P less than .05), and there was a linear relationship between this percentage and NEFA levels (r = .788, P less than .01). During the insulin and glucagon tests, the progressive increase in NEFA induced by the triglyceride emulsion infusion was associated, despite the increase of insulinemia, with an increase in KB production rate (P less than .05) and in the proportion of NEFA used for ketogenesis in the presence (8.1% +/- 1.2% to 14.2% +/- 6.3%, P less than .05) and absence (15.7% +/- 2.8% to 25.2% +/- 3.99%, P less than 0.05) of glucagopenia. In both tests, this percentage was always linearly related with NEFA levels (P less than .05) and the slopes of these relationships were comparable to that observed in the control test. However, the fraction of NEFA used for ketogenesis was always higher (P less than .05) during glucagon substitution than in its absence.(ABSTRACT TRUNCATED AT 250 WORDS)

Interactions of glucagon and free fatty acids with insulin in control of glucose metabolism.

To study the interactions of physiological glucagon and free fatty acids (FFA) concentrations with insulin in the control of glucose metabolism, we determined in normal subjects the response of endogenous glucose production (EGP) and glucose utilization (Rd) to a progressive and moderate increase of insulinemia in the presence of glucagon and FFA levels either decreased (somatostatin [SRIF] and insulin infusion, C test) or maintained to normal postabsorptive values isolated (SRIF + insulin + glucagon infusion, G test; SRIF + insulin + Intralipid infusion, IL test) or in association (SRIF + insulin + glucagon + Intralipid infusion, IL + G test). Compared with the C test, maintenance of glucagon level had only small and inconsistent effects on glucose Rd, but induced a shift to the right of the dose-response curve to insulin of EGP (apparent ED50: C test, 10.9 mU.L-1; G test, 15.2 mU.L-1). Intralipid infusion resulted, whether glucagon was substituted or not, in a near total suppression of the insulin-induced increase of glucose Rd (Rd at the end of the tests: C test, 6.13 +/- 0.85 mg.kg-1.min-1; G test, 7.29 +/- 0.87 mg.kg-1.min-1; IL test, 3.30 +/- 0.65 mg.kg-1.min-1; IL + G test, 3.57 +/- 0.42 mg.kg-1.min-1). In the absence of glucagon, substitution Intralipid infusion also antagonized the action of insulin on EGP. However, this effect was no longer apparent when glucagon was replaced (dose-response curve to insulin of EGP during the G and the IL + G test were comparable).(ABSTRACT TRUNCATED AT 250 WORDS)

Specific changes in n -6 fatty acid metabolism in patients with chronic intestinal failure.

BACKGROUND AND AIMS: In patients presenting severe malabsorption, essential fatty acid (EFA) deficiency can be corrected by intravenous lipids, but EFA abnormalities persist. The purpose of this study was to evaluate the role of large resection of the small bowel or malabsorption on plasma phospholipid EFA profile. METHODS: The plasma phospholipid EFA composition was measured by gas chromatography in home parenteral nutrition patients with (n=13) or without small bowel resection (n=7) and in 14 healthy subjects. RESULTS: The two groups of patients had the same nutritional status and comparable amounts of intravenous fat. In both groups, plasma fatty acid concentrations were significantly different from those observed in healthy subjects without EFA deficiency. Among them: a decrease in 18:2n -6, 22:5n -3, 22:6n -3 and an increase in 18:3n -3, 20:4n -6, 22:4n -6. Moreover, arachidonic acid to linoleic acid ratio was higher in both groups of patients, suggesting a stimulation of the elongation and desaturation of 18:2n -6. In multiple linear regression, 18:2n -6 and 20:4n -6 levels were not associated with the small bowel length, only 22:6n -3 concentration was correlated with small bowel length. CONCLUSIONS: The patients with chronic intestinal failure on home parenteral nutrition presented specific change in their EFA and an increase in the n -6 fatty acid pathway. This could be related to the severe malabsorption.

Home parenteral nutrition and AIDS.

The evolution of AIDS in 25 patients enrolled in a home parenteral nutrition(HPN) programme was analysed retrospectively. All patients were grade 4C or 4D (CDC criteria). All suffered from major gastrointestinal symptoms, 13 had anorexia (< 700 kcal/day) and the overall mean weight loss was 21%. HPN involved administration of an all-in-one nutritional formula (caloric intake = 148% of MREE) which was infused at night through a Broviac type silastic catheter or a subcutaneous infusion port. It was continued until the patient's death or temporary recovery. 19 patients died during PN, 4 showed a temporary stabilisation. The average duration of PN was 180 days (54-358). Because of rehospitalizations for opportunistic infections or PN complications, the mean time spent at home was only 101 days (13-296), or 58.5% of the total duration of PN. 21 patients experienced weight gain and the Karnofsky activity index increased in half the patients. A temporary return to work was possible in only 3 patients. 15 PN related septicaemias were diagnosed for 4400 days of PN (0.34 for 100 days). On the whole, HPN seems to have been beneficial in 13 out of 25 patients, but the criteria for identifying patients who are likely to respond are not clearly established.

