Family partnership in care: integrating families into the coronary intensive care unit.

Since the introduction of Family Partnership in Care in the CICU and other pilot units, many changes have been made. Education sessions are now unit specific rather than in groups with multiple units. This facilitates the discussion of unit-specific educational and implementation needs. In addition, unit-specific sessions allow for some case scenario/role playing activities to facilitate learning and application of the FPCP elements to the unique culture of the unit. Finally, less emphasis is placed on the documentation, while greater emphasis is placed on the philosophy behind the program and the nurses values and attitudes towards families. Overall, the implementation of the FPCP in CICU has had a positive impact on staff and patients. Staff awareness regarding the importance of involving family in the patient's care and the benefits of this has been heightened. Staff who were initially very skeptical have become strong advocates for the program. The successful shift with families in "doing for" to "working with" has enhanced the professional practice of many nursing staff and contributed to the overall unit functioning. Finally, the feedback from patients and their care partners and the independence and informed decision-making fostered by designing a plan of care with staff validates the importance of this program in a critical care area.

Metabolic and clinical consequences of changing from high-glucose to high-fat regimens in parenterally fed newborn infants.

To evaluate the metabolic and clinical consequences of changing from high-glucose to high-fat regimens during initiation of parenteral nutrition, we performed 22 studies in 11 newborn infants (birth weight (mean +/- SD) 2.54 +/- 0.54 kg, gestational age 37 +/- 3 weeks, postnatal age 8 +/- 3 days) maintained in a constant thermal environment. In a paired design, two isoproteinic (2.4 +/- 0.2 gm/kg/day) and isocaloric (64 +/- 6 kcal/kg/day) regimens differing by source of energy (high glucose vs high lipid) were infused on consecutive days. Environmental and body temperatures were recorded during a 4-hour period, and 24-hour urinary excretions of catecholamines, nitrogen, and C peptide were measured. Despite constant incubator and average skin temperatures, the rectal and interscapular temperatures rose significantly when the high-glucose regimen was changed to a high-lipid regimen. The specific locations of these changes in body temperature suggested brown fat activation. A significant drop in nitrogen retention (63 +/- 9% vs 56 +/- 10%) during the lipid infusion could be further evidence of a metabolic adaptation to the rapid change in energy substrates.

Beneficial effect of coinfusing a lipid emulsion on venous patency.

The hypothesis that infused fat could prolong venous patency was tested in a paired crossover design. Parenterally fed newborn infants received, for a given level of energy, (60 vs 80 kcal/kg/day), two 6-day isocaloric and isonitrogenous (434 +/- 3.4 mg/kg/day, n = 32) regimens differing only by the fat intake (LF: 1.03 +/- 0.02, HF: 2.78 +/- 0.05 g/kg/day). Paired comparisons of osmolarities within isocaloric (60 or 80 kcal/kg/day) infusions showed that high fat regimens were associated with significantly lower osmolarities. A paired comparison of patency times showed that the drop in osmolarity produced by the high fat regimen at 60 kcal/kg/day led to a significantly longer venous patency time. The comparison of patency times between regimens (LF, 60 kcal/kg/day) and HF, 80 kcal/kg/day) with same osmolarities (702 mOsm/liter) and glucose intakes (11 g/kg/day) documented that the fat emulsion per se had a vascular protective effect. This observation demonstrates that the coinfusion of a lipid emulsion exerts a beneficial effect, whether biochemical or biophysical, on the vascular endothelium of peripheral veins.

Total parenteral nutrition in the newborn: energy substrates and plasma total fatty acids.

Carbohydrate and lipid intakes have both been found to modulate the metabolism of long-chain fatty acids. To define the respective influence of these two energy substrates on plasma fatty acid concentrations, 32 studies were performed in 16 parenterally fed newborn infants (mean +/- SEM, birth wt: 2.15 +/- 0.1 kg, age: 10 +/- 1 d). In a paired cross-over design, the infants received for a given level of energy (60 versus 80 kcal/kg/d) two 6-d isonitrogenous and isocaloric regimens constructed so that the level of fat intake, 1 or 3 g/kg/d varied inversely with that of glucose. Total plasma fatty acid levels did not reflect the composition of the emulsion and varied with energy substrates. Plasma levels of three fatty acids rose inversely to the lipid intake, during the high glucose regimen: 16:1w7, 20:3w9 biologic markers of essential fatty acid deficiency, and 20:3w6 a derivative of 18:2w6. Glucose intake could exert its influence on 20:3w9 and 20:3w6 via insulin, an activator of delta 6 desaturase. Both glucose and fat should be taken into account when evaluating plasma fatty acid profile.

