Biochemical changes associated with severe trauma.

The effects of different intravenous nutritional regimens on a number of biochemical indices of nutritional status were studied during the 8-day period following severe trauma. The inclusion of large amounts of amino acids (high nitrogen (N) was shown to greatly improve N balance over an isocaloric regimen containing no amino acids (O g N). The concentration of serum albumin, transferrin, prealbumin, and retinol-binding protein all fell during the study period in both patient groups, whereas the serum concentrations of acute phase reactants and of ribonuclease increased in the two groups. The sum of plasma levels of branched-chain amino acids and the essential amino acids was increased to a greater extent in the high N group. These amino acid totals and the ratio of glycine/valine showed a significant correlation with N balance in this group. Despite the marked difference in N balance, 3-methylhistidine excretion was increased but equal in the two nutritional groups, suggesting an increased rate of muscle protein breakdown in both groups, which appears not to be influenced by amino acid nutrition. It is concluded that N balance can be significantly improved in the immediate posttrauma period by provision of amino acids together with energy substrates. None of the biochemical variables measured, with the exception of plasma levels of essential amino acids, reflected these marked differences in N balance.

Urinary excretion of carnitine in multiply injured patients on different regimens of total parenteral nutrition.

Carnitine derives from intake of preformed exogenous carnitine and synthesis from lysine and methionine, but is absent in parenteral fluids. Urinary excretions of carnitine and its derivatives was measured in 30 patients 2-8 days after severe multiple injuries and compared with controls. The patients received five different isocaloric parenteral nutritional regimens;group 1 glucose and fat, group 2 glucose, fat and amino acids, group 3 glucose and insulin, group 4 glucose and amino acids, and group 5 branched-chain amino acids. The mean total carnitine excretion in healthy men was 420 mumol/24 h +/- 57 (SEM), and in women 266 mumol/24 h +/- 29, 41% of which was free carnitine. Mean excretion of total carnitine during days 2-8 after trauma for the five groups was: 900 +/- 100, 1169 +/- 112, 1251 +/- 102, 1023 +/- 117, and 668 +/- 128 mumol/24 h, being significantly higher in groups 1-4 than in healthy men. The free carnitine fraction in the patients was significantly higher than in controlled healthy subjects. Total carnitine excretion was unaffected by different nutritional regimens in the very first days. During days 6-8, group 5, receiving branched-chain amino acids had lower excretion of total carnitine (compared to groups 2-4) and free carnitine (compared to groups 3-4). Groups 3 and 4 excreted a higher percentage as free carnitine compared to the other groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term parenteral therapy by percutaneous tunneled silicone central venous catheter--a follow-up of 300 catheters.

We have developed a technique for the management of central venous catheters which incorporates percutaneous insertion and daily care for routine use in different wards. A follow-up of the first 300 catheters is presented. When intravenous therapy was planned for more than two weeks, a silicone rubber catheter was introduced percutaneously with a skin tunnel and the position of the tip in the lower superior vena cava checked by venous pressure measurement. The metal hub of the catheter was disinfected daily by heating with a modified soldering iron which has been proved to be effective by in vitro testing with different microorganisms. The external jugular vein was used in 164 cases (55 per cent) the internal jugular vein in 115 (38 per cent) and the remaining catheters were inserted by the subclavian or antecubital route. Correct positioning was obtained in 96 per cent and serious early or late complications were rare there being only one case of septicaemia in a total treatment period of 270 months. One patient developed a lung infarct, but no case of pneumothorax has been seen. The mean duration of the catheters was 27 days (range 1-239) and the common reasons for termination were cessation of need in 84 per cent, mechanical obstruction in 6 per cent and inadvertent removal in 6 per cent. The described method has proved to be safe and to function well on ordinary wards.

Muscle and plasma carnitine levels and urinary carnitine excretion in multiply injured patients on total parenteral nutrition.

Carnitine is necessary for the transport of long-chain fatty acids across the mitochondrial membrane. Thirteen severely injured patients on total parenteral nutrition were studied during days 2-8 post injury. Initially plasma and skeletal muscle carnitine values were within the range earlier found for normal subjects, whereas the urinary carnitine excretion was markedly increased. On day 4 there was a simultaneous decrease in the carnitine concentration in plasma (alpha < 0.01) and urine (alpha < 0.05) as well as in skeletal muscle tissue (alpha < 0.05 using only the values that could be paired i.e. from eight subjects), whereas no difference was found between day 2 and 8. One explanation of this pattern might be that a redistribution of carnitine occurs to other organs not measured, for example the liver. In skeletal muscle tissue, statistically significant positive correlations were found between the carnitine level and ATP (alpha < 0.01) and phosphocreatine (alpha < 0.02) as well as between carnitine and glycogen (alpha < 0.05).

