[Influence of zinc administered by total parenteral nutrition on plasmatic zinc levels, on reactive C protein, on serum interleukin-6 and on serum interleukin-6 soluble receptor, in critical patients]. / Influencia del zinc administrado a pacientes críticos con nutrición parenteral sobre los niveles de zinc plasmático, proteína C reactiva, interleuquina-6 y receptor soluble de interleuquina-6.

OBJECTIVES: To study the interrelationship between serum Interleukin-6 (IL-6), serum Interleukin-6 soluble Receptor (IL-6 sR), C-Reactive Protein (C-RP), plasmatic Zinc levels (PlZn) and their response in relation to Zn administered by TPN, in critical patients. METHODS: 17 patients, receiving TPN as a consequence of acute pancreatitis (n = 4) or after a major abdominal surgery due to intestinal cancer (n = 7), intestinal fístula (n = 3), intestinal obstruction (n = 2) or intestinal íleus (n = 1) were studied. At the beginning (To) and at the end of the TPN administration (6-21 days) serum IL-6 and IL-6 sR were determined by ELISA; C-RP ultrasensitive (C-RP us) by inmunoturbidimetric method; Zn was determined in TPN and in plasma by Atomic Absorption Spectrometry. Characteristics of the patients were (mean +/- SD and ranges): age: 60.6 +/- 11.7 (37-77) years; BMI (kg/m(2)): 26.0 +/- 3.4 (19.9-34.0). RESULTS: The results (mean +/- standard deviation and ranges) were: Zn provided by TPN (mg/d): 6.1 +/- 2.0 (range 2.8 to 10.8). Biochemical levels were, at To and Tf, respectively: (mean+/-SD and ranges) were at To y Tf, respectively: Zn Pl (microg/dl): 104 +/- 46 (35-177); 120 +/- 55 (52-229); IL-6 (pg/mL) 93 +/- 74 (10-262); 117 +/- 180 (7-761); IL6sR (pg/mL): 1,012 +/- 322 (589-1855); 1,269 +/- 451 (631-2195); C-RP us (mg/L): 71 +/- 63 (2-196); 65 +/- 43 (0-137). There was no correlation between variations of IL6, IL6sR, C-RP, PlZn levels and the daily amount of Zn administered in the TPN mixtures. Two patients presented a bad evolution; they received 4.2 and 5.2 md/d of Zn and showed an increase of IL6 levels, maintained high levels of IL6sR but C-RP levels decreased. CONCLUSIONS: the range of 2.8 to 10.8 mg/d of Zn administered in TPN mixtures did not exacerbate the inflammatory response.

Influencia del zinc administrado a pacientes críticos con nutrición parenteral sobre los niveles de zinc plasmático, proteína C reactiva, interleuquina-6 y receptor soluble de interleuquina-6 / Influence of zinc administered by total parenteral nutrition on plasmatic zinc levels, on reactive C protein, on serum interleukin-6 and on serum interleukin-6 soluble receptor, in critical patients

Objetivos: Estudiar, en pacientes críticos, la respuesta de los niveles de Zn en plasma (ZnPl), de IL-6 sérica, del IL-6sR y de la PCR en relación al Zn administrado en la NPT, para evitar la deficiencia o el exceso de Zn. Métodos: 17 pacientes que recibieron NPT, por pancreatitis aguda o luego de una cirugía abdominal mayor. Al inicio (To) y a la finalización (Tf) de la NPT (6 a 21 días) se determinó en suero: IL-6 y IL-6 sR (ELISA); PCR (inmunoturbidimetría); ZnPl y Zn en NPT (Espectrometría de Absorción Atómica). Características físicas: edad, años (promedio ± DE y rangos): 60,6 ± 11,7 (37-77); BMI (kg/m2): 26,0 ± 3,4 (19,9-34,0). Resultados: Promedio ± DE (y rangos): aporte de Zn en la NPT: 6,1 ± 2,0 mg/día (2,8 a 10,8); parámetros bioquímicos, a To y Tf, respectivamente: Zn Pl (μg/dl): 104 ± 46 (35-177); 120 ± 55 (52-229); IL-6 (pg/mL) 93 ± 74 (10-262); 117 ± 180 (7-761); IL6sR (pg/mL): 1012 ± 322 (589-1.855); 1.269 ± 451 (631-2.195); PCR (mg/L): 71 ± 63 (2-196); 65 ± 43 (0-137). Dos pacientes, que fallecieron, incrementaron más de 4 veces los niveles de IL6, mantuvieron altos niveles de IL-6sR, pero disminuyendo los de PCR, recibiendo 4,2 y 5,2 mg/d de Zn. El 60% de los pacientes con evolución clínica favorable presentó una disminución de los niveles de IL6. Conclusiones: en los pacientes críticos, con evolución favorable, dosis de Zn de 2,8 a 10,8 mg/d en la NPT no exacerbaron la respuesta inflamatoria, evaluada mediante los niveles de IL-6, IL6sR y PCR (AU)

