Resting energy expenditure in patients with newly detected gastric and colorectal cancers.

Resting energy expenditure (REE) was measured in 104 patients with newly detected gastric or colorectal (GCR) cancer and was compared with two groups of control subjects without cancer: healthy subjects (H control subjects) and patients with nonmalignant diseases of the gastrointestinal tract (GI patients). REE in GCR-cancer patients was not significantly different from REE in GI patients or H control subjects. Comparison of measured REE with predicted REE obtained from prediction equations may erroneously suggest that increased REE is a contributing factor in the development of cancer cachexia. No significant differences in REE were found when patients with liver metastases were compared with patients without metastases. There were no differences in REE between gastric and colorectal cancer patients. The decrease in energy expenditure, which normally occurs during starvation and weight loss in healthy men and women, could not be demonstrated in weight-losing, GCR-cancer patients. In conclusion, elevation of REE contributes little to the pathogenesis of cancer cachexia in GCR-cancer patients.

Preoperative total parenteral nutrition (TPN) in severe Crohn's disease.

This study was performed to evaluate the effect of preoperative total parenteral nutrition (TPN) on the results after surgical treatment of patients with severe Crohn's disease. Of 67 patients admitted with complications of Crohn's disease, 51 had severe active disease and abdominal masses, fistulas and/or obstruction (mean Crohn's disease activity index score, 301). Forty-four patients received preoperative TPN for a mean period of 33 days. Complications of TPN were limited. Spontaneous closure of fistulas was achieved in 75% of the cases. Serum albumin levels improved significantly, from 29.1 +/- 1.1 gm/L to 35.4 +/- 0.7 gm/L (p less than 0.001). Mean body weights improved from 81% to 89% ideal body weights or 52.6 kg to 57.2 kg, respectively (p less than 0.05). Surgical procedures were facilitated by remission of the active inflammatory process and associated with a major complications rate of only 6%. No deaths occurred. the mean hospital stay for the TPN-treated group of patients was 63 days. TPN is an effective preoperative treatment for patients with severe complicated Crohn's disease. The prolonged hospital stay and high costs, however, are disadvantages of this approach. Preoperative TPN treatment should therefore be limited to patients with severe active disease.

Perioperative nutritional support: a randomised clinical trial.

Ever since methods of artificial nutritional support became available, attempts have been made using this form of treatment to reduce mortality and morbidity in surgical patients. Many trials have addressed this question, but very few have given a meaningful answer because of conceptual and methodological flaws. We therefore undertook a prospective randomised trial investigating the effects of at least 10 days pre-operative total parenteral nutrition (TPN) (n = 51) or total enteral nutrition (TEN) (n = 50) providing 150% basal energy expenditure (BEE) non-protein energy, to reduce major postoperative complications and mortality in a homogeneous patient group with signs of depletion. 50 patients served as a depleted control group (D) and 49 patients served as a non-depleted reference group (ND) and were operated upon without delay. Depleted control patients suffered significantly more septic complications than did patients in the non-depleted reference group (p < 0.05). There was no significant difference, however, in septic complications between either of the nutritional support groups and the non-depleted control group. In high risk patients, with weight loss >10% of body weight and over 500 ml blood loss during operation, a significant decrease in major complications was observed (p < 0.05) as a result of nutritional support. We conclude that pre-operative nutritional support, in patients with severe depletion, results in a reduction in major complications to a degree that justifies its routine use in this selected group of patients.

Vitamin K status and parenteral nutrition; the effect of Intralipid on plasma vitamin K1 levels.

Parenteral nutrition may affect the patient's vitamin K status. This imposes a risk when using drugs that interfere with the vitamin K-dependent clotting factor synthesis, such as N-methyl-thiotetrazole-containing cephalosporins. Intravenous lipid emulsions based on plant oils may contain phylloquinone (vitamin K1). We estimated the vitamin K1 content of the intravenous lipid emulsion product Intralipid (20%), an emulsion based on soybean oil, and estimated the vitamin K1 status of recipient patients. The emulsion was found to contain 0.6-0.7 micrograms/ml of the vitamin. Patients supplied with the product per continuous intravenous infusion, showed a steady increase of their plasma vitamin K1 levels, 3-30-fold over 4 days of infusion. In conclusion, the study shows that fat emulsions prepared from plant oils may contain vitamin K1 in sufficient amounts to meet the daily requirement.

Serum cobalamins and cobalamin-binding proteins during total parenteral nutrition.