Delayed hypersensitivity. A critical evaluation of five recall antigens in a large reference population.

The reactivity to five recall antigens, candida, mumps, PPD, varidase and trichophyton and the corresponding diluents was tested in 840 healthy persons aged between 17 and 101 years. Candida antigen was tested in a lower (l) and a higher (h) dose. The size of reactions did not follow a Gaussian distribution and we therefore used the 10th and 5th percentiles instead of standard deviation to define the limits between positive, weak and negative reactions. The number of positive reactions to each of candida-h, mumps, PPD and varidase was between 80 and 95 per cent in patients less than 60 years of age and above this age it varied between 0 and 85 per cent. The number of positive reactions to candida-l and trichophytin was low in all ages. The reactivity was regarded as normal if there was a positive reaction i.e.sum of right angle diameters >10 mm to atl east one antigen, relatively anergic if there was only a weak reaction (7-9 mm) and anergic if there was a negative reaction (0-6 mm) to all antigens. A normal reaction was found in 100 per cent of subjects up to 60 years of age, and in 95 per cent up to 30 years. Among those with normal reactivity, positive results were found with candida-h alone in between 67-93 per cent, candida-h + mumps between 92-100 per cent and candida + mumps + PPD in 100 per cent irrespective of age.

Metabolic effects of four intravenous nutritional regimens in patients undergoing elective surgery II.--Muscle amino acids and energy-rich phosphates.

Muscle amino acids and energy-rich phosphates have been determined in 28 patients before and after resection of a carcinoma of colon or rectum. Before operation the patients received a synthetic diet (Vivasorb for four days and postoperatively four different intravenous regimens with different amounts and proportions of amino acids were given for six days, the energy intake being the same for all groups. When compared with age-matched healthy controls the patients showed only slight increases in phenylalanine and isoleucine concentration in muscle and plasma with elevated plasma glutamate during the four days prior to the operation. Vivasorb treatment increased the concentration of alanine, glycine and methionine in both muscle and plasma while increases of threonine and histidine were seen only in muscle. Decreased concentrations of valine were found in muscle and plasma, while lysine and leucine decreased only in plasma. As an effect of operation, but independent of the nutritional regimen, muscle asparagine increased and muscle glutamine and glutamate decreased in all groups. The unique pattern of amino acid changes in postoperative trauma was confirmed in the present investigation but few differences in amino acid concentrations could be related to the various nutritional intakes. Alterations in the individual amino acid concentrations were not influenced by the intake of amino acids and seemed to have little relationship to the composition of any solution infused. Prior to operation there were low levels of ATP in muscle possibly due to immobilisation and chronic semistarvation but no changes in the energy rich phosphates could be attributed to trauma or nutrition. The content of muscle glycogen increased as a result of the Vivasorb supply indicating that the preoperative carbohydrate administration promotes muscle glycogen synthesis and postoperatively muscle glycogen was reduced significantly indicating enhanced glycogenolysis in the postoperative state. This finding emphasizes the importance of providing the patients with ample amount of glucose before and after surgery.

Changes in nutritional assessment variables caused by total parenteral nutrition in anorexia nervosa.

Nutritional assessment variables were measured weekly in 10 young women with severe anorexia nervosa during treatment with total parenteral nutrition (TPN) for a 5 week period. Before the start of treatment the patients had lost 25-53% of their habitual weight, triceps skin fold (TSF) and arm muscle circumference (AMC) measurements were below the 5th percentile and all were anergic in the delayed hypersensitivity (DH) response. Plasma protein levels were normal except in fibronectin and prealbumin where levels below the reference interval was found in five patients. During TPN the body weight increased most likely due to rehydration and increase in lean body mass. Significant increases were seen in body weight weekly, but in TSF and AMC only after 4 and 3 weeks respectively. TSF and AMC were still below or at the 5th percentile after 5 weeks of TPN. DH response as well as fibronectin and prealbumin levels normalised in all patients. Despite only partial recovery in body cell mass the clinical picture had changed markedly so that the patients now were amenable to psychotherapy and had an adequate intake of food orally, enabling further nutritional therapy to be completed without parenteral support.

Metabolic effects of four intravenous nutritional regimens after elective surgery. I. Clinical data and biochemistry.

Biochemical variables have been determined in 28 patients before and after resection of carcinoma of colon or rectum. A synthetic oral diet was given for four days before operation, (0.1 gN.kg/day and 165 kJ.kg/day) and four isocaloric intravenous regimens with different amounts and proportions of amino acids were given for six days after operation. During the preoperative diet the serum urea, glucose, urate, inorganic phosphate and cholesterol concentration decreased while those of triglyceride, iron and alanine amino-transferase increased. After operation the serum triglyceride, protein, albumin, iron, TIBC and urate concentrations decreased. The serum calcium fell in all groups receiving amino acids after operation while magnesium increased in all groups except the one receiving the highest amount of amino acids. The urea concentration decreased when no amino acids were given but increased when amino acids were administered whereas the reverse situation occurred with cholesterol. The highest increase in glucose level was observed when the highest amount of amino acids were given.