Objectives: To study the interrelationship between serum Interleukin-6 (IL-6), serum Interleukin-6 soluble Receptor (IL-6 sR), C-Reactive Protein (C-RP), plasmatic Zinc levels (PlZn) and their response in relation to Zn administered by TPN, in critical patients. Methods: 17 patients, receiving TPN as a consequence of acute pancreatitis (n = 4) or after a major abdominal surgery due to intestinal cancer (n = 7), intestinal fístula (n = 3), intestinal obstruction (n = 2) or intestinal íleus (n = 1) were studied. At the beginning (To) and at the end of the TPN administration (6-21days) serum IL-6 and IL-6 sR were determined by ELISA; C-RP ultrasensitive (C-RP us) by inmunoturbidimetric method; Zn was determined in TPN and in plasma by Atomic Absorption Spectrometry. Characteristics of the patients were (mean ± SD and ranges): age: 60.6 ± 11.7 (37-77) years; BMI (kg/m2): 26.0 ± 3.4 (19.9-34.0). Results: The results (mean ± standard deviation and ranges) were: Zn provided by TPN (mg/d): 6.1 ± 2.0 (range 2.8 to 10.8). Biochemical levels were, at To and Tf, respectively: (mean±SD and ranges) were at To y Tf, respectively: Zn Pl (μg/dl): 104 ± 46 (35-177); 120 ± 55 (52-229); IL-6 (pg/mL) 93 ± 74 (10-262); 117 ± 180 (7-761); IL6sR (pg/mL): 1,012 ± 322 (589-1855); 1,269 ± 451 (631-2195); C-RP us (mg/L): 71 ± 63 (2-196); 65 ± 43 (0-137). There was no correlation between variations of IL6, IL6sR, C-RP, PlZn levels and the daily amount of Zn administered in the TPN mixtures. Two patients presented a bad evolution; they received 4.2 and 5.2 md/d of Zn and showed an increase of IL6 levels, maintained high levels of IL6sR but C-RP levels decreased. Conclusions: the range of 2.8 to 10.8 mg/d of Zn administered in TPN mixtures did not exacerbate the inflammatory response (AU)

Relacion entre las cantidades de cobre y zinc administradas a pacientes graves con nutrición parenteral total y los niveles de cobre y zinc en plasma y eritrocitos / Relationship between the amount of copper and zinc given to critically ill patients on total parenteral nutrition and plasma and erythrocyte copper and zinc levels