Perioperative artificial nutrition in elective surgery: an impact study of French guidelines.

OBJECTIVE: In France, the consensus conference, held on 16 December 1994, produced guidelines on perioperative artificial nutrition (AN) use in patients undergoing elective surgery. The aim of this study was to assess the impact of these guidelines on practice patterns. METHODS: The study was a practice pattern study with a 'before-after' design and a control group in England. A retrospective cross-sectional sample of adult patients undergoing elective resection of the digestive tract was collected in France and England before and after the consensus conference. RESULTS: Malnourished patients received postoperative AN in 94% of 'before' cases and 82% 'after' but inadequate preoperative AN (40% 'before' and 26% 'after'). Postoperative AN appeared to be over-prescribed in non-malnourished patients without prolonged postoperative fasting (70% 'before' and 65% 'after'). In the English sample there was no significant variation in AN use between 'before' and 'after' periods. CONCLUSION: This study shows that clinical guidelines disseminated by consensus conference had a low impact on practice patterns in France and thus confirms the need to enforce the dissemination of the guidelines.

Energy expenditure during allogeneic and autologous bone marrow transplantation.

Resting energy expenditure (REE) was measured by indirect calorimetry during allogeneic and autologous bone marrow transplantation in order to evaluate the evolution in allogeneic and autologous recipient patients. REE values obtained with indirect calorimetry and compared with values using the Harris-Benedict formula were different. Evolution of REE during aplasia were significantly different in autologous and allogeneic recipients with an increase 11.5 ' 10.8 cent for autologous and a decrease of - 7.3 ' 8.9 cent in allogeneic bone marrow transplantation (BMT) patients. There were no differences in nutritional status and REE before BMT, at discharge and 1 month after discharge between the two groups but all patients had inflicted damage on their nutritional status at discharge from hospital after BMT. However, these patients differed because of the decrease in oral nutritional intake and an increase in the length of aplasia and hospital stay in allogeneic patients. Currently, there is no proof that recommendations for nutritional interventions or results of nutritional investigations in allogeneic BMT can be extrapolated in autologous patients. Harris-Benedict formula does not estimate the energy expenditure of patients submitted to massive chemotherapy and BMT with enough precision because of the great differences in individuals.

Medium- and long-chain triacylglycerols in postoperative patients: structured lipids versus a physical mixture.

Forty patients, scheduled for abdominal surgery, were randomized to receive postoperatively either a structured or a physical mixture of long-chain triacylglycerols/medium-chain triacylglycerols (LCT/MCT) emulsions to assess the tolerance and the effectiveness of the structured triacylglycerol emulsion. Total parenteral nutrition started the day after surgery and covered 100% of measured energy expenditure with nitrogen (0.2 g N.kg-1.d-1) and non-protein calories: glucose (50%) and lipids (50%). Blood samples for liver function tests, albumin, transthyretin, and triacylglycerols were checked at 0800 h on the day before surgery and on day 1, day 3, and day 6 after surgery. Urine samples were taken each day from day 1 to day 7 for 3-methylhistidine (3 Me His) and total nitrogen measurements. Aspartate transaminase (ASAT), alanine transaminase (ALAT), and triacylglycerol plasma levels in routine clinical biochemistry increased significantly in the physical mixture group. Nitrogen balance and 3 Me His excretion were not significantly different between groups. Structured triacylglycerol (STG) lipid emulsions are as efficacious as the physical mixture on nitrogen balance in postoperative patients. They could have some advantages: no disturbances were found to occur in liver function tests or plasma triacylglycerol levels.

Total-body-water measurement with (18)O-labeled water in short-bowel patients with an ileostomy.