Total parenteral nutrition in the newborn: amino acids-energy interrelationships.

As part of an ongoing study on the influence of intravenous glucose and fat on nitrogen metabolism we evaluated the relationship between the source of infused energy and plasma amino acid levels. Thirty-two studies were performed in 16 appropriate-for-gestational-age newborn infants (birth weight, 2150 +/- 115 g; means +/- SEM). In a crossover design each patient received two 6-d periods of isocaloric and isonitrogenous infusions, differing only by the source of calories (high or low fat intakes). For an energy intake of 80 kcal.kg-1.d-1 (335 kJ.kg-1.d-1) there was a significant hypoaminoacidemia (2338 +/- 185 vs 2937 +/- 196 mumol/L, high fat vs low fat) under the high-glucose intake. These data suggest that above an energy intake of 60 kcal.kg-1.d-1 (251 kJ.kg-1.d-1) there is a threshold at which changes in plasma amino acid levels are triggered by variations in the source of infused energy. Careful examination of all variables, including energy sources, is essential when aminograms are compared.

Total parenteral nutrition in the newborn: impact of the quality of infused energy on nitrogen metabolism.

To separate the respective influence of the level and source of infused energy on nitrogen metabolism, 32 studies were performed in 16 appropriate-for-gestational-age newborn infants (birth weight 2150 +/- 115 g, means +/- SEM). In a cross-over design, each patient received two 6-d periods of isocaloric and isonitrogenous (450 mg.kg-1.d-1) infusions, differing only by the source of calories (high or low fat intakes). Half of the patients were studied at 60 kcal.kg-1.d-1, the other half at 80 kcal.kg-1.d-1. Nitrogen balance, urinary 3-methylhistidine excretion, glycemia, and insulin were compared. The results suggest that for an intravenous energy intake ranging from 60 to 80 kcal.kg-1.d-1, glucose and fat provide an equivalent nitrogen sparing effect in the newborn infant. At an energy level covering maintenance requirements, it is the infant's clinical condition rather than the source of energy which affects most the magnitude of amino acids participation in energy metabolism.

Determination of the average molecular weight of nonionic emulsifiers by vapor-phase osmometry.

Standard nonionic emulsifiers are heterogeneous by nature. Their reported molecular weight is unreliable, especially when several lots of the product are used in a study. The number-average molecular weights of two nonionic emulsifiers, poloxamer 188 and polyoxyethylene (23) lauryl ether were determined by vapor-phase osmometry. This determination is essential when the concentration should be given in molarity rather than in weight per volume. A discrepancy was noted between the number-average molecular weights of two lots of poloxamer 188. That difference is taken into account prior to the establishment of any comparison of the behavior of the emulsifiers.

Retardation of dissolution and growth of calcium oxalate monohydrate.

The kinetics of dissolution and growth of calcium oxalate monohydrate were examined in the presence of small concentrations of pyrophosphate, chlorophyll, and other agents. Data presented show that the retardation in mass transport in both processes is controlled by the nature of the additive, its concentration, and the way the additives are combined in the dissolution medium. Dissolution was studied using a particle counter method, and growth was conducted in a gel system under the slow diffusion of the reacting ions. Results obtained show that chlorophyll is more active than other inhibitors studied and suggest a higher surface adsorption intensity on the primary sources of the crystal surface.

Growth of calcium oxalate in gel systems.

Methods are described for growing calcium oxalate in silica and gelatin gels under different conditions. The results obtained indicate that, in silica gel, calcium oxalate grows into single individual crystals, twins, and rosettes. Bipyramidal calcium oxalate dihydrate crystals similar to those present in the urine of stone formers were prepared in the silica gel system. The gelatin gel offered a suitably structured substrate on which calcium oxalate monohydrate crystals grow into aggregates. The orientation pattern of calcium oxalate crystals suggests that the growth process is controlled by the stereospecificity of the gelatin medium supporting growth.