Objetivos: Evitar tanto las complicaciones por deficiencia de zinc y de cobre como los efectos adversos del exceso en pacientes graves que requirieron nutrición parenteral, estudiando la relación entre las cantidades de zinc y de cobre administradas en las mezclas de nutrición parenteral y los cambios en algunos indicadores bioquímicos de los pacientes, con respecto a zinc y cobre. Pacientes y metodología: 29 pacientes graves, adultos, con pancreatitis o sometidos a cirugía mayor abdominal. Se determinó, al inicio y al final del tratamiento (5-21 días): cobre y zinc en las mezclas de nutrición parenteral administradas y en eritrocitos (GR), zinc en plasma y cobre en suero (Espectrometría de Absorción Atómica). Resultados (promedio ± DE, rangos: entre paréntesis): los valores de zinc y cobre en las mezclas de nutrición parenteral fueron (μg/mL): zinc: 4,2 ± 1,7 (1,8 a 9,3); cobre: 0,94 ± 0,66 (0,1 a 3,1); zinc plasmático (μg/dl): inicio 80 ± 45 (29-205); final: 122 ± 56 (37-229); zinc eritrocitario (μg/dl): inicio: 2.300 ± 1.070 (790-5280); final: 2.160± 920 (790-4.440); cobre sérico (μg/dl): inicio: 124 ± 35 (62-211); final: 128 ± 41 (60-238); cobre eritrocitario (μg/dl): inicio: 72 ± 39 (4-183); final: 70 ± 41 (9-156). Los cambios porcentuales de los niveles de zinc eritrocitario correlacionaron con el zinc (mg/d) en las mezclas de nutrición parenteral (r = 0,38). Las variaciones de cobre sérico y eritrocitario correlacionaron positivamente con los valores de cobre administrado (mg/d) en las mezclas de nutrición parenteral (r = 0,31 y 0,26, respectivamente). Conclusiones: Estos resultados evidenciaron que: 1) las determinaciones de zinc eritrocitario, cobre sérico o eritrocitario serían de utilidad para controlar los niveles de zinc y de cobre administrados en las mezclas de nutrición parenteral a los pacientes graves; 2) las dosis de zinc deberían ser menores a 8,1 mg/d, y 3) no sería aconsejable administrar dosis de cobre superiores a 1,2 mg/d (AU)

Objectives: Complications resulting from zinc and copper deficiency, or adverse effects from excessive zinc and copper intake should be avoided during total parenteral nutrition (TPN). This study was conducted on critically ill patients requiring TPN to determine the relationship between the zinc and copper levels of the TPN mixtures, patients' clinical progression, and changes in plasma levels of zinc, serum levels of copper, and erythrocyte levels of zinc and copper. Patients and methods: 29 adult critically ill patients following pancreatitis or after a major abdominal surgery were studied. Zinc and copper levels in TPN, plasmatic zinc levels, copper serum levels and erythrocyte levels of zinc and copper were determined at the onset and at the end of the treatment (5-21 days) (using Atomic Absorption Spectrometry). Results: The mean ± standard deviation (and ranges in parenthesis) of zinc and copper levels in TPN were (μg/mL): zinc: 4.2 ± 1.7 (1.8 a 9.3); copper: 0.94 ± 0.66 (0.1 a 3.1). Biochemical parameters at the onset and at the end of the treatment were, respectively: (μg/mL): plasmatic zinc: 80 ± 45 (29-205) and 122 ± 56 (37-229); erythrocyte zinc: 2,300 ± 1,070 (790-5,280) and 2,160 ± 920 (790-4,440); serum copper (μg/dL): 124 ± 35 (62-211) and 128 ± 41 (60- 238); erythrocyte copper (μg/dl): 72 ± 39 (4-183) and 70 ± 41 (9-156). Plasmatic and erythrocyte zinc levels did not correlated neither at the onset nor at the end of the treatment. Changes in erythrocyte zinc levels correlated with daily administered zinc (mg/d) in the parenteral nutrition (r = 0.38). Serum copper and erythrocyte copper showed significant correlation at the onset (p = 0.0005) and at the end of treatment (p = 0.008). Changes of serum or erythrocyte copper levels showed a significant correlation with daily administered copper (r = 0.31 and 0.26, respectively). Conclusions: These results show that: 1) determination of erythrocyte zinc and copper levels in these critically ill patients would help to control zinc and copper administration levels in TPN and avoid adverse effects; 2) TPN Zn levels should be less than 8.1 mg/d, and 3) TPN Cu levels higher than 1.2 mg/d would not be recommended (AU)

[Relationship between the amount of copper and zinc given to critically ill patients on total parenteral nutrition and plasma and erythrocyte copper and zinc levels]. / Relación entre las cantidades de cobre y zinc administradas a pacientes graves con nutrición parenteral total y los niveles de cobre y zinc en plasma y eritrocitos.

OBJECTIVES: Complications resulting from zinc and copper deficiency, or adverse effects from excessive zinc and copper intake should be avoided during total parenteral nutrition (TPN). This study was conducted on critically ill patients requiring TPN to determine the relationship between the zinc and copper levels of the TPN mixtures, patients' clinical progression, and changes in plasma levels of zinc, serum levels of copper, and erythrocyte levels of zinc and copper. PATIENTS AND METHODS: 29 adult critically ill patients following pancreatitis or after a major abdominal surgery were studied. Zinc and copper levels in TPN, plasmatic zinc levels, copper serum levels and erythrocyte levels of zinc and copper were determined at the onset and at the end of the treatment (5-21 days) (using Atomic Absorption Spectrometry). RESULTS: The mean+/-standard deviation (and ranges in parenthesis) of zinc and copper levels in TPN were (microg/mL): zinc: 4.2+/-1.7 (1.8 a 9.3); copper: 0.94+/-0.66 (0.1 a 3.1). Biochemical parameters at the onset and at the end of the treatment were, respectively: (microg/mL): plasmatic zinc: 80+/-45 (29-205) and 122+/-56 (37-229); erythrocyte zinc: 2,300+/-1,070 (790-5,280) and 2,160+/-920 (790-4,440); serum copper (microg/dL): 124+/-35 (62-211) and 128+/-41 (60- 238); erythrocyte copper (microg/dl): 72+/-39 (4-183) and 70+/-41 (9-156). Plasmatic and erythrocyte zinc levels did not correlated neither at the onset nor at the end of the treatment. Changes in erythrocyte zinc levels correlated with daily administered zinc (mg/d) in the parenteral nutrition (r=0.38). Serum copper and erythrocyte copper showed significant correlation at the onset (p=0.0005) and at the end of treatment (p=0.008). Changes of serum or erythrocyte copper levels showed a significant correlation with daily administered copper (r=0.31 and 0.26, respectively). CONCLUSIONS: These results show that: 1) determination of erythrocyte zinc and copper levels in these critically ill patients would help to control zinc and copper administration levels in TPN and avoid adverse effects; 2) TPN Zn levels should be less than 8.1 mg/d, and 3) TPN Cu levels higher than 1.2 mg/d would not be recommended.

[Zinc and copper content in individual components used to prepare pediatric total nutrition mixtures]. / Contenido de zinc y cobre en los componentes individuales de las mezclas para fórmulas pediátricas de nutrición parenteral total.

OBJECTIVES: 1) to determine zinc and copper levels of contamination in the individual component solutions used to prepare the pediatric total parenteral nutrition mixtures in Argentina; 2) to compare zinc and copper amounts prescribed by the physician with the true amount given to a neonate weighing 1.2 kg and to a child weighing 10 kg, who would receive total parenteral nutrition formulas prepared with those component solutions. MATERIALS AND METHODS: Zn and Cu were determined by atomic absorption spectrophotometry in 59 individual solutions belonging to 14 components chosen between the commercial products available in Argentina. RESULTS: zinc and copper, as contaminants, were found neither in the sterile water, nor in the potassium chloride or in the vitamin solutions. Zinc, but no copper, was detected in sodium chloride, manganese sulfate, chromium chloride and seleniose acid solutions. Zinc and copper were detected in dextrose, amino acids, calcium gluconate and lipid solutions at variable levels. Zinc sulfate solutions contained between 90.4% and 140% of the declared content and a variable contamination with copper. Copper sulfate solutions presented between 4% and 18% less the declared copper concentration and a variable contamination with zinc. Dextrose and lipid solutions presented the highest amount of zinc and copper. Therefore, the total parenteral mixtures prepared with the analyzed solutions must have had an excess of zinc and copper in relation to the prescription: ranging between 103% and 161% and between 7%-426% higher than the Zn and Cu amounts prescribed for neonates, respectively; the excess in the total parenteral nutrition for a child weighing 10 kg would ranged between 105% and 189% and between 7%-365% higher than the prescribed for Zn and Cu, respectively. CONCLUSIONS: 1) Nine components presented Zn and five Cu, both of them not declared in the label; 2) the usually prescribed total parenteral nutrition mixtures must have had a zinc and copper amount higher than the prescribed one according to international recommendations; 3) those figures would be safe in patients without complications, but it would be harmful in renal failure, hepatic compromise or colestasis mainly in pediatric patients; 4) It would be advisable to declare in the label the true content of zinc and copper, with the aim to avoid deficiencies and excess which would compromise the evolution of pediatric patients.

Contenido de zinc y cobre en los componentes individuales de las mezclas para fórmulas pediátricas de nutrición parenteral total / Zinc and copper content in individual components used to prepare pediatric total nutrition mixtures

Objetivos: 1) Determinar el contenido de zinc y cobre presente como contaminante en los componentes individuales destinados a preparar mezclas pediátricas de nutrición parenteral total; 2) Comparar los valores prescriptos con las cantidades reales de zinc y cobre que tendrían las mezclas de nutrición parenteral total para un neonato de 1,2 kg de peso y para un niño de 10 kg de peso. Materiales y métodos: Se determinó zinc y cobre por espectrofotometría de absorción atómica, en 59 productos de distintos laboratorios y lotes, correspondientes a 14 componentes diferentes, utilizados para preparar mezclas pediátricas de nutrición parenteral total, en Argentina. Resultados: El agua estéril, las soluciones de cloruro de potasio y las mezclas de vitaminas no presentaron cantidades detectables de zinc y cobre. Se encontró contaminación en 11 componentes, con valores variables según el fabricante y el lote de cada producto. El cloruro de sodio, sulfato de manganeso, cloruro de cromo y el ácido selenioso contenía zinc y no contenían cobre. La solución de dextrosa y los lípidos presentaron las mayores cantidades de zinc y cobre. Algunas soluciones de sulfato de zinc contenían cobre y todas las soluciones de sulfato de cobre contenían zinc. Conclusiones: 1) Se encontró zinc en nueve componentes y cobre en cinco, ambos no declarados en los rótulos. 2) La mezcla de nutrición parenteral total de prescripción habitual en Neonatología y Pediatría podría alcanzar una concentración final de zinc y cobre superior a las recomendaciones internacionales. 3) Las cantidades halladas de zinc y cobre no traerían inconvenientes en pacientes clínicamente estables, pero serían perjudiciales en aquellos con enfermedades inflamatorias, insuficiencia renal, alteración hepática o colestasis. 4) Sería aconsejable solicitar la declaración en el rótulo del contenido real de zinc y cobre, para evitar tanto las deficiencias como los excesos, que pueden comprometer la evolución del paciente pediátrico grave

Objectives: 1) to determine zinc and copper levels of contamination in the individual component solutions used to prepare the pediatric total parenteral nutrition mixtures in Argentina; 2) to compare zinc and copper amounts prescribed by the physician with the true amount given to a neonate weighing 1,2 kg and to a child weighing 10 kg, who would receive total parenteral nutrition formulas prepared with those component solutions. Materials and methods: Zn and Cu were determined by atomic absorption spectrophotometry in 59 individual solutions belonging to 14 components chosen between the commercial products available in Argentina. Results: zinc and copper, as contaminants, were found neither in the sterile water, nor in the potassium chloride or in the vitamin solutions. Zinc, but no copper, was detected in sodium chloride, manganese sulfate, chromium chloride and seleniose acid solutions. Zinc and copper were detected in dextrose, amino acids, calcium gluconate and lipid solutions at variable levels. Zinc sulfate solutions ® contained between 90,4% and 140% of the declared content and a variable contamination with copper. Copper sulfate solutions® presented between 4% and 18% less the declared copper concentration and a variable contamination with zinc. Dextrose and lipid solutions presented the highest amount of zinc and copper. Therefore, the total parenteral mixtures prepared with the analyzed solutions must have had an excess of zinc and copper in relation to the prescription: ranging between 103% and 161% and between 7%-426% higher than the Zn and Cu amounts prescribed for neonates, respectively; the excess in the total parenteral nutrition for a child weighing 10 kg would ranged between 105% and 189% and between 7%-365% higher than the prescribed for Zn and Cu, respectively. Conclusions: 1) nine components presented Zn and five Cu, both of them not declared in the label; 2) the usually prescribed total parenteral nutrition mixtures must have had a zinc and copper amount higher than the prescribed one according to international recommendations; 3) those figures would be safe in patients without complications, but it would be harmful in renal failure, hepatic compromise or colestasis mainly in pediatric patients; 4) It would be advisable to declare in the label the true content of zinc and copper, with the aim to avoid deficiencies and excess which would compromise the evolution of pediatric patients

[Plasmatic and erythrocytic zinc and copper levels in critically ill patients on parenteral nutrition and their relationship with formulas content: preliminary study]. / Niveles plasmáticos y eritrocitarios de zinc y cobre en pacientes críticos con nutrición parenteral y su relación con el contenido de las fórmulas: estudio preliminar.

OBJECTIVES: To study in severe patients that required parenteral nutrition the relationship between Zn and Cu amounts present in formulas, the clinical course and changes in some biochemical parameters (plasmatic and erythrocytic Zn and Cu levels) during the parenteral nutrition therapy. PATIENTS AND METHODOLOGY: Five adult severe patients were studied, submitted to major abdominal surgery, and that required parenteral nutrition. Determinations were done for: 1) Zinc and copper in parenteral formulas; 2) in patients, at the beginning (T0) and at the end (Tf) of treatment, in erythrocytes: zinc (Zn-E) and cupper (Cu-E); in plasma, zinc (Zn-Pl) and in serum, cupper (Cu-S). Zinc and cupper were determined by means of atomic absorbance spectrometry. RESULTS: mean +/- standard deviation values and ranges (between brackets) were: parenteral formulas (microg/g): zinc: 0.6 +/- 1.1 (2.2 - 7.0); Cupper: 2.4 +/- 0.7 (0.5-3.7). Biochemical parameters: at T0 (n = 5): Zn-E (microg/mL): 21.6 +/- 10.0 (13.6-36.1); Zn-Pl (microg/dL): 88 +/- 72 (29-205); Cu-E (microg/dL): 113 +/- 22 (60-102); Cu-E (microg/dL): 139 +/- 29 (106 +/- 156); Cu-S (microg/dL): 172 +/- 20 (158-195). Individual values compared to reference ones (normal individual from Buenos Aires with adequate nutrition) indicated that the three patients with favorable course normalized Zn-Pl and Zn-E levels. However, Cu-S increased in the three cases and Cu-E in two of them. CONCLUSIONS: These results make clear that in the studied patients Zinc levels in parenteral formulas would be adequate to prevent deficiency while Copper levels could be too high.

[Enteral nutrition: reduction in the contamination risk]. / Nutrición enteral: reducción del riesgo de contaminación.

Enteral nutrition is used as a routine therapy in patients with caloric-protein malnutrition, severe dysphagia, major burns, intestinal resection, and enterocutaneous fistulae, as long as a portion of the digestive tract still has an active absorptive function. The administration takes place by means of surgical (ostomies) or non-surgical (nasogastric) tubes. In our country, a significant number of hospitalized patients with various diseases receive this type of nutrition. Given that the colonization of the digestive tract by hospital flora is the first step towards developing intra-hospital infections, the contamination implies serious risks. The objective of this study was to study the most appropriate conditions for the manufacturing, storage and administration of the mixture of nutrients of enteral nutrition, to guarantee nutrition with a lower contamination risk. This study was conducted by the Unit of Nutritional Assistance of the Mater Dei Clinic, by means of bacteriological controls, from January 1991 to December 1992, and in 1993 in which the work systematics were reviewed. The study was prospective, and those solutions whose bacteriological counts were lower than 100.000 colony forming units (CFU), and which showed an absence of enteropathological micro-organisms, were considered acceptable, and those solutions which had a bacteriological count greater than or equal to 100.000 CFU and or the presence of enteropathological micro-organisms, were considered unacceptable. During the first period, "usual working conditions", we analyzed the infra-structure, the personnel, the constituents, and the apparatus used in the manufacturing, for which 36 samples were studied at t0 (moment of preparation). Afterwards, in the second period "special working conditions", we analyzed the manufacturing procedures, the storage and the administration of 103 solutions, corresponding to 36 patients, taking samples at t0 and t24 (after 24 hours of preparing). In the first phase, we found a 53% contamination. In the second phase, 99.03% of the solutions were within the limits of acceptability, and only 0.07% were unacceptable. We conclude that it is necessary to have access to a working area which meets the biosecurity norms, to use sterile technique in the preparation, to prefer pharmacologically sterile products for the preparation, to store the prepared mixture between 4 and 8 degrees C, and to keep it cooled during the administration. Lastly, we saw the need to continuously capacitate the nursing, dietary (ABSTRACT TRUNCATED)