ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology.

These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) in patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They have been discussed and accepted in a consensus conference. EN by means of oral nutritional supplements (ONS) or tube feeding (TF) enables nutritional intake to be maintained or increased when normal oral intake is inadequate. No data are yet available concerning the effects of EN on cachexia in CHF patients. However, EN is recommended to stop or reverse weight loss on the basis of physiological plausibility. In COPD patients, EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function. Frequent small amounts of ONS are preferred in order to avoid postprandial dyspnoea and satiety as well as to improve compliance.

Evaluation on the effectiveness of perioperative nutritional therapy.

In the last three decade very important advances in venous access, enteral feeding techniques and parenteral and enteral nutrient formulations have made it possible to provide sufficient nutritional support to almost all patients. The clinical nutritional therapy became a progressive medical subspecialty. Despite the widespread use of nutritional management of different patient groups, many fields of nutritional support remain controversial. The critical review of the current medical literature is necessary evaluating the effectiveness of nutritional support in the perioperative period. This document represents a critical review of the available literature and contains suggestions, recommendations for the clinical practice. The historical background and development of perioperative artificial nutritional therapy are cited. Whenever possible, prospective randomised clinical trials (PRCTs) are evaluated because this is the most reliable method for evaluating clinical efficacy of a treatment. The incidence of postoperative complications, the length of postoperative hospitalisation and the mortality are considered good general indicator of effectiveness of perioperative nutritional therapy.

Comparison of propofol-fentanyl or midazolam-fentanyl intravenous anaesthesia for carotid endarterectomy.

Carotid endarterectomy has become a standard surgical operation in the therapy of cerebrovascular insufficiency. The cardiovascular status of the patients needs special attention, since the long-term prognosis is predominantly influenced by concomitant coronary artery disease. General anesthesia techniques are raising the challenge of maintaining cardiovascular stability and establishing adequate cerebral monitoring. Randomly selected 30 patients gave informed consent to this approved study. Fifteen patients were anaesthetised with propofol-fentanyl or midazolam-fentanyl combined with N2O-O2. Haemodynamic parameters (mean arterial pressure, heart rate) showed not significant changes during anaesthesia. Recovery profil proved to be significantly better after propofol-fentanyl compared to midazolam-fentanyl anaesthesia.

[Artificial nutrition of patients with toxic epidermal necrolysis (Lyell syndrome)]. / Toxicus epidermalis necrolysisben (Lyell-szindróma) szenvedó beteg mesterséges táplálása.

The authors report the case of a 30-year-old man treated with toxic epidermal necrolysis. Toxic epidermal necrolysis was due to anticonvulsive drug treatment. The patient was admitted with denudated skin surface similar to second-degree burn that covered 90 per cent of the patient's body surface. The patient was isolated and treated, receiving sterile wound care, broad spectrum antibiotic and corticosteroid. Total parenteral nutrition was instituted until the 5th day of care because the patient was unable to take normal food. The energy intake reached 146 kJ/kg bodyweight containing 4 g/kg bodyweight carbohydrates and 2 g/kg bodyweight fat emulsion supplemented with 10-15 g of nitrogen per day. The enteral nutrition was commenced gradually with decreasing parenteral nutrition. The nutritive solutions were supplemented with ions, vitamins and trace elements. The patient left the intensive care unit after 23 days of care. The toxic epidermal necrolysis is a life-threatening dermatological disease and should be treated at intensive care unit. The early recognition of the disease, the intensive care and nutritional therapy may improve the survival of patients with toxic epidermal necrolysis.

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. I. Investigations on fistula output, nutritional status complications.

Prospective evaluation were made of 45 patients with postoperative small bowel fistulas treated with total parenteral nutrition (TPN) and enteral nutrition (EN) between 1971-1988. The administration of TPN in the early treatment of enteric fistulas decreased the mean fistula output significantly (p < 0.05-0.001) and provided an effective tool in the control of high-output fistulas. The electrolyte contents of different fistula secretions were unchanged and the losses through the fistulas depended on the daily output. In patients with high-output fistulas acid-base balance disturbances had to be corrected. When comparing two parenteral nutrition regimens (carbohydrate+amino acids /CH + AA/ versus carbohydrate + amino acids + fat /CH + AA + F/) both facilitated the reduction of fistula secretion (in high-output fistulas. CH + AA = -50.2%; CH + AA + F = -49%). Positive nitrogen balance was achieved in non septic patients after 13 days of treatment. Improvement of serum protein and albumin occurred by the time of fistula healing. In non surviving patients significant decrease in protein synthesis was observed. Out 7 of 75 central venous catheters yielded positive bacterial cultures (9.3%). In 5 patients autopsy proved generalized sepsis. The use of parenteral and enteral nutrition proved to be a powerful method for controlling the enterocutaneous fistulas and maintaining the nutritional integrity of patients.