Levels of serum cobalamin and both saturated and unsaturated serum cobalamin-binding proteins (transcobalamin II and R-binders) were determined prospectively in 43 patients before and after 2 weeks of total parenteral nutrition (TPN). Nine patients showed subnormal serum levels of cobalamin but none of them had clinical signs of cobalamin deficiency. Serum cobalamin levels significantly declined after 2 weeks of TPN as did both saturated and unsaturated R-binder levels whereas transcobalamin II levels remained constant. Since cobalamin in serum is entirely bound to proteins, of which R-binders comprise 80-90%, the changes in R-binder levels will markedly influence serum cobalamin levels, in fact they adequately explain the short time fluctuations of serum cobalamin levels observed. It is argued that the changes in serum cobalamin levels may reflect a changed distribution of cobalamins over the various body compartments rather than decreased or increased body stores. Moreover, only cobalamin bound to transcobalamin II is delivered to the tissues. Therefore, serum cobalamin levels alone may inadequately reflect cobalamin availability in patients receiving TPN.

Complications of central venous catheterization of the subclavian vein: the influence of a parenteral nutrition team.

Early and late complications of central venous catheterization were investigated in 488 consecutive catheters, 389 introduced in the subclavian vein by a percutaneous puncture technique, 84 by a cut down technique of the cephalic vein, and 15 by a peel away technique. Care and introduction of the catheters was controlled by the parenteral nutrition team in 239 cases. Immediate and late complications were found using both the puncture and venous cut down techniques, but immediate complications differed in the two groups due to the different methods of insertion. The rate of catheter related sepsis (CRS) did not differ significantly when the group under control of the nutrition team was compared with the group without nutritional control (5.9 vs. 6%). The rate of CRS was 1 CRS/220.7 days of therapy in the puncture group and 1 CRS/342.2 days of therapy in the venous cut down group. Catheter tips and blood were cultured from both CRS and non-CRS patients, and the micro-organisms identified. Catheters were withdrawn, under supervision of the nutrition team, for a number of reasons including death, thrombosis, and technical problems, but suspicion of CRS accounted for a high percentage of withdrawals (18% in the puncture group, 16.6% in the venous cut down group). It is suggested that, when CRS is suspected, removal of the catheter should be delayed until all other possibilities have been investigated.

Prospective randomized double-blind trial of branched chain amino acid enriched versus standard parenteral nutrition solutions in traumatized and septic patients.

The addition of branched chain amino acids (BCAA) to total parenteral nutrition (TPN) solutions of balanced aminoacid composition has been reported to result in improved nitrogen balance, preservation of plasma protein levels, and improved immune function; however, only a few large clinical studies have been performed, yielding conflicting results. We, therefore, studied in a prospective, randomized double blind trial, the effects of BCAA enrichment of an otherwise isonitrogenous and isocaloric TPN solution on plasma protein levels in 101 traumatized and septic patients. TPN-derived nitrogen intake was similar in both study groups. Nitrogen balances in the BCAA group (n = 49) were not different from those in the standard group (n = 52). Plasma total protein levels increased significantly in the standard group resulting in a significant difference between study groups on day 7. Pre-albumin levels increased significantly in the BCAA group and in the standard group. The number of neutrophils (rods) was significantly lower in the standard group compared to the BCAA group on day 7. Lymphocytes increased significantly in the standard group as did the number of platelets, resulting in a significant difference between study groups on day 7. We conclude that BCAA enrichment of standard TPN solutions does not result in more efficient nitrogen metabolism in septic or traumatized patients.

Effect of branched chain amino acid enrichment of total parenteral nutrition on nitrogen sparing and clinical outcome of sepsis and trauma: a prospective randomized double blind trial.

Administration of extra branched chain amino acids (BCAA) has been associated with a nitrogen sparing effect in septic and traumatized patients. Whether nitrogen sparing is associated with decreased morbidity and mortality rates is unknown. We therefore undertook a prospective, randomized, double blind trial investigating the effects of BCAA enrichment of a total parenteral nutrition (TPN) regimen on nitrogen balance, 3-methylhistidine excretion, morbidity as evidenced by disturbances in organ function, severity of sepsis and mortality. One hundred and one patients entered the study; 52 received a standard TPN solution and 49 a BCAA-enriched solution. Both groups received 30 kcal kg-1 body-weight, 15 per cent fat calories and 0.17 g nitrogen kg-1 body-weight. In the BCAA-enriched group, patients received 0.56 g BCAA kg-1 body-weight (50.2 per cent BCAA). Standard group patients received 0.18 g BCAA kg-1 body-weight (15.6 per cent BCAA). Nitrogen balances and 3-methylhistidine excretion were not significantly different between groups. Although morbidity scores tended to decrease during the study no difference was observed between groups. Mortality (early or late), sepsis or stress-related, did not differ significantly between groups. We were not able to confirm the reported beneficial effects of BCAA-enriched TPN solutions for use in septic and traumatized patients.