Influence of total parenteral nutrition on plasma fibronectin in malnourished subjects with or without inflammatory response.

Plasma fibronectin, which is an alpha 2-glycoprotein of importance for the immunodefence, has been reported to decrease after starvation and in severely ill patients with cancer. To evaluate the usefulness of fibronectin as an indicator of nutritional repletion, 18 patients with gastrointestinal disorders were studied over a 2-wk period of total parenteral nutrition (TPN). According to nutritional assessment on admission the patients were divided into well nourished (n = 6) and malnourished (n = 12). For comparison nine patients with anorexia nervosa were also studied over a 3-wk period of TPN. Before and after TPN fibronectin, albumin, prealbumin, transferrin, and two acute-phase reactants, haptoglobin and orosomucoid were measured in plasma. The majority of the malnourished patients had an inflammatory reaction in contrast to only a few of the well-nourished and anorexia nervosa patients. Of the proteins measured, only fibronectin rose significantly in the malnourished patients (malnourished and anorexia nervosa), but not in the well nourished patients during TPN. Our results may indicate the usefulness of fibronectin as an indicator of short-term TPN in malnourished subjects, irrespective of the presence or absence of inflammatory response.

Rapid determination of cold insoluble globulin by laser nephelometry. Application in patients receiving preoperative total parenteral nutrition.

A simple and rapid method for determining plasma fibronectin or cold insoluble globulin (CIG) based on immunochemical precipitation and laser nephelometry is described. The coefficient of variation within the series was 4.2% and between the series 9.1%. The mean value for 37 control subjects was 100.1% +/- 20.6 (SD). Nineteen patients with gastrointestinal carcinoma or Crohn's disease were investigated on admission. The mean value of their plasma CIG was 104.7 +/- 26.9 (SD), which was not statistically different from the control subjects. Twelve of the patients received total parenteral nutrition (TPN) during the two preoperative weeks. The concentration of CIG was significantly increased after one and two weeks of TPN compared to the initial value. Six out of seven patients that postoperatively showed signs of infection had CIG values below 90% on admission. Of several other plasma proteins determined on admission, only a statistically significantly negative relationship to transferrin was found. CIG did not significantly relate either to the acute phase reactants, haptoglobin and orosomucoid, or to visceral proteins albumin, choline esterase or prealbumin.

The present view of RES and shock.

Conclusive evidence emphasizes the need for a functionally intact RES function in shock states and in the critically ill patient. Effort must be made to restore and maintain homeostasis also with regard to the RES. RES-research must be intensified in order to define the exact mechanism of the post-traumatic RES depression, since little seems to be gained from pharmacological stimulation of the RE cells, but more from replenishing apparently missing plasma factors. Attention must also be paid to the RES in the therapeutic situation by restricting the use of potential RES depressors.

Bilateral chylothorax - complication in malignancy.

Bilateral chylothorax is a rare condition caused by traumas and disorders with perforation or destruction of main lymphatics in the thorax leading to lymph leakage. Two patients with bilateral chylothorax are presented one of whom was successfully operated on. Etiology, diagnostics and therapy of this condition are discussed.

Cardiac output determinations with ear piece densitometry.

The results of cardiac output determinations by a dye dilution technique were compared using (a) a dichromatic earpiece which was calibrated as a flow-through cuvette, but also permitted automatic computing by virtue of a pressure capsule, and (b) an ordinary flow-through densitometer. Eleven subjects, some with cardio-pulmonary disease, were investigated. Cardiac outputs were systematically overestimated when automatically computed. The results obtained by manual calculation with the ear-piece corresponded more nearly with those derived from the flow-through cuvette, but still with a deviation from the identity line and with a residual standard deviation of 0.8 l/min. Double determinations had a residual standard deviation of 0.7 l/min. Despite its ease of handling, an earpiece densitometer seems to be too unreliable to be suitable for routine use.

Experience of an active regimen in the treatment of massive upper gastrointestinal haemorrhage.

Three-hundred and ninety-five cases of massive upper gastrointestinal haemorrhage were treated in the Surgical and Anaesthesiological Departments of the University Hospital in Linköping over a 5-year period. The mortality was 13%, or 10% when oesophageal varicosities are excluded. Results of a consistent policy concerning surveillance, diagnostic measures, and different forms of therapy are described. From the surgeon's point of view, emphasis is laid on the importance of endoscopy as a means of decreasing the number of exploratory gastroduodenotomies and increasing the proportion of patients in whom surgery is directed against a known source of bleeding. This leads to an enhancement of surgical expediency.