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. II. Factors influencing the outcome of treatment.

An 18-year review of 64 patients treated with 71 postoperative enterocutaneous fistulas of the stomach /4/, duodenum /21/, jejunum /9/ and ileum /37/ was carried out to identify the factors affecting morbidity and mortality. Age, localization, output, inflammatory or malignant bowel disease, nutritional status and associated sepsis were analysed. The administration of total parenteral nutrition (TPN) or/and enteral nutrition (EN) as adjuvant therapy in the management of gastrointestinal fistulas increased the fistula closure rate (64%) and decreased mortality (33%). In patients over 65 years a rise in mortality rate (69%) was found. TPN and EN support yielded the best results in duodenal and jejunal fistula patients (closure rate 83% and 71%; respectively). In patients with high-output fistulas, inflammatory bowel disease and malignancy good results could be achieved with nutritional treatment. The presence of malnutrition had an adverse effect on the outcome in the non-TPN group with a mortality rate of 49%. In 43 patients severe septic complications occurred and 21 died due to septic multiple organ failure proved by autopsy. The overall mortality rate was 39%. Timing of fistula surgery had little impact on the fistula closure rate, but better results were obtained when reconstructive surgery was deferred beyond 6 weeks from fistula onset. Mortality has decreased since 1980. While many factors influence the outcome of fistula disease, adequate antiseptic treatment is assumed of primary importance. The nutritional therapy facilitated the spontaneous fistula healing and allowed the elective intestinal reconstruction to be scheduled at an optimal time.

Effect of different intravenous nutrients on upper gastrointestinal secretion in rats.

Total parenteral nutrition has been advocated for nutritional support of patients with proximal small bowel fistula. Data on the direct effects of different nutrients on upper gastrointestinal secretion are controversial. Therefore, we examined the effects of glucose, amino acid, fat and mixed parenteral solutions on gastric juice secretion, hydrochloric acid and pepsin content, duodenal juice secretion, and pancreatic protein, amylase, bilirubin and bicarbonate content in thirty rats with chronic gastric and duodenal fistulas. Gastric secretion was increased by glucose solution (D10W) and by amino acid solution (5% AA) (13% and 12% increase respectively) but not to significant degree by fat emulsion (2% F). Both D10W and 5% AA caused comparable increase in hydrochloric acid secretion (D10W: +34%; 5% AA: +28%) and the pepsin secretion (D10W: +37%). The single infusion of hypertonic glucose, amino acids and fat were associated with decreases in duodenal fistula volume (p less than 0.05) or content output. Mixed nutrients decreased both gastric secretion (volume: -28%; HCl: -19%; pepsin: -65%) and duodenal juice volume (p less than 0.05), protein and amylase content (p less than 0.05). The elevated bilirubin in reduced volume of duodenal juice caused by mixed nutrients may be responsible for bile sludge formation. This study indicates that the use of parenteral nutrition can provide full nutritional support while decreases the fistula output.

Indirect calorimetry methods for determination of energy expenditure.

Brief history and development of calorimetric methods for the determination of energy expenditure are discussed. The author demonstrates the measuring principles of direct and indirect calorimetry. In two clinical studies the practical use of closed and open technique of indirect calorimetric measurements are presented. In 10 operated patients under isoflurane-nitrous oxide anaesthesia in closed breathing circuit dose related decrease of oxygen consumption and carbon dioxide production was found. The indirect calorimetry showed higher mean energy expenditure (+14%) than was calculated by the Brody-Kleiber formula. These values indicate that the metabolic response due to surgical stress exceeds the metabolism decreasing effect of anaesthesia. The modalities of exact determination of energy expenditure of septic patients under respiratory treatment are discussed. Data of modified Harris-Benedict equation adapted to clinical conditions and of continuous indirect calorimetric measurement of energy expenditure were compared in 25 septic patients. The measured and the calculated mean values showed good correlation (r = 0.82). The modified Harris-Benedict equation may be properly used in clinical practice, when indirect calorimetric measuring instrument is unavailable.

Comparison of respiratory and cardiovascular effects of halothane, isoflurane, and enflurane delivered via the Jackson-Rees breathing system in rats. New anaesthesia model for small animal surgery.