The aim of this study was to evaluate the use of H(2)(18)O for total-body-water (TBW) determination in patients with short bowel because ileostomy losses of labeled water can falsify TBW. Thirteen adult short-bowel patients were studied after an overnight fast. Saliva, blood, urine and ileostomy output were collected before and 30, 60, 90, 120, 240, and 360 min after oral ingestion of 0.88 g/kg of 2.5% H(2)(18)O to measure (18)O abundance by isotope-ratio mass spectrometry. TBW was calculated from the dilution of the isotopic water in saliva and plasma. The quantity of labeled water lost in the ileostomy was calculated from the isotopic enrichment of the ileostomy output from T0 to T360. The values obtained from saliva or plasma with (corrected) and without (uncorrected) considering H(2)(18)O lost in the ileostomy output were compared with a paired t test. Agreement was evaluated using the Bland-Altman method. From T0 to T360, the ileostomy output and the percentage of lost labeled water were 490 +/- 314 mL and 6.38 +/- 8.52%, respectively. TBW calculated from plasma or saliva isotopic enrichment was different, and a significant difference was also observed between corrected and uncorrected TBW values (saliva: uncorrected TBW = 32.35 +/- 7.52 L, corrected TBW = 30.29 +/- 6.09 L; plasma; uncorrected TBW = 30.80 +/- 7.29 L, corrected TBW = 28.79 +/- 5.79 L). The agreement between the values obtained from the two dilution spaces or between the two calculation methods was poor. Because of the large discrepancies between calculation methods, determination of TBW from oral ingestion of (18)O-labeled water in patients with short bowel should be calculated only from plasma (18)O space dilution and should consider ileostomy losses.

Is vitamin K1 supplementation necessary in long-term parenteral nutrition?

BACKGROUND: I.v. lipid emulsions contain vitamin K in substantial quantities and in 1989, we therfore stopped supplying vitamin K1 to patients receiving home parenteral nutrition (HPN). METHODS: Nine patients (group I) receiving HPN before 1989 (10 mg i.v. vitamin K1 supplementation weekly until 1989, which was discontinued thereafter) and six patients with an initial low plasma vitamin K1 concentration (related to their malabsorption) (group II) receiving HPN after 1989 were studied. Prothrombin time (PT), plasma vitamin K1 concentration, and vitamin K1, content in lipid emulsions were measured throughout the period of HPN. RESULTS: All lipid emulsions, except for Eurolip 20% and Clinoleic 20% (Baxter SA, Maurepas, France) contained vitamin K1, with concentration ranges from 179 +/- 39 to 353 +/- 78 ng/L. Group I patients had an initial high plasma vitamin K1 concentration due to the vitamin K1 supplementation. After this supplementation was discontinued, plasma vitamin K1 decreased and remained in normal ranges with a normal PT. Throughout the HPN period after 1989, patients received 255 +/- 104 micrograms of vitamin K1 weekly through lipid emulsions. The PT and plasma vitamin K1 concentrations in group II patients were restored by lipid emulsions, which contained 418 +/- 143 micrograms/wk of vitamin K1. CONCLUSIONS: In patients receiving i.v. lipids (except for Eurolip and Clinoleic), a normal vitamin K1 status can be maintained during long-term HPN without vitamin K1 supplementation. However, vitamin K supplementation cannot be abandoned until the vitamin K content of emulsions is standardized by manufacturers. A weekly supply of 250 to 400 micrograms of vitamin K1 is enough to maintain and even restore a normal vitamin K1 status in HPN.

Effects of intraoperative glucose administration on circulating metabolites and nitrogen balance during prolonged surgery.

STUDY OBJECTIVES: To compare the effects of intraoperative administration of 2.5% glucose or Ringer's solution on metabolism during prolonged surgery. DESIGN: Prospective, randomized study. SETTING: Teaching hospital. PATIENTS: 20 ASA physical status I and II adults patients scheduled for thoracic or abdominal surgery lasting at least 3 hours. INTERVENTIONS: Patients received Ringer's solution (Group R) or 2.5% glucose solution (Group G) 10 ml.kg-1.h-1 during surgery and 2 ml.kg-1.h-1 during the first two postoperative hours (Ringer's or glucose), then 40 ml.kg-1.day-1 of 5% intravenous (i.v.) glucose postoperatively. MEASUREMENTS AND MAIN RESULTS: Plasma glucose, free fatty acids, ketone bodies, lactate, insulin, glucagon, cortisol, and growth hormone concentrations were determined after an overnight fast (T0), on induction of anesthesia (T1), at the end of surgery (T2), 2 hours thereafter (T3), and on the following morning (T4). Capillary blood glucose was determined every 30 minutes from T1 to T2. Urinary nitrogen and 3-methylhistidine were measured every day for 5 days. There were no differences between groups in demographic data, anesthesia, or surgical procedures. All data were comparable at baseline and on the following morning. In Group R, no patient experienced hypoglycemia, but plasma fatty acids and ketone bodies increased during surgery. In Group G, glycemia rose to very high levels, with a significant increase in insulin during surgery. Other hormones were the same within the two groups. Urinary nitrogen and 3-methylhistidine were similar in both groups. CONCLUSION: The absence of glucose infusion in prolonged surgery did not cause hypoglycemia, and no increase in protein catabolism was observed.