Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents.

OBJECTIVE: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition. METHODS: Fifty-three consecutive residents who were > or = 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality. RESULTS: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05). CONCLUSIONS: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

Utilization of parenteral nutrition in patients receiving peripheral blood stem cell transplantation.

A paucity of information is available on the use of parenteral nutrition (PN) in patients undergoing peripheral blood stem cell transplantation (PBSCT). To characterize the utilization of PN in patients undergoing PBSCT, we conducted a retrospective chart review study on adult patients receiving autologous and allogeneic PBSCT. Data collection included nutritional parameters such as indications for PN, days of PN administration, and PN-associated complications (i.e., metabolic, infectious, and mechanical). Outcome parameters assessed included length of hospitalization, days to engraftment, graft versus host disease (GVHD), and veno-occlusive disease (VOD). A total of twenty-one consecutive patients were evaluated with 12 receiving allogeneic PBSCT and 9 receiving autologous PBSCT. The allogeneic group received PN for a mean of 25 days compared to 21 days for the autologous group. The rate of metabolic abnormalities was significantly higher in the allogeneic group compared to the autologous group (1.02 abnormalities/PN days vs 0.61 abnormalities/PN day, p < 0.05), but mechanical and infectious complications were similar between the two groups. Length of hospitalization, days to engraftment, incidence of GVHD and VOD did not differ significantly between the two groups. However, mortality prior to discharge was significantly higher in the allogeneic vs autologous group (58% vs 0%, p < 0.05). We conclude that allogeneic PBSCT patients appear to be at a greater risk for metabolic complications while receiving PN as compared to autologous PBSCT patients. As nausea and vomiting are two primary reasons for initiation of PN in this patient population, further studies of aggressive antiemetic therapy may prove to decrease the need for PN in PBSCT patients.

Skin necrosis induced by extravasation of glycerol-containing peripheral parenteral nutrition formulation.

Administration of parenteral nutrition (PN) via a peripheral vein has gained support over the last decade due to serious complications associated with central venous catheterization. Extravasation and tissue necrosis have been reported with both peripheral and central dextrose-containing PN formulations. The following case report represents the first documented case of skin necrosis due to extravasation of a glycerol-containing PN formulation. Our patient's condition resolved with local therapy such as elevation of the affected extremity and cold compresses. Routine evaluation of proper catheter placement is recommended to prevent this serious morbid event, while various treatment recommendations are outlined for severe injuries that do not respond to general measures such as cold compresses.

Glutamine supplementation in catabolic patients.

OBJECTIVE: To evaluate the safety and efficacy of parenteral and enteral glutamine supplementation in patients who are catabolic. DATA SOURCES: English-language clinical trials and review articles identified by MEDLINE searches (January 1970-December 1997) and from bibliographies of selected articles were considered for possible inclusion. Key words used in the search strategy were glutamine, critical illness, stress, catabolism, injury, enteral nutrition, and parenteral nutrition. STUDY SELECTION AND DATA EXTRACTION: Inclusion was restricted to pertinent studies that evaluated the safety of glutamine supplementation, as well as effects of glutamine on amino acid metabolism, immune function, and patient outcome. Data from 18 clinical trials and multiple review articles were compiled into a review format. DATA SYNTHESIS: Glutamine is an important metabolic fuel for intestinal enterocytes, lymphocytes and macrophages, and metabolic precursors such as purines and pyrimidines. Although originally considered a nonessential amino acid, experimental work suggests that glutamine is essential for maintaining intestinal function, immune response, and amino acid homeostasis during periods of severe stress. In the past decade, clinical trials conducted in metabolically stressed patients indicate that glutamine improves nitrogen balance, increases cellular proliferation, decreases the incidence of infection, and shortens hospital stay in some catabolic patients. CONCLUSIONS: Glutamine has been studied extensively over the past decade for its role during critical illness. Clinical trials conducted in humans demonstrate glutamine to be well tolerated without adverse consequences, even during times of stress. Although glutamine has shown promise in select groups of catabolic patients, additional studies are needed to define which patient populations derive the greatest benefit from supplemental glutamine and the mechanisms by which these effects are exerted.

Mononuclear blood cell magnesium content and serum magnesium concentration in critically ill hypomagnesemic patients after replacement therapy.

Magnesium (Mg) deficiency, commonly diagnosed as hypomagnesemia based upon low serum Mg concentrations, is a frequent electrolyte abnormality in critically ill patients. Intravenous replacement therapy is empiric and serum Mg concentrations have traditionally been used as guidelines for measuring efficacy. Recent studies have shown that the Mg content of mononuclear blood cells (MBCs) may provide a better index for Mg status than serum concentrations. The purpose of this study was to evaluate the effects of intravenous Mg replacement therapy on MBC Mg content and serum Mg concentrations in critically ill hypomagnesemic patients. Adult patients admitted to the trauma intensive-care unit (ICU) with serum Mg concentration < or = 0.6 mmol/L (< or = 1.5 mg/dL) were considered for study entry. Patients with severe renal disease (Scr > 133 mumol/L), pregnancy, or those who were seropositive for HIV were excluded. Ten patients with moderate (> 0.4-0.6 mmol/L [> 1.0-1.5 mg/dL]) and severe (< or = 0.4 mmol/L [< or = 1.0 mg/dL]) hypomagnesemia received 0.5 and 0.75 mmol/kg of intravenous MgSO4, respectively, over 24 h. MBC Mg content and serum concentrations of magnesium, phosphorus, calcium, sodium, potassium, blood urea nitrogen, creatinine, glucose, and albumin were measured at baseline (0 h), end of infusion (24 h), 36 h, and 48 h. Data were analyzed using ANOVA with repeated measures and a P value < 0.05 was considered significant. Serum Mg concentrations increased significantly from baseline to 48 h (0.5 +/- 0.1 to 0.8 +/- 0.2 mmol/L, P < 0.001). MBC Mg content did not change significantly within the study period (2.6 +/- 1.0 to 3.0 +/- 1.3 fmol/cell, P > 0.7). The doses of MgSO4 (0.5-0.75 mmol/kg) used in this study increased serum Mg concentrations, but did not result in a statistically significant change of MBC Mg content in this group of trauma ICU patients.

Treatment of hypophosphatemia in patients receiving specialized nutrition support using a graduated dosing scheme: results from a prospective clinical trial.

OBJECTIVE: To determine the safety and efficacy of a graduated dosing scheme of phosphorus replacement therapy in patients with hypophosphatemia receiving specialized nutrition support. DESIGN: Prospective clinical trial. SETTING: A 455-bed tertiary care institution, with Level I trauma designation. PATIENTS: Seventy-eight adult patients, followed and co-managed by a multidisciplinary Nutrition Support Service, with a serum phosphorus concentration of < 3 mg/dL (< 0.97 mmol/L) and no evidence of renal insufficiency, calcium or parathyroid disorders, or obesity. INTERVENTIONS: Patients were enrolled into one of three categories based on their serum phosphorus concentration: mild hypophosphatemia (2.3 to 3 mg/dL [0.74 to 0.97 mmol/L]), moderate hypophosphatemia (1.6 to 2.2 mg/dL [0.52 to 0.71 mmol/L]), or severe hypophosphatemia (< 1.5 mg/dL [< 0.48 mmol/L]). Each patient received one intravenous phosphorus bolus dose, based on the assigned category of hypophosphatemia, according to a graduated dosing scheme: 0.16 mM/kg (mild), 0.32 mM/kg (moderate), or 0.64 mM/kg (severe). Serum/blood concentrations of phosphorus, calcium, albumin, magnesium, urea nitrogen, and creatinine were measured for three consecutive days. MEASUREMENTS AND MAIN RESULTS: Sixty-seven patients completed the protocol. There were 31 patients with mild hypophosphatemia, 22 patients with moderate hypophosphatemia, and 14 patients with severe hypophosphatemia. Serum phosphorus concentrations increased significantly (p < .001) in all groups after the phosphorus bolus: 2.6 +/- 0.6 to 3.3 +/- 0.6 mg/dL (0.84 +/- 0.19 to 1.1 +/- 0.19 mmol/L) for the mild group; 1.9 +/- 0.6 to 2.7 +/- 0.6 mg/dL (0.61 +/- 0.19 to 0.87 +/- 0.19 mmol/L) for the moderate group; 1.3 +/- 0.8 to 2.3 +/- 0.8 mg/dL (0.42 +/- 0.26 to 0.74 +/- 0.26 mmol/L) for the severe group. There were no clinically significant changes in serum/blood calcium, albumin, urea nitrogen, or creatinine concentrations and no adverse reactions to the phosphorus regimens throughout the 3-day study period. CONCLUSION: The graduated dosing scheme of phosphorus replacement therapy is both safe and efficacious in patients receiving specialized nutrition support.

Early nutrition support modifies immune function in patients sustaining severe head injury.

BACKGROUND: Immunosuppression after severe head injury has been characterized by a depressed CD4 (T-helper/inducer)-CD8 (T-suppressor/cytotoxic) ratio and decreased T-lymphocyte responsiveness. Some investigators propose that this immunocompromized state is the result of an injury-associated hypermetabolic response and inadequate nutrient delivery during the immediate postinjury recovery phase. Previous observations from our institution demonstrated a preserved CD4-CD8 ratio in severe closed-head injury (CHI) patients receiving early parenteral nutrition (PN). It was unclear whether early PN or other aspects of patient care eliminated the characteristic depression in cellular immunity. The purpose of this study was to further investigate the effect of early PN on the immune function of CHI patients. METHODS: Nine patients sustaining severe CHI were prospectively randomized to either early PN (n = 4) at day 1 or delayed PN (n = 5) at day 5. Total nutrient administration was delivered at 2 g of protein/kg per day and 40 nonprotein kcal/kg per day for at least the first 14 days of hospitalization. Analysis for T-lymphocyte expression of CD4 and CD8 cell surface antigens and interleukin-6 was performed on days 1, 3, 7, and 14 of hospitalization. T-lymphocyte activation in response to stimulation by concanavalin A (Con A), phytohemagglutinin (PHA), and pokeweed mitogens (PWM) was also assessed on these days. RESULTS: Significant increases in total CD4 cell counts (2048 +/- 194 to 2809 +/- 129 vs 1728 +/- 347 to 1825 +/- 563, p < .05) and CD4% (42.6 +/- 4.4% to 56.2 +/- 2.6% vs 36.6 +/- 6.6% to 36.6 +/- 11.3%, p < .05) were observed at day 14 in patients receiving early vs delayed PN. An improved lymphocyte response from baseline to day 14 after Con A stimulation was demonstrated in the early PN group (3850 +/- 1596 to 16144 +/- 5024 cpm, p < .05). A significant rise in the CD4-CD8 ratio over baseline to day 14 was also noted in the early PN group (1.43 +/- 0.17 to 2.38 +/- 0.54, p < .05). CONCLUSIONS: The early aggressive nutrition support of CHI patients appears to modify immunologic function by increasing CD4 cells, CD4-CD8 ratios, and T-lymphocyte responsiveness to Con A.

Observations of hypophosphatemia and its management in nutrition support.

Severe hypophosphatemia is associated with significant morbidity in hospitalized patients. Specialized nutrition support is an important factor that contributes to the development of this metabolic disorder. Current treatment regimens for hypophosphatemia are empiric and often fail to normalize serum phosphorus concentrations in these patients. Patients who develop hypophosphatemia during the administration of specialized nutrition support exhibit increased phosphorus demands and require aggressive replacement therapy.

Failure of topical vegetable oils to prevent essential fatty acid deficiency in a critically ill patient receiving long-term parenteral nutrition.

This case report describes the failure of topical vegetable oils containing esters of linoleic acid to prevent essential fatty acid deficiency in a critically ill patient with trauma. A 40-year-old black man injured in a motor vehicle accident developed essential fatty acid deficiency after being maintained on long-term, fat-free parenteral nutrition plus topical vegetable oil application because of the presence of severe hypertriglyceridemia. Biochemical evidence of this deficiency included a decrease in serum linoleic, a-linolenic, and arachidonic acid levels with a corresponding increase in oleic and palmitoleic acid levels. Cutaneous manifestations consistent with this syndrome were also present. After 3 weeks of daily topical treatments with vegetable oils rich in linoleic acid, biochemical abnormalities of deficiency were still evident. Over the following 2 1/2 months, 4% to 22% of the total caloric intake was delivered as intravenous fat in addition to continued topical administration of vegetable oil. Only after supplementation with intravenous fat did the patient demonstrate clinical and biochemical signs of improvement. The results show that cutaneous administration of vegetable oils as the sole source of linoleic acid may be unable to prevent or treat essential fatty acid deficiency in a critically ill surgical patient.