We studied the respiratory (R) and cardiovascular (CV) effects of 1.25 MAC halothane (H), isoflurane (I) and enflurane (E) in oxygen, delivered by the Jackson-Rees breathing system in 5 normothermic rats. Mean arterial pressure (MAP), heart rate (HR) were depressed after 30 minutes than stabilized after 2 hours anaesthesia regardless of the inhalational agent. Respiratory rate (RR) slowed down markedly unter I and E anaesthesia. Significant R depression was developed (PCO2 53.5 +/- 2.44 Torr) under E. Stabil metabolic condition was maintained. The R and CV changes caused by H and I were far less than changes produced by E. H or I is preferable to E for small animal anaesthesia with spontaneous breathing. Maintenance of constant temperature minimizes the CV and R disturbances.

Respiratory and cardiovascular effects of halothane, isoflurane and enflurane delivered via a Jackson-Rees breathing system in temperature controlled and uncontrolled rats.

We studied the respiratory and cardiovascular effects of 1.25 MAC halothane, isoflurane and enflurane in oxygen delivered via the Jackson-Rees breathing system in 10 rats. Mean arterial pressure, heart rate and respiratory rate were depressed significantly (P less than 0.05) in rats (n = 5) whose body temperature was not controlled after 2 hr of anesthesia regardless of the inhalational agent. Respiratory and metabolic acidosis developed. The respiratory and cardiovascular depression was most marked under enflurane anesthesia. In normothermic rats (n = 5) the initial cardiovascular depression stabilized after 30 min of halothane and isoflurane anesthesia. Moderate respiratory depression developed (PCO2 48.42 +/- 2.48 torr with halothane vs. 41.02 +/- 1.68 torr with isoflurane). Because the cardiovascular and respiratory changes caused by halothane and isoflurane were far less than changes produced by enflurane, halothane or isoflurane is preferable to enflurane for maintaining anesthesia in rats. Maintenance of constant temperature minimizes the cardiovascular and respiratory disturbances.

[Treatment of enterocutaneous small intestine fistula using parenteral nutrition therapy]. / Behandlung der enterokutanen Dünndarmfistel mit Hilfe der parenteralen Ernährungstherapie.

A retrospective and prospective analysis was carried out of 48 patients with 54 enterocutaneous small bowel fistulae. 31 patients received total parenteral nutrition (TPN) by 17 patients only the daily losses of fluids and electrolytes were covered. In 19 fistulae (39,5%) closed spontaneously (48,5% with TPN and 14,3% without TPN). 10 patients underwent surgery; 5 fistulae closed operatively. The efficacy of treatment of enterocutaneous fistulae was influenced by the location of fistula, by the daily output, by the septic complications and by the use of TPN. Total parenteral nutrition can be the primary treatment or an effective adjunct to supplement the surgical management of postoperative small bowel fistulae.

[Total parenteral nutrition in patients with enterocutaneous intestinal fistulas]. / Vollständige parenterale Ernährung bei Patienten mit enterokutaner Darmfistel.

This is a retrospective analysis out of 49 patients suffering from enterocutaneous fistulae. 25 patients received total parenteral nutrition. The enteral feeding of 17 patients was completed by parenteral nutrition: 7 patients were fed perorally. 13 fistulae (27%) healed up by conservative treatment, 10 underwent surgery and 8 patients had persistent fistulae. The total mortality rate came up to 41%. Total parenteral nutrition can be the only treatment or is an effective adjunct to supplement the surgical management of enterocutaneous fistulae.

Total parenteral nutrition in management of external small bowel fistulae.

Prospective and retrospetive analyses were made of 34 patients with small bowel fistulae treated with and without total parenteral nutrition (TPN) between 1970--1981. The administration of TPN in the management of small bowel fistulae increased their rate of closing and decreased the number of permanent fistulae. No improvement was observed in mortality (44%). More than 90% of the deaths occurred in patients with uncontrolled sepsis. In patients older than 65 years a decreased healing tendency and a rise in mortality rate up to 80% was found despite TPN. In patients with high-output fistulae, inflammatory bowel disease and malignancy, good results could be reached with TPN. The suggested plan for management of small bowel fistulae is based upon initial nonoperative therapy, nutritional support, vigorous control of sepsis. These facilitate spontaneous healing or allow surgical closure in the optimal time.

Tissue pH in the assessment of ischaemic muscle damage.

Measurement in vivo of the pH of superficial muscles of dogs was found suitable for the assessment of the severity of ischaemic muscle damage and for the detection of irreversible